This is a great article to get a thumbnail overview of all the proposed recommendations. John lists 38 criteria and provides a quick commentary on how challenging he sees each of them. (Keep in mind that he’s CIO at one of the most HIT-advanced health systems in the country — your definition of “easy” and his might not be alike.)
It caught my eye that the more challenging criteria generally are ones involving inter-organizational health data exchange, care coordination and care management. See his comments on the following criteria: 7, 17, 20–21, and 23–34.
Dr. Halamka concludes:
…areas of concern are chemotherapy automation, recording patient communication preferences, judging clinician performance based on patient adoption of PHRs, EMAR implementation, maturity of HIE capabilities, widespread rollout of longitudinal care planning, and public health readiness.
Here’s my analysis of the proposed Stage 2 and 3 criteria.
1. CPOE – Stage 1 requires more than 30% of unique patients with at least one medication in their medication list have at least one medication order entered using CPOE Stage 2 expands this to 60% of patients for at least one medication, lab or radiology order. Stage 3 expands this further to 80%. CPOE orders do not need to be transmitted electronically to pharmacies/labs/radiology departments. This is a very reasonable rate of CPOE adoption. The hardest part of implementing CPOE is getting started, which happens in Stage 1. Adding different types of transactions (without requiring electronic transmission to back end service providers) is more about workflow and behavioral change than technology change.
2. Drug-drug/drug-allergy interaction checks – Stage 1 requires that interaction technology be enabled. Stage 2 adds that it will be used for high yield alerts, with metrics for use to be defined. The idea is that many drug databases contain too many false positive interaction rules, so adoption is slowed by alert fatigue. If only high yield alerts are required (here’s what we’ve done at BIDMC ), clinicians are more likely to trust drug interaction decision support. Stage 3 adds drug/age checking (such as geriatric and pediatric decision support), drug dose checking, chemotherapy dosing, drug/lab checking, and drug/condition checking. These are all reasonable goals, but automating chemotherapy protocols is quite challenging. BIDMC built an Oncology Management System and added a full time research nurse to ensure all chemotherapy protocols are updated and accurate. It may be asking too much to require chemotherapy dosing decision support nationwide by 2015.