The meaningful use criteria for use of Electronic Health Records are coming into focus

I got a tip to subscribe to the free Becker newsletters that focus on Ambulatory Surgical Centers (ASC’s), and I see that they are also covering EHR meaningful use criterion. The rubber is starting to hit the road as the Federal definitions are of sufficient fine-granularity to be operationalized. Is that a mixed metaphor? Anyway:

The march towards meaningful use (MU) has created a sense of urgency within the physician community to adopt EHRs for their offices — as it should. Hospitals and eligible professionals (EPs), which include physicians, began attestation for MU incentive payments on April 18, and the first payments were issued in May.

 

Central to physicians qualifying for stimulus payments is the use of certified EHR technology. Vendors began applying for certification in July of 2010, and physicians have begun the process of either choosing appropriate technology or making needed changes to existing systems in order to qualify.

 

With $27 billion in incentives up for grabs over the next five years and the potential for penalties hanging in the balance for providers who do not meet criteria, the stakes are high. But like any rush to a deadline, it’s important that providers and ambulatory surgery centers understand the full picture and take a careful, thoughtful approach to choosing systems that align with both workflow needs and future expectations to avoid the potential for costly mistakes.

 

ASCs are becoming increasingly aware of the MU provisions — specifically as they relate to the perceived need to deploy a certified EHR as opposed to a system that may be more appropriately aligned to their environment. Since ASCs are not eligible for stimulus payments, and MU certification criteria for ASCs were never developed, there has been no real incentive or benefit for them to invest in certified systems. However, some ASCs are now feeling pressure to purchase a certified EHR and make costly technology decisions in order to satisfy the needs of their physician base.

 

This pressure is the result of a little-known clause in the meaningful use regulations, referred to as the 50 percent rule. A clear understanding of the 50 percent rule and four other aspects of MU is imperative for ASCs and EPs as they weigh their responses to the mounting external pressures to deploy certified EHR technology.

 

1. 50 percent rule. According to CMS, ”any eligible professional demonstrating meaningful use must have at least 50 percent of their patient encounters during the EHR reporting period at a practice/location or practices/locations equipped with certified EHR technology capable of meeting all of the meaningful use objectives.”

 

The latest guidance from CMS is that, when they refer to a “practice/location,” ASCs are included in that definition. Additionally, CMS has commented that “equipped” means that the technology needs to be available in such a way that the EP can use a certified EHR to accomplish all of their MU objectives.

 

This clause can potentially have the unintended consequence of leading ASCs to believe that they need to adopt certified technology that is not designed for their environment, and for which they receive no stimulus payments, unlike EPs and hospitals.

 

2. Potential solutions. ASCs under pressure to adopt a certified EHR product should first have their physicians determine where their encounters occur. If at least half occur at an office or offices equipped with certified EHR technology, then there is no need for that physician to be concerned about the 50 percent rule.

 

In cases where a physician does have more than 50 percent of patient encounters occurring at an ASC, there are two options that exist for the center: 1) significantly change the workflow within the ASC and the physician’s office to capture data associated with MU objectives, or 2) encourage physicians to carefully review the CMS definition of an encounter and potentially change the way in which they schedule their patient activity to avoid falling short of the 50 percent rule.

 

According to CMS, for the purpose of calculating this 50 percent threshold, any encounter where medical treatment and/or evaluation and management services are provided should be considered a “patient encounter.”

 

3. Workflow challenges. MU criteria were designed to address longitudinal patient care and a move towards the efficient electronic capture of patient data over time. To meet this need, EHR vendors have designed products to capture patient information over the course of many encounters.

 

It is a workflow that fits well in a physician office environment. But an ASC is much different. To efficiently address the workflow needs of an ASC, products need to be designed around procedures. That is, data capture needs to address the specific needs of a particular procedure being performed. This will not typically require the extensive evaluation that may occur in a physician office.

 

There are numerous examples of MU objectives that do not fit well within an ASC’s workflow. For example, a meaningful user must use a certified system for the following types of workflows, many of which do not translate well into the ASC environment:

• Computerized provider order entry
• Drug/drug interaction checking
• Drug formulary checking
• Prescribing electronically
• Reconciling medications
• Incorporating clinical lab results into the EHR
• Calculating and reporting clinical quality measures to CMS
• Providing clinical summaries to patients
• Submitting data to immunization registries and public health agencies
• Keeping problem lists, medication lists and medication allergy lists updated

 

Why are doctors afraid of moving to EHR’s? Fear of losing productivity, mainly

More scuttlebutt and chatter about the EHR adoption survey done by MGMA I mentioned a few weeks back. Below is a synopsis from a good resource I just learned about. But hey, Uncle Sugar knows that it will hurt to go from your paper and Word (or Wordperfect) patient record system to an EHR solution. That’s why the Feds are offering 44K now, and 39K if the practice makes the change 2013. Anyway:

Productivity was the pervasive issue. The only group that reported some productivity gains was the 16.3% self-proclaimed “optimized users” of EHRs—those who have had sufficient time following implementation to master the EHR. (The report did not define “sufficient time.”) Among this group, 41% reported that physician productivity has increased. What is disturbing about this statistic, however, is the implication of the converse—that even among these most accomplished EHR users, the majority of physicians (59%) are seeing a decrease, or at best no increase, in productivity. For the total population studied, 43% have just worked their way back up to where they were before implementation, and 31% of respondents are experiencing an actual productivity decrease.

Productivity was the major factor accounting for why 8% of survey participants are in the process of replacing their EHR with another, while anticipated productivity loss was reported as the most significant barrier to EHR implementation for physicians still using paper charts. Among these paper users, 78% fear productivity loss during implementation and 67% worry about the effect even after the transition to an EHR.

This data confirms past experience regarding productivity loss and raises these critical questions:

• Why do only 16.3% of EHR owners categorize themselves as “optimizing their use of an EHR”?
• While government incentives will certainly address the financing concerns expressed by small practices, how will this money address the productivity obstacle for all adopters?
• What accounts for the loss of productivity?
• When technology has replaced an antiquated paper process in other industries, it has always brought increases in productivity. How do we deliver the same results in healthcare?

EHR usability and quality assurance: do the Feds understand what is at stake?

So, 2011 is the year the checks for EHR get issued. The IT industry seems to me to be adopting a bit of a wait-and-see attitude about the Federal push to implement and integrate EHR, possibly because the standards for “meaningful use” are only now being rolled out. This is such heavily bureaucratized terrain; not every vendor wants to mess with it. A certain Zen-like patience is required for this market, what with business rules, such as they are, based on the sometimes inscrutable calculations of public-sector analysts and specialists who issue Federal guidelines. I used to work as an analyst for a Health IT company, tracking  state compliance to the Federal Medicare data transaction standards, and every time a bureaucrat put me on hold, one more little part of my youth expired, joylessly.

But after all the regulations and rules have been parsed, the rubber must hit the road. Whether doctors and nurses and admins can use the EHR systems being implemented remains the $100 Billion question, no?

From the January 18 PC World:

Dr. Tom Handler, a radiologist and analyst for the research firm Gartner, said one of the main barriers to adoption, “valid or not,” are concerns about the productivity and usability of EHR systems. Many physicians also believe that the data collected by the government through EHR reporting criteria will be used to decrease Medicare and Medicaid reimbursements, Handler said.

“Ultimately, what I hear doctors saying is, ‘Let me get this straight. You want me to spend money to put in a system that will be harder to use and slow me down, so I will earn less money, and that the end result is that someone else makes more money,” Handler said. “If you phrase it that way, it’s not illogical to see why they don’t want to do it.”

E-prescribing is another example. “Docs say, ‘I didn’t go to medical school to become a data entry clerk so Walgreens could hire one less pharmacy tech to enter the system.’”

Handler said current meaningful use criteria also doesn’t take aim with incentives that address what physicians consider some of the most critical reforms needed in healthcare today.

For example, Handler said, a computer-based patient record system can catch duplicate patient test orders, but the current meaningful use incentives don’t penalize physicians for ordering duplicate tests.

Ultimately, it’s the patient — the insurance company and then society — that pays for the duplicate test, and yet, its the physician who’ll have to foot the cost for the system that can prevent the duplicate tests, he said.

Dr. Harry Greenspun, chief medical information officer for Dell and a member of the Healthcare Information and Management Systems Society (HIMMSS), said resistance to EHR adoption can be as simple as a physician not wanting to add steps to a process that has worked for decades.

“It’s really easy to write a prescription; you just jot it down on note paper. On a computer screen it can take a lot longer,” he said. “If you go have to through a check list or a menu-driven program, it can be clunky, and a barrier to adoption.”

“On the other hand,” he continued, “If I can share [radiological] images, pull data from other systems, write a prescription all from one screen … and get valid prescription alerts and find out about public health threats, then the value is obvious.”

Everyone wants doctors and other medical professionals to interact with systems that are as intuitive as possible. The Feds know that usability is make-or-break, and they are developing appropriate usability and quality assurance standards…one hopes. But this is a non-trivial business folks, and there are issues lurking under the surface that give me pause. For instance, there is the crucial distinction between usability and learnability that Andrew Dillon highlights (scroll down to comments):

Distinguish between usability and learnability. Most usability tests are short run tests of people’s initial reactions to a technology. This privileges the earliest phases of human reactions, the making sense of something new. This is important but it is not the full story. I have shown repeatedly in my own work that people’s later reactions take time to emerge and often run counter to their initial ones.

Are your eyes glazing over with this inside-baseball arcana yet? Are you thinking, we pay good money so those nerds with advanced degrees in cognitive psychology or human factors have to worry about this kind of hair-splitting, not us. THAT’S THE WRONG ATTITUDE. Too-big-to-fail projects can fail, and with as much money is at stake with EHR, failure can mean the entire universe is sucked into a fiscal black hole.

Oh, and people can die if we don’t get it right.

How are hospitals dealing with changing government definitions of “meaningful use” of EHR’s?

Anthony Guerra is poking around in the murk so you don’t have to. The feds need to get their story straight about “meaningful use” of EHR’s. Now, larger institutions should have the resources to patiently deal with the tweaking and modifications, which may legitimately reflect ongoing interpretation and absorbing of response and comments from interested parties. But at what point does the pain become too great for smaller practices and lone-wolf clinicians? What is they refuse to play ball, or simply wait until mid-decade or later for the dust to clear and the standards to emerge. This part of ARRA is not too big to fail.

Why — organizations like the American Hospital Association (AHA) ask — do hospitals have to buy and implement technologies they will not be using (at least not for now)?

In a letter to Department of Health and Human Services (HHS) secretary Kathleen Sebelius (copying ONC’s David Blumenthal and CMS’s Tony Trenkle), AHA president and CEO Rich Umbdenstock wrote, “this will delay many hospitals in their efforts to qualify as meaningful users of health IT.”

The letter continued, “the lack of consistency between CMS and ONC, and the changing interpretation of rules when hospitals are in the middle of planning their meaningful use implementations, creates confusion and will likely delay the progress of hospitals working diligently to comply with the already challenging meaningful use requirements in a very short timeframe.”

It closed, “we do not understand why CMS would provide an exception in these circumstances, but still require hospitals to pay for the acquisition and installation of the technical capacity to meet the objectives.”

While the AHA, and much of the industry, doesn’t understand CMS’ actions in this case, you had better make sure your CEO, CFO, COO and board understand yours. I’m talking about taking care of the justifications (i.e., covering your backside or “CYA”) that will become such a part of hospital CIOs keeping their jobs over the next five years.
As healthcare IT executives, you need to keep key people informed of all the roadblocks that come up as you move down the Meaningful Use path, whether they be thrown up by clinicians, the government or those key people themselves. If it looks like you’re going to need more modules right now than you thought, they will have to be purchased and paid for. You must explain that situation to whomever holds the purse strings, including sharing both the ONC’s requirements and the AHA’s letter. They should know what you’re dealing with, and that you’re not alone.

If your vendor is unable to provide the certified modules for all 24 Meaningful Use measures, find out when they’ll be able to, or starting looking for one-off sources to fit the bill. You can also check out CCHIT’s new EACH program for self-certifying both vendor and home-grown modules. Through it all, keep everyone in the loop, whether they want to be or not. Put this information sharing in emails so you have a record. There is enough money on the line that, “you never told me we were in trouble on this Meaningful Use thing,” may be heard around the industry over the next few years.

A poll on adoption of EHR’s

We are at the stage now where Federal writ must be interpreted and scrutinized by those planning budgets and personnel decisions. Institutions and organizations such as Regional Extension Centers face serious financial and logistical challenges concerning EHR’s. While these challenges certainly present opportunities for those of us in the healthcare informatics/healthcare IT world, the history of implementing complex upgrades to institutions that must provide mission-critical services during the upgrade is daunting. Healthcare CIO’s and CTO’s and directors must proceed with caution as the Feds operationalize the logistics of the ARRA EHR meaningful use provisions.

Houston Neal from www.softwareadvice.com/ passed along a note that they are running a poll on an important issue concerning the adoption of EHR’s and how the Feds are structuring incentives to do so.

One of the major components of the the American Recovery and Reinvestment Act of 2009 (ARRA) was the allocation of $19 billion to jump start the adoption of electronic health records (EHRs). One of the major uses of those funds was the establishment of Regional Extension Centers (RECs) to support EHR adoption by primary care physicians.

The entity spearheading this effort, the Office of the National Coordinator for Health IT (ONC), is specifically charged with helping 100,000 priority primary care providers become “meaningful users” of EHRs in 24 months. Eight months have passed since the ONC began funding RECs, and we’re skeptical that they will deliver.

Don’t get us wrong. We’re big advocates of EHRs. We’re glad to see such an energized EHR market. We’re just skeptical that throwing money at the problem will lead to efficient and successful adoption of this important technology.

In our opinion, there are five fundamental flaws with RECs:

1 Doctor’s aren’t moving as fast as the money is flowing
2 The market already delivers on what RECs promise
3 “Preferred vendor lists” limit choice and free markets
4 RECs won’t get doctors to “meaningful use” fast enough
5 The REC model leads to under-staffed, ephemeral entities“

What do you think about how electronic health records (EHRs) will be imlemented in the key category of Regional Extension Centers ? Take the poll at : http://www.softwareadvice.com/articles/medical/five-reasons-we-think-recs-are-reckless-1092310/#survey#ixzz10rpWUNdV

a year later, the details of “meaningful use” are coming into focus

Almost one year ago, the President signed the HITECH Act: “Health Information Technology for Economic and Clinical Health” as part of ARRA, the “American Recovery and Reinvestment Act.” This part of the stimulus bill is intended to incentivize the migration away from legacy paper health records and non-standard health records towards electronic health records (EHRs), via incentive payments to physicians of up to $44,000, starting next year.

Since the passage of ARRA, there has been much speculation and some tentative analysis of how the criteria for “meaningful use” of EHR/EMR will play out. With the recent announcements by the Feds, the details are at last becoming more-or-less apparent. There is still the period of review and input from stakeholders and the public, so there may be some changes, but at this point the basic operational definitions can be characterized. My friends at Software Advice.com put together a very useful summary and representation of how the suits at CMS and ONC are making sense of the “meaningful use” provision:

“In the table below, we’ve combined the meaningful use objectives for both eligible professionals (physicians) and hospitals for the Stage 1 adoption year, the required EHR technology criteria to accomplish those objectives and what criteria the government will use to measure meaningful use.

CMS defines “meaningful use” as using an EHR for the objectives listed in the first column. The objectives fall under these general topics:

* Improving quality, safety, efficiency, care coordination, population and public health;
* Reducing health disparities;
* Engaging patients and their families; and,
* Ensuring adequate privacy and security protections for personal health information

For the first time, CMS has also outlined specific measurements for how the government will determine if an EHR is being used in a meaningful manner for the Stage 1 (2011) adoption year. Updated definitions of meaningful use for Stage 2 (2013) and Stage 3 (2015) EHR adoption periods will be released in the year before those periods begin.

This table outlines what Stage 1 objectives define meaningful use, what software features are necessary to accomplish those objectives and what criteria the government will use to measure meaningful use. EP refers to eligible professional.

For the full article, see http://www.softwareadvice.com/articles/medical/the-stimulus-bill-and-meaningful-use-of-qualified-emrs-1031209/

Discussing ARRA’s “meaningful use” provision: how to define it?

Picking through the July print edition of Healthcare Informatics, and surfing the blog, I see the debate by analysts over what constitutes “meaningful use” of Electronic Health Records/Electronic Medical Records is reaching a crescendo.  “Meaningful use” refers to the criterion for accessing some of the massive funds allocated by the American Recovery and Reinvestment Act for development and implementation of Electronic Health Records/Electronic Medical Records. As Woodward and Bernstein (allegedly) said: “follow the money“.

There is lots of good discussion and fine-grained debate over the definitions and implications of the “meaningful use” provision at http://www.meaningfuluse.org/ . I see at Health Data Management.com a nice summary:

“The federal HIT Policy Committee has approved revised recommendations of a workgroup for an initial definition of “meaningful use” of electronic health records systems. Among the changes made in the recommendations are refinements in computerized physician order entry criteria and a shorter timeline for implementing personal health records.

The definition is important because providers must demonstrate meaningful use of EHRs to qualify for Medicare and Medicaid incentive payments starting in 2011 under the economic stimulus law. The recommendations now go to the Office of the National Coordinator for Health Information Technology and other units of the Department of Health and Human Services. HHS officials will use the recommendations for guidance as they develop rules to implement the incentive programs. A proposed rule is expected by the end of this year.

The policy committee’s Workgroup on Meaningful Use recommends that 2011 criteria apply not just to 2011, but also to a provider organization’s first adoption year. That means if a provider cannot be ready for incentive payments until 2012 or 2013, the organization still will start with 2011 criteria. In other words, 2011 criteria would be considered Adoption Year 1 criteria.

Consequently, 2013 criteria would be in effect in 2013 or in an organization’s third adoption year.

The workgroup’s adopted definition of meaningful use is a matrix of more than two dozen requirements that have been revised to some degree since it first was unveiled a month ago. The workgroup made several clarifications, particularly in the area of requirements for adoption of CPOE. But many of the details remain to be fleshed out during the administrative rules process.”

Meanwhile, over at Modern Medicine, an analyst writes:

“The first public draft of the “meaningful use” definition, the linchpin of the $44,000, five-year Medicare incentive for improving electronic health record adoption, includes too many requirements for physicians to comply by the 2011 deadline, according to a healthcare technology analyst.

“The bar has been set too high, and the recommendations put forth will be virtually impossible to implement within the aggressive time schedule of the HITECH Act,” says John Moore, managing partner of Chilmark Research of Cambridge, Massachusetts, in reference to the EHR incentive legislation. “Simply put, it appears that not enough attention was paid to the processes/workflow changes that are required as part of a successful HIT rollout to meet these recommendations.”

ARRA grants for academic health informatics programs

Houston Neal of softwareadvice.com pointed me to a timely post about upcoming funding that will be disbursed via the ARRA bill for academic health informatics programs. Remember that Congress recently allocated $51 Billion for ARRA. As a medical informatics researcher finishing a PhD, I am of course very interested!

(http://www.softwareadvice.com/medical/electronic-medical-record-software-comparison/)

“We recently called the Office of the National Coordinator for Health Information Technology (ONC) to learn more. All they could tell us is funding will be available, but the details have yet to be confirmed and set in writing. We quickly learned we were not the first people to call; many others are wondering the same things as us.

While we can only speculate about when and how much will be available, one thing is for certain: there will only be so much to go around.

Here’s what you need to know and what you need to do to be prepared.

Who is Eligible?
There are two different grant programs described in the stimulus bill. The grants are for universities that wish to:

Carry out a demonstration project to develop academic curricula integrating certified EHR technology in the clinical education of health professionals (section 3015), or;
Establish or expand medical health informatics education programs (section 3016).
The grants will be available to the following institutions of higher education:

A school of medicine, osteopathic medicine, dentistry, or pharmacy;
Graduate programs in behavioral or mental health, or any other graduate health professions school;
Graduate schools of nursing or physician assistant studies;
A consortium of two or more schools described in the lines above;
An institution with a graduate medical education program in medicine, osteopathic medicine, dentistry, pharmacy, nursing, or physician assistance studies, and’
Certification, undergraduate and masters degree programs for information technology”

Ephraim Schwartz: Financial and technology issues make Obama’s EHR push not so easy to execute

from www.infoworld.com/article/09/03/11/10FE-electronic-medical-records_1.html

Up until now, the benefits of electronic medical records that have occurred accrue to just about everybody — patients, employers, state and federal governments, and medical insurers — but the actual health care providers. Doctors get the least benefits, especially in small practice groups (those with fewer than five physicians) that make up most medical practices.

But even those who might benefit from electronic health records don’t, says Homer Chin, associate medical director for clinical information systems at Kaiser Permanente Northwest. Why? Because there is little incentive to share information, the core of an electronic health record (EHR; also called an EMR for “electronic medical record”). For example, hospitals make money by doing tests. But once EHRs are up and running, a doctor ordering a test electronically might immediately receive an alert saying the test was unnecessary because the patient had the same test or procedure at another location. “There is not much revenue and profitability in putting in an EHR. There is little financial incentive,” Chin says.

An ironic consequence of EHRs is that, by helping raise the quality of health care, they penalize doctors and other medical providers for success, says Wes Rischel, a vice president at Gartner. The bottom line: Doctors will see fewer patients.

Beyond the income factor, the high cost of EHR systems today — not only the systems, but the setup and training — also dissuades adoption by doctors, especially those in small groups. Physicians have been unwilling to invest anywhere from $20,000 to $50,000 in an EHR system where the economic benefits tend to go to someone else. Today’s EHR systems are not as easy to use as they could be, so there is a large learning curve required, Chin says: “There is something intuitive about paper chart and prescription pad.”

Recognizing these factors, the stimulus package tackles these financial challenges head on by offering money to health care providers. Hospitals submitting via EHR systems to Medicare and Medicaid will receive up to $6 million a year in additional payments for sending data electronically. This incentive will remove much of the adoption inertia seen so far, says Richard Archer, a principal in the health care IT advisory practice a KPMG.

<snip>

But now Microsoft, Google, and AOL founder Steve Case’s Revolution Health are looking at entering the health care information exchange market. All three offer individuals a personal health record, which puts the patient in control of his medical information. But the business aspect is in giving health care providers access to a person’s complete health record from a single site.

There are two major questions around the reliance on health records from these providers, say industry analysts. One is whether users will trust a for-profit organization to care for the most personal kind of information. The second is whether each of us can be trusted to manage and keep such a life-and-death record up to date or if it’s safer to leave that responsibility to organizations whose only job it is to keep the health data updated.

The prognosis for EHRs
EHR providers are, not surprisingly, bullish on the future of EHR efforts. Greg Mancusi-Ungaro, a senior director at Exigen Systems, says deploying an EHR system is just like implementing any big enterprise application, only the enterprise in this case is bigger and the stakes are higher. “The technology exists today and despite the fact that we lack some core standards, we are enabling the development of a flexible infrastructure to stay in tune with requirements. I can visualize a successful national system,” he says.

As Kaiser’s Chin points out, there is a convergence occurring around health care technology regarding how to share it and use it to assist delivery of services and treatment. But the challenge of orchestrating and satisfying so many stakeholders remains. Plus, even if the solutions are mandated rather than eventually negotiated, the task of gathering the many pieces that are still in flux, then integrating them remains a complex technical and process task.

Over time, both industry representatives and analysts expect that every U.S. citizen will have an EHR available nationwide. But to make it happen will require a great deal of cooperation, innovation, and an investment in health-oriented IT. This shift will likely start at a less ambitious level than the political rhetoric suggests, with local practitioners sharing patient information in a local health care ecosystem.

5 guiding principles for spending EHR stimulus funds wisely

John Halamka, MD,  on Making Smart Investments In Health Information Technology: Core Principles

http://content.healthaffairs.org/cgi/reprint/28/2/w385.pdf

Over the past five years, thousands of public- and private-sector employees, many volunteering their time, have worked to advance the cause of interoperable, certified, secure electronic health records. As new federal funds become available, should we invest right away or wait for technology and policy perfection? Do we leverage the accomplishments of existing national organizations, or do we start from scratch? The time to invest is now, building on the organizations we already have. To ensure wise investment, I suggest guiding principles assembled from the input of hundreds of providers, patients, payers, vendors, government employees, and standards-development organizations.

No other industry has had such a mismatch between the sophistication of the technology being introduced and the lack of technological sophistication on the part of those who are supposed to manage it. Placing servers in clinicians’ offices and expecting office staff to back up, secure, and maintain technology is likely to be expensive, frustrating, and highly risky. Investments in EHRs should focus on achieving economies of scale through the funding of regional, hospital based, or vendor-hosted “software as a service” providers that provide Web-based/remotely accessible solutions that require very minimal new technology in clinicians’ offices.