Today was a big day in health care information technology (HIT). There are so many acronyms in HIT that I probably should publish a list, not today though. The Office of the National Coordinator of HIT (ONC) of the Department of Health and Human Services (HHS) issued its final rule on meaningful use criteria. As we know, these are the requirements that ‘providers’ (mainly physicians) have to meet to receive incentive payments from the Centers for Medicare & Medicaid Services (CMS) for the use of electronic health records (EHR) and other specific information technology (such as electronic ordering, electronic prescribing & exchanging of health information). The incentive payments start as early as this year for Medicaid providers, the rub is that after 2015, if you haven’t qualified, you will receive smaller Medicare or Medicaid payments (you can only qualify for one). These criteria were first published early last year & have been in comment periods or under revision ever since.
Despite this long period of evolution (over 2000 comments were evaluated), the question for providers continues to be “Is it worth it to me or my practice to even try to qualify?” The incentives are supposed to be based on the cost to acquire & adopt the necessary technology, but the total incentive (paid over as much as five years) is well under $100K for Medicaid providers. This may be close to the actual cost of the technology, but that does not take into account the disruption in practice caused by training, workflow changes & differences in usage caused by the technology. Providers who have been used to talking to their patients (even in the small amounts of time that modern clinical workflows allow) must now also do data entry (into the EHR) & spend part of their time filling out electronic order & prescription forms. This disrupts the clinical visit for both the provider & the patient. I have had not a few people (it’s people who are patients after all) tell me that they refuse to allow their doctor to enter data & consult “the computer” during their visit. They feel it’s disrespectful, regardless of how productive it may potentially be.
Large practices, hospitals & practice networks that have IT departments & support staff will have a hard enough time qualifying for meaningful use, even though HHS has relaxed its “all or none” interpretation for qualification. Small practices, community health centers, critical care hospitals (& other rural health care practices) and many more of the safety net health care organizations will have substantial difficulties qualifying, even over the 5 year time frame. Is the law’s intent to reduce the reimbursement these critical pieces of our health care safety net receive? Probably not. Will this happen? Possibly…
Is there a solution? The same legislation that codified meaningful use also created the Regional Extension Center for HIT program. This program is based on the highly successful agricultural extension center program. Will it work? We don’t know yet, but it would have to work “really really well” to assist the majority of provider & provider organizations that will need help. Maybe in a few years…
What might work better is an even further relaxation of the qualifying requirements. The guidance for State HIE organization (also issued by HHS) focused on three specific technology-enabled functions for the 2011 effort. All three are actually meaningful use criteria. Perhaps instead of the current 15 + 5 qualification standard for (Stage 1) meaningful use – providers must qualify on 15 core criteria plus five of ten additional criteria – 2011 (Stage 1) should focus on a small number like 3. Perhaps they should even be the same three as for State HIEs (e-prescribing, receipt of structured lab results & sharing patient case summaries across unaffiliated organizations).
I could be just too close to the problem, having worked with health care organizations, mainly community health centers & related organizations, for the last 10 years or so. I understand the motivation to begin using HIT to reduce costs & improve outcomes for patients. I think, however, that ONC, HHS & the rest of the Federal health care alphabet soup needs to look at what will make the largest improvements for the necessary investment, & incent that. Providing incentives to do everything at once can actually be like providing incentives to do nothing, especially if there is little common understanding of, or support for the large changes in the affected community. Sometimes less really is more.
David Hartzband is a Lecturer in Engineering Systems at MIT, teaching courses in large-scale software systems and Director of Technology Research at the RCHN Community Health Foundation. In his role at the Foundation, Dr. Hartzband spearheads the organization’s continued evaluation, assessment and findings dissemination related to health information technology. He also works with early stage HIT companies on security, identity & integration issues.