AMDIS/HIMSS: Dos and don'ts of Meaningful Use

NEW ORLEANS—Meaningful Use (MU) served as not an IT project but “recognition of something we had already done,” said Leland A. Babitch, MD, MBA, assistant professor of pediatrics at Wayne State University School of Medicine and former CMIO of Detroit Medical Center, who presented the inpatient perspective of MU during the AMDIS Physicians’ IT Symposium during the HIMSS annual convention.

MU resulted in approximately $33 million to the hospital system. “We can finally put a dollar amount to it. The return on investment is hard to measure with EHRs, but this was very tangible. It was easy for the CEO to understand why we did that.”

Stage 1 attestation involved reporting, revising and reporting again, Babitch said. “We created useful views that our CFOs could understand and that our chief nursing officers could use. We really took it as a tweaking of processes that we had already put in place.”

Stage 1 didn’t move the bar that much, he said, but it creates standardization in practice. “There were areas where as we found variability among our eight hospitals so we had to standardize the practice.” Stage 1 also gives focus to areas that lacked support like medication reconciliation, he said. Medication reconciliation was a menu item so “we didn’t use it but we measured it and reported it.” Now, medication reconciliation is a core item for Stage 2 so the organization will be ready for the medication reconciliation requirements.

While MU may not stifle innovation, because vendors have narrowed down their focus on what needs to be done, it does stifle budgets, he said. “Within my own organization, if it isn’t about Meaningful Use, with a clear line of ROI, they don’t want to do it. It’s all about getting to Meaningful Use and almost nothing else matters right now.”

Michael Zaroukian, MD, PhD, CMIO of Sparrow Health System in Lansing, Mich., provided the outpatient perspective on MU. The organization focused on ambulatory MU in 2011 and 2012, going from Stage 0 on the ambulatory CEHRT AIU (certified EHR technology adopt, implement, upgrade] scale in July 2010 to Stage 5-6 by December 2011. “We’re hoping to prove Stage 7 this year,” he said.

Sparrow focused on human nature, Zaroukian said: “what is measured and matters motivates.” They improved their functional measures and clinical quality measures. In 2011, 90 percent of its eligible providers successfully tested. In 2012, the 10 percent not meeting MU criteria in 2011 did so.

Staff feedback indicated a general sense of improved efficiency over paper, more efficient use of staff time, more efficient and accurate coding and billing and greater convenience and efficiency in remote chart access. There was a decrease in charting efficiency, Zaroukian said, but an increase in completeness of records. There also was timelier results to guide therapy and prevent adverse events.

One problem lay in clinical summary length and sequence of instructions. For example, when clinicians changed the order for furosemide from 20mg/day to 40mg/day for heart failure patients, it was translated to one instruction. A discontinue order in the EMR with the new prescription said start taking furosemide at 40mg/day and a separate instruction said stop taking furosemide at 20mg. day. The patients only read the last instruction that said to stop taking furosemide and had an urgent visits for chronic heart failure exacerbation one week later. “Little things like that were sprinkled throughout the implementation,” Zaroukian said.

Unintended consequences of the focus on MU led to some EMR processes feeling bolted on, clinical quality measurement performance was emphasized or optimized and true interoperability was a lower priority, he said.

Zaroukian said the final rule was too difficult to read, understand and search, and the FAQs often lacked clear answers. However, “we’re getting better and better at understanding and they’re getting better and better at explaining.”

There are numerous opportunities and challenges to MU Stage 2, he said. For example, “people are paralyzed by what constitutes medication reconciliation. Note bloat for recording electronic notes is a concern.” There also is a continued focus on functional measures rather than outcomes and a lack of accountability for improved patient outcomes.

Regarding opportunities, the certification criteria require more robust clinical decision support which is “good news.” And, timely notification of significant events, such as arrival in the emergency department, is “a big win for tracking these kinds of things.”

Zaroukian’s list of suggestions to ONC and CMS includes introducing new CEHRT functional requirements only after adequate testing and market availability; choose EHR note documentation rules wisely; require usability testing; avoid intensive vendor focus on MU requirements; make interoperability a priority; and invest in clinical quality measure alignment, infrastructure and standards.