1. The Emergency Department is mentioned in 9 Core Measures and 3 Menu Measures, yet industry discussions seem to focus on the ED for CPOE and Discharge instructions. What functions do ED Information Systems need to support? Are these functions for just admitted patients or all ED Patients?
In my conversations with CMS, I believe that CMS will be issuing a corrections notice to clarify the role of the ED in the rule.
2. There are 44 Quality measures for Eligible Professionals. Do EHRs need to support all 44 measures to be certified?
To achieve certification, EHRs must support the 3 Core Measures, the 3 Alternate Quality Measures and at least 3 others from the remaining 38 measures.
3. Can eligible professionals from ancillary service providers such as stand alone radiology imaging centers qualify for meaningful use?
Although it seems a bit of stretch, if these professionals can meet all the meaningful use measures, then can qualify. This implies that radiologists will have to chart weight/height, ask about smoking status, record race/ethnicity etc.
4. The original implementation guide for the CCD specified one preferred vocabulary for each data content type. The Final rule includes SNOMED-CT and ICD9 as problem list vocabularies. Is there an inconsistency?
No, the C32 2.5 implementation guide supports all the vocabularies specified in the final rule. See Keith Boone’s blog for details.
The XML for CCD in the C32 v. 2.5 implementation can accept any vocabulary for structured data elements.
5. The Quality Measures in Meaningful Use mention vocabularies like RxNorm and SNOMED-CT to compute numerators and denominators. The Standards Final Rule offers vocabulary options. Is this an inconsistency?
No. The Final Rule for certification indicates “Any source vocabulary that is included in RxNorm, a standardized nomenclature for clinical drugs produced by the United States National Library of Medicine.” The Final Rule further defines the following source vocabularies as being included in RxNorm: GS – Gold Standard Alchemy, MDDB – Medi-Span Master Drug Data Base, MMSL – Multum MediSource Lexicon, MMX – Micromedex DRUGDEX, MSH – Medical Subject Headings (MeSH), MTHFDA – FDA National Drug Code Directory, MTHSPL – FDA Structured Product Labels, NDDF – First DataBank NDDF Plus Source Vocabulary, NDFRT – Veterans Health Administration National Drug File – Reference Terminology, SNOMED-CT – SNOMED Clinical Terms (drug information), and VANDF – Veterans Health Administration National Drug File. “Consequently, an one of these “source vocabularies” identified by NLM may be used, or any other source vocabulary successfully included within RxNorm.” (pages 132-133 of DHHS Final Rule 45 CFR Part 170, RIN 0991-AB58)
In creating value sets for the measures, providing 11 options (those listed in the Final Rule) was overly cumbersome, as was selecting NDC codes. By listing medications with RxNorm codes, the measures allow any user of an acceptable source vocabulary to map to the medications required by the measure. The measure criteria, therefore, can be used by any compliant EHR that uses a source vocabulary.
In general the measure specifications provide currently used terminologies as expected in the Final Rule. However, since there is a requirement for billing to use ICD-10 by 2013, the measures also provide, for those considering future implications, ICD-10 and SNOMED for appropriate concepts. While ICD-10 and SNOMED are not required, many have appreciated the ability to consider how to map their local term usage to these potential future options. Note, all measures provide “Groupings” (or nested) value sets which include a number of options. For example, all conditions (diagnoses) include ICD-9, OR ICD-10, OR SNOMED. There is one exception: persistent asthma is not an available concept in ICD-9. Therefore the measure provides an option of “persistent asthma” in ICD-10 OR SNOMED; it also provides the option of “asthma” using ICD-9 with a constraint that severity = persistent. The measures do not seek to require any terminology that is not specified in the Final Rule. The decision to include ICD-10 and SNOMED options was a conscious decision made in concert with CMS.
6. The Syndromic Surveillance implementation guide in the Final Rule seems to be the wrong document – it’s the CDC’s “Public Health Information Network HL7 Version 2.5 Message Structure Specification for National Condition Reporting Final Version 1.0 and Errata and Clarifications National Notification Message Structural Specification” which is for disease reporting, not symptom reporting.
It’s true that the wrong implementation guide is included in the final rule. ONC is hard at work correcting this. We’ll discuss it today at the HIT Standards Committee August meeting.
John Halamka is the CIO at Beth Israel Deconess Medical Center and the author of the popular “Life as a Healthcare CIO” blog, where he writes about technology, the business of healthcare and the issues he faces as the leader of the IT department of a major hospital system. He is a frequent contributor to THCB.