The EHR “Final Rule” (Finally)

Six months to the day after the Centers for Medicare and Medicaid Services (CMS) released the “preliminary rules” for Meaningful Use, the final rules are in.  For clinicians and policymakers who want to see Electronic Health Records (EHRs) play a key role in driving improvements in the healthcare system, there’s a lot to like here.

For the Office of the National Coordinator (ONC), the agency that oversees the federal health information technology incentive program, the Meaningful Use rules are a balancing act. On one hand, ONC wants to get as many clinicians and hospitals on board with simply adopting EHRs (and thus, the need to set a low bar). On the other hand, they want to ensure that once people start using EHRs, they are using them in a “meaningful” way to drive improvements in care (and thus, the need to set a high bar).  I think ONC got that balance just about right.

Let me begin with a little background.  In 2009, Congress passed the Health Information Technology for Economic and Clinical Health (HITECH) Act, setting aside about $30 billion for incentives for ambulatory care providers and acute-care hospitals to adopt and “meaningfully use” EHRs.  Congress specified that the executive branch would define Meaningful Use (MU) and would do so in three stages.  The first stage was finalized in 2010 and its goals were simple – start getting doctors and hospitals on board with the use of EHRs.  By most metrics, stage 1 was quite successful.  The proportion of doctors and hospitals using EHRs jumped in 2011, and all signs suggested continued progress in 2012.  Through July 2012, approximately 117,000 eligible professionals and 3,600 hospitals have received some sort of incentive payment.

When Stage 2 preliminary rules were released in March 2012, I blogged that there were no surprises.  ONC had foreshadowed many of the additions: that a majority of prescriptions be written electronically, that quality measures be generated from the EHR, and that there be a greater demonstration of health information exchange.  These additions remain in the final rules.  Yet, as I skimmed through the 600+ pages of federal register that answer all the comments and describe the final rules, I was struck by the importance of Stage 2 – an importance that can be lost in the details.

A gentle start at shifting the way doctors use EHRs. Most experts will view Stage 2 as simply building on Stage 1 (e.g. more data in electronic format, etc.)  This is true, but it’s not really what’s interesting here.  What I think is so important is that Stage 2 begins, gently at first, to get doctors to start using EHRs differently. Six months ago, I said that CMS would likely drop the requirement that patients actually engage with the EHR to download or otherwise share their data.  Holding doctors and hospitals accountable for what their patients do seemed untenable to me.  I’m happy to say that I was wrong. ONC set the bar very low:  providers only have to show that 5 percent of their patients are doing it.  It’s a small number but it’s really important.  The new rule holds providers accountable for what their patients do, and that’s a fundamental shift.

There are other important shifts, such as getting providers to actually start sharing data with other providers.  Provider organizations have guarded clinical data jealously, seeing it as a tool to keep their patients coming back.  This begins to change in Stage 2.  Finally, automating clinical quality measures is the holy grail of quality measurement and improvement.  Having EHRs automatically generate quality measures can facilitate larger efforts geared toward payment and delivery system reform.  The Stage 2 rules move us forward.

Some providers are still left out and others are lagging. There are challenges ahead to be sure, many of which have to do with the broader incentive program.  HITECH leaves thousands of providers out of the incentive program altogether – nursing homes, rehabilitation facilities, and psychiatric facilities are just some of the institutions that will not be getting financial resources for using EHRs.  As we have written previously in Health Affairs, these providers are starting off from a miserable baseline of adoption and are likely falling further behind.  Given that so many of the sickest, costliest patients end up at these institutions, not having their clinical data available in electronic format will make care improvement much, much harder.  There are others that seem to be falling off as well:  small, rural hospitals, for instance, are struggling, as are providers in small practices.  Regional Extension Centers are supposed to be helping these entities, but early evidence of their impact is not as encouraging as it could be.

It is worth remembering that the point of Meaningful Use, at least as I see it, is to be the infrastructure for broader healthcare reform.  EHRs unto themselves may not be a panacea for the cost and quality problems that plague our healthcare system, but they are fundamentally important to addressing those problems.  Want to run an Accountable Care Organization without using interoperable EHRs?  Good luck.  What Stage 2 does is subtle but important:  it slows down the on-ramp enough to give doctors and hospitals a chance to get on board.  But, it also shifts the focus so that providers start using EHRs in ways that engage their patients, share their data, and measure quality in a robust way.

Will it work?  Given my track record on predictions, I’d rather not say.  But if CMS and other payers can do their job of creating the right incentives for broader payment and delivery system changes, ONC can claim credit for having created the infrastructure necessary to make it work.

Ashish Jha, MD, MPH is the C. Boyden Gray Associate Professor of Health Policy and Management at the Harvard School of Public Health. He blogs at An Ounce of Evidence. This post first appeared at the Health Affairs Blog.

4 replies »

  1. Isn’t that because “they” really aren’t interested in usability?