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New and Improved Meaningful Use

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By MARGALIT GUR-ARIE
HHS_ONC

The long anticipated final rule on Meaningful Use was unveiled yesterday with much pomp and circumstance in a rather unusual ceremony which, interestingly, also marked the first public appearance of Dr. Berwick as CMS Administrator. The Final Rule is contained in an 846 page document. Accompanying the CMS ruling is the 228 pages final EHR certification rule issued simultaneously by ONC. Fortunately for all of us scrambling to figure out what has changed, Dr. Blumenthal released a synopsis in NEJM (recommended). Already many articles and dissertations have appeared and indubitably many, many more will be written in the next few days and weeks analyzing every change and every nuance of the new, and now binding, Meaningful Use. For those who don’t care much about nuances, preferring a bigger and lower resolution picture, here are the major changes to the old version of Meaningful Use.

The Good

  • By far the biggest relaxation was to divide the original 25 measures (23 for hospitals) into two groups – 15 mandatory measures and 10 optional measures of which only 5 need to be fulfilled, per provider choice. This is in effect a 20% reduction of the Meaningful Use burden.
  • They added back a requirement for hospitals to record advanced directives. It is listed in the optional group, which means that some hospitals could choose not to implement it, but one must be grateful for having it back on the list.
  • Although CPOE is not optional, it has been scaled back to medication orders only.
  • The bewildering array of quality measures has been trimmed to 3 simple core measures (weight, BP, smoking) and only 3 more per provider’s choice.
  • Another relief for providers is that EHRs will be required to automatically perform all the calculations of nominators and denominators for all measures that involve percentages, and there are many of those. These calculations were initially supposed to be performed manually by the practice or hospital.
  • Several measures which required tracking and reporting, such as CDS alerts, now only require attestation that the functionality is turned on.
  • If you are a physician with a nice little EHR that will surely be certified, but has no online PHR, there’s no need to despair. PHRs, Patient Portals or the need to provide online medical records is now optional. Even providing electronic clinical summaries for transitions of care is purely optional.
  • You don’t have to rush to the office on weekends to give patients copies of their records. Everything is now measured in business days instead of hours from patient request.

    • The Bad

    • In the ONC certification rule, Immunizations have been removed, along with procedures, from the minimum requirements for data elements to be shared with patients and other providers. For Pediatricians and all parents of young children, particularly this time of year, this is not welcome news. Hopefully vendors will go above the minimum here, since it is rather trivial to provide immunization histories to any interested party.
    • The two Administrative requirements of submitting claims electronically and verifying eligibility with payers have been removed. On the surface this makes sense when talking about the use of EHRs. However, the vast majority of providers, hospitals and private practices, already meet both criteria since Medicare and Medicaid require electronic submission of claims, not to mention the potential cost savings from automating such process.

    The Inconsequential

    • For most measures, the minimum percentage for compliance has been dropped to about 50% or less. This gives the impression of further concessions, however it is rather meaningless. If you are going to manage medications in the EHR, you will do that for all patients, not just a select 30%. Not to mention that if you use electronic prescribing for some allowed prescriptions and not for others, you will end up with a reconciliation nightmare when electronic renewal requests start flowing in from pharmacies for all your paper scripts. Anyway, placing the bar lower is a friendly gesture from CMS
    • Many previously required standards for terminology and data exchange have been relaxed in the ONC document, particularly for labs and medications. While completely irrelevant to physician users, this is a huge win for vendors whose efforts to retool their EHRs are now postponed by a couple of years.

    All in all, the new Meaningful Use is a bit more flexible than the old version and what was bound to become a typically painful bureaucratic attestation for physicians, is now a rather straightforward process. Other than that, you still have to buy a certified EHR, install it and meaningfully use it by October 1st 2011. If you’re considering hopping on the bandwagon, call your Regional Extension Center and see if you can get some free services to get the ball rolling. Meaningful Use has been officially declared the Law of the HIT Land and there is no turning back now.

    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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    9 replies »

    1. On calls with ONC or CMS (or people on their committees) I’ve heard the presenters alluding to clarifications to the final rule and a comprehensive FAQ from CMS… do you know if these are published yet in draft or when they they’ll be published> CMS has a list of 68 FAQs on their “EHR incentiive program” page… but I take it the open questions are in the hundreds (I can list 5-6 of the brain twisters from the last call if this would be helpful)… many are followed with “CMS will be clarifying this…”… question is, when? …and where?… also, there are great calls from ONC that I missed… in mid-August they had a 90-minutes Q&A, but I don’t see any replay options on the HHS website… am I missing something?

    2. Question on EP eligibility: If seven primary care physicians work for a CHC (Community Health Center)do the EPs become eligible for the medicaid reimbursement schedule or would the CHC receive that money? $63K per MD has some value but the funds invested in an EHR came from the CHC – do the doctors owe the CHC money? Or is this a question of contracts, or of individual choice?

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    4. Once again “meaningful use” like most everything else in health care is defined by experts and not the people they serve. And so our health care system will continue to serve the beliefs and interests of experts rather then the people the experts allegedly say they serve

    5. Michelle,
      If you look at each specific criteria (i.e. §170.306(f) – Exchange clinical information and summary record.), you will see that immunizations along with procedures has been removed from the minimum requirements.
      And this is why:
      “Comment. A commenter noted that the certification criterion references immunizations but the Medicare and Medicaid EHR Incentive Programs proposed rule did not include immunizations in the objective. The commenter suggested that we modify our certification criterion to match the proposed rule.
      Response. We have removed this term, consistent with the previous revisions we have made to other certification criteria above.”

    6. I haven’t taken a look at the certification rule, so I can’t comment on the what it says about immunization. The MU rule does require the “Capability to submit
      electronic data to immunization registries or Immunization
      Information Systems and actual submission in accordance with applicable law and practice,” though I notice it doesn’t say anything about parents or other providers. Might that fall under the part requiring patient access to information?
      Overall I’m glad that there’s more flexibility: the division of a core and menu set is a relief for many, as is the extension from hours to business days for some of the requirements’ deadlines. I created a little video (3 minutes) that very briefly summarizes the final rule’s changes. Now that we know what’s required, and the HHS is open to applications for accredited certification bodies, here’s hoping HITECH will really pick up speed soon. It’s going to be a fast rest of the year.

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    9. Thorough presentation. One problem, at the NIST Usability Conference, it was demonstrated that the Rule is being applied to meaningfully unusable euipment.
      What is needed first is a meaningful usability requirement. The cart has been placed before the horse, and the horses have run away without a functioning gate.
      Now, they need to figure out how to make these devices usable.
      Safety and Efficacy, forget about it. This is enforced largesse for the HIT industry with a kickback loop. Criminal.
      It is unethical for doctors and hospitals to use HIT devices on their patients that are being sold in violation of the F D and C Act. Berwick should know.