Now that the Interim Final Rule (Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology) and the Notice of Proposed Rulemaking (Medicare and Medicaid Programs Electronic Health Record Incentive Program) have been published, we can all finalize our policy and technology strategies for achieving Certification and Meaningful Use in our organizations and communities.

It's important to use these two documents together to understand what is required for Certification and to achieve Meaningful Use stage 1 measures (2011) by professionals and hospitals.

Certification is a guarantee of software capabilities and Meaningful Use describes the way software features should be implemented in actual workflows. Certification and Meaningful Use are related but different concepts. For example, Certification requires that a complete EHR or EHR module have the capability of recording, retrieving, and transmitting immunization information using HL7 2.3.1 or HL7 2.5.1 with the CVX vocabulary. The Meaningful Use stage 1 measure is to perform at least one test of the certified EHR technology's capacity to submit electronic data to immunization registries if local public health agencies are capable of receiving them. Thus, for 2011, actual submission of immunization data is not required, just the capability and a single test of that capability. Of course, by Stage 2 (2013), I expect that actual data submission will be part of every patient immunization.

How should you prepare for Meaningful Use in your own organization? I recommending printing 3 tables

1. Certification Criteria - pages 51-61 of the Interim Final Rule

2. Adopted Content Exchange, Vocabulary, and Privacy/Security Standards - pages 79-81 and page 85 of the Interim Final Rule

3. Stage 1 Criteria for Meaningful Use - pages 103-108 from the Notice of Proposed Rulemaking

Use these three documents to guide all your planning efforts. That's what I've done and here's a 25 item strawman strategy for BIDMC (which runs largely self built systems) and its affiliated community hospital, BID-Needham (which runs Meditech).

1. Use CPOE

a. For ambulatory settings - support electronic ordering of 80% of medications, laboratory, radiology/imaging, and referrals. webOMR (our self built EHR) or eClinicalworks (eCW) will be implemented based on the workflow requirements of the practice as it interacts with hospitals, labs, radiology centers, and the community. At BIDMC we will need to make improvements to our self built lab system to support lab data exchange with sites that use us as reference lab. At BID-Needham, the combination of eClinicalWorks, Quest, and Meditech will meet the need.

b. For inpatient settings - support electronic ordering of 10% of medications, laboratory, radiology/imaging, blood bank, physical therapy, occupational therapy, respiratory therapy, rehabilitation therapy, dialysis, provider consultants, and discharge/transfers. At BIDMC, our self built CPOE system already does this. At BID-Needham, Meditech version 5.6 is being implemented to do this.

2. Implement drug-drug, drug-allergy, drug-formulary checks.

a. For ambulatory settings - webOMR or eCW connected to Surescripts will meet the need.

b. For inpatient settings - our self built CPOE system or Meditech will meet the need.

3. Maintain an up to date problem list of current and active diagnoses (at least one coded entry or "No Problems exist") in ICD9-CM or SNOMED-CT for at least 80% of all patients

a. For ambulatory settings - webOMR or eCW will meet the need. Note that we have already implemented the NLM's SNOMED Core vocabulary to map our proprietary vocabularies to SNOMED-CT before we sent them to Google Health or Microsoft Healthvault, but we will need to create a new problem list picker for webOMR that uses SNOMED-CT natively. Luckily, we already have a prototype.

b. For inpatient settings - webOMR plus IMDSoft's Metavision for ICUs or Meditech will meet the need.

4. Generate and transmit permissible prescriptions electronically (the DEA does not yet allow controlled substances to be e-prescribed) for 75% of all ambulatory prescriptions. webOMR or eCW connected to Surescripts do this today. 

5. Maintain an active medication list (at least one coded entry or "No Medications taken") for at least 80% of all patients

a. For ambulatory settings - webOMR or eCW will meet the need. We are using First Data Bank in webOMR and Medispan in eCW. Both qualify as appropriate controlled vocabularies in 2011 because they are included in RxNorm.

b. For inpatient settings - our self built CPOE system or Meditech will meet the need.

6. Maintain an active allergy list (at least one entry or "No Allergies reported") for at least 80% of all patients. Note that no coding/vocabulary is required for 2011

a. For ambulatory settings - webOMR or eCW will meet the need.

b. For inpatient settings - our self built CPOE system or Meditech will meet the need.

7. Record demographics including preferred language, insurance type, gender, race, ethnicity, date of birth, and date of death/cause in the event of inpatient mortality for 80% of patients.

a. For ambulatory settings - webOMR or eCW will meet the need. Note that we already do this using controlled vocabularies and report the data to the Boston Public Health Commission as part of their effort to measure disparities in healthcare.

b. For inpatient settings - our self built registration/scheduling system called CCC or Meditech will meet the need.

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