OpenEMR Certification

Meaningful Use Certification

Incentive payments under Medicare will be slower in coming. Physicians who have registered in that program must then report to CMS that they have met meaningful-use requirements over a 90-day period. Because registration begins January 3, the earliest they can attest to this is in April. The first EHR incentive checks under Medicare are expected to go out in May. The last day for physicians to begin a 90-day reporting period in 2011 is October 3.

NIST Testing Requirements

• 170.302 (a-n): General requirements --> Applies to both ambulatory and inpatient EHRs
• 170.302 (o-v): Security requirements --> Mandatory for all EHR certifications
• 170.302 (w): Security requirement --> Optional
• 170.304 (a-j): Ambulatory requirements

Preliminary pilot run with ICSA Labs was very successful, all things tested passed. We tested things we thought would pass per ViCare+ and proved that they actually did pass. --Tony - www.mi-squared.com 01:39, 1 February 2011 (UTC)

Project Tracking, Testing and QA for ONC Certification

• OpenEMR QA against NIST - QA using NIST Test scripts - Barometer and Results notes

• ARRA ONC MU Project Issues List - Issues list for the tracking spread sheet

Archive Data

File:ARRA ONC MU Project-Master-20100927.pdf - --Tony - www.mi-squared.com 03:02, 28 September 2010 (UTC), this file is the last one to be tracked externally. All tracking is done here on the wiki pages now.

CCHIT_MU_2011_Project - Past meeting notes, target dates and SPRINT logs are located here as well as some team decisions about design choices.

Completion Barometer

Meaningful Use

Color Key:

Not Started

In Progress

Coded

Completed

Status By MU ID

1

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27

Status and Summary - Updated: --Tony - www.mi-squared.com 03:31, 1 February 2011 (UTC)

We are really a lot closer to being ready than the barometer can show in this situation (ie: volunteer).

TARGET IS END OF MARCH 2011

Details, Dependencies and Links to the Individual Items

Contributors are encouraged to update this page with information as they know it.

Summary of Projects that cross multiple MU

CPOE

• Order Entry (specifically lab/Xray)
  • Basic Testing is OK, Visolve identified some issues re NIST
  • MI2: Jeremy will own this.
    • LEN working in test site and will be ready for code review this week --Tony - www.mi-squared.com 01:37, 1 February 2011 (UTC)
    • Lab Results need to be mapped back into CCR/CCD, structure is not fixed, so we need to understand this can be identified discrete information.
    • May need a higher level way to link up the the reference lab -> then Order type
  • MMF: has a Labcorp and Quest LEN in progress
  • Xrays
    • Sam Sent a config file that includes Xray orders, Tony will upload it for use

E-Prescribing

• Phyaura --Tony - www.mi-squared.com 17:53, 27 January 2011 (UTC)
  • • Update: will be submitting a new code revision soon which will include the Phyaura "Save CCD As XML". You can catch me online tomorrow as I'll be testing against the code sets and NIST. --Tony - www.mi-squared.com 03:15, 1 February 2011 (UTC)
    • OpenEMR tests include, CCD download, save as XML, e-script
    • Some MU items are covered by Relay Health e-script: Medication Rec, CCD/with Meds, Med Allergy,
    • Drug/Drug Interaction - included
    • Drug/Food Interaction - not part of the system
    • Demographics are automatically transfered
  • MMF --Tony - www.mi-squared.com 17:53, 27 January 2011 (UTC)
    • H2H Integration code posted for review 12-10-2010
    • https://github.com/bradymiller/openemr/commit/34afff0116c6af2bc0a37ea7c45855a3e1ac9e4d
    • This is a direct contract physician -> H2H, vs reseller model
    • MMF and Garden will pursue cost reduction, H2H offers $3000 to sign up and $40/month per Phy + $300 starter at practice (per ZHH email)
  • A link to Allscripts work (Modular Certification)
    • https://eprescribe.allscripts.com/Login.aspx?ReturnUrl=%2fdefault.aspx

CCD/CCR

• Need Save As and Print for feeding 18, 19 and 21.
  • Connie seems to have done Save As (XML) - ability to upload this to a CCD/CCR compliant portal. This covers 18, 19, 21 and 23.
  • MicroSoft Health Vault interface will be released Feb 9th
  • Garden will provide a test bed for Visolve to test against
  • Print function nominal done, print as PDF would be better - *need owner*
• Need people to start helping add data collection modules to the CCD/CCR viewers
  • Garden will document how to run the CCD/CCR validator to do testing on the each added module --Tony - www.mi-squared.com 17:53, 27 January 2011 (UTC)
  • Multiple contributors needed to write the feeds. - Visolve: Problems and Medication (maybe)
  • Import of CCR/CCD - XML Mime type needs to be fixed: Mike F. owns this
• Alfonso is going to be testing this against and HIE he has a relationship with
• Garden will add transition of care to CCD/CCR by end of March (this will be ready for stage two)
• Garden Demo to Vicare+ HIE CCD/CCR use for NIST.

Clinical Desc Rules

• MI2 and Ensoftek
• Posted Admin UI. Functional Spec and got it approved by Brady
  • UI development in progress first code release targeted Feb 7

Patient Educational Resources

• Meeting with Healthwise to discuss possibilities

  No call back from them yet .. --Tony - www.mi-squared.com 01:32, 1 February 2011 (UTC)

  Dr Brody said was list some educational websites, like Healthwise and Advancedweb.com

CQM Reporting

• Ensoftek
• Format identified, some new data fields are needed, see wiki links --Tony - www.mi-squared.com 01:35, 1 February 2011 (UTC)
  • Need to identify owners for each report.

Encryption Model SHA -vs- MD5

• Visolve working on a report for this
  • Will change on Login and Audit to SHA
  • Some questions NIST

Ready to Test

• Public Surveillance : NIST Test Procedure for §170.302

Meaningful Use Requirement Details

1. Foundations: Security and Privacy - Done

2. Computer Physician Order Entry

• Combination of eRx, Lab Results and Transactions Systems meets the requirement.

3. Drug Decision Support

• Resource needed for Lexicomp testing and completion - need to review the original test
• Phyaura's option: no external dependencies, some cost involved
  • Common interface under development that would be usable for other e-prescribing

4. Problem List

5. Electronic Prescribing--Tony - www.mi-squared.com 03:00, 14 December 2010 (UTC)

• Phyaura's option: no external dependencies, some cost involved as above
  • Common interface under development that would be usable for other e-prescribing
  • Merged Prescription Table with Medications Lists may cause the need for some tweaks or changes to the UI around the Meds List
  • Connie will look into creating a dummy loopback server for testing e-Rx
  • Code has been posted for review on github by Connie --Tony - www.mi-squared.com 20:21, 27 December 2010 (UTC)

6. Medication List - visolve has committed code to meet NIST

7. Medication Allergy List - visolve has committed code to meet NIST

8. Demographics - visolve has committed code to meet NIST

9. Vital Signs - Done

10. Smoking Status - visolve has committed code to meet NIST

11. Lab Test Results

• Submitted code for review --Tony - www.mi-squared.com 02:09, 22 February 2011 (UTC)

12. Patient Lists

• Tests on the report (clinic_reports.php) find some minor issues with the 'Problem List' output
• Visolve posted a new design and is working on it. --Tony - www.mi-squared.com 03:34, 1 February 2011 (UTC)

13. CMS Quality Reporting

• Dependent on Clinical Decision Rules
• Primary Report is coded, need XML (official) output format
• Need to confirm the hard stop list that is required - Tony will confirm with ICSA

14. Patient Reminders

• Code is waiting review as part of CDR project
• MI2:Ensoftek

15. Clinical Decision Rules

• Project Kick-off happened last week, team meeting 12/27, project page updated --Tony - www.mi-squared.com 20:13, 27 December 2010 (UTC)

16. Insurance Eligibility - Not Needed for Cert

17. Electronic Claims Submission - Not Needed for Cert

18. Patient Electronic Copy of Health Information

• Dependent on ability to produce on CCR/CCD format (Garden), supposed to be coming from Phyaura
• Could just save a standard report as PDF

19. Patient Electronic Access to Health Information

• Interface to Microsoft Health Vault demonstrated vi Garden's HIE
• Dependent on ability to display in Human Readable (CCD/CCR already does this)

20 Patient Clinical Summaries

• Dependent on ability to produce on CCR/CCD format (Garden)
• Dependent on ability to display in Human Readable (CCD/CCR already does this)

21. Exchange Clinical Information

• Dependent on ability to produce on CCR/CCD format (Garden)
• Dependent on Data Element Review
  • Documents posted for review, but process stalled. --Tony - www.mi-squared.com 03:00, 14 December 2010 (UTC)
  • Produce specs for any UI/DB changes needed
• Import and view CCR/CCD (coded) (Garden)

22. Medication Reconciliation

• Updates posted for review by Visolve --Tony - www.mi-squared.com 02:09, 22 February 2011 (UTC)

23. Summary Care Record for Transition of Care/Referral

• Dependent on CPOE tests above and integration with existing referral
• Dependent on CCR for data exchange and UI changes to support it.

24. Immunization Registries

• Dependent on Minor Data Changes
• Dependent on CVX Coding
• Dependent on HL7 output required

25. Electronic Syndromic Surveillance - Done

26. Patient Specific Education resources

• Can reference known sites with kind of database

27. Automatic Measure Calculation

• This can be done with the CDR engine (as the CQM reporting), however the rules need to be entered and some algorithm modifications will be required(this is analogous to the CQM reporting).

CQM/PQRI and Patient Data Mappings

Mapping_OpenEMR_Data_for_CCD/CCR_and_CQM - This page has a table for each of 17 basic CCD/CCR data structures that need to be extracted from OpenEMR. It also has the discrete data elements (selection lists) required for much of MU Certification.

Direct Interface

This interface will be needed as a standard model to allow communication of CCR/CCD and other messages meet electronic exchange of data requirement.

Direct Project Wiki

The interface is basic SMTP interface to a known target with directory list of know targets

• phpmailer can be used to send a TLS (secure attachment) is a possibility
• Receiving responses need to be fetched and analyzed for routing. This could happen in any number of ways similar to EDI clearing houses
• Key management is handled by the HISP or a similar keystore
• Delivery to the end target is pull model, internally HISP talk to each talk bi-directionally

Dropped MU Items

As of 12/30/2009, the following MUs are no longer required:

1. Advance Directives - Completed and included in 4.x release
2. Progress Note - Already part of OpenEMR

Full 'C' Certification

This project follows successful Meaningful Use certification.

Funding

Requirements

Teams Identified

Development Started

Submitted to and ONC Certification Body

OSCON Presentation by Tony and Sam

Dr Sam Bowen and Tony McCormick were speakers at the O'Rielly Open Source Convention in Portland. I have attached the presentation.

Slide Show PDF + notes, Taking OpenEMR, a GPL EMR to ARRA Meaningful Use Certification and beyond Presentation:

• File:OpenEMR-MUCert.pdf

It was recorded for video and is available on YouTube: Watch it at 240p resolution or it freezes up after about 16 minutes ,,,,

• http://www.youtube.com/watch?v=zxd-ZJuiCEk

Blog Posts:

• Day One: http://radar.oreilly.com/2010/07/day-one-of-the-health-care-it.html
• Day Two: http://radar.oreilly.com/2010/07/vista-scenarios-and-other-cont.html
• Wrap Up: http://radar.oreilly.com/2010/07/wrap-up-of-the-health-care-it.html

Links

• Approved Certification Bodies
• Final of NIST Test Scripts for 2011
• Main HHS Site for ONC Rules
  • Initial Certification Criteria for EHR Technology (ONC) *deprecated PDF*
  • Electronic Health Record Incentive Program (CMS) *deprecated PDF*
  • Interim Final Rule (HHS) *deprecated PDF*
• CCHIT Preliminary and IFR Gap Analayis (CCHIT)
• NIST awards contract to create EHR certification system: http://www.govhealthit.com/newsitem.aspx?nid=72951
• Drummond Group Inc (DGI) EHR blog: http://www.drummondgroup.com/blog/
• HITPC's Recommended Changes to Meaningful Use
• Wikipedia ARRA: http://en.wikipedia.org/wiki/American_Recovery_and_Reinvestment_Act_of_2009
• Establishment of the Temporary Certification Program for Health Information (ONC)

Bradford-Scott Summary

By 2011:

   * use computerized physician order entry for all orders including medications;
   * incorporate lab tests and results into EHRs and share results electronically with public health agencies;
   * generate lists of patients by specific condition to use for quality improvement;
   * provide clinical summaries for patients after each encounter;
   * exchange key clinical information among health professionals.

By 2013:

   * generate and transmit prescriptions electronically;
   * manage chronic conditions using patient lists and decision support tools;
   * use bar coding for medication administration;
   * offer secure patient-physician messaging capability;
   * record patient preferences in EHR.

By 2015:

   * achieve minimal levels of performance on quality, safety and efficiency;
   * give patients access to self-management tools;
   * access comprehensive patient data from all available sources;
   * conduct automated real-time surveillance on occurrences such as adverse events, disease outbreaks and bioterrorism;
   * incorporate clinical dashboards into EHR.

HHS Definition Summary

• Feb 12, 2010

The Secretary adopts the following certification criteria for Complete EHRs or EHR Modules designed to be used in an ambulatory setting. Complete EHRs or EHR Modules must include the capability to perform the following functions electronically and in accordance with all applicable standards and implementation specifications adopted in this part:

Sec. 170.304 Specific certification criteria for Complete EHRs or EHR Modules designed for an ambulatory setting.

The Secretary adopts the following certification criteria for Complete EHRs or EHR Modules designed to be used in an ambulatory setting. Complete EHRs or EHR Modules must include the capability to perform the following functions electronically and in accordance with all applicable standards and implementation specifications adopted in this part:

    (a) Computerized provider order entry. Enable a user to 
electronically record, store, retrieve, and manage, at a minimum, the 
following order types:
    (1) Medications;
    (2) Laboratory;
    (3) Radiology/imaging; and
    (4) Provider referrals.
    (b) Electronically exchange prescription information. Enable a user 
to electronically transmit medication orders (prescriptions) for 
patients in accordance with the standards specified in Sec.  
170.205(c).
    (c) Record demographics. Enable a user to electronically record, 
modify, and retrieve patient demographic data including preferred 
language, insurance type, gender, race, ethnicity, and date of birth.
    (d) Generate patient reminder list. Electronically generate, upon 
request, a patient reminder list for preventive or follow-up care 
according to patient preferences based on demographic data, specific 
conditions, and/or medication list.
    (e) Clinical decision support.
    (1) Implement rules. Implement automated, electronic clinical 
decision support rules (in addition to drug-drug and drug-allergy 
contraindication checking) according to specialty or clinical 
priorities that use demographic data, specific patient diagnoses, 
conditions, diagnostic test results and/or patient medication list.
    (2) Alerts. Automatically and electronically generate and indicate 
in real-time, alerts and care suggestions based upon clinical decision 
support rules and evidence grade.
    (3) Alert statistics. Automatically and electronically track, 
record, and generate reports on the number of alerts responded to by a 
user.
    (f) Electronic copy of health information. Enable a user to create 
an electronic copy of a patient's clinical information, including, at a 
minimum, diagnostic test results, problem list, medication list, 
medication allergy list, immunizations, and procedures in:
    (1) Human readable format; and
    (2) On electronic media or through some other electronic means in 
accordance with:
    (i) One of the standards specified in Sec.  170.205(a)(1);
    (ii) The standard specified in Sec.  170.205(a)(2)(i)(A), or, at a 
minimum, the version of the standard specified in Sec.  
170.205(a)(2)(i)(B);
    (iii) One of the standards specified in Sec.  170.205(a)(2)(ii);
    (iv) At a minimum, the version of the standard specified in Sec.  
170.205(a)(2)(iii); and
    (v) The standard specified in Sec.  170.205(a)(2)(iv).
    (g) Timely access. Enable a user to provide patients with online 
access to their clinical information, including, at a minimum, lab test 
results, problem list, medication list, medication allergy list, 
immunizations, and procedures.
    (h) Clinical summaries.
    (1) Provision. Enable a user to provide clinical summaries to 
patients for each office visit that include, at a minimum, diagnostic 
test results, problem list, medication list, medication allergy list, 
immunizations and procedures.
    (2) Provided electronically. If the clinical summary is provided 
electronically it must be:
    (i) Provided in human readable format; and
    (ii) On electronic media or through some other electronic means in 
accordance with:
    (A) One of the standards specified in Sec.  170.205(a)(1);
    (B) The standard specified in Sec.  170.205(a)(2)(i)(A), or, at a 
minimum, the version of the standard specified in Sec.  
170.205(a)(2)(i)(B);
    (C) One of the standards specified in Sec.  170.205(a)(2)(ii);
    (D) At a minimum, the version of the standard specified in Sec.  
170.205(a)(2)(iii); and
    (E) The standard specified in Sec.  170.205(a)(2)(iv).

[[Page 2047]]

    (i) Exchange clinical information and patient summary record.
    (1) Electronically receive and display. Electronically receive a 
patient's summary record, from other providers and organizations 
including, at a minimum, diagnostic tests results, problem list, 
medication list, medication allergy list, immunizations, and procedures 
in accordance with Sec.  170.205(a) and upon receipt of a patient 
summary record formatted in an alternate standard specified in Sec.  
170.205(a)(1), display it in human readable format.
    (2) Electronically transmit. Enable a user to electronically 
transmit a patient summary record to other providers and organizations 
including, at a minimum, diagnostic test results, problem list, 
medication list, medication allergy list, immunizations, and procedures 
in accordance with:
    (i) One of the standards specified in Sec.  170.205(a)(1);
    (ii) The standard specified in Sec.  170.205(a)(2)(i)(A), or, at a 
minimum, the version of the standard specified in Sec.  
170.205(a)(2)(i)(B);
    (iii) One of the standards specified in Sec.  170.205(a)(2)(ii);
    (iv) At a minimum, the version of the standard specified in Sec.  
170.205(a)(2)(iii); and
    (v) The standard specified in Sec.  170.205(a)(2)(iv).

ONC Meaningful Use - Final Rules for 2011

Health and Human Services - Standards & Certification

• http://healthit.hhs.gov/portal/server.pt?open=512&objID=1153&mode=2

ONC Initiatives

• http://healthit.hhs.gov/portal/server.pt?open=512&objID=1497&parentname=CommunityPage&parentid=1&mode=2&in_hi_userid=10741&cached=true

NIST Test Scripts

• http://xw2k.nist.gov/healthcare/use_testing/index.html

14 organizations have applied to become ONC-ATCB so CCHIT will definitely not be the only one.

• http://community.advanceweb.com/blogs/nurses_17/archive/2010/06/23/onc-establishes-temporary-certification-program-for-ehrs.aspx

CCHIT Summary

The Certification Commission for Healthcare Information Technology (CCHIT) has published ambulatory certification criteria on their web page: CCHIT Web Site - look here for for the most current information. CCHIT has been in existence since about 2006 and the criteria have been revised several times.

• http://www.cchit.org/get_certified/open_eligible_providers

The United States Department of Health and Human services and the Office of the National Coordinator of Health Information Technology have published a definition of what they consider to be Meaningful Use of Electronic Health Records. These criteria have divided into five very broad policies:

1. Improve quality, safety, efficiency, and reduce health disparities
2. Engage Patients And Families.
3. Improve Care Coordination.
4. Improve population and public health
5. Ensure adequate privacy and security protections for personal health information

Other References

Ronald Leemhuis did some early testing of how OpenEMR stacks up against the 2008 criteria: Initial CCHIT Functionality Testing

This topic had been much discussed by the OpenEMR project at SourceForge:

• http://sourceforge.net/forum/forum.php?thread_id=2154323&forum_id=202506
• http://sourceforge.net/forum/forum.php?thread_id=2042768&forum_id=202504

Organizational Meeting Notes

We have had four organizational teleconferences and here are the transcripts:

• CCHIT Organizational Teleconference #1 07/10/2009
• CCHIT Organizational Teleconference #2 07/14/2009
• CCHIT Organizational Teleconference #3 08/24/2009
• CCHIT Organizational Teleconference #4 10/24/2009

Criteria Breakdown Categories

The Criteria are further subdivided into the large categories of Functionality, Interoperability, and Security:

Functionality

The ability to create and handle electronic records for all of a physician practice's patients, as well as computerize the flow of work in the office. There are approximately 400 functionality criteria. The areas covered are:

• Organizing patient data
  
• Compiling lists
  
• Receiving and displaying information
  
• Creating orders
  
• Supporting decisions
  
• Authorized sharing
  
• Administrative and billing support
  
• Graphical reports
  
• Automatic alerts
  
• Maintaining documents and guidelines
  
• Disease and drug management
  

Interoperability

The ability to receive and send electronic data between an EHR and outside sources of information such as labs, pharmacies and other EHRs in physician offices and hospitals. There are approximately two dozen Interoperability criteria.

The broad areas required are:

• Laboratory results
  
• Electronic medication prescribing
  
• Exchange summary of documents
  
• Improve Population and Public Health.

Security

• Ensure adequate privacy and security protections for personal health information
  • The ability to maintain patient information safe and private. CCHIT requires ambulatory EHR products to provide state-of-the-art technical capabilities.

The broad areas covered are:

• User Authentication.
• Controlling Access.
• Audit Control.
• Encryption During Transmission.
• Protection at Rest.
• Practitioner Data Integrity.
• Backup Strategies.
• Individual Patient Access.

CCHIT Security To Do List - Created by Visolve

Exchange Clinical Information

• Requirements
• HIE User Interface
• Interoperability with openpixpdq and openxds
• Workflow Diagrams

Provide Patient with Timely Electronic Access to Health Information

• Requirements

Provide Patient with Electronic copy of their Health Information upon Request

• Requirements

Capability to Submit Electronic Data to Immunization Registries

• Requirements

Capability to Provide Electronic Syndromic Surveillance Data to Public Health Agencies

• Requirements

Testing and QA for ONC Certification

CCHIT_Project_QA_Testing_Page

HHS Certification Updated for 2010

Current Status

• Test Scripts: Media:ARRAIFR01-EP_0.zip‎

Certification Criteria

The Certification Criteria for Meaningful Use Stage 1 by Eligible Professionals:

1. Use Computerized Provider Order Entry (CPOE)
2. Implement drug-drug, drug-allergy, drug-formulary checks
3. Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT®
4. Generate and transmit permissible prescriptions electronically (eRx)
5. Maintain active medication list
6. Maintain active medication allergy list
7. Record demographics
   1. Preferred language
   2. Insurance type
   3. Gender
   4. Race
   5. Ethnicity
   6. Date of birth
8. Record and chart changes in vital signs:
   1. Height
   2. Weight
   3. Blood pressure
   4. Calculate and display: BMI
   5. Plot and display growth charts for children 2-20 years, including BMI
9. Record smoking status for patients 13 years old or older
10. Incorporate clinical lab-test results into EHR as structured data
11. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, and outreach
12. Report ambulatory quality measures to CMS or the States
13. Send reminders to patients per patient preference for preventative / follow up care
14. Implement 5 clinical decision support rules relevant to specialty or high clinical priority, including diagnostic test ordering, along with the ability to track compliance with those rules
15. Check insurance eligibility electonically from public and private payers
16. Submit claims electronically to public and private payers
17. Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, allergies) upon request
18. (Not Applicable to Eligible Physicians) Provide patients with an electronic copy of their discharge instructions and procedures at time of discharge, upon request
19. Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies) within 96 hours of the information being available to the eligible professional
20. Provide clinical summaries for patients for each office visit
21. Capability to exchange key clinical information (for example problem list, medication list, allergies, diagnostic test results) among providers of care and patient authorized entities electronically
22. Provide summary care record for each transition of care and referral
23. Perform medication reconciliation at relevant encounters and each transition of care
24. Capability to submit electronic data to immunization registries and actual submission where required and accepted
25. Capability to provide electronic submission of reportable lab results (as required by state or local law) to public health agencies and actual submission where it can be received
26. Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice
27. Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities

Gap Analysis

The gap analysis will be started once the certification criteria have been reviewed.

Project Plan

The project plan will completed following the gap analysis.

Action Items & Backlog

The outstanding items for HHS Certification process will be tracked here.