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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  • Paul Roemer

    As usual, a very well thought through piece.

    My lamentations of a drive-by-mind—mine.

    In analyzing the value of Meaningful Use (MU) for your organization, one must ask two questions:

    • Why does MU exist?
    • How would you approach EHR if MU did not exist?

    Let’s examine each of these. Is the purpose of MU to make your organization better, or is its purpose to get your organization to comply with the government’s attempt to nationalize healthcare. You’re saying “Whoa.” Remember Congress saying, “We don’t care what we pass, we just need to pass something.”

    There is an Arab fable, “Once the camel gets its nose under the tent, it wants to get all the way in.” It is akin to the “slippery slope”, the “foot in the door”, the “domino effect”, “for want of a nail”, boiling the frog”, and “give them an inch and they’ll take a mile.”

    The detail being overlooked, the nit to which nobody is paying attention is the forest in the trees. A feint. Where is everyone looking? Where is everyone’s attention directed? “Pay no attention to the man behind the curtain”—doth quote the Wizard in the Wizard of Oz. Healthcare providers have had their focus shifted to MU, Certification, RECS, RHIOs, and the N-HIN. (Permit me an editorial comment—as though the rest of this is not—what is the Wizard doing to the Payors and Pharma? Say it with me; nothing.)

    Back to the camel jockeys. Does MU exist for when your mother or mine comes in for care their care will be better, or so your organization will be enabled to be part of the nationalization of healthcare? If it walks like a duck and talks like a duck—you decide. I think not on the bit about the moms.

    How would you approach EHR if there were no MU? Picture this. Let’s assume for the moment that each of the 4,200 hospitals, and all the physicians, on their own, decided to implement EHR—I wholeheartedly support implementing EHR.

    Picture a square dart board whose axes are the timing and functionality of MU. A healthcare provider throws a dart at the board, removes it, the next provider throws, until all providers have tossed their dart. The final toss is made by the ONC. Wherever the dart lands are the MU standards.

    All providers are different, operating under different business strategies and goals for their organization. Clearly, almost all providers will be some distance away from the standard. Now what? Do they decide to sacrifice their business model in pursuit of the standard? If the elect to chase the standard, will they in fact meet it? If they meet it, what is the cost to their business strategy?

    To me it seems like providers are on a path—each driving to their own destination. The government then offers the providers money to forego wherever they were headed and drive to Des Moines. Should you go to Des Moines because someone is offering you the possibility of receiving a check? I would at least think it through before abandoning my plans.

  • David Harlow

    Brian —

    I think that the lower e-Rx threshholds and the like are illusory concessions. It seems unlikely that a meaningful user, ratcheted up to 40% of scripts going the e-Rx route, would not very easily hit 75%. It actually seems like it would be harder/more expensive/less efficient to keep that figure down to 40% once the infrastructure is there.

    Paul —

    While I agree that providers need to think clearly and look before they leap, many if not most will consider their options and decide to take the leap — not as a leap of faith, but as a rational decision which may have some short term costs not covered by the incentive payments but which will ultimately deliver a positive ROI. The key, of course, is successful planning and execution. Plenty of providers have taken the leap without incentive dollars dangled before them and have not only lived to tell the tale but are reaping the benefits of improved efficiencies, improved clinical information when and where needed, etc., etc.

    For more, please see my post on the new regs and related issues:

  • Paul Roemer

    Thanks David. I am in agreement with an ROI for EHR. However, I do not think there is an ROI for Meaningful Use.

    I also agree that many providers took on EHR prior to learning of MU. I am not suggesting not to do EHR. I think EHR, done right, is a winner. I just don’t believe it makes sense to consider receiving ARRA money as a valid business driver for EHR

  • John Boyd

    For Tim O’Reilly,

    I would appreciate a discussion that explores the parties who are fighting for control of our health data OODA Loop, and some high level discussion of how usurpation of health data OODA will be employed to exert societal controls, and on what actors the controls will be exerted.

    While these operational discussions are interesting, I would really like to explore the strategic rationale behind these efforts for open data systems.

    If we’re going to do this, then let’s at least have a grown-up conversation about the strategic relevance and societal impact of such enormous undertakings. I’m sure your contacts in DC are well briefed on these issues. It would be great if they would simply start sharing some of the rudimentary issues at least.

    There’s no way to stop this machine now, so at least put the cards on the table.

  • karunesh

    The traditional emphasis in medical records management around the world has been on what data to get, and not on how to get it. The more efficient health information systems of today, however, are interested in what data to get, how to get it, and how to synthesize these data into an understanding of the patient’s total situation. Disease classification and coding is the principal tool used by medical records personnel to accomplish this, and is, therefore a skill, which the effective healthcare managers, medical records administrators, clinical statisticians, statistical technicians, and medical transcriptionists also must master. This book is designed to present the principles that will help the learner to acquire or improve that skill. The roots of the book go back to the teaching of ICD coding to doctors, medical records personnel and statistical technicians at the Department of Statistics & Medical Records, Ministry of Health, Kuwait for over two decades. While teaching the principles and techniques of disease coding through various revisions of the ICD we came across many areas which were not within easy reach of our students, leading to frustration among them. This led us to bring out this comprehensive guidebook on ICD-10 coding with detailed explanations, suitable examples and appropriate coding exercises for better comprehension. The book is divided into eight units. Unit 1 provides an introduction to disease coding. Unit 2 gives a brief history of the development of ICD Units 3 and 4 deal with the main classification and alphabetic index of ICD-10. Unit 5 explains the principles and techniques of using ICD-10 and Unit 6 does this on a chapter-by-chapter basis. Units 7 and 8 consider the special features of morbidity and mortality coding. Unit 9 emphasizes the various aspects of statistical presentation in accordance with the WHO regulations. Care has been taken all through these units to keep the matter as simple as possible. Appropriate examples are provided wherever needed. Suitable exercises are presented at the end of each unit, which the students can take to test their level of comprehension before embarking on to the next unit. Many people have contributed to this final product. Of these, special mention should be made of Dr. Abdul Aziz Khalaf, Director of Statistics & Medical Records Department at the Ministry of Health, Kuwait for his continuous support and encouragement. We are deeply indebted to Miss Zahra Awadh who reviewe d most of the chapters and made many helpful contributions to both style and content; and to Mr. Mohamed Bader and Mrs. Jaya Umaputhiran for secretarial assistance. We are especially grateful to hundreds of doctors, medical records administrators and technicians, health statisticians, and ICD coders who participated in our training programmes and workshops on ICD in Kuwait and other countries during the past 25 years. We trust that these many colleagues will find our account of some small value.