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Relaxing Meaningful Use? Not Really

by John Moore | February 19, 2010

There has been a lot of talk this week in the trade pubs about the HIT Policy Committee (HITPC) meeting on Wednesday wherein the committee recommended a relaxation of meaningful use (MU) requirements.  But if one looks closer, the “story” is far deeper and certainly of more significance.

If you frequent this site, you already know that providers will only receive ARRA (Stimulus funding) reimbursement under the HITECH Act if they demonstrate meaningful use of certified EHRs.  The Center for Medicare and Medicaid Services (CMS) defined MU and all it entails (some 25 specific measures) in a proposed rule that is currently in the public comment period, which ends March 15th.  Since release of those rules, there has been much discussion and hand-wringing as to whether or not the MU rules were asking for too much in too short a time or simply were not clear enough to assist healthcare IT professionals in making appropriate decisions for their institutions.  Thus, when the HITPC came out this week recommending that CMS adopt greater flexibility and relax MU requirements, well this is just what many were hoping.

But while one hand gives, another takes away.

Indeed, it is a very good thing that the HITPC has recommended that some flexibility be built into the MU requirements.  While it may be easier for HHS/CMS to enforce an all or nothing approach to meeting MU requirements to receive incentive payments, in reality such inflexibility will lead many a provider (especially small ambulatory practices) to think twice before committing to adopting an EHR.  Seriously, why would I as a provider commit to a certified EHR wherein I have to pay for it up-front and then strive to meet all 25 MU criteria in 2011 to get my first reimbursement check?  A highly risky proposition in 2011 that only looks more risky further down the road for we still do not know what CMS will be asking of providers (definitive terms) in 2013 and 2015 for demonstrating meaningful use of certified EHRs.

But I digress.

What the HITPC did on Wednesday was to make public their comments/recommendations to CMS (by way of ONC head, David Blumenthal) regarding MU rules. Among the 12 recommendations, the majority (eight) of recommendations seek a strengthening of MU rules.  They are:

1) Include “Document a progress note for each encounter” for Stage 1 EP MU definition. For acute care, HITPC recommends that this requirement occur in Stage 2 (2013). Basically what they are asking for here is that the progress notes a clinician records in a patient encounter be documented in digital form.  Sure makes a hell of a lot of sense as it is during those encounters that significant information is exchanged and when we start thinking about transitions in care, these notes will prove critical in maintaining continuity of care.  Many a clinician will push back on this recommendation.

2) Providers should produce quality reports stratified by race, ethnicity, gender, primary language, and insurance type. If we truly wish to assess and ultimately address disparities in care, combining quality reports with demographic information is required.  This is a very logical recommendation and fairly simple to implement as the all of this information is already being collected.  It is simply a matter of employing an analytics overlay.

3) Eligible Providers (EPs) and hospitals should report the percentage of patients with up-to-date problem lists, medication lists, and medication allergy lists. Again, this should not be that hard to do provided one has some simple reporting features built into their EHR.  The big question here, however, is how many EHRs in the market today can automatically produce such reports?  Likely, not too many but there are a number of solutions/work-arounds that are not that difficult to deploy and use and should this indeed become part of MU rules, EHR providers will build this capability into their offerings.

4) EPs and hospitals should record whether the patient has an advance directive as part of the Stage 1 MU criteria. CMS, is their all too common myopic way, only required advanced directives for those 65 and older.  Well CMS, as HITPC has rightly pointed out, many of us may not make it till 65 and it is wise to have advanced directives recorded for all who have one.  Really quite simple to provide this function as it could be as easy as attaching a file to a given patient record.

5) EPs and hospitals should report on the percentage of patients for whom they use the EHR to suggest patient-specific education resources. Why CMS took this out in the first place is beyond me as there are a multitude of services, both free (eg from CDC or NLM) or paid (A.D.A.M., Healthwise, WebMD, etc.) available in the market. The HITPC is correct: If one of the purposes of HITECH is to truly engage patients in the management of their health, such educational resources are a prerequisite.  Come on CMS, wake up.

6) Include measures of efficiency for Stage 1 MU definition for EPs and hospitals. Another tighten of MU requirements wherein HITPC wants clinicians to report (record) percentage of patients using a generic drug alternative and have at least one of the efficiency measure reported (the requirement is for five) to directly address diagnostic testing.  Pretty clear why CMS stayed away from this one and did not prescribe specifc measures – what a political minefield.  Doubt if much headway will be made here and can already hear the drumbeats from the You Won’t Ration Our Care coalition.

7) The numerator for the CPOE measure should define a qualifying CPOE order as one that is directly entered by the authorizing provider for the order. OK Docs, the HITPC does not believe it a good idea for you to just handover the CPOE process to some underling, you will be the responsible party.  Nice in theory but virtually impossible to enforce.  This is definitely a K.I.S.S. and let any licensed clinician with such authority/knowledge perform this function.

8 ) Make patient reminders specific to the individual and not limit it to only those 50 and older. Again, CMS is looking at only those it primarily serves (the elderly) and not looking more broadly at the original legislative intent of HITECH to serve all citizens.  Thankfully, there are bodies like the HITPC that have significant clout and can step-up and give CMS some mid-course direction.  The challenge here will be exactly how “personalized” to the individual such reminders might be and again, how does one actually measure such parameters of personalization.

The Wrap:

While it is easy to understand why the federal government would like to use some form of quantifiable measurements (MU rules) to insure that it is indeed getting its money’s worth for this multi-billion dollar investment in HIT, stepping back, one really has to wonder if this is truly the best approach and the best use of precious tax-payer dollars. It is increasingly looking like what HITECH is creating is yet another layer of bureaucracy, truly a jobs bill (isn’t that what the Stimulus bill was all about anyway), that will ultimately have very little impact on the costs and delivery of care for the incentives are misaligned.

To drive adoption and use of HIT/EHRs it will take far more than what is basically a one time incentive payment and the potential for penalties down the road.  What s truly needed is a core business benefit, something that to date, EHR vendors have struggled to demonstrate.  How that might manifest itself is where we as a nation and industry need to focus.  Unfortunately, in the rush to jump-start the economy with ARRA, we appear to be heading down a path that while paved with good intentions, may ultimately result in little forward movement.

Thanks to David Harlow of Healthblawg for the Wordle image.

5 responses to “Relaxing Meaningful Use? Not Really”

  1. Michael Jahn says:

    Wow ! And all I was worried about was item 17 in MU !


    Seems like you have it called right, the cart is underneath the horse !

  2. […] Article John Moore, Chilmark Research, 19 February 2010 SHARETHIS.addEntry({ title: "Relaxing Meaningful Use? Not Really", url: "http://articles.icmcc.org/2010/02/21/relaxing-meaningful-use-not-really/" }); […]

  3. I agree with your analysis, particularly your statement that “what is needed is a core business benefit…something that to date, EHR vendors have struggled to demonstrate.” It’s easy to get sidetracked by the details of “meaningful use,” but the real issue for high- volume, community-based providers is the difficulties posed by the EHR’s themselves. These are the same products which have not experienced large-scale success in the past, particularly among specialists. Nothing has fundamentally changed about the EHR products that the government would like physicians to use; if anything, they will only become more complex when they are modified to meet the additional HHS certification requirements.

  4. John says:

    Yes, far more within that messy MU than meets the eye. How the govt/CMS will actually accurately measure MU is a whole other story that is fraught with opportunities for abuse and even more fool-ups and mis-management.

    The train has definitely left the tracks but I am increasingly feeling that this is a train is beginning to look a lot like that bridge to nowhere in AK. Another initiative, compliments of the US citizens.

    Have read many of your posts over on the SRSoft site. We seem to have very similar views on the market and how it may develop in the future. Yes, you are quite correct that the layering of MU on top of a software solution that has yet to deliver value to the actual end users will only complicate matters. Hopefully, we may see a move to far more modular apps within a PaaS like system, that may alleviate such complexity but again, how will HHS certify such remains to be seen and we may ultimately end up with a bureaucratic morass.

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