Tie Meaningful Use Definition to Desired Behavior

Last week’s NCVHS hearings on meaningful use highlighted the growing disconnect between the change that many hope to see health IT support in our healthcare system and the emerging definition of “meaningful use.”

Improving our healthcare system will require much more than paying clinicians to implement health IT systems (certified or otherwise) or report clinical outcome measures.  It will require incorporation of health IT into the daily processes of care delivery…as well as changes in clinician behavior.

I propose a definition of meaningful use, especially for the small physician practices that deliver that deliver most care, that is tightly linked with the changes in behavior that will be necessary for actual improving the quality, safety, and coordination of care.

First, the initial requirements for meaningful use should require both the implementation of a “certified” EHR and the “certification” by the appropriate regional extension service that the practice has considered process redesign issues in implementing and using its system.  While this will require extensive interaction of practices with the forthcoming extension services (funded as part of ARRA), it will drive clinicians to available resources and encourage the kinds of process redesign changes necessary for improving care processes.

Next, the initial requirements for meaningful use should require that healthcare providers sign (electronically or paper) data sharing agreements with the majority of healthcare providers that interact with the majority of their patients.  While this will require the government to (follow through on its HISPC efforts) and develop and make available standard state-level (and inter-state) data sharing agreements (that include liability protection), it is an action that does not require the existence of HIE infrastructure and other yet-to-be build dependencies.  It simply requires clinicians to know who their patients are, to know what other providers see their patients, and to formalize the basis for working together to coordinate their care.  Perhaps the use of social networking tools could further reduce the burden of this process.  The failure of most HIEs and RHIOs to gain participation of the clinicians in their communities reflects the reality that sharing information among practices is not something that is natural for them: without standard data sharing agreements (with liability protection), sharing data quickly devolves into a resource-sucking, risk shifting legal battle.  Spending hundreds of millions on HIE infrastructure…and then expecting clinicians to use it, which is, of course, the current thinking, is bound to fail.

While future requirements for meaningful use should require reporting of a variety of process and outcome measures, initial requirements should be tightly coupled with the behavior at the individual clinical-level that reflects actual clinical use of EHRs (i.e. not just for documentation / billing).  Such measures as the percent of practices that are using “problem lists” in their EHRs, the percent of immunizations that have been recorded in a structured way (vs. in notes), the number and use of CDS alerts, and the number of electronic prescriptions and others orders by clinicians are all ways to assess whether practices are actually using their EHRs .  We learned at the NCVHS hearing that Micki Tripathi uses such measures in assessing the “meaningful” use of EHRs by clinicians in Massachusetts.

Finally, the initial definition of meaningful use should require practices to demonstrate the ability to develop an accurate panel of patients for a chronic disease population of their choosing.  While this might seem like a trivial requirement by some who wish to hold practices accountable for outcomes, it will challenge many, many practices (to say nothing of most “certified” EHRs on the market today).  Developing panels of patients is the foundation for quality improvement activities.  If we want practices (or communities) to support quality improvement, this represents a good start.  And it will push vendors to support this functionality in their products.

While these initial measures of meaningful use fall short of the outcome-based accountability-that some would like (and requires much more than simply buying and “implementing” certified health IT), it clearly ties health IT to behavioral change at the practice and community levels…and sets the stage for greater future expectations.  In addition, these measures respect the awesome burdens that transformation will place on individual practices.

Establishing requirements of this type, I hope, will lead clinicians in communities to realize that taking a collaborative approach from the start will allow them to become meaningful users faster, better, and cheaper than if they take an approach on a practice by practice basis.

By setting the bar too low or too high (and not tightly linked with achievable, measurable activities by practices), the administration risks funding the implementation of health IT systems at the individual practice level that don’t support better coordination of care…and funding HIEs (health information exchanges) and other infrastructure that clinicians don’t use.  Aligning initial definitions of meaningful use with achievable, logical steps and actual desired behavior at the practice level, the administration can set the foundation for improving care delivery and drive success in more rigorous future requirements.

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7 replies »

  1. I agree with most of the above. It is important to remember that the prime reason for the EMR’s being responsible for a single cent of money for the development of EMR’s is to save money. I guess we should also include providing better medical care. There is no proof that the US can provide better medical care under any circumstances. We are already outspending every country in the world and providing 38th rank medical care for US citizens and our medical costs are rising at an unprecedented 17% (roughly doubling every 4 years).
    As far as the government goes, EMR’s will actually enable the curtailment in medical cost with the same or worsening medical care, WHICH WILL BE WHAT HAPPENS IF THE EMR PEOPLE DON’T GET THEIR ACT TOGETHER SOON. Its a fact that budgetary issues are a yearly issue and the nation WHO standings every 20 to 30 years. So budget trumps health and a premature death looks pretty much the same as a timely death.
    Its not really a guessing game at all. It is how do we cut medical spending in the US where basically “greed” has been the operative word US business since the mid 80’s and everyone in the medical food chain is looking to please the stock holders most and patients haven’t the slightest idea what they are getting for their money.
    Just look around, hospitals are evaluated by architecture and advertising while the floors and ancillary services are short staffed. After delays have killed patients for a while, they become invisible. Do what one state did when they were having trouble with child deaths in their foster system, stop counting the people that die.
    Like being drugged and raped, at least the US public can carelessly be exploited without having to really face the fact that without transparency (proof that we are getting quality medical care for our money) Americans will die younger but together.

  2. Anonymous?? No credibility here. Major flaw….the elephant in the room (or is it the gorilla?) Control of the data should be with the patient..!! In a group practice where multiple specialsts share the same business structure, or the group structure infers to the patient it is one practice….probably not an issue.
    However the patient would have to sign a privacy waiver for different practices to share their medical information. This post bespeaks of the worst lack of moral and ethical protection of patient’s privacy rights by their “trusted care givers”….I don’t know who wrote this post….but if it is a physician, it also bespeaks how our professionalism has eroded.

  3. Ditto to David Kibbe’s comments. However, the interesting points raised in this post contribute to the vital dialogue on EHR implementation, “meaningful use” and how to use the stimulus money to best effect being led by Dr. Kibbe and others.
    Re: “the initial definition of meaningful use should require practices to demonstrate the ability to develop an accurate panel of patients for a chronic disease population of their choosing. While this might seem like a trivial requirement by some who wish to hold practices accountable for outcomes, it will challenge many, many practices (to say nothing of most “certified” EHRs on the market today)”.
    Applications focused on population management of panels of patients with specific chronic illnesses do not seem to be a high priority for many EHR vendors. However, this area is a primary focus of some web-based patient registries, such as DocSite, which are available for a fraction of the cost of most EHRs (not counting Practice Fusion’s no cost model). Many of the PCPs and medical specialists in my IPA are using these low-cost web-based tools to achieve outstanding process and outcomes scores for their chronically ill patients. These tools also permit easy reporting for P4P and Medicare’s PQRI.
    Unfortunately, the current payment environment is focused on episodic and acute care and does not support and reward the management of chronically ill patients to anywhere near the level needed. Medicare has run a few pilot programs and some payors (Anthem/Wellpoint in New England) have fairly good P4P programs which focus on this issue to a limited extent. Most health plans seem to be continually trying to race to the bottom on how low they can pay physicians, especially PCPs, to reward their executives for short tems financial gain and trying to break up any physician organizations which stand up to them. Instead, they need to be working with physician organizations to create real incentives for chronic care management and shared savings to reward physicians for excellence.

  4. Why is this an anonymous post? Why should we tolerate anonymity at THCB? Does this person have something to hide? Matthew, let’s not continue to publish anonymously.
    regards, DCK

  5. Am I wrong in seeing much more discussion about health IT and EMR as a diversion from what will actually reduce health costs and serve as a panacea for fixing healthcare? Is it because the feds are throwing money out there for it, so it doesn’t really matter if it works. This reminds me of Reagans “Star Wars” defense , scientists/researchers knew it wouldn’t work but wanted in on the research grants.

  6. Two recommendations in Markle Foundation’s framework for meaningful use are very powerful:
    1. “Achievability” of the meaningful use by providers in the first years of implementation (2011-2012)without creating undue burden on clinicians and practices.
    2. The definition of meaningful use should gradually expand to encompass more ambitious health improvement aims over time.
    The goals should be operational metrics based for meaningful usage in the first year like percentage of prescriptions or orders that were electronic, percentage of decision support alerts that were accepted, percentage completion of medical records and such. First year of implementation should also be the year for benchmarking key clinical, quality and outcomes indicators. Meaningful usage in subsequent years of implementation should require % improvement in these indicators until industry standard benchmarks have been achieved. These indicators need to be very carefully defined to incentivize physicians for leveraging the medical history information available for decision-making and taking actions in compliant with recommended clinical protocols. End outcomes are sometimes dependent on complex human biology unique to each individual.
    ARRA requires “certified” EMRs to have reporting capability on quality indicators. However, improving these quality indicators may require performance monitoring across business processes, often spanning multiple Healthcare IT systems. You can check out Infosys’ offering in this area : http://www.infosys.com/industries/healthcare/industry-offerings/clinical-quality-compliance.asp

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