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Urgently Needed: Useful Meaning of Meaningful Use

One day before 2009 passed into history, the much anticipated final definition of “meaningful use” was released by CMS and ONC, 556 pages and 136 pages, respectively. The blogosphere experts rushed to summarize the contents, some accurate and some less so, and just like everything that has to do with health care reform, for every rule making there are a dozen new questions being raised by the already thoroughly confused stakeholders at large.

Just so that THCB is not left out, here is a quick qualitative summary of the contents:

Requirements:

1. Data Collection – The following structured data elements will need to be collected by the software: Demographics, Vitals (plus Smoking status), Electronic Lab Results, Problem Lists, Medications and Allergies. The important thing to note here is that the requirement to record Advanced Directives has been dropped in the final ruling.

2. Medical Records for Patients – Providers will need to provide patients with electronic copies of Visit Summaries, Care Summaries, Discharge Summaries and Complete Medical Records upon request. In addition, continuous on-line access to medical records is also to be provided.

3. CPOE – With the exception of Electronic Prescribing, which needs to actually send scripts to pharmacies, all other orders need to be electronically recorded, but not electronically sent. So it’s OK to just print those requisitions.

4. Decision Support – The software needs to perform Drug-Drug, Drug-Allergy and Formulary checks. Reconciliation of medications should be performed upon transition of care. Five guide lines, based on specialty, need to be implemented and the software should provide alerts based on the guide lines selected.

5. Outreach – The software should create lists of patients by health and demographic status and the list should be used to reach out to those patients. Follow-up and other reminders should be similarly handled.

6. Information Exchange – The software should have the ability to exchange clinical data with other EMRs and to report to State and Federal agencies. Only one test per reporting period is required. There is no requirement for an ongoing, working exchange of information. Note that the only operational clinical interfaces required are eRx and Lab results.

7. Quality Reporting – This is very similar to current PQRI reporting requirements.

8. Security – Standard security measures and disclosure management.

9.Administration – The software should perform electronic Eligibility checks and submit Claims electronically.

These are the general requirements for 2011 and the required compliance rates range from 10% to 80% depending on the novelty of the requirement. All these activities need to be reported somehow, which translates into a new and meaningful reporting burden on most software vendors.

Technology

Physicians may acquire, or subscribe to, either one comprehensive product that has the ability to satisfy all requirements and is certified as such, or cobble together an array of modular products, each capable of a subset of the required functionality. The provider is responsible for successful integration of such modules.

Certification processes for comprehensive and modular technologies are to be defined at a later date.

Schedule

The big news here is that the “drop dead” start date for meaningfully using technology has been pushed from January 1st 2011 to October 1st 2011 and it only takes 90 days of reported meaningful use in order to qualify for the full incentive payment in 2011.

The remainder of the CMS document deals mainly with various payment structures under Medicare, Medicare Advantage and Medicaid, and the ONC document is attempting to estimate costs to vendors building and certifying appropriate technologies.

The Message

Both documents contain repeated requests for public comments on most rulings in order to clarify feasibility of implementation. It is my impression that both CMS and ONC are genuinely open to listening, considering and implementing guidance from the interested public.

I have no doubt that large vendors, large hospitals, patient groups and the usual experts will indeed provide public comments according to their inclinations and business interests. However, what is really needed is a critical mass of comments from practicing physicians who are usually “too busy seeing patients”.

Of course having all doctors engaged in reading almost 700 pages of rule making is not very likely, and the language in many places is rather tedious.

This is probably our last opportunity to actively engage grass roots physicians in the creation of a roadmap for Health Care Information Technology. Failure to do so will dramatically slow down the adoption rates and force us through a myriad of detours through tried and failed approaches.

Therefore, this is a call to ONC and Dr. Blumenthal to waste no time in disseminating the information contained in the meaningful use final rulings throughout the physician community. These documents need to be distilled and presented through various physician associations, regional hospitals, webcasts, conference calls, email campaigns and any other public education means available. Clear and simple instructions on how to provide public comments should be included and a prompt announcement that such effort is underway would help set expectations.

Lastly, this is a call to all practicing physicians to engage in the process, to take the time to understand the meaningful use final ruling and to provide the guidance requested by CMS and ONC. Regardless of personal preferences, the move to Electronic Medical Records is all but inevitable now. Earnest participation in shaping the future of Clinical Information Technology will go a long way towards making the transformation less painful for each and single doctor who is currently busy seeing patients.

ONC IFR (PDF) http://tinyurl.com/ya7bn2k

CMS NPRM (PDF) http://tinyurl.com/yb62fcr

More information available at http://healthit.hhs.gov

Margalit Gur-Arie blogs frequently at her website, On Healthcare Technology. She was COO at GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS and billing services for physicians. Prior to GenesysMD, Margalit was Director of Product Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large non-profit hospital organization.

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19 replies »

  1. Hi,
    It was really good post lot of useful information. On the point of usability and defining the term ‘meaningful use’, I would add further that the medical practitioners are looking to avail of this federal incentive by trying to comply with the definition of meaningful use but at the same time EHR providers are looking at their own set of profits.
    This misunderstanding is mostly I believe as a result of wrong interpretation of the federal guidelines. The EHR providers need to look at these guidelines from the prospective of the practitioners who deal with different specialties.
    Each specialty EHR has its own set of challenges or requirements which I believe is overlooked by most EHR vendors in a effort to merely follows federal guidelines. This is resulting in low usability to the practitioners, thus less ROI, finally redundancy of the EHR solution in place.
    There are few good links which I came across when I was browsing on these topics.
    Usability/meaningful use<a href=" http://www.waitingroomsolutions.com/wrs/arra-stimulus-money-44k-arra-emr-stimulus-bill-arra-ehr-stimulus-incentives
    Certification criteria for EHR:
    http://www.waitingroomsolutions.com/wrs/arra-stimulus-money-44k-arra-emr-stimulus-bill-arra-ehr-stimulus-incentives#Certification_Criteria_EHR
    A pretty handy ROI calculator for any practitioner:
    http://www.waitingroomsolutions.com/wrs/emr-ehr-roi-calculator

  2. Excellent post! As an IT Professional for a Major Hospital in NYC, this entire concept is very exciting. This is a great opportunity to streamline processes and reduce data redundancy.

  3. Parts of what you all are saying are supported in the research literature. The promise of efficiency through technology already brings an abundance of food to our grocery stores (bar coding), overnight packages to our doorsteps and a myriad of other services. Why not health care? Wouldn’t an electronic scrip be easier to read and less open to mis-interpretation than handwriting? The problem is that healthcare is infinitely more complex than delivering packages or charging customers for groceries, and the software companies have been able to get by with selling mediocre products. In academic programs, the emphasis is all on HCI – human computer interaction, and other forms of working closely with computer users to design software. This hasn’t been done often so far in Healthcare IT, and definitely must be done now for the promise of this technology to be realized.

  4. e-dollar Bill writes:
    > Is this how it works??
    Yep, pretty much. I have a rant about the corporate capture of professional organizations (my personal pet peeve is the IEEE) which was caused/enabled by the professionals themselves “depending” on their employers to pay the dues and fund their travel to conferences &c. Professionals interested in professionalism don’t do that but “knowledge workers” interested in perqs do. And so HIMSS is totally in the pocket of the vendors…
    t

  5. Certification has nothing to do with safety yet dupes Congress to think that it does.
    CCHIT, an arm of HIMSS, the wealthy HIT trade organization, is declaring the computers made by the electronic health record vendor members of HIMSS fit for purpose? Is this how it works??

  6. Dr. Kibbe, I am very happy to hear that you are engaged in an in-depth analysis for the AAFP members and I am looking forward to reading your thoughts on this forum. I hope other medical associations are engaged in similar efforts for their members.
    This post here was not meant to analyze and/orthe c provide advice on purchase. It is only an urgent (in my opinion) call to physicians to take the 10-15 minutes necessary to let ONC know how they feel about this ruling.
    If you feel that CPOE is onerous and possibly dangerous (Confused Doctor), ONC should be made aware. If you think that your small safety net hospital in rural Iowa is unable to muster the capital for implementing the necessary tools in the allotted time, ONC should know that.
    If you as a dermatologist don’t collect the required data in the course of normal business, or as a psychiatrist don’t really order too many labs to justify the cost of an interface, or anything else that can only be gleaned from practicing in the trenches, ONC should be made aware of all these things.
    The language of both documents reflects a flexible and open attitude to physician needs. I think this is a great time to get involved. These comments are all going to be available for public viewing. If one thousand physicians all say the same thing, their public voice will have to be taken into consideration.
    Frank, regarding certification, CCHIT is currently the only certifying authority. However, ONC has indicated that it will allow others to apply for the job and at least one organization (Drummond Group) has indicated an interest in becoming a certifying body.
    The EHR software will need to be certified in order to qualify for meaningful use, either by CCHIT or any new government approved entity.

  7. Dear Margolit: Thanks for doing this nice summary. I will be writing on both the Meaningful Use regs and the HHS Certification regs for THCB, but am still analyzing them from the perspective of physicians for the AAFP. We’d like to provide our members with a succinct yet comprehensible set of guidelines regarding one’s approach to the EHR incentive programs and EHR technology purchases, and so we’re taking the necessary time.
    Kind regards, DCK

  8. Doctors worry about life and death of their patients. HIT folks rendering the legislation worry about their cash register and getting elected again. The HIT folks do not care about what the doctors say. Doctors have responded to earlier requests for comments and have obviously been ignored. These documents are obtuse and not in the interest of patient care or safety.
    Best advice for the doctors who are hearing from the HIT hucksters: DON’T BUY

  9. Thanks for the easy to understand explanations. Not many can take over 500 pages and trim them down to a few paragraphs that make sense. Thanks!

  10. This was an outstanding summary of the subject. Count on ONC disseminating a bunch of gobbledygook, that most docs won’t have time to read, or understand…..

  11. Is it true that CCHIT Certification is not required for ARRA HITECH provider incentives?

  12. Very well done and concise summary. Haven’t spent a significant amount of time reviewing the new rules I can assure you that this high quality summary is a real service to the community.
    I really like the idea of getting the word out to the Docs, and ONC should push hard regarding this effort, but I am not holding my breath that the Docs are actually going to pay attention.
    The healthcare industry, if it were a nation, would should all the signs of decline, with monumental changes beating at its door, it prefers to believe it is more or less untouchable.

  13. My economic analysis of the cost of doing business with the additional overhead and inefficiency from the meaningfully useful HIT reconciled with the penalties proffered by the US government for noncompliance indicates it is best to not buy yet and take the penalty.

  14. These are basic requirements for any EMR to be useful. Ours does all this now- and I am confident that we are more safe, efficient and provide better care because of our EMR.

  15. I agree that the doctors must comment. They are busy trying to establish work arounds and patient defenses for the EMRs and POEs already purchased. Many have succumbed to the forces unleashed by HIMSS and the HIT industry.Medical care is under siege.
    Marg, the best way to achieve meaningful response to the rules is to have the FDA and/or CMS send out letters to all physicians,nurses and other health care professionals in the US asking for comment on the rules and to report the adverse outcomes their patients have already suffered from these instruemnts of medical care.

  16. This is a well stated report and I thank you.
    I am confused about who exactly benefits from the meaningful use. Are these systems and the abundant detail contained within meaningfully useful to the government, to the patients, or to the doctor?
    These computerized care record and ordering computers may cause adverse events and bad outcomes even though they meet the arbitrary and capricious definition in the documents. How has it been determined that the computerized care contrivances that are supposedly meaningfully useful indeed are safe and effective?
    I am confused about how a system of medical care providing devices can be designated “meaningfully useful” not having been approved for safety and efficacy. The HIT industry has intellectually and probably financially captured those making the decisions.
    Have you ever used one of these CPOE things? I have and they are an impediment to efficient and safe care. Too many mistakes go unnoticed.

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