Analysis: A defining moment for "meaningful use"

How new rules will affect patients, providers, and electronic records.

We have reached a fulcrum point in the history of health care in our country. The announcement on Tuesday of the final rule establishing Medicare and Medicaid incentive programs for the meaningful use of electronic health records (EHR) creates a framework for change that will have reverberations throughout the health care industry. An important companion rule (pdf) was also released that establishes standards, specifications and certification criteria for EHRs.

Health IT at OSCON 2010David Blumenthal, the national coordinator for health information technology at Health and Human Services (HHS), and Marilyn Tavenner, principal deputy administrator of the Centers for Medicare and Medicaid Services (CMS), published an overview of the meaningful use rule in the the New England Journal of Medicine. John D. Halamka, of both Harvard Medical School and Beth Israel Deaconess Medical Center, wrote an excellent analysis of the final standards rule on his blog. I expect in the coming months there will be a great deal of parsing of the language of these two rules, which total 1,092 pages.

The rule defining meaningful use will now allow health care providers to adopt health information technology that aligns with the goals of the incentive program included in the American Recovery and Reinvestment Act. The criteria for achieving meaningful use has been substantially scaled back from the proposed rule, which came out at the beginning of the year. After receiving more than 2,000 comments, the rule has some significant changes that could make reaching stage one of meaningful use easier.

A major shift is the move away from an all-or-nothing approach, where providers had to meet every single measure to be eligible for payments. Instead, there’s now a set of must-have core requirements and an a la carte menu of discretionary options. There are 15 core requirements for physicians and 14 for hospitals. Health care providers can then choose five of 10 menu options to meet phase one of meaningful use. This strategy will enable a great many hospitals and small practices in rural and underserved areas to have a shot at cashing in on incentive payments.

Meaningful use in action

It’s important to note there will still be second and third phases of meaningful use. Ultimately, the final stage must be met. After 2015, when the incentive payments end, penalties will kick in. By lowering expectations for the first phase the slope to reach succeeding phases only gets steeper.

Let’s take Computerized Physician Order Entry (CPOE): more than 30 percent of unique patients being seen by an eligible provider or admitted to a hospital, must have at least one medication order entered using CPOE. But the final rule actually states that phase two will require a 60 percent threshold:

For stage 1, we are finalizing a threshold for CPOE of 30 percent for EPs, eligible hospitals, and CAHS. We believe this relatively low threshold, in combination with the limitation to only medication orders, will allow hospitals and EPs to gain experience with CPOE. However, as providers gain greater experience with CPOE, we believe it is reasonable to expect greater use of the function.”

As difficult as small physician practices and critical access hospitals might find initial adoption and implementation, it will take a sustained effort to attain the results we need to see so that costs can actually be lowered and the quality of care will improve.

The Emergency Department (ED) is now included in the mix for hospital CPOE. “Nearly every commenter who commented on CPOE objected to our proposal to limit this measure to the inpatient department,” the rule says. “Commenters stated that this limitation was inappropriate given the manner in which hospitals use EHR technology. To account for current practice, the commenters recommended the measures be expanded to include the emergency department.” The rule then goes on to say: “We agree with the commenters, and therefore are expanding this objective and its associated measure to the emergency room.”

This is significant because many hospitals are depending on CPOE orders coming from the ED to meet their 30 percent adoption requirement for meaningful use. Since orders coming from the ED, which is actually an outpatient department, are not included in ambulatory care, it wouldn’t make sense to exclude them from hospital orders.

Another important relaxation is in the area of e-prescribing. This is the ability to electronically send an accurate and understandable prescription directly to a pharmacy. The e-prescribing requirement was lowered from the 75 percent under the proposed rule, to only 40 percent in the final rule for phase one. The requirements for phases two and three are not yet spelled out clearly. Eventually we need to reach 100 percent, and a lower initial bar only makes it a steeper climb to get to the goal line in the succeeding stages.

One huge barrier to physician adoption of e-prescribing has been the restriction on electronically sending prescriptions for narcotics. The Drug Enforcement Agency proposed a rule on June 27, 2010 that will allow e-prescribing controlled substances. This move has been cheered by providers and pharmacies alike. However, the rule will require two-factor authentication, which is going to require vendors to set up systems to enable this technology. So the final rule on meaningful use for phase one is not going to include requiring e-prescribing for the newly allowed controlled substances prescriptions.

The final rule also decreased the number of clinical quality measures that must be met to demonstrate meaningful use. The proposed rule listed 90 measures, of which eligible providers had to select and comply with three general measures and three specialty-specific measures. The final rule lists 44 measures for physicians with a requirement to comply with six, with no requirement to meet specialty-specific measures. Hospital clinical quality measures have been reduced from 35 to 15. For 2011, reporting will be through attestation; for 2012, electronic submissions will be required. HHS stated that they cut the clinical quality measures to reduce the burden on EHR vendors to meet the criteria. But since quality is such an important aspect of the overall goals of the program, these measures will certainly need to be ramped up in succeeding phases.

The final rule on meaningful use defers until phase two the requirement to submit claims and eligibility transactions electronically. With the forthcoming HIPAA 5010 and ICD-10 adoption, and creation of operating rules to make HIPAA standards more uniform, additional transaction processing criteria will be coming in 2013. The rule states, “In order to meet these and other administrative simplification provisions, most providers will have to upgrade their practice management systems or implement new ones.”

Electronic copy of medical records required

The rule has added the recording of advanced directives and a provision for providing patients with educational materials, which were not included in the proposed rule. However, the proposed rule’s requirement to provide an electronic copy of a patient’s medical record is maintained in the final rule. This record must contain diagnostic test results, problem list, medication list, medication allergies, and for hospitals, discharge summary and procedures for at least 50 percent of patients within three business days. This requirement may prove to be one of the most difficult to achieve, but as Regina Holliday’s poignant testimony during the press conference proves (video below), it is vital to include consumers in the process.

Regina Holliday is a 37-year old mother of two and an art teacher. Last summer, her husband, Fred, died from kidney cancer at the age of 39. She writes at the Medical Advocacy Blog and tweets at @ReginaHolliday.


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