At first glance, the concept of an EHR appears simple: the software helps organize and share data; manage patient populations and order fulfillment; but possibly the most important function as a tool for physicians and other prescribers to improve patient outcomes, is its Clinical Decision Support (CDS) system guides caregivers in making decisions when treating patients. In fact, CDS systems are one of the most effective means of minimizing serious errors in clinical environments. Clinicians enter data into the EHR, and the CDS engine performs a complex series of checks to ensure the accuracy or appropriateness of the diagnosis. The system then either recommends a course of therapy or alerts the user of any diagnostic errors or oversights. Though the means to accomplish this task differ based on system, they all aim to improve and expand Clinical Decision Support. The result is a facility-wide reduction of preventable errors and increase of positive patient outcomes. Nearly all clinicians can agree upon the foundational importance of CDS – take away the other bells and whistles, and what remains is a solid Clinical Decision Support system – as all other features and functions ultimately serve to facilitate this, critical component of any EHR.
Though CDS is widely accepted as one of the most essential aspects of EHR technology, it is also one of the most-often overlooked. The CMS has established set criteria for these systems, such that they may qualify providers for Meaningful Use, and defines Clinical Decision Support as the following:
HIT functionality that builds upon the foundation of an EHR to provide persons involved in care processes with general and person-specific information, intelligently filtered and organized, at appropriate times, to enhance health and health care.
[CDS systems must] Enable a limited set of identified users to select (i.e., activate) one or more electronic clinical decision support interventions (in addition to drug-drug and drug-allergy contraindication checking) based on each one and at least one combination of the following data:
(A) Problem list (a list of current and active diagnoses as well as past diagnoses relevant to the current care of the patient);
(B) Medication list (all past and present meds);
(C) Medication allergy list;
(D) Demographics (defined as preferred language, gender, race, ethnicity, and DOB);
(E) Laboratory tests and values/results ;
(F) Vital signs.
While these requirements provide a solid foundation, the list is not comprehensive. These criteria merely scratch the surface of what it actually means to provide comprehensive decision support to clinicians.
So what’s missing, and what can be improved upon? The answer merits a more complicated response than a simple list revision. Meta’s belief, one that is reflected in our system’s functionality, is that HIT systems should utilize intelligent technology to create a database that grows in efficiency and potency with each new data entry.
But our attention to the small details allows us to ensure safety during the care process. Our system, because of this, provides decision support in areas that many EHR developers tend to neglect:
- Food/Environmental Allergies (Non-medication allergies) – pollen, chocolate, nuts, etc.
- Family History
- Vaccination History
- Travel History (especially in light of events regarding Ebola)
- Missed Step warning (alerts clinicians to clinical action requiring attention)
- Medication Dosage Calculation
- Automatic integration of electronic clinical documentation
- IntelliMed™ Rules-based Engine (allows for the creation of rules, triggered based on data input or available on the patient record)
This list is by no means a complete account of our CDS system’s full range of capabilities; but it does provide an idea of our attention to the minute details. Especially with IntelliMed™, our dynamic and intelligent decision support rules engine, MetaCare users can prevent unnecessary patient complications with the flexibility to address facility and organization-specific protocol. The desired result of our attention to detail is to create a knowledge-based healthcare environment capable of supporting clinicians during diagnosis and decision-making.
The fact that CDS systems comprise such a vital part of EHR processing is troublesome when considering how little attention is paid to them by EHR developers. The Meaningful Use criteria for this objective should be taken with a grain of salt, as they only provide the base for responsible CDS processing. By choosing a system, such as MetaCare Enterprise, that pays closer attention to the more unique and often ignored aspects of patient information, facilities can expect a CDS system that works to stop error before it occurs.
To make myself clear, I do not wish to disparage the Meaningful Use program. Its benefits have been undeniable; after all, EHR adoption has more than quintupled since the enactment of ARRA and the HITECH Act. However, the results are less than spectacular when non-rural care centers are removed from the picture. To many the answer is all too apparent, yet the question has been continually ignored.
Without the more privileged facilities, what remains is a fragmented network of hospitals and clinics struggling to adapt to the changes being forced upon them. Delayed deadlines were not a sufficient solution the problems they faced; and the Regional Extension Centers (RECs) established as part of HITECH often opt to either not to work with rural facilities or charge exorbitant and unrealistic fees. The Stage 1 and Stage 2 objectives treated everyone as equals, in spite of the consequences; it’s the American way, right? Well in this particular case, in modern medicine and healthcare, we’re not all equals. Some needed more help than other, and Meaningful Use made this all too clear.
Rural and critical access facilities constitute a vital part of the United States healthcare system. For many Americans, they are the sole means of obtaining medical attention, and the difference between life and death in emergency situations. But instead of being nurtured and helped along in what is certainly a difficult transitory process, they have been slowly squeezed out. The shortcomings of the Meaningful Use program are visible in the sheer amount of deadline extensions that have been made up to date. If as the ONC reports, “Over nine in ten (93%) hospitals possessed a certified EHR technology in 2013,”1 then why push back deadlines any further? Clearly, the program was a success, and should be nearing its end.
The reason is due to the ONC’s definition of the word “hospital,” a seemingly transparent term that has been restricted to the realm of “non-federal acute care hospitals.”1 Dig a little further and what does this actually mean? It means that 93% of non-CAHs have adopted EHR software; the wording is just subversive enough to mask the reality of the situation. CAHs are almost forgotten amidst the shuffle.
The Meaningful Use initiative has proven to be incapable of addressing the specific needs of rural clinicians. The staff, experience, and IT infrastructure found in many of these facilities just cannot sustain the kind of federal mandates expected of them; and what’s more, not only are these same providers held to unrealistic standards, but also penalized should they fail. There’s no help, no encouragement, and no end in sight.
Based on the inference that rural care facilities in general face problems similar to those confronted by Rural Health Clinics (RHCs), CAHs can be expected to perform better on those objectives relating to the improvement of overall quality, safety, efficiency and the reduction of health disparities, and fall short in reporting quality measures and the implementation of clinical decision support (CDS) rules. They also typically struggle to satisfy requirements that involve engaging patients and families, improving coordination of care, and protecting the privacy and security of personal health information.
The only viable means to address the problems facing this demographic, therefore, is to redirect federal efforts in a way that addresses the specific needs of rural facilities. With reform looking less and less likely to be incorporated as part of Stage 2, the only hope for these facilities falls on the upcoming Stage 3 guidelines. Hopefully the governing bodies have had time to address the program’s shortcomings and will be able to adjust the new requirements accordingly: particularly that objectives be differentiated and designated based on a facility’s status as either a CAH or a non-CAH. The blanket approach was not the solution, and Stage 3 may be the chance for reprieve.
So what can be done to address the issue? First, there should be an increased emphasis on the adoption of clinical decision support systems; this is an absolutely fundamental component of modern health technology, one that has had tremendous success in preventing error. To address the issues faced in reporting quality, there needs to be a push for electronic clinical documentation to collect, record, and share patient information. This, along with the use of secure messaging applications, will further improve the coordination of care. Encouraging the use of web-based systems will serve to further the program’s aims to engage patients and their family. Lastly, standards must be established to regulate the secure protection of sensitive patient data. These should constitute the majority of core requirements for CAHs, such that if met they would qualify facilities for financial reimbursement. The practice of penalizing non-compliant facilities must also be abolished.
However, there is also much to be done on the side of rural clinicians and facility administrators. They need to stay informed on the changing requirements and how to meet them, especially with the shadow of Stage 3 looming larger every day. This is an important step to ensure facilities contract an EHR vendor that is both reliable and qualified. However, it is important to remember that an EHR vendor should not only be certified, but also experienced and familiar with software implementation and Meaningful Use reimbursement in rural settings. Some larger vendors simply cannot provide the same level of personalized support, for the same logic that Meaningful Use objectives have been so successful among larger providers, and so much less among smaller ones.
The real solution to the problem ultimately lies in the collaboration between two factions that are often at odds at each other: the government that imposes reform on one side; and the rural facilities that resists on the other. In the end, however, the people who suffer the consequences are the patients at these facilities. We can all anxiously await the change the program so desperately needs, but without a conscious effort on the behalf of both parties, we may end up having to settle once again.
 Charles, Dustin, MPH, Meghan Gabriel, PhD, and Michael F. Furukawa, PhD. “Adoption of Electronic Health Record Systems among U.S. Non-federal Acute Care Hospitals: 2008-2013.” www.HealthIT.gov. Office of the National Coordinator for Health Information Technology (ONC). ONC Data Brief, No. 16, May 2014.
 Joynt, K. E., Y. Harris, E. J. Orav, and A. K. Jha. “Quality of Care and Patient Outcomes in Critical Access Rural Hospitals.” JAMA: The Journal of the American Medical Association. (July 2011).
 Gale, John A., David Hartley, and Zach Croll. “Meaningful Use of Electronic Health Records by Rural Health Clinics.” Muskie School of Public Service, University of Southern Maine, Feb. 2014.
Patient care is like a house of cards, a delicately constructed hierarchy. Without the proper foundation, the whole house collapses, just as one misstep – one clinical oversight during diagnosis – can often constitute the difference between obtaining a successful patient outcome and the mistreatment of a patient, or worse. Like a house of cards, the strength of our EHR depends on the sum of its parts; yet at the heart of any clinical system, there often lies a troublingly overlooked aspect of care that leaves both clinicians and patients vulnerable to error. The ability to positively identify both patients and users is an important first step in administering care. But without proper reinforcement, this simple but fundamental concept can sabotage the entire care process, like a single unstable card at the base of the house.
Patient identification has long been a point of contention for healthcare providers, but with the increased emphasis on Role-Based Access Controls (RBAC) in recent years, the clinician identification has become equally important. In the aims of maintaining a more secure care environment, clinical systems such as MetaCare Enterprise EHR™ have placed more rigorous authentication measures on users. These technologies are designed to increase attention and awareness during diagnosis, holding clinicians more accountable for their actions. Similar methods have been deployed for the identification of patient and clinician alike.
The most prominently used measures include biometric validation of users, barcoded identification and medication administration systems, Radio-Frequency Identification (RFID) technology for inventory and user validation, and encrypted passkey technology. Meta is capable of successfully integrating these and many other identification technologies, but those listed above rank as today’s most widely-used methods for the positive recognition of patients, clinicians, devices, and medications.
One of Meta’s longest-standing partners was instrumental in paving the way for identification technology usage among MetaCare users. In 2008, when the client had had already successfully completed the implementation of our EHR, we were contacted by hospital administrators and asked to identify a creative solution for the identification of users and patients beyond the typical user ID, password, and non-repudiation software security. After carefully examining the criteria given to them, our team determined that the most advantageous solution to the request was through the pairing of the eMAR system already in place, and dongle technology. Though the use of barcoded identification technology was not previously unheard of in health facilities, the introduction of the dongle provided an extra layer of protection to the hospital’s already formidable security system. The encrypted passkey technology contained within the dongle requires the physical insertion of the key into the system computer, acting as a barrier to restricted users attempting to access the system. This was then paired with proximity readers to trip locks on automated drug dispensing machines and medication cabinets to provide the site with a complete and efficient solution to their identity crisis.
The combination of these technologies continues to act as a model for Meta and our clients. The use of barcode scanners at the point of care enables users to positively identify patients, while the Dongle allows for increased security by mandating verification of the user with the use of an external passkey. Today, we have found the most success in patient and user identification through the pairing of these two methods; but that does not mean we limit ourselves to one approach. We work with administrators and clinicians to determine which identification technology would most suit their facility. By doing so, we continue to explore new innovative solutions to the identification needs of our clients
The widespread use of these types of technologies will only improve the overall security and safety during the administration of care. Facilities that implement this technology can expect to see a drastic reduction of errors and an increase in positive patient outcomes, most notably by helping prevent serious medication errors and adverse drug events. However, they are also capable of minimizing dosing, documentation, timing and transcription errors, preventing cases of fraud and identity theft, and eliminating duplicate medical records, overlay records, and patient mix-ups. Overall, these positive identification technologies can have quantifiable benefits for providers, regardless of protocol or departmental standards, allowing for a safer and more responsible care environment.
After the first case of Ebola in the United States was reported in Dallas back in September, many critics, including hospital staff of the same facility at which the patient was treated, were quick to chastise the EHR in place as having a critical system flaw. However, though contradictory reports hindered the genuine critical analysis warranted by a case of such paramount importance, most experts agreed that the oversight was not due solely to the EHR. Rather, it was a combination of factors that caused the diagnostic lapse, principle among them human error.
The case highlighted some of the biggest flaws that currently plague the United States health system, namely the inadequacies of the Meaningful Use incentives program. Though the federal government attempted to normalize electronic health information system usage, its efforts fell short of its goals. The “shopping list”-like nature of Stage One and Stage Two requirements was myopic in mandating and prioritizing certain EHR features for vendors and providers based on monetary incentives. Physicians were not consulted; this much was clear. The ensuing legislation inhibited the software from addressing the needs of those most affected by it. Clinicians remained vulnerable to many of the same problems they faced before implementation. They were still prone to error and unable to actualize the true potential of technology in healthcare.
After the case was made public, an article began to circulate entitled “Ebola US Patient Zero: lessons on misdiagnosis and effective use of electronic health records.” The article, authored by Dr. Hardeep Singh (Chief of the health policy, quality, and informatics program at the Veterans Affairs Center for Innovations in Quality, Effectiveness, and Safety) and his research team, addressed some of the most important issues of “diagnostic decision-making in EHR-enabled health care” in light of the case in Dallas. The conclusions that Dr. Singh and his team determined were astounding: among them, they exposed the flawed nature of “pre-defined symptom options” standard in many EHRs; criticized the tendency of physicians to ignore nursing notes; and advocated policy and practice reform to address error in the developing field of electronic healthcare.
As a solution, they called for a refocusing of national efforts to encourage collaboration be-tween software developers and clinical users. The team criticized existing policies that promote complacency and inaccuracy in patient diagnoses, and determined that a balance between developer and provider was the only viable means for the development of a safer and more efficient software solution:
Physicians and health care organizations ultimately need to own the responsibility for addressing diagnostic errors, but several national-level initiatives can help, including working with software developers to improve EHR usability… [D]iagnostic errors are largely ignored by policy-makers, industry, and health care institutions in part due to their complexity and measurement challenges. Within the many initiatives attempting to improve patient safety and value-based purchasing being promoted… virtually none relate to accuracy and timeliness of diagnosis. Outpatient reimbursement policies do not reward diagnostic decision-making, teamwork, or quality time spent with the patient in making a diagnosis. 
The first case of Ebola in the United States prompted national attention (and rightly so) on several very important issues concerning US healthcare, chief among them clinician misdiagnosis and EHR misusage. But while the threat of a major outbreak should have been enough to catalyze reform, reform was not forthcoming. The responsibility lands at the feet of federal agencies, the ONC, the CDC, and others, to promote EHR usage that transcends the prominent “one-size-fits-all” mentality; but even in light of the Ebola threat, no developments have surfaced to improve overall functionality, interoperability, and effectiveness of these systems.
So the question remains: why have we put our faith in complacent requirements, circulated by complacent governmental agencies? Rolling requirements and monetary incentives are not the solution to maximizing EHR potential; rather it is fair and honest business practices that encourage the partnership of developers and clinicians, and competition among EHR vendors. We must learn from our past shortcomings and adopt a new strategy that is dynamic as the problem we are facing. For as the research team concluded their report, though “Diagnostic errors typically have affected only one patient at a time… Patient Zero reminds us that in certain cases, a single misdiagnosis can have widespread and costly implications for public health.”
 Hardeep Singh, et al. “Ebola US Patient Zero: Lessons on Misdiagnosis and Effective Use of Electronic Health Records.” October 23, 2014.
Transitioning into ICD-10 seems to be the only responsible option available to healthcare providers. The upgraded classification system is the most elaborate coding available to monitor and diagnosis disease, and a compulsory component in the evolution of American healthcare. But the switch, which has in reality been in the works for more than thirty years, was delayed yet again.
Though the problem is complex in nature, it is one that requires attention. The current system, ICD-9, lacks the processing capabilities necessary to confront the particular needs of today’s healthcare professionals (notably, there is not even an existing code for Ebola). ICD-10 will be able to provide a more comprehensive and inclusive coding system for specific patient conditions, symptoms, and diagnoses. The ability to code, group, and analyze data on a scale this large will make our healthcare professionals smarter, more responsible, and more prepared to treat their patients.
The switch from ICD-9 to ICD-10 was set for Oct. 1, 2013. Across the country accommodations were made by healthcare providers: systems were upgraded; EHRs were improved; clinical documentation was reinforced; training programs were begun; funds were dedicated. And though the HHS and CMS repeatedly reaffirmed healthcare providers that the deadlines would not change, the date was ultimately delayed and set for Oct. 1, 2015.
The progress that came with the certainty of the initial deadline was replaced by perpetual doubt and stagnancy. Facilities that had allotted resources to reach the 2013 deadline had to deal with the blowback: resources, time, and personnel that had been dedicated to a fruitless initiative could no longer be regained to support more worthwhile programs. But many providers, often smaller facilities, simply lacked the capital and resources to prepare themselves for the initial date. Without help from organizations such as the HHS and CMS, these providers were unable to meet the requirements within the allotted timeframe. They were effectively abandoned by the same governmental agencies conceived to assist and regulate in times like these; and as a result these undermanned facilities, through no fault of their own, forced American healthcare to remain retrograde and obsolescent.
From this chain of events it is difficult to discern the correct course of action. Many detractors argue that this new date is not to be trusted, that we are better off looking forward to ICD-11, and that as a whole the ICD-10 initiative was a failure. However, the fact of the matter is that, regardless of one’s opinion, the only responsible response is preparedness. Even if the governing bodies delay the switch once again, there are certain steps that healthcare providers and facilities must take, regardless of ICD-10 qualifications, to improve quality of care. These include reassessing reimbursement procedures and diagnoses codes, increasing coder training, placing increased emphasis on clinical documentation, implementing fiscally responsible business practices to increase revenue, and upgrading existing clinical information and EHR systems to ensure improved enterprise-wide patient care.
The end result of all of this, however, is doubt and distrust in regards to the federal government’s attempts at healthcare reform. They have proven their ineptitude in the healthcare field time and time again: the ICD-10 saga and the Meaningful Use incentive program are prime examples. However the reality of the situation is that the world has entered a new era of data processing and handling. By implementing practices like those mentioned above, along with others that may be facility-specific, providers can help improve the quality of care, regardless of the verdict made on the ICD-10; but if healthcare professionals feel they cannot rely on the federal government for guidance, they must take the initiative themselves. The rules in medicine have changed immensely in a matter of just a few years, and in the game today, the only way to keep up is to not fall behind.