Rush University Medical Center Meaningful Use Case Study
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Rush University Medical Center Meaningful Use Case Study

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The Healthcare industry is in the midst of converting its current patient healthcare records system over to an Electronic Health Record (EHR) or Electronic Medical Record (EHR) system. An EHR is “a ...

The Healthcare industry is in the midst of converting its current patient healthcare records system over to an Electronic Health Record (EHR) or Electronic Medical Record (EHR) system. An EHR is “a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting and includes information about patient demographics, diagnosis, treatments, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. When properly aligned with the definition of Meaningful Use, EHR provides ways of collecting, analyzing and presenting relevant patient data about patient demographics, diagnosis, treatments, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports.

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Rush University Medical Center Meaningful Use Case Study Rush University Medical Center Meaningful Use Case Study Document Transcript

  • IS 574-701 Business IntelligenceMeaningful Use and EHR Systems
  • Final IS-574-701 Hoppe - MEANINGFUL USE AND EHR SYSTEMSTable of ContentsProject Introduction 2Clinical Research 7Care Delivery Organizations (CDO) 9Rush University Action Plan 11Process to Evaluate Clinical Metrics 15Rush University Conclusion 16Metric Sources 16Conclusion 21References 22Project Introduction The Healthcare industry, due to President Obama’s enthusiastic endorsement, is in themidst of converting its current patient healthcare records system over to an Electronic HealthRecord (EHR) or Electronic Medical Record (EHR) system. An EHR is “a longitudinalelectronic record of patient health information generated by one or more encounters in any caredelivery setting and includes information about patient demographics, diagnosis, treatments,progress notes, problems, medications, vital signs, past medical history, immunizations,laboratory data and radiology reports. When properly aligned with the definition of MeaningfulUse, EHR provides ways of collecting, analyzing and presenting relevant patient data aboutpatient demographics, diagnosis, treatments, progress notes, problems, medications, vital signs,past medical history, immunizations, laboratory data and radiology reports. These statisticsshows a steady increase in the percentage of office-based physicians with some form of EHRsystems in use. Although there is steady progress of acceptance, change agents must get theword out to educate and inspire other physicians to understand the benefits or EHR. Blogs andLinkedIn group’s discussions might be a few ways of spreading the word. 2009 survey data (mail survey and in-person survey) concluded that 48.3% of physicians reported using all or partial EMR/EHR systems in their office-based practices. Nearly 21.8% of physicians reported having systems that met the criteria of a basic system, and about 6.9% reported 2
  • Final IS-574-701 Hoppe - MEANINGFUL USE AND EHR SYSTEMS having systems that met the criteria of a fully functional system, a subset of a basic system. 10 Preliminary mail survey 2010 estimates showed that 50.7% of physicians reported using allor partial EMR/EHR systems, similar to the 2009 estimate. About 24.9% reported having systemsthat met the criteria of a basic system, and 10.1% reported having systems that met the criteria of afully functional system, a subset of a basic system. 10 Between 2009 and 2010, the percentage of physicians reporting having systems that met thecriteria of a basic or a fully functional system increased by 14.2% and 46.4%, respectively10.Reluctance in getting a fully functional system may result in either trying to limit financialinvestments due to uncertainty of continued acceptance or not fully realizing the benefits of EHRsystems. 10 3
  • Final IS-574-701 Hoppe - MEANINGFUL USE AND EHR SYSTEMS 10 10 4
  • Final IS-574-701 Hoppe - MEANINGFUL USE AND EHR SYSTEMS 10 Understanding hospital’s levels of electronic medical record (EHR) capabilities is achallenge in US Healthcare IT. Healthcare Information and Management Systems Society(HIMSS) AnalyticsTM has created an EHR Adoption Model that classifies the electronicmedical record (EHR) capability levels, ranging from limited ancillary department systemsthrough a paperless EHR environment. HIMSS Analytics developed a methodology andalgorithms to automatically score more than 5,000 U.S. and nearly 700 Canadian hospitalsrelative to their IT-enabled clinical transformation status, to provide peer comparisons forhospital organizations as they strategize their way to a complete EHR and participation in anelectronic health record (EHR). The stages of the model include: 5
  • Final IS-574-701 Hoppe - MEANINGFUL USE AND EHR SYSTEMS Detailed explanation of EHR Adoption Stages 11 HIMSS Analytics has tracked the progress of U.S. hospitals as they successfully progressthrough the eight stages (Stages 0-7) of the EHR Adoption Model. The chart below exhibits theprogress of each stage from 2008 to current day (3rd quarter 2011). Each stage shows steadyprogress with Stage 3 displaying the highest percentage of achievement and Stage 7 showing thelowest. The themes of Stages 0 through 3 focus on hospital participation in general with Stage 3highlighting nursing and clinical documentation. Stages 4 through 7 exhibits more clinician andmedication reconciliation involvement with the eventuality of full physician documentation forStage 6 and paperless records in Stage 7. The trend seems to indicate the more EHR 6
  • Final IS-574-701 Hoppe - MEANINGFUL USE AND EHR SYSTEMSinvolvement required the less interest exhibited by required individuals due to time, money andeducational investments. U.S. Hospital EHR Adoption Stage Progress Q4 2008 – Q3 2011 Business Intelligence, examining data visually, can provide stimulating means ofpresenting comprehensible data while helping to connect with the definition of Meaningful Use.The concept of “Meaningful Use” rests on the ‘5 pillars’ of health outcomes policy priorities, Improving quality, safety, efficiency, and reducing health disparities Engage patients and families in their health Improve care coordination Improve population and public health 7
  • Final IS-574-701 Hoppe - MEANINGFUL USE AND EHR SYSTEMS Ensure adequate privacy and security protection for personal health information1 The American Recovery and Reinvestment Act (ARRA) lays out the three main components of Meaningful Use definition and achievement. The ARRA provides three main components of Meaningful Use: - The use of a certified EHR in a meaningful manner, such as e-scribing. - The use of certified EHR technology for electronic exchange of health information to improve quality of health care. - The use of certified EHR technology to submit clinical quality and other measures2.Clinical Research Through EHR data collection and storage, there is a potential to provide Meaningful Usewhile enhancing the clinical research process in hospital settings by applying a BusinessIntelligence (BI) framework to create Clinical Research Intelligence (CLRI) frameworks foroptimizing data collection and analytics3. As the healthcare industry undergoes this paradigmshift, clinical researchers confront opportunities and challenges to acquire knowledge using a BIapproach to recruit stakeholders, collect and analyze data with prospects of hypothesesgeneration. The use of clinical decision support, with EHR rules and alerts, can alert physicians ofpatient’s clinical trials eligibility. While engaged in a patient encounter, if the patient satisfiesthe clinical trial criteria, the physician receives a potential clinical trial candidate alert. Onestudy found using the EHR clinical trials alerts significantly increased the number of physiciansparticipating in clinical trial recruitment process while minimizing referral bias and extendingrecruitment to a wider patient population. Furthermore, there is more productive EHR basedhypotheses creation and research-study completion potential performed electronically rather thanthe once tedious and manual method. 8
  • Final IS-574-701 Hoppe - MEANINGFUL USE AND EHR SYSTEMS Business Intelligence (BI) is defined as “the process of turning data into information andthen into knowledge3” and is used for organizational decision support and performancemanagement. BI’s main objective is providing users with interactive data access and providingbusiness managers and analysts the ability to conduct analysis. In the same fashion, clinicalresearchers abstract or collect data through database reporting or patient record review and usehistorical and current data, situations and outcomes to determine potential issues and generatehypotheses and support studies. Normal transactions occur within normal workflow processessuch as patient registration, transcribed or structured reporting, computerized physician orderentry (CPOE) and clinical documentation. Business Analytics is a term used to for the tools and techniques used to gather andanalyze data for business and strategic decisions3. Additionally, Business Analytics helps ingathering, collecting and storing clinical research data, and categorized under clinical researchintelligence (CLRI). Business Analytics has three categories information and knowledgediscovery; decision support and intelligent systems and visualization and they contribute to theframework for clinical research data needs. Information and Knowledge Discovery uses OLAP(on-line analytical processing,) ad hoc queries, data mining, text mining, web mining, and searchengines, which are useful and relevant to the clinical research data collection and analysisprocess. Decision Support and Intelligent systems includes statistical analysis, data mining andpredictive analysis used in hypothesis generation as well as data collection, analysis supportingresearch goals and initiatives. Finally, clinical researchers may utilize visualization, scorecardsand dashboards in clinical trial progress reports and trending patient outcomes. With theirproven value to any organization, clinical business intelligence capabilities is expected to be 9
  • Final IS-574-701 Hoppe - MEANINGFUL USE AND EHR SYSTEMSincluded in EHR offerings as required by the American Recovery and Reinvestment Act of 2009.The table below highlights to four values that clinical business intelligence provides: 4 Value of Clinical Business Intelligence in the Delivery of Patient CareIntegration – merges clinical and financial data to Risk Mitigation – perform data analysis to see into allow providers to make more informed decisions the future and be productive in order to avoid risksPerformance management – tracks and measures Collaboration – enhances the ability of providers clinical performance and how it directly impacts to work together to monitor the progress of patients patient outcomesCare DeliveryOrganizations (CDO) Inside of Care Delivery Organizations (CDO), utilization reduction, nursingadministrative time, inpatient drug usage and outpatient drug and radiology usage activitiesprojected the most significant efficiency gains. Computerized order entry alerts and reminders,that reduce adverse drug events, provide necessary safety benefits. Nurses play an important roleas designers and users of electronic documentation system, since they are the largest consumersof HIT and use data from the electronic health record to tell the patient story. Priorities formnursing executive include streamlining documentation, optimizing workflows, accessingMeaningful Use data, nursing alerts to promote evidence based practice and matching hardwareinvestments to desired timeliness of documentation. Sometimes the only way to see Meaningful Use in action is to review a realimplementation and measure the results and one such implementation occurred at RushUniversity Medical Center in Chicago. Rush University Medical Center (Rush) is an academicmedical center which includes a 671-bed acute care hospital serving adults and children, a 61-bed Johnston R. Bowman Health Center and Rush University. Rush launched a 10-year projectstarting in 2006, titled the Rush Transformation, to build new facilities and implement anintegrated EHR system because of the recognition that such a system would significantly 10
  • Final IS-574-701 Hoppe - MEANINGFUL USE AND EHR SYSTEMSimprove quality of care. Rush broke the project down into the following phases and timelinesfocusing on certain modules during each phase.Rush University Implementation Phases 2 11
  • Final IS-574-701 Hoppe - MEANINGFUL USE AND EHR SYSTEMSRush UniversityAction Plan Rush University identified clinical metrics to aid in evaluating electronic health recordquality improvement elements.Rush University Phase 1 Clinical Metrics 2 The project’s goal zeroed in on creating processes for ongoing data collection evaluation,analysis and clinical metrics reporting. The end data will provide evidence of the impact of thecommercially developed electronic health record on the quality of patient care. Meyer5 identifiesfour basic steps for creating process measures: 1. Define critical factors 2. Map cross-functional processes 3. Identify critical tasks 4. Design measures to track critical factors. 12
  • Final IS-574-701 Hoppe - MEANINGFUL USE AND EHR SYSTEMSRush leaders wanted to focus their process measures on Process Improvement, PatientExperience, Quality Outcomes and Fiscal Responsibility and within this strategic framework,and included these critical factors for EHR clinical aspects: 1. Medication Reconciliation 2. Nursing Assessment 3. Diagnosis Documentation 4. Discharge Instructions 5. Clinician Satisfaction 6. Timely Care Delivery 7. Timely Documentation 8. Screening for prior to admission conditions 9. Patient Satisfaction.For pilot testing, Rush University leaders recognized the following three critical factors: 6 13
  • Final IS-574-701 Hoppe - MEANINGFUL USE AND EHR SYSTEMS After implementing the EHR system, partial medication reconciliation increased from88.9 percent to 94.6 percent while sustaining improvements for the entire study period. Fullmedication reconciliation increased from 75.1 percent to 80.2 percent7, with unsustainableimprovements and all results fell within a 95-percent confidence interval. The task forceidentified three factors that contributed to incomplete medication reconciliation: patients do nothave complete information on home medications; clinicians enter duplicate medications whenusing both brand and generic names; and clinicians lack full knowledge of designed workflows.Medication Reconciliation2 • The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) National Patient Safety Goal 8: Accurately and completely reconcile medications across the continuum of care • JCAHO identifies goal 8’s five steps: 1) develop a list of current medications 2) develop a list of medications to be prescribed 3) compare the medications on the two lists 4) make clinical decisions based on the comparison 5) communicate the new list to appropriate caregivers and to the patient. Electronic health records medication list studies discovered data is only accurate if enteredcorrectly. Data entry errors account for 28 percent of the discrepancies, while clinician’s failure toenter medication changes into the electronic record account for 26 percent. This demonstrates thatstandardized medication reconciliation process implementation reduces the number of unintendedpatient discrepancies by 43 percent, thereby significantly decreasing the potential for medicationerrors. Use of an EHR order entry system can reduce errors at the time of discharge by generating alist of medications used before and during the hospital admission and can be printed and used foreducation and patient review. This system’s usefulness depends upon the prior implementation of anadmission medication reconciliation system. 14
  • Final IS-574-701 Hoppe - MEANINGFUL USE AND EHR SYSTEMS Some electronic discharge medication ordering systems allow for direct transfer of the ordersto the community pharmacy and to the primary care physician, as well as keeping a permanent recordon the electronic health record. Electronic systems make it easier to access medication histories, withfrequent updates and information correlation with patients’ actual medication use. Electronicprescribing also allows for decision support such as checking for allergies, double prescribing andcounteracting medications. The Joint Commission’s standard for discharge instructions requires clear documentationthat the patient/caregiver received a copy of the written instructions; including dischargemedication list at discharge. Due to this Joint Commission’s requirement and the impact thatdischarge instructions have on safe medication practices, Rush leaders identified dischargeinstructions as a high priority clinical metric. Survey results analysis found that patientsatisfaction with discharge instructions did not significantly change after EHR implementation.Key nursing operations stakeholders speculated that premature evaluation of this metric occurredas it is a new, complicated process and required a longer learning curve. Expectations focusedon the eventuality of clinicians becoming more comfortable with the discharge process, leadingto increased patient satisfaction. In order to comply with the medication reconciliation process, Rush University adoptedthe process created by Dr. Spath7, which outlines the seven-step outcomes management process: Define objectives Identify performance measures Select measurement tools Define measurement methods Collect data Transform data into information (data analysis) Use the information to improve performance 15
  • Final IS-574-701 Hoppe - MEANINGFUL USE AND EHR SYSTEMS Three additional steps help to evaluate the EHR metrics process: Determine data significance Create report templates Identify gaps between designed workflows and actual practice.Process to EvaluateClinical Metrics The Rush University EHR metrics project objective evaluated the EHR impact on highquality and safe care’s closely related critical tasks by developing an evaluation process andpiloting this process with the following three metrics: Medication reconciliation o Patients will have complete medication reconciliation at discharge. Problem list documentation o Patients will have at least one current problem documented on problem list. Discharge instructions o Patients will receive home medications information at discharge.After Rush clinical leaders identified and selected high priority outcomes performance measuresfor this project, the project director met with the clinical leaders, EHR technical support (TS)staff and a Rush patient satisfaction manager to determine and discuss monthly metricmeasurement methods. Next, the project director cleaned the medication reconciliation data, calculated andcreated individual metric monthly totals and graphs for trending over time. Comparing January,February and March 2009 baseline data with post implementation data from April 2009 throughApril 2010 provided a timeframe to analyze the findings. Determining and displaying datasignificance proved to be an important process step followed by creating report templates totrend results over time followed by key stakeholder meetings to review reports and identify gapexistence between designed workflows and actual practice. 16
  • Final IS-574-701 Hoppe - MEANINGFUL USE AND EHR SYSTEMSRush UniversityConclusion Rush University’s EHR system implementation provided a significant step in theirtransition to provide high quality, patient-centered healthcare. The design and implement anongoing process to evaluate clinical metrics project aids in validate the impact of the EHR on thequality of healthcare. Rush University developed and piloted the following process to evaluateclinical EHR metrics7: 1. Define objectives. 2. Identify performance measures. 3. Select measurement tools/data sources. 4. Define measurement methods. 5. Collect and analyze data. 6. Determine data significance by use of confidence intervals. 7. Create report templates to present data. 8. Use information to improve performance. 9. Identify gaps between designed workflows and actual practice. Rush University piloted this process and validated significant changes followingimplementation in March 2009 including: 1. An increase in partial medication reconciliation at discharge sustained for six months. 2. An increase in full medication reconciliation at discharge not sustained during the study period. 3. No increase in patient satisfaction with discharge instructions. 4. An increase in documentation of at least one diagnosis in the problem list sustained for five months. 5. An increase in updates to problem list documentation not sustained during the study period.Metric Sources Metrics help in ‘Meaningful Use’ alignment and provide Business Intelligence data forstrategic planning decisions. The United States Department of Health and Human Services(HHS) is the United States government’s principal agency for protecting the health of allAmericans and providing essential human services, especially for those who are least able to 17
  • Final IS-574-701 Hoppe - MEANINGFUL USE AND EHR SYSTEMShelp themselves. The HHS intends to continue to raise thresholds and expectations to ensure thatMeaningful Use encourages patient-centric, interoperable health information exchange acrossprovider organizations regardless of provider’s business affiliation or EHR platform. The followingis the HHS’ Electronic Health Records 2011 ‘Meaningful Use’ criteria8.Improving quality, safety, efficiency and reducing health disparities Computerized Physician Order Entry (CPOE) used for at least 80 percent of all orders Implement drug-drug, drug-allergy, drug formulary check function Up-to-date problem list and active diagnoses (using ICD-9-CM or SNOMED CT®) for at least 80% of patients (at least one entry or indication of no active problem). Seventy-five percent of permissible pharmaceutical prescriptions generated and transmitted electronically with certified EHR technology Maintain active medication list for at least 80 percent of patients Maintain active medication allergy list (at least one entry or “none”) for at least 80% of patients Record demographics (preferred language, insurance type, gender, race, ethnicity, date of birth) for at least 80 percent of patients Record and chart changes in vital signs [height weight, blood pressure, body mass index, growth chart (children 2 to 20)] for at least 80 percent of patients. Record smoking status for at least 80 percent of patients (over 13) Incorporate at least 50 percent of clinical lab test results into EHR Generate at least one list of patients with a specific condition (for use in quality improvement, reduction of disparities, and outreach) Report ambulatory quality measures to CMS (or state Medicaid agency) Reminders of preventive or follow-up care sent to at least 50 percent of patients age 50 and over. Implement five clinic decision support rules relevant to practice Check insurance (public and private) eligibility electronically for at least 80% of patients Submit at least 80% of claims to public and private insurance plans electronically.Engaging patients and families in their health care 18
  • Final IS-574-701 Hoppe - MEANINGFUL USE AND EHR SYSTEMS Offer patients electronic copies of their health information (with 80% of those who request copies provided them within 48 hours). Provide patients timely (within 96 hours) access to their health information (lab results, problem list, medication list, allergies) to at least 10 percent of patients.Improving care coordination Capability to exchange key clinical information (e.g. problem list, medication list, allergies, diagnostic test results) Perform medication reconciliation at relevant encounters and at each transition of care and referral Provide summary care record of each transition of care and referralImproving population and public health Perform at least one test of the certified EHR program’s capacity to submit electronic data to an immunization registry Perform at least one test of the EHR system’s capability to provide electronic syndromic surveillance data to public health agencies. Conduct a Health Insurance Portability and Accountability Act (HIPAA) security risk analysis (or review past analysis) Another source of metrics comes from the National Quality Forum (NQF), a nonprofitorganization that operates under a three-part mission to improve the quality of Americanhealthcare by: Building consensus on national priorities and goals for performance improvement and working in partnership to achieve them; Endorsing national consensus standards for measuring and publicly reporting on performance; and Promoting the attainment of national goals through education and outreach programs. 19
  • Final IS-574-701 Hoppe - MEANINGFUL USE AND EHR SYSTEMS While measures come from many sources, those endorsed by the National Quality Forum(NQF) have become a common point of reference. An NQF endorsement reflects rigorousscientific and evidence-based review, input from patients and their families, and the perspectivesof people throughout the healthcare industry. The science of measuring healthcare performancehas made enormous progress over the last decade, and it continues to evolve. The high stakesdemand our collective perseverance. Measures represent a critical component in the nationalendeavor to assure all patients of appropriate and high-quality care. Listed below are the EHRrepresentations of the many NQF measures9.NQF 0019 Percentage of patients having a medication list in the medical record.NQF 0020 Percentage of patients having documentation of allergies and adverse reactions in themedical record.NQF 0487 Of all patient encounters within the past month that used an electronic health record(EHR) with electronic data interchange (EDI) where a prescribing event occurred, how manyused EDI for the prescribing event.NQF 0488 Documents whether provider has adopted and is using health information technology.To qualify, the provider must have adopted and be using a certified/qualified electronic healthrecord (EHR).NQF 0489 Documents the extent to which a provider uses certified/qualified electronic healthrecord (EHR) system that incorporates an electronic data interchange with one or morelaboratories allowing for direct electronic transmission of laboratory data into the EHR asdiscrete searchable data elements.NQF 0490 Documents the extent to which a provider uses a certified/qualified electronic healthrecord (EHR) system capable of enhancing care management at the point of care. To qualify, thefacility must have implemented processes within their EHR for disease management thatincorporate the principles of care management at the point of care which include: a. The ability to identify specific patients by diagnosis or medication use b. The capacity to present alerts to the clinician for disease management, preventive services and wellness c. The ability to provide support for standard care plans, practice guidelines, and protocol 20
  • Final IS-574-701 Hoppe - MEANINGFUL USE AND EHR SYSTEMSNQF 0491 Documentation of the extent to which a provider uses a certified/qualified electronichealth record (EHR) system to track pending laboratory tests, diagnostic studies (includingcommon preventive screenings) or patient referrals. The Electronic Health Record includesprovider reminders when clinical results are not received within a predefined timeframe.NQF 0648 Percentage of patients, regardless of age, discharged from an inpatient facility tohome or any other site of care for whom a transition record was transmitted to the facility orprimary physician or other health care professional designated for follow-up care within 24 hoursof discharge.Conclusion The Healthcare industry is in the midst of converting its current patient healthcare recordssystem over to an Electronic Health Record (EHR) or Electronic Medical Record (EHR) system.When properly aligned with the definition of Meaningful Use, through the use of BusinessIntelligence and metrics, EHR provides ways of collecting, analyzing and presenting relevantpatient data that will help to improve the patient care processes. These statistics shows a steadyincrease in the percentage of office-based physicians with some form of EHR systems in use butwe are still along ways away from becoming having paperless free health records. Efforts mustcontinue in order to create meaningful metrics to successfully monitor processes and proceduresto not only satisfy Meaningful Use requirements but also patient care satisfaction whilemaintaining fiscal responsibility. 21
  • Final IS-574-701 Hoppe - MEANINGFUL USE AND EHR SYSTEMSReferences1. Meaningful Use Introduction, in Center for Disease Control and Prevention. Retrieved fromhttp://www.cdc.gov/ehrmeaningfuluse/introduction.html2. Stefan, Susan. Rush University Medical Center. Evaluation of EHR Clinical Metrics to Demonstrate QualityOutcomes, in Healthcare Information and Management Systems Society. Retrieved fromhttp://www.himss.org/content/files/proceedings/2011/NI8.pdf3. Keeling Terri, L. Issues in Information Systems. Clinical Research: Using Business Intelligence Framework,Volume XI, No. 1, 2010, 372-3764. Florida Alcohol & Drug Abuse. FADAA Training. Session 1: Introduction to Electronic Health Records (EHRs)Retrieved fromhttp://www.fadaa.org/services/resource_center/PD/WebEx/20110512_EHR/EHR_session_1_training_content.pdf5. Meyer C. How the Right Measures Help Teams Excel. Harvard Business Review on Measuring CorporatePerformance. 1998:99-122.6. Stefan, Susan. Focus Quality Outcomes and Patient Safety. Evaluation of Clinical Metrics MedicationReconciliation, Problem List and Discharge Instructions. Retrieved formhttp://www.himss.org/content/files/jhim/24-4/8_STEFAN.pdf7. Spath PL. (1997). Beyond Clinical Paths: Advanced Tools for Outcomes Management. Chicago: AmericanHospital Publishing Inc.8. HHS proposes EHR ‘meaningful use’ criteria, in Michigan Optometric Association. Retrieved fromhttp://michigan.aoa.org/documents/mi/EHR_Meaningful_Use.pdf9. NQF-Endorsed® Standards, in National Quality Forum. Retrieved fromhttp://www.qualityforum.org/Measures_List.aspx10. Hsiao Chun-Ju, Ph.D.; Hing ,Esther, M.P.H.; Socey, Thomas C.; and Cai, Bill M.A.Sci., Division of Health CareStatistics, Electronic Medical Record/Electronic Health Record Systems of Office-based Physicians: United States,2009 and Preliminary 2010 State Estimates. Retrieved fromwww.cdc.gov/nchs/data/hestat/ehr_ehr_09/ehr_ehr_09.pdf11. U.S. EHR Adoption ModelSM Trends HIMSS Analytics Retrieved fromwww.himssanalytics.org/docs/HA_EHRAM_Overview_ENG.pdf 22