Top 10 Stage 1 challenges for eligible professionals

1. Capture the Data
Almost all data needed for Stage 1 has to be entered as structured data elements or entered using specific coding systems or vocabularies. In order to meet Stage 1 criteria, data capture has to focus on the specific data elements associated with Stage 1, including field entries specific to the provider, such as CDS rule parameters and specialty performance measure metrics. This will require an EHR system that has structured fields needed for each criteria, acquiring and loading content databases, configuring data-entry templates that assist and remind users to enter the correct data, and designing/developing methods to download eligibility, test results and other data from other systems. It will also require training the physicians or other users on how to accurately enter patient data.

2. Establish Effective Workflows to Reinforce Data Entry (Including Medication Reconciliation)
The key to the success of many workflow redesigns is developing teams and assigning roles. Data entered by medical assistants or nurses should be checked by a provider, who can then confirm findings and signs off on them as patient record entries. Medical assistants and nurses can also play roles in medication reconciliation by questioning patients about medications and queuing up medication information from patient transition records and notifications. Workflows should always include the provider taking the final responsibility for patient record entries made as a result of workflows and in some cases may need to manage the workflow alone.

3. Drive Provider Involvement in Adoption of the EHR
Providers must become committed EHR users to realize meaningful use. In order to have EHR data that is consistent and comprehensive every provider must use (and consistently uses) the system. The same is true of the success of functions and features such as CPOE, CDS and healthcare maintenance. Provider commitment requires at least training and some kind of discipline (such as peer pressure or upper management decree).
An even more effective level will be realized if providers are involved with system planning and rollout (the earlier the better), and when they are prepared for and then see the value they can get from using system features.

4. Computer-Based Provider Order Entry (CPOE)
There are two facts eligible professionals and practices need to understand about CPOE meaningful use criteria: The first is that the measure for all stages (including Stage 1: 80 percent) applies to all orders, including laboratory, radiology, referral, medication, physical therapy and other services. The second is that to satisfy Stage 1 (and subsequent Stage 2 and Stage 3) rates, each qualified order has to be directly entered by the authorizing provider. (This does not mean that for Stage 1, 80 percent of each type of order has to be entered via CPOE, but it does mean that 80 percent of cumulative orders must be entered via CPOE.) The key to meeting this challenge is getting authorized providers to use CPOE, which workflows can help. Nurses and other users can queue some orders to relieve providers of unnecessary "clerical" work without relieving them of their responsibility for actually placing the order. Standard orders and order sets associated with specific problems and visit types can also make it easier. Every ordering provider should gain an understanding of how CPOE works and how to use it, and enforce its use. Practices are also encouraged to integrate order transmittal and tracking when implementing CPOE. It is not specifically required for Stage 1, but the resulting provider convenience (of being able to track order status and link to results) goes a long way toward reinforcing CPOE use.

5. Start E-Prescribing — as Soon as Possible
The Stage 1 e-prescribing criteria requires provider to e-prescribe at least 75 percent of permissible prescriptions. Part of what is necessary to overcome the challenge is under the direct control of eligible professional practices: configure the EHR with an e-prescribing module, subscribe to networks that facilitate transmittal, and train users in and enforce use of the systems. Other challenges outside providers direct control that they need to track and pressure other stakeholders to resolve are: a) pharmacies that are still not equipped to receive and process e-prescriptions (40 percent of independents), and b) current Drug Enforcement Agency (DEA) prohibitions of e-prescribing controlled substances.

6. Develop a Process for Managing Clinical Decision Support (CDS)
In the clinical decision support criteria the required Stage 1 meaningful use of five CDS rules has to be demonstrated by each eligible professional. In multi-specialty and multi-provider practices, that may mean having to implement a separate subset of rules for each specialty and/or provider, because those five rules also have to be relevant to the specialty or otherwise a high clinical priority. Every practice that wants to meet the Stage 1 CDS requirement is encouraged to design and use a robust process for designing, developing and implementing rules. That process should include review and approval, specification documentation, development and testing, and finally formal release of each rule, including version documentation and control. This process puts practices in a position to get started with rules (and rule components) that can be shared among providers and specialties, and expand them both to qualify more providers and expand the kinds and number of rules used — as Stage 2, Stage 3 and healthcare demands in general expand.

7. Implement Patient Health Information Exchange Workflows
Patient health information exchange criteria require communication with patients based on and using the EHR. It includes sending patient notifications and sharing care information such as visit summaries and test results. One of the challenges arising from Stage 1 criteria is that in order to both make the communication convenient for patients and accommodate practices without PHRs and/or patient portals, ONC has specified options. Sharing the information and managing the options represent yet another need for workflows. Examples include:
• Notification: processes to collect and store information about how patients choose to be notified when they are due for routine or follow-up care, plus management of separate system-triggered alert delivery processes (e.g., automatic patient portal messaging, printed letters, telephone reminder lists).
• Visit Summaries: a visit exit process that includes printing and delivering summaries to patients, or if patient portal or PHR delivery is an option, logging/fulfilling that request.
• Copies of Electronic Data: processes for collecting, logging, and fulfilling requests. If portable media, such as CDs and USB drives are used, this includes manual controls to be sure copies get to the right patients and that confidentiality and security of the information is not otherwise compromised. Mobile media security and confidentiality standards, such as whether passwords or other protection such as encryption are required, are also still being defined and must be tracked for compliance.

8. Formulate a Provider Health Information Exchange Strategy
Stage 1 demonstration of interoperability with other EHR systems is limited to, "one test of a certified EHR technology's capacity to electronically exchange key clinical information." Although a network for exchanging data in production mode (HIE network, interfaces, etc.) is not required for testing, EHR system exchange functions and features need to be installed, configured and readied for use. Those functions and features are required for certification, but with most EHR products they are new and require the latest version of the system, and in many cases separate purchase of one or more additional system modules. They also should be informally tested before formal testing, as well as production use. Key features to look for include the ability to create summary patient data packets (such as problem list, drug allergies and test results) for transmittal, receive packets from other systems for display and incorporation into the record, and preserve the coding and structure of the data exchanged. Eligible professionals (particularly those selecting new EHR products) are strongly advised to also examine the features for usability, particularly how much manual intervention by the provider is required, whether that intervention is reasonable (e.g., contributes to data integrity), and includes an intuitive and otherwise straightforward user interface.

9. Ensure Privacy and Security Compliance
The challenge to privacy and security criteria compliance comes from concern that existing HIPAA regulations have not been carefully addressed and that enforcement of breaches is being increased. That makes the required privacy and security assessment important — as a means of identifying and addressing potential workflow and other weaknesses. However, many of these are common sense steps practices should look for and take as the EHR makes it easier to share and access patient information. Examples include being sure to password or otherwise protect electronic patient records distributed via mobile media, logging distribution and receipt of that media, and instituting workflows (such as HIE "opt in/opt out" processing) to obtain and record (and of course enforce) patient agreement or refusal to share their electronic records with other providers and stakeholders.

10. Initiate EHR-Based Quality Performance Measurement Support
The key to successfully meeting quality performance measurement is in capturing the data. In the context of performance measurement this means ensuring that every data element in the notice of proposed rulemaking that applies to participating eligible professional(s) is both: a) configured as a structured data element that is captured or stored as a code or other appropriate format, and b) is reliably and accurately captured via downloads from other systems or data entry. The need is having this data in formats that the system can subsequently search, retrieve and aggregate and compare for reporting. Two logistical issues surrounding this challenge: a) demonstration requirements for 2011 will be attestation, and electronic submission of one measure for 2012, and b) required measures are still being determined.

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