John D. Halamka, MD, HITSP chair and CIO of the Beth Israel Deaconess Medical Center Image source: Healthcare IT Standards Panel (HITSP)

Although there's some confusion regarding EHR meaningful use and EHR certification requirements, there is one question on everyone’s mind, said John Halamka, CIO of Beth Israel Deaconess Medical Center, CIO at Harvard Medical School, Chair of the Healthcare Information Technology Standards Panel and Co-Chair of the HIT Standards Committee. He was speaking at a recent CHIME webinar about EHRs, meaningful use and certification requirements.

That question is: “How can my eligible professionals get $44,000, and how can my hospitals get the roughly $2 million per year for four years by using certified systems in a meaningful way?”  he said.

Halmaka’s presentation focused on the standards that are foundational to achieving meaningful use, in three areas: Content, vocabulary, and privacy and security.

Meaningful use calls for two kinds of summary document exchanges: provider-to-provider and provider-to-patient.

What should those summary documents include? “When I think of a medical summary, I think of a problem list, a medication list, an allergy list, current labs and some narrative text,” Halamka said. Narrative text might describe an operation or the thought process in reaching a diagnosis, or it could specify diet or work restrictions the patient might have, he added.

Currently, there are two approaches to transmitting this kind of continuity of care information. The first is embodied in the HL7 Clinical Document Architecture (CDA) release 2, Continuity of Care Document (CCD) standard. The implementation guide, called C-32, constrains the CCD “so you have very specific guidance as to what fields you should include and how to populate those fields,” Halamka said. The other approach is to use the Continuity of Care Record (CCR) standard. “The CCR is its own implementation guide because it does not have a separate set of rules beyond the ASTM E2369 standard,” he said..

Both CCD and CCR are valid standards for transmitting data to patients or providers. However, “ideally we’d like to get to one standard, so vendors don’t have to [support] submission and receipt of both of these standards,” said Halamka.

CCD has been embraced by much of the EHR community, especially those that create enterprise systems and larger practices. But others, especially modular and "EHR lite" type systems, use CCR. In the interest of getting the country beyond a 15 percent adoption rate of EHRs, “saying we will foster the use of EHRs, EHR lites, modular EHRs and summary exchanges using the CCR format seems like a reasonable way to accelerate from where we are today,” he said.

"If I were to fast-forward to 2013, I suspect that the demands for patient summary information in 2013 meaningful use will include many other structured types of summary documents: structured histories and physicals, structured op notes, structured discharge summaries. Structured documents contain many components: chief complaint or history of present illness, review of systems, assessment plan, these kinds of things,” he said. In any event, “assume, if you have CCD or CCR capabilities today, you will adhere to the patient summary record requirement [for EHR certification].”

The standards for transmission of electronic prescriptions are more straightforward, according to Halamka. You can use NCPDP SCRIPT Standard Implementation Guide 8.1, or NCPDP SCRIPT Implementation Guide 10.6. Modular EHRs and e-prescription systems that support either one are compliant. Both standards support five electronic prescription capabilities: e-prescribing, formulary, eligibility, history and refill, but Stage 1 meaningful use requires only e-prescribing, he said.

For the required public health reporting transaction, HL7 2.5 Implementation Guide Release 1 can be used for all types of public health transactions. Massachusetts and other states are working toward one transaction set for all types of public health reporting for multiple purposes, said Halamka. Standards HL7 2.3.1 and 2.5.1 are standards for public health surveillance and syndromic surveillance activity, he added.

Quality measures have been retooled by the National Quality Federation to be EHR-friendly, Halamka said. Quality measures use the same standards: “any of the vocabularies that are cross-mapped in RxNorm: ICD-9 CM, SNOMED CT, LOINC,” he said. “There is no requirement to use ICD-10 in 2011 for any measure. Don’t burden clinicians with having to memorize ICD-9 or ICD-10; just start with SNOMED CT and all ICD complexity can be done in the back office.”