Meaningful Discussion on Meaningful Use: What You Need to Do Now

Meaningful use. Learn those two words. Understand them. They likely will consume our professional lives for years to come—if they haven’t already begun to. Meaningful use is, of course, the standard by which hospitals and medical practice will qualify for federal stimulus funding for adopting electronic health records. The Health Information Technology for Economic and Clinical Health (HITECH) Act, the health IT portion of the American Recovery and Reinvestment Act, calls for providers to demonstrate “meaningful use” of health IT starting in 2011.

“HHS is saying no money just for buying [an EHR],” says William F. Bria III, MD, the CMIO of Tampa, Fla.-based Shriners Hospitals for Children and president of the Association of Medical Directors of Information Systems (AMDIS).

Indeed, it’s up to the Department of Health and Human Services (HHS) to define meaningful use. National Health IT Coordinator David Blumenthal, MD, said in August not to expect the final specifications until about the second quarter of next year—which pushes past the previously imposed Dec. 31st deadline. The most recent draft should offer some clues, though.

As proposed in July by the Health IT Policy Committee, an HHS advisory panel, to prove meaningful use physicians will have to:

• Use computerized physician order entry (CPOE)  for all medication, laboratory, procedure, imaging, immunization and referral orders;
• Have electronic checks for drug interactions;
• Keep up-to-date problem lists for patients;
• Incorporate test results into the EHR as machine-readable “structured” data;
• Report to CMS on ambulatory quality measures;
• Include at least one specialty-specific rule for clinical decision support; and
• Check insurance eligibility and submit claims electronically

Doctors also will have to prove that they are using the EHR to improve coordination of care and provide patients with the data they need to make informed decisions about their own health. Physicians also have to comply with HIPAA privacy and security regulations to earn Medicare bonuses of up to $44,000 or Medicaid payments as high as $63,750.

The proposed rules for hospitals are similar, although the threshold for meeting the CPOE requirement is only 10 percent of all orders and practitioners won’t initially be required to document progress notes in the EHR or send reminders for preventive and follow-up care. Also, the reporting obviously will be based on CMS hospital quality measures rather than outpatient standards.

Hospitals that achieve meaningful use of EHRs starting in 2011 can earn a baseline annual incentive of $2 million, plus an extra $200 paid per discharge for the 1,150th through 23,000th discharge per year. The total will be adjusted according to each hospital’s level of charity care and Medicare population.

Will the money be sufficient to spur the kind of IT adoption that will help the nation achieve President Obama’s ambitious goal of a system of interoperable EHRs for all Americans by 2014? “Maybe that’s enough,” says Bria. “What I come back to is the idea of value.” Some $44,000 per physician or a minimum of $2 million per hospital sound like big numbers, but the money will be inadequate if the technology does not add value to the practice or the institution, according to Bria.

Deborah Leyva, RN, BSN, a St. Petersburg, Fla., health informatics consultant who co-chairs of the ambulatory EHR workgroup of the Certification Commission for Healthcare Information Technology (CCHIT), is heartened that the matrix of requirements that HHS released in July has points that involve patients and their families. “Comprehensive patient information, is, in my humble opinion, the way of achieving better outcomes,” Leyva says.

And that is what meaningful use is all about. “The focus on meaningful use is a recognition that better healthcare does not come solely from the adoption of technology itself, but through the exchange and use of health information to best inform clinical decisions at the point of care,” is how the HIT Policy Committee explains it.

“In essence [the proposal] says that meaningful use involves implementing EHRs to enhance healthcare quality, safety and affordability and to foster better patient engagement, increase security, advance care coordination and generally improve the health of the entire population,” says David St. Clair, founder and CEO of payer-side health IT and analytics company MEDecision, Wayne, Pa.

“All of it boils down to better care and outcomes for patients,” Leyva says. “It’s meaningful because if you can improve patient care, you can improve outcomes.”

David Kibbe, MD, senior consultant to the American Academy of Family Physicians’ Center for Health Information Technology, notes that meaningful use is but one of a set of specifications, along with standards and certification of EHRs. At the same time the HIT Policy Committee released its latest plan, the Clinical Quality Workgroup of another federal panel, the Health IT Standards Committee, recommended 31 standards for performance and data capture that can help demonstrate meaningful use. Most already have the endorsement of the National Quality Forum.

In an August 13th piece on E-Care Management Blog, Kibbe joined with health IT consultant Vince Kuraitis and vendor executive R. Steven Adams to say that meaningful use, as currently proposed, helps to bring together numerous programs that now have run largely in vacuums, including the patient-centered medical home, health information exchange, payer-side disease management programs, personal health records and state and regional programs for chronic care.

However, providers still in many ways are at the mercy of other entities. The big national laboratories like Quest Diagnostics and Laboratory Corp. of America have interfaces to all the major commercial EHRs, but can small, independent labs accept electronic orders and send the results back electronically?  “There are some dependencies here that are very critical,” Kibbe tells CMIO.

Even with a full EHR, Kibbe says there may not be a way of knowing a patient has been readmitted. He says that members of the HIT Policy Committee admitted they didn’t know exactly what interoperability will mean.

Carrots and sticks

For hospitals and practices alike, the initial set of standards would be for 2011 and requirements would ratchet up in 2013 and 2015. For 2013, providers would have to establish care processes for improving outcomes, add rules for clinical decision support and receive public health alerts by 2013. The 2015 proposal calls for providers to be able to measure quality and achieve better outcomes.

The HIT Policy Committee offered some flexibility, though, effectively giving providers until 2014 to achieve meaningful use based on the 2011 criteria, which would cover the first year of participation. The 2013 standards correspond to a provider’s third year of meaningful use, regardless of what calendar year that happens to be. Late-comers may not be eligible for all possible funding, since the HITECH Act requires physicians to start by 2012 in order to earn the full subsidy.

“We thought there was a kind of double jeopardy in that, if a provider couldn’t make the 2011 or 2012 criteria, and coming into 2013 the bar would be raised higher, it’s almost like you can’t get into the game at all,” committee member Paul Tang, MD, was quoted as saying after the panel approved the plan. “We’re trying to find a way for people to participate even if it’s a little bit delayed,” added the vice president and CMIO at Palo Alto Medical Foundation in California.

“The proposed meaningful-use definition recognizes that it is simply too much to expect physicians to go from using little or no EHR technology at all to a full-blown, highly complex and technical system virtually overnight,” says St. Clair. “The workflow disruptions alone would be extraordinary, as would the necessary up-front investment.”

He thinks there could be some tweaking, such as exempting certain specialties from some of the quality reporting standards. For example, not many of the proposed data points apply to eye doctors, be they optometrists or ophthalmologists. “I don’t expect that there will be any major changes.”

Medicare penalties for not using EHRs start in 2015. For this reason, and because HHS is proposing that the initial standards for meaningful use to apply for the first year of participation, some expect the big push for adoption not to come all at once in late 2010, but to stretch out over several years, right up until the end of 2014. “That’s human nature,” Bria says.  It’s a “delusion that there will be a tsunami of activity in December of next year and everyone will be holding hands, [singing] Kumbaya,” he adds.

Because of Blumenthal’s pronouncement that the final rules for meaningful use won’t be out until well into next year, the provider community likely will have six to nine months from that point until “meaningful use” kicks in. That may seem like a rush, but the new policy of flexibility should temper the effect.

“I think it’s a long timeframe,” says Leyva.

Kibbe largely agrees. “I think it is fair and I think it is attainable,” he says. “I think the bar has been set just where it ought to be, though there still are some things that need to be worked out,” Kibbe says.

There may be more concern on the inpatient side. “Hospital systems take years. They take years,” notes Jim Tate, president of EMR Advisor, a consulting firm in Asheville, N.C., that is particularly interested in helping vendors achieve CCHIT certification. Tate believes that CPOE is likely to get the most pushback, even though the threshold is only 10 percent for inpatient systems. With so many physicians in private practice, hospitals may have trouble convincing doctors to learn the inpatient EHR while they are busy trying to install technology in their own practices.

“Physician resistance is a child of the inability of informatics leaders to articulate the value [of IT],” says Bria. “Value isn’t as clear medically as a CT scan.”

In comments submitted to Blumenthal’s Office of the National Coordinator for Health Information Technology in June, AMDIS actually suggested that CPOE requirements be deferred to 2013 or later, with the exception of ambulatory e-prescribing, what the group describes as a “mature” technology. “This is not another billing system. This is a healthcare quality system,” Bria explains. It’s important to put in place the clinical decision support that backs the CPOE and to make sure that everyone is well trained on this advanced technology.

“The thing that has lagged the most has been the education,” Bria says. Many medical schools and teaching hospitals have EHRs, but usage really isn’t well integrated into the medical training. “You need people on the ground who understand what you’re trying to do and how to do it well. It’s not too soon to start because it will take two years to get the curriculum together.”

But is it worth moving forward on a full-fledged EHR project, given that the requirements for meaningful use won’t be final for another half year or so?

For his part, St. Clair would like to see the incentives broken down some more. He suggests that physicians should earn a portion of the bonuses for showing that they can print out a community-provided electronic record. “If they’re willing to use a full-fledged system, then they could earn the maximum,” he says. “Lower the payment, but also lower the entry threshold.”

Health IT programs so far have gone after the low-hanging fruit. “There’s still plenty unpicked,” St. Clair says. “The focus there has to be on information rather than necessarily information technology.”

“Is it meant to get all physicians moving toward an electronic future? Or is it for the federal government to protect its money or a show to make it look like there’s progress?” he wonders. “What we ought to be focused on initially is getting people to use better information.”

M. Michael Shabot, MD, chief medical officer of Memorial Hermann Healthcare System in Houston, voices similar concerns. “I worry about the unintended consequences of the stimulus act,” he says. “So many hospitals are going to be in such a rush to implement that they won’t have time to go through the unintended consequences [of installing an EHR].”

Still, the timing is a delicate balance. “Wait a little while until we know what the definition of meaningful use is,” suggests Leyva. But don’t wait too long, looking for the devil in all the details. “Analysis paralysis leads to nowhere.”

Tate, who managed hospital laboratory systems for about 10 years, ran the clinical side of a pulmonology practice and was a project manager for ambulatory EHR vendor A4 Health Systems prior to that company being absorbed by Allscripts, says the whole industry “went into a standstill” with the stimulus passage in February, but should be moving into action mode now. He believes that HHS essentially will rubber-stamp the July version of meaningful use since it’s been accepted by the Health IT Policy Committee.

For providers that don’t have an EHR now, Tate suggests they spend the rest of 2009 conducting their due diligence and selecting a system so they can begin implementing it by the spring. “They really need to make the most critical decisions in the next 12 to 18 months, and if they don’t do it right, it will be the worst mistake of their careers,” he warns those involved in the selection, including CMIOs.

Providers must apply for the payments, so they should know when and what forms are available. “Keep your eyes and ears open,” Tate says.

EHR failure is nothing new, as hospitals have long bought systems that didn’t meet their specific needs and regretted it later. “It happens all the time,” Bria notes. Now, with so much money on the line, it would be a particularly big mistake to rush into something haphazardly while chasing the federal funding for 2011. “If you can’t do it now, then don’t,” advises Bria.

Complicating the task is the fact that HHS is working to update HIPAA regulations, as the HITECH Act closes the “treatment, payment, healthcare operations” exemption to the privacy rules, among other new safeguards to patient-specific data.

“I think it could be done by [2011],” Leyva says of the HIPAA revisions. “I think it can be done from a technology perspective.” But the heated political discourse around more comprehensive healthcare reform could make things more difficult from a cultural standpoint.

“It’s also the responsibility of the people who are using the software,” Leyva says.

And that’s where the CMIO comes in. “Among this noise, provide at least a calming voice and a reassuring hand,” says Bria.