Meaningful Use Stage 3Through Nalashaa’s lens

There are standards to navigate, tools to decide, workflows to be planned, security to be ensured and documentation to be main-tained. In this paper, we go over our learnings across domains and how to sail smoothly through a MU3 certification.

An MU3 certified product is the first step towards achieving analytics in healthcare IT if requisite standards are followed and the implementation is future-proof.

And how do you get to a MU3 certified product?

With many successful certifications under our belt, one thing that stood out in the MU3 journey is the major focus on interoperability. CMS’s focus on establishing an interoperable nationwide health information infrastructure was indeed what MU3 intended to achieve. This was obtained with additional focus on reducing health IT developer and provider burden alongside. 2015 Edition has equal weightage to all the key pillars of EHR from Patient engage-ment to possessing relevant Privacy and Security capabilities.

The Three StandardsPost implementing MU3 measures, we observed that 65% of the certification focused primarily on the implementation of these three standards.

The Key Challenges

Consolidated Clinical Document Architecture (C-CDA)

Quality Reporting Document Architecture (QRDA)

Application ProgrammingInterfaces (API)

How do we ease development and generate faster XMLs?

A common data

binding platform

Reusable base

components

APIs gave a liberty to the health IT vendor to implement any standard or have an in-built custom implementation. Most of the EHRs wanted to build capabilities which will be scalable and help integrate with other software. Fast Healthcare Interoperability Resources (FHIR) in its draft version is the best standard describing data formats and elements (resources) and using API for exchanging elec-tronic health information. Adoption of FHIR standard for API implementation not only uses the latest RESTful-based APIs but also allows for customization of response by using extensions.

During the upgradation of clinical coding, the major hurdle was faced during the implementation of the tool dependent measures. Validation tools ensure accuracy in data entry and generation for all the relevant mea-sures. The major challenge was with the Cypress tool, in the implementation of importing, calculating and gener-ating a QRDA file while ensuring the de-duplication logic is executed. The tool also underwent a major version upgrade in mid-October, making it more stringent, during the certification process for numerous EHRs.

How do you decide on tools?

With the newer version for C-CDA and QRDA implementation, the XML generation became more structured and the base line identified was the same for all HL7 standards. This baseline ensured we build the C-CDA and QRDA XML on the same bridge by re-using the base classes.

Similarly, we have other programs where the physicians are required to report and Nalashaa’s expertise has helped clients easily align business requirements with physician workflow.

How can data security be ensured

Will it impact the work-flow?

Complying with MU3 standards for an in-use EHR is tricky as one need to ensure the implementations complement the physicians’ workflow and the application follows the relevant coding standards. It is important to blend the features of MU3 in your products such that it adds value to the current prod-uct and helps providers score better in the regulatory/ quality programs.

Some prominent features to enhance the application would be

Be it CAT 3 Export, CDA Incorporate, API Access or printing a CDA. All audit logs follow the same clock? Q

AQA

CDA generators, CQM calculators, Patient Portal and APIs, need to imple-ment Network Time Protocols to synchronize the consolidated audit results.

Are all CDAs / QRDA / HL7 files stored on local instances encrypted?

Any files stored on local instances should not be left unencrypted.

Automated measure calculation and CQMs can be refined to fall under the Quality Pay-ment program (QPP) umbrella through Improvement Activities; score can be calculated and shown to the physicians and they can ensure they meet the threshold way before the submission date

Helping physicians perform some activities on signing off an encounter, for example, send-ing a visit summary to the patient or an educational material –This ensures that they are kept away from the technical jargons and the standards followed like C-CDA, Info button, etc.

Aligning the CQMs with CDS by building a robust rule engine which will help physicians with their quality measures

Meaningful Use certification requires many documents to be filled, and hence it is advisable to start working on documentations early on during

the project to avoid any deluge.

Here are some key highlights to manage documentation:

How to tackle MU3 documentation?

With the Self-declare rule released by ONC focusing on random surveil-lance that CMS will conduct, EHRs need to submit the measures which they would like to self-disclose and also to keep a copy of screenshots once the

measure is implemented.

Quality Management System now imposes EHRs to follow a standard or map the complete workflow with the standard – a step from CMS to ensure quality from the root.

Some documentation, such as ‘auto-mated measure calculations’ screenshots for every required test, is to be sent to the proctor before the certifi-cation date.

1

The GAP measures need to be prop-erly filled to ensure there are no techni-cal implementation changes to the

measures already certified in Stage II.

3

4

2

MU3 Certification Management

Be ready with the pre-loaded test data within the application, before the certification day and conduct internal mocks to be in line with proctor’s estimated timelines.

The 5 step approach for a smooth certification

Better utilize certification time; pre-send documentations for review with screenshots, eg: API documentation.

Use the latest test scripts received

from the certifying body to avoid miscommu-nications at time of certification.

Testing tool (NIST, CYPRESS, ETT) get updated without prior intimation. It’s imperative to plan for more regressions till the date of certification.

During certifi-cation, follow the test script and proctor’s guidelines,

without spending too much time on showing other workflows, unless requested.

How we mastered the MU3 certification process?How we mastered the MU3 certification process?How we mastered the MU3 certification process?How we mastered the MU3 certification process?

Implementation Planning and workflowIt is important for an EHR vendor to focus on the basics of design and standards as these areas mostly take a lot of implementation time. If you develop the minor features first, leaving the major design concepts for later, it will mostly lead to diffi-culties faced or a loss of time. We tackle the Big three measures first and simulta-neously work on the dependent measures like Demographics, problem list etc.

Intelligent story building Ensuring the measures are tied up with other dependent measures and require-ments should be an in-built part of the story. This is specifically pertinent in the case of Automated Measure Calculation (AMC), ideally a part of scoring for the main measure, similar is the case with audit log. We identify dependent mea-sures initially so the calculations for AMC do not lead to any re-work of the mea-sure. Once the base for audit is ready, one can clout its presence across the application ensuring every transaction gets included in the audit.

Leveraging Third party vendorsWhile leveraging third party software for example, ePrescribing, DIRECT messag-ing, ensure the communication is started sooner and impact analyzed at an early stage. Ideally, a certification or a dry run is recommended with the third party vendor prior to the date of certification. While dealing with third-party ven-dors, if you would like to leverage their certification IDs, then it should be clarified with the physicians that they will need to enter the third party vendor’s certifica-tion IDs during the attestation process also. We have helped our vendors save time for physicians by being on top of third party vendor communications.

Nalashaa believes in simple solutions to derive meaningful insights and in exceeding your expectations. Our clarity of thought has earned us many laurels in this fast paced world where healthcare technology advancements are rolling out con-tinuously.

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ConclusionWhile we go through the processes & challenges of getting a MU3 certification for an EHR, that is not the final goal. A bigger chunk of work is in helping the providers score better in different programs like MIPs Individual reporting, MIPs group reporting, CPC+ etc. But, the initial step is getting the EHR certified. This is achieved through Planning (Identify the best order in which mea-sures need to be developed so we meet the certification timeline effectively), Designing (Understand current provider workflow in the system, so MU3 implementation don’t alter their workflow, rather easily help them score easily) and Extendable Execution (Easy extension to different programs in the near future).

Working backwards from the target reporting date, i.e. March 2019, providers need to start using the system at the earliest and capture data so that they are able to submit the reports to the respective programs as mandated by CMS. The EHR vendors are required to provide help docu-mentations so that the providers are able to utilize the newly certified system effectively.

The initiation for all these programs is that an EHR should be MU3 certified.

Vijayalaxmi Kudekar Healthcare Consultant

Vijaya is a Healthcare Expert at Nalashaa and has experience in business transfor-mation, payer-provider integration, product design & implementation and healthcare system evaluation & selection. She has been actively involved in Mean-ingful Use, PQRS, HHVBP, CPC+, CCM and MACRA implementations and has exten-sive exposure to Clinical and Financial areas of the US healthcare ecosystem.

Keerthi Sudha ChavvaHealthcare Consultant

Keerthi is a subject matter expert at Nalashaa with hands on experience on different clinical and billing workflows, analyzing and embedding different regulations within regular workflows, identifying solutions that improves care and helps providers with a better A/R outcomes. Also passionate about creat-ing generalized solutions that indicates providers from multiple perspectives w.r.t different regulatory programs.