Meaningful Use and Health Care Reform

Since my last commentary on "meaningful use" of an electronic health record (EHR) on June 22, 2009, much progress has been made in elaborating relevant definitions as well as specific metrics for evaluation and measurement. Progress has also been made in developing and applying certification criteria for EHR software products available on the market. Chris Thorman of Software Advice has published a very useful article, "Updates on Meaningful Use, Certified EHR Technology and the Stimulus Bill", to help physicians and hospitals evaluate their software needs and qualify for EHR incentive payments under the HITECH Act. An earlier article, "Don't wait for the Government to Start Your EHR Implementation," provides important background information on EHR return on investment (ROI).

The following resources contribute to my updated commentary on "meaningful use":

Proposed Rule: Medicare and Medicaid Programs: Electronic Health Record Incentive Program – CMS-2009-0117-0002- Posted 01-13-10

National Committee on Vital and Health Statistics
Observations on “Meaningful Use” of Health Information Technology
June 1, 2009

Adler-Milstein, J., Landefeld, J., Jha, A. Characteristics Associated with Regional Health Information Organization Viability, Journal of the American Medical Informatics Association, 2010, 17(1), 61-65.

Sweeney, L. The Medical Billing Framework as the Backbone of the National Health Information Infrastructure. Carnegie Mellon University, AdvanceHIT Project. Working Paper 1001. October 2009. PDF

Wright, A. Soran, C., Jenter, A., et al., Physician Attitudes Toward Health Information Exchange: Results of a Statewide Survey, Journal of the American Medical Informatics Association, 2010, 17(1), 66-70.

The Proposed Rule on the CMS Electronic Health Record Incentive Program, published on January 13 in the Federal Register, builds on previous consultations and hearings concerning definition and measurement of "meaningful use" of EHRs. "This proposed rule would implement the provisions of the American Recovery and Reinvestment Act of 2009 (ARRA) (Pub. L. 111-5) that provide incentive payments to eligible professionals (EPs) and eligible hospitals participating in Medicare and Medicaid programs that adopt and meaningfully use certified electronic health record (EHR) technology." (Page 1844, Federal Register, Vol. 75, No. 8) This comment focuses on the context of the U.S. health care system as well as the definitions of "meaningful use" and software certification.

On December 30, 2009, CMS proposed a definition of meaningful use of EHR technology. In summary this definition considers three phases of EHR adoption and meaningful use. In Stage I (2011): "... criteria for meaningful use focus on electronically capturing health information in a coded format, using that information to track key clinical conditions, communicating that information for care coordination purposes, and initiating the reporting of clinical quality measures and public health information." Definitions to be applied for stages 2 and 3 remain to be finalized in time for 2013 and 2015 incentive payment years, as do corresponding dimensions of EHR certification. (In the proposed rule published on January 13, CMS refers to ONC definitions of qualified and certified EHR technology.)

Discussion of the EHR reporting period for determination of ARRA incentive payments (page 1849) reveals concern for a tradeoff between "robust verification and and time available to achieve compliance." To resolve this tradeoff, the EHR reporting period in the first incentive payment year is defined as any continuous 90 day period, while subsequently the reporting period should be extended over the entire payment year for more robust measurement of compliance rates. This provision recognizes neither the dynamic and nonlinear character of this complex process nor the critical importance of the initial determination of meaningful use. It might be more reasonable to establish a process of continuous monitoring, for example over a period of the previous 3 to 6 months of EHR use. Measurement of health information exchange (HIE) would further require identification of the organizational configuration of associated RHIOs or the Nationwide Health Information Network.

The policy priorities for meaningful use presented in the proposed rule are generally consistent with the recommendations of the HIT Policy Committee: 1- To improve quality, safety, efficiency and to reduce health dispartities; 2- To engage patients and families in their health care; 3- To improve care coordination; 4- To improve population and public health; and 5- to ensure adequate privacy and security protections for personal health information. Stage 1 criteria for meaningful use include a set of objectives for each policy priority, along with the requirement that all objectives be satisfied for provider qualification. This requirement may be too rigid to accommodate the increasing diversity of health care providers in the U.S.. For example, physician and emerging mid-level provider organizations may satisfy different objectives.

(Commentary to be continued...)