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Our Meaningful Use Comments

by John Moore | June 26, 2009

OliphantIn the FWIW column, Chilmark Research submitted its comments on the Draft Recommendations for Meaningful Use, which were released on June 16th.  Today at 5pm was the deadline and we barely made it (email time-stamp of 4:59pm).  Following is the text of the email/comments we submitted to HHS and we certainly welcome your feedback, e.g. we are totally nuts, reasonable or wimped out and did not push hard enough?  Also, we purposely did not try to cover everything, simply not enough time, instead choosing to focus on a couple of areas we felt were critical.  Lastly, Chilmark also reviewed, made suggestions to and endorsed comments by a collaborative group that was submitted by the Markle Foundation.

Now time to rest and prepare for round two.

Dear HIT Policy Committee of ONC within HHS

Chilmark Research has followed closely the ongoing developments within HHS as it lays the foundation to successfully fulfill the legislative intent of ARRA and in particular the HITECH Act.  We recognize the significant task you have been given, the responsibilities they entail and recognize the numerous challenges that lie ahead.  Indeed, the small actions you will take may indeed lay much of the foundation for the success of future healthcare reform efforts.

Core to the successful execution of the HITECH Act is insuring that the significant amount of US taxpayer’s money that will be invested to digitize portions of the healthcare sector achieve objectives that indeed improve health, mitigate if not even lower costs and ultimately, deliver value back to the taxpayer that is readily recognized and appreciated.  Therefore, how clinician’s actually “meaningfully use” technology that is relevant to taxpayers is critical.

Also critical to the success of subsidized technology adoption is to set objectives sufficiently high to be meaningful, but not so high where the risk to reward ratio acts counter to adoption.

With these thoughts as a backdrop, our comments to the Draft Recommendations for Meaningful Use are as follows:
The Meaningful Use Workgroup has done an exemplary job of incorporating the intent of the legislation into the meaningful use criteria.  We also applaud their efforts to focus on what we wish to see as outcomes from the successful deployment and use of HIT and the tiered approach that is taken to raise the bar on meaningful use over the 2011-2015 time period.

Meaningful use objectives are correctly structured focusing on broad, thematic needs that do not define specific technological solutions.  This will provide the flexibility needed for new innovations to develop and ultimately be adopted. 

Some aspects of meaningful use criteria however, do not appear to take into account the significant challenges that are present in successfully deploying an IT solution.  For example, the requirement for CPOE in 2011 is not reasonable, particularly in the context of a hospital where there are numerous interactions, workflows and processes that must be reconfigured to successfully deploy such a solution, and that does not even begin to address internal training issues as well. Serious rethinking is required regarding meaningful use timeframes that account for process and workflow reconfiguration.

The draft meaningful use criteria do take into account the patient and their family/caregivers with regards to access to medical records, secure communication, use of home monitoring devices etc.  But the criteria do not go far enough.  Chilmark recommends the following:

Access rights to personal health information:
2011:  

  • Patient be given access to their complete medical record through a patient portal/tethered PHR or via common standards compliant digital file.
  • Patient portal/tethered PHR provide the capability for patient to annotate & make notes to the record, including suggested corrections.

2013:

  • Patient be provided fully portable medical record whereby they can export PHI from a physician’s tethered-PHR to PHR, data repository, etc. of their choosing, without cost.
  • Provide patient, within context of the tethered-PHR, quality & cost metrics of the physician practice/hospital (use metrics collected for reporting in other section of meaningful use) with comparison  benchmarks to regional and national averages increasing cost and quality transparency in the market.

2015:

  • Allow the automated collection and import for analysis of personal, patient device data into the EHR for enhancing care. (Note: we us the term personal patient device data and not “home monitoring devices” as used in the draft recommendations for the future will see smaller, wearable sensors, not confined to a home setting.
One of the largest challenges we foresee is the adoption of “certified EHRs” by small ambulatory practices where nearly 75% of all amublatory care occurs. It is also in this sector of the market that we have the lowest adoption of HIT.  The benefits to adopt, logically, need to be greater than the risks.  However, as currently proposed, the criteria for meaningful use will actually increase over 2011, 2013 and 2015, while reimbursement to physicians will concurrently decrease.  For those physicians that do not have a large CMS population that they care for, follow-on penalties are unlikely to have much effect.  Therefore, HHS/ONC will need to develop policies and incentives that will encourage these practices not to exit the program after say the first three years of receiving reimbursement, which for those beginning in 2011, will receive over 85% of reimbursement by end of 2013.

Again, we reiterate that the inital draft of meaningful use was an excellent start to the process but unfortunately has many fatal flaws and most importantly, does not provide enough value back to the taxpayer, the citizen.  It is our sincere hope that follow-on recommendations more strongly advocate for the patient and their rights to what is ultimately their data .

Sincerely,
John Moore

9 responses to “Our Meaningful Use Comments”

  1. Rob says:

    Comments:
    1. Define “complete” medical record. I think that is a bad word as it is difficult to define and involves many parties. I think a more reasonable goal by 2011 would be to have some interaction between PHR and EMR products. Our practice is 13 years ahead of most, but is only rolling out some of this within the next 12 months. There will also be significant physician resistance to “complete.” If the goal is to get physician adoption, this may stand in the way.
    2. Who is to “provide” the PHR? I think integration with some of the bigger platforms will allow interaction between physician and patient records. If the onus is on the physician again, it will make adoption more difficult.
    3. My approach would be to make “meaningful use” as broad as possible. The real goal is to get all physicians using an EMR in a meaningful way (not as a note-taking device). Once docs are all on EHR, then being more aggressive for connectivity and patient communication will be possible. I think you put the horse before the cart if you push too quickly for radical change. This will probably just drive more primary care physicians out of business. The goal of HITECH is to get docs on quality EMR products. Once this is in place, much more meaningful and substantial changes can be made.

    Truthfully, this seems daunting to me. If that is the case, it probably would seem impossible for the average doc.

    I personally think the debate over ownership of the record could be extremely divisive. It’s going to be a hard transition for doctors to EMR. If the perceive that loss of control of their records will be at the end of this road, many if not most will quit. I am a strongly patient-oriented doc, and I feel the patient advocates don’t really try to understand the doctors’ position here.

  2. […] Article John Moore, Chilmark Research, 26 June 2009 SHARETHIS.addEntry({ title: "Our Meaningful Use Comments", url: "http://articles.icmcc.org/2009/06/27/our-meaningful-use-comments/" }); […]

  3. Jan Oldenburg says:

    You’ve done a nice job, John, of laying out both a practical and challenging vision on meaningful use.

    I also agree with Dr. Rob that we have to figure out how to have a meaningful dialogue about both doctor’s needs to have a medical record that they can control and attest to and consumers’ desire to own and control their medical record. Without careful and thoughtful dialogue about what the balance is between those two poles, we run the risk of creating a mess, where we have multiple digital records of an individual’s care, all claiming to have “the truth” about one person’s medical history. We run the risk of too much noise and not enough clarity.

    It may be helpful for all of us to spend time thinking about the use cases in a future world. Imagine that I get a copy of my record from my doctor’s EHR and place it into a stand-alone PHR, then change, delete, or hide a diagnosis on that record. Following the Markle Foundation’s principles, there is no indication that I have deleted anything when I present my PHR to my next physician. Will he/she trust it enough to act on it without verifying everything through costly testing? In that situation, wouldn’t good medicine indeed be defensive medicine?

    It’s certainly true today that doctors never assume that their patients are telling them the whole truth, and that records received from another provider may have HIPAA-authorized omissions, but aren’t we trying to create a future where there’s accurate data and defensive medicine doesn’t need to be standard practice?

    I’m hoping that these are some of the issues being explored at the various Health Camps that are taking place.

  4. John Moore says:

    Thank you Rob and Jan for your thoughtful comments. Now in response…

    Rob, you raise a good point on what is meant by complete and you are correct in assuming that with the exception of some psych notes, I am referring to the complete record available to the patient/consumer. 2011 may be too aggressive of a schedule for a complete record in light of the cultural challenges that such a move presents, but ultimately this is a goal to strive for. So for 2011, lets strive for labs, meds, immunizations, allergies and summary record.

    As to who actually pays for the PHR, eg is this a cost borne by a practice to create and support such? No, see two paths here: For those with the resources, they can create/host a PHR for their customers which does have benefits. For smaller entities, they can facilitate customer’s use of a PHR by providing portability of the record.

    And Jan, while you state that providing the patient their own complete record could lead to greater confusion due to multiple records, is that not what we have today? A cousin of mine with a couple of serious illnesses has 1 GP and 5 specialists. She must compile the complete longitudinal record, carries the stack of clinical notes, etc. to each appt to share with the various clinicians for they do not share the info amongst themselves. Now that is a mess.

    What I am suggesting is to take that mess we have today and put it into a digital construct that the patient has complete rights of ownership to and allow them to lead the care effort. After all, do they not have the most to gain or lose?

    That being said, do agree with you that certain safeguards/policies need to be put in place to insure overall public health & safety, e.g., a citizen who has a history of drug abuse, suicidal tendencies, etc.

    Again, thank you both for your thoughtful and insightful comments. It will require discussions such as this to reach a comment ground of understanding to indeed move from defensive medicine to one that is inclusive and proactive.

  5. I like the patient centric access comments because at the end of the day it is the patient that needs empowerment. Patients will no longer tolerate being treated as a sideshow to be dictated to by the government, insurance companies and providers.

    Also, the focus on small practices is critical. The adoption of EHRs will force small providers to pay attention to the HIPAA Security Rule in a way that will overwhelm them by an order of magnitude vis-a-vis there attempts at compliance with HIPAA Privacy Rule.

  6. […] the HIT Policy Committee along with some 900+ written comments in the comment period that followed (here’s Chilmark Research’s own comments).  The meaningful use workgroup chaired by Paul Tang and Farzad Mostashari (don’t be […]

  7. […] would be one of the greatest challenges in adoption and use of EHRs and recommended to ONC in our 2009 comments that ONC consider relaxing the schedule to allow to allow sufficient time for process […]

  8. […] would be one of the greatest challenges in adoption and use of EHRs and recommended to ONC in our 2009 comments that ONC consider relaxing the schedule to allow to allow sufficient time for process […]

  9. […] would be one of the greatest challenges in adoption and use of EHRs and recommended to ONC in our 2009 comments that ONC consider relaxing the schedule to allow to allow sufficient time for process […]

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