Mapping appears to be right on. It will be interesting to see how the defs of Meaningful Use change over the next months. It will clearly be a challenge for the vendors to keep up and for the clinicians to decide where to put their efforts.

Thanks Don, appreciate the review and feedback. It's my sense that the meaningful use definition won't change from the July version that much more going forward - though clearly CMS still has to weigh in on the details of how the MU definition will be used in reimbursement. To get around the 'wait and see' pressures you mention, it looks like there will be some type of interim MU certification early this fall from CCHIT - we'll see how that pans out. For now though, I think it's safe/useful to continue this mapping exercise with the info that's currently available.

I agree that the mapping effort that has been started appears sound. One of the benefits of the discussions around meaningful use is the greater awareness that has been generated of the pivotal role of CDS in achieving the objectives in the MU matrix.

Jerry, another way of approaching this might be to frame the meaningful use components in terms of the CDS roadmap that you and your colleagues introduced in the first HIMSS Implementer's Guide. There is an alignment between the CDS steps and the high-level framework of the MU matrix that appears to lend itself to this.

For example:
1. Identify CDS stakeholders and determine CDS goals and objectives:
MU / CDS Goal: use evidence-based order sets and CPOE
MU / CDS Objectives: % of all orders via CPOE (10% inpatient, 100% ambulatory)

2. Catalog IS infrastructure available to address objectives:
CPOE system
Clinical alerts

3. Select CDS interventions to achieve goals and objectives:
Evidence-based order sets, electronic and paper-based (if not yet live with CPOE)
Reference links to evidence-based clinical guidelines
Online risk assessment calculators
Clinical alerts to prompt clinician if no VTE prophylaxis ordered

4. Validate and develop proposed interventions:
Engage stakeholders in review and validation of proposed CDS interventions: consider content and workflow implications

5. Test and launch CDS interventions

6. Evaluate intervention impact and enhance CDS as needed
Report % of orders entered via CPOE
Report % of eligible surgical patients receiving VTE prophylaxis

Thanks very much Ferdi, excellent point! You'd made a similar, impactful point regarding organizing our work around VTE/CDS best practices. I'm still struggling to identify the framework/perspective that will catch the attention of implementers (e.g. folks in the TF) and immediately add value to their MU-related efforts. It may be the scheme you outline above, the one I outlined on this page (http://himssclinicaldecisionsupportwiki.pbworks.com/f/CDS+and+Meaningful+Use-+JO+notes.doc), or perhaps some combination or other. I'd be interested in feedback from you and others, what organizing scheme or outline would most draw you in and lead you to say "this will really help me with my MU efforts," and then provide the drill down to actually provide that help.

Some interesting points made, but a little confusing from my perspective. I think the big value of MU and CDS is the ability to query the system (IP or OP) and see if the clinical outcome measures are being met or not. If they are being met, no need to intrude on the user and if not, a gentle reminder with option to initiate an order at that time is ideal, accomplishing quality care and compliance.

I'm not certain CDS will measure rates as seems to be implied. Rather, CDS attempts to help achieve goals. I also don't see CDS being a part of measuring per se, but that rather is in the venue of a CDW (Clinical Data Warehouse) which is fed by a system that encourages users to do the right things (via CDS).

Finally, for CDS Related Objectives, a glaring omission is workflow and usability. We have not concentrated enough on these and MU will not be achieved unless users find them helpful in their daily work and not intrusive.

Thanks Joel, really appreciate these thoughtful comments. I think we're pretty much on the same page about your key points - e.g. the purpose of CDS regarding the MU metrics is to facilitate outstanding performance on those metrics, rather than focusing on measuring them (as we're illustrating in the VTE work, there's a lot that can be done 'up front' in this regard, prior to needing alerting). Similarly, with the CDS related objectives the point is to connect the dots with guidance we've already produced (and hopefully set up richer guidance) on making the CDS interventions usable in workflow and of high value. We'll clarify these points further on subsequent rounds with this document.

Adding to Joel's point, one underlying theme/need in achieving any of the MU is 1) an assessment framework on progress and 2) a rapid cycle improvement strategy that involves frontline evaluation and editing of the change process. I think Chapter 6 of the guide goes into this nicely. The four worksheets in the chapter can perhaps serve as operational tools to monitor the change process as it may or may not move closer to a MU goal. For example, something as seemingly easy to do as 'Generate lists of patients who need care and use them to reach out to patients" can get quite complicated and still need operational tools to execute - what would be the intervention?, the launch plan?, monitoring implementatino status? Feeback and resolution?...so one can do the same for other goals...

As we discussed at the MU CDS call today (10/20), we will add some content related to the MU measure "High risk meds in the elderly". I've taken the liberty of adding a placeholder under section II. One thing to consider is whether to keep this page at a high level and have the user navigate to a separate page for each of the topics or add all of the content here. What may be easier for us in terms of content creation may not necessarily translate into usability down the road.

A bit delayed response, but to John's comment about rapid cycle improvement: No question this is ideal, however, TAT for system changes is at best frustrating. Assuming there is concensus to the change, we've realized the imperative of testing the change extensively before implementing. This includes testing to see if what you're adding/changing doesn't break some other process in the software, plus user verification testing to see if the "in vitro" is practicable "in vivo". So, while we'd like to make rapid changes, don't throw caution to the winds.

Thanks again Joel/Ferdi/John for this engagement and these insightful comments. Now that we've re-engineered this page - and created a workspace for a deeper dive into a specific issue [safet medication use in elderly - see link to sub-page from blue header in outline above], hopefully we can migrate this great thinking over into that arena. Hopefully that will help us and others contribute to and review these ideas in a more specific and action-oriented way.

Thoughts on how we'd like folks to engage with the new med safety in elderly page and other parts of this MU project: We're hoping that the combination of stuff HIMSS has already written on safe med use in the elderaly (see link within the page connected to the header in blue above on this topic), reference material (e.g. Beers criteria update article we've posted), and a place for folks to come together to talk about their strategies for addressing these challenges will be useful to you and others like you. Our sense is that this 'gathering place' will be more limited and focused than the whole CDS/VTE part of the wiki, and less ephemeral than an AMDIS exchange on the topic.

So the 'ask' is that you peek at that part of the wiki, at the blurb from the CDS guide and Annals article (if that stuff is useful), and that on the linked discussion page you start a thread about whether/how you're approaching this issue, what challenges/needs you have and/or what lessons you've learned, etc. Hopefully such a seed will grow as others pile on, and the net will be a bunch of separate care delivery organizations moving farther faster on these types of things, and a trail of useful implementation pearls that results from these exchanges and that will help scale these good things. If you look this stuff over and feel that all this would be a waste of your time, that's important feedback too.

Dear colleagues,

On Dec. 30, CMS and ONC released the highly anticipated proposed rule for meaningful use and interim final rule for HIT standards and certification. Those that have been participating in the CDS collaborative effort will be pleased with the prominent inclusion of CDS language in the meaningful use proposed rule.

The meaningful use document proposes a phased approach to EHR deployment and explicitly includes CDS in the description of the first stage:
"The Stage 1 meaningful use criteria focuses on electronically capturing health information in a coded format; using that information to track key clinical conditions and communicating that information for care coordination purposes, implementing clinical decision support tools to facilitate disease and medication management, and reporting clinical quality measures and public health information."

There are a couple of meaningful use criteria (objective/measure clusters) directly related to CDS:

Eligible Provider (EP)/Eligible Hospital Objective: Implement drug-drug, drug-allergy, drug-formulary checks
EP/Eligible Hospital Measure: The EP/eligible hospital has enabled this functionality

This criterion was included in the original meaningful use matrix approved by the HIT Policy Committee. It appears that measurement of compliance will be through attestation by the provider/hospital that it has enabled the required capability included in certified EHR technology.

EP/Eligible Hospital Objective: Implement five clinical decision support rules relevant to specialty or high clinical priority, including for diagnostic test ordering, along with the ability to track compliance with those rules
EP/Eligible Hospital Measure: Implement five clinical decision support rules relevant to the clinical quality metrics the EP/Eligible Hospital is responsible for as described further in section II.A.3.

In this case, CMS and ONC expanded upon the HIT Policy Committee's original recommendation for one decision support rule (to 5). From the CMS proposed rule:
"Clinical decision support at the point of care is a critical aspect of improving quality, safety, and efficiency. Research has shown that decision support must be targeted and actionable to be effective, and that “alert fatigue” must be avoided. Establishing decision supports for a small set of high priority conditions, ideally linked to quality measures being reported, is feasible and desirable. Meaningful use seeks to ensure that those capabilities are utilized. Therefore, we believe in order to meet this objective an EP or eligible hospital should implement five clinical decision support rules relevant to the clinical quality metrics described in section II.A.3 before the end of the EHR reporting period and attest to that implementation."
(I found the discussion regarding quality measures in section II.A.3 very confusing, containing many references to specific sections in the HITECH Act. If anyone can sort it out all out, that would be greatly appreciated!)

For eligible providers, there is also an MU criterion for preventive care reminders:
EP Objective: Send reminders to patients per patient preference for preventive/follow-up care
EP Measure: Reminder sent to at least 50 percent of all unique patients seen by the EP or admitted to the eligible hospital that are 50 and over

As already discussed in this Wiki, there are several other aspects of meaningful use and certified EHR technology that are related to and/or are prerequisites for successful and effective implementation of CDS. Additional details will emerge as we study the documents and learn more in the coming weeks. I look forward to your comments and observations.

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