Under the gun

A federal advisory panel sought to strike a balance between too much of a stretch and too little when it released a first draft of its so-called “meaningful use” recommendations last week.

Their work was an early attempt at setting the bar for office-based physicians and hospitals by defining the criteria they must meet to qualify for an estimated $34 billion in Medicare and Medicaid payments to subsidize the purchase of electronic health-record systems under the American Recovery and Reinvestment Act of 2009.

In a three-page preamble to the report, the group invited feedback on whether the balance it sought to strike was “overly aggressive based on the current state of technology and the demands on new provider workflows, or not challenging enough to result in significant transformation.”

Multiple healthcare industry groups plan to answer the invitation. How successful the advisory panel was in finding the proper balance depends on whom you ask. Still, a consensus of healthcare information technology users and experts said that the committee produced an imperfect but serviceable framework.

“There is good news and not so good news,” said Robert Tennant, senior policy adviser at the Medical Group Management Association. “The good news is they sort of heeded the advice of the MGMA and other providers in tiering the process. They’re going to phase it in.”

Tennant also lauded the work group for keeping things simple. “They produced a matrix that does a good job of outlining the goals and objectives and measures,” he said.

Rod Piechowski, senior associate director of policy for the American Hospital Association, along with Tennant and several others, expressed worry, however, that the work group may have set the bar too high in several places—such as an early call for adoption and use of a complex EHR subsystem called computerized physician order entry, or CPOE. If the group stands pat with that recommendation, it could risk slowing EHR adoption, several experts said.

Piechowski said that the AHA is still polling its members’ reactions, but added that figures the first draft got things headed in the right direction. “We have to see whether it’s achievable in their time frames,” Piechowski said. “I expect they’ll have plenty of input on that.”

William Bernstein, the New York-based partner and chairman of the healthcare division of the law firm Manatt, Phelps & Phillips, said, “I like the fact that this proposal is about functionality and use and wasn’t about products. I think that’s a good thing. I think technology is going to change in tremendous ways, and tying this to products would be a mistake. They were clearly trying to say this is about clinical results.”

For better or worse, it is now the starting point for what surely will be months of debate on “meaningful use” before the federal rulemaking is completed. That is expected to happen sometime early next year.

Even then, the meaning of “meaningful use” will remain fluid throughout the life of the EHR subsidy program, which is now slated to run through 2015.

The work group, following congressional guidance in the stimulus law, recommended ratcheting up the meaningful use standards over time. The CMS, which will oversee final rulemaking on meaningful use, also may have thrown a wrench into the works. A CMS official said that the agency’s interpretation of the stimulus law won’t allow physician practices or hospitals that get off to a late start in their IT programs—say, not until 2013—to qualify for subsidies using the same lower, initial meaningful use standards afforded earlier adopters with IT programs begun or already under way in 2011.

That interpretation also could have several unintended adverse effects on nationwide EHR adoption, IT experts said. “There is such an opportunity for a too-rapid, headlong rush, that will just set us back,” says William Bria, chief medical information officer for Shriners Hospitals for Children, Tampa, Fla., and chairman of the Association of Medical Directors of Information Systems.

AMDIS is one of many organizations, including the MGMA, AHA and Healthcare Information and Management Systems Society, that is preparing a written response to the draft definition. The public-comment period opened June 16 and will run just 10 days. The work group is to review the comments for possible incorporation in a second draft of its “meaningful use” definitions due for submission at the next HIT Policy Committee meeting July 16.

High stakes

EHR subsidy payments under the stimulus law could run up to $48,400 per physician over a five-year payment period and, at base, $2 million per hospital over a four-year payout program. The law makes those payments contingent upon an office-based physician practice or hospital using a “certified” EHR in a “meaningful manner.” Congress, meanwhile, only loosely defined what it was looking for in meaningful use.

For physicians, the law says meaningful use must include electronic prescribing. For both physicians and hospitals, the law says meaningful use also should include some form of information exchange to improve quality of care, and it should include the use of an EHR to submit information on clinical quality “and such other measures” as HHS selects.

Otherwise, Congress left it up to HHS to fill in some sizable blanks in the definition while also directing the agency to improve healthcare quality over time by requiring “more stringent measures of meaningful use.”

The 10-member meaningful use task force first met on May 28. After just 2½ weeks of work, it reported out its initial findings to the full HIT Policy Committee June 16. The task force called for creating three sets of increasingly more stringent standards to achieve meaningful use, each set changing after two years and targeting subsidy payment years 2011, 2013 and 2015.

The work group began with a broader list of goals than that supplied by Congress. It fashioned the bulk of its “meaningful use” definitions around outcome priorities drawn from a 2008 report by National Priorities Partnership, a consortium of organizations convened by the National Quality Forum.

The work group added privacy and data security to its list and came up with a spreadsheetlike matrix of its own five health outcomes policy priorities. In addition to privacy and security, the other four meaningful use priorities chosen by the work group were: improve quality, safety, efficiency, and reduce health disparities; engage patients and families; improve care coordination; and improve population and public health.

For each of the five it set multiple care goals, and for each of the goals it produced lists of objectives and measures for each of the three payment years.

Seeking balance

Work group Co-Chairman Paul Tang, the physician chief medical information officer for the Palo Alto (Calif.) Medical Group, said that the statutory definitions of “meaningful use” were too limited to administer. But by broadening the scope, there also was a risk of going to the other extreme and producing “hundreds of criteria” and making compliance too difficult, he said.

The years 2011, 2013 and 2015 were selected based on an assumption that a two-year change cycle was doable and because they logically coincide with break points in the subsidy payment regime, Tang said. For example, physicians who qualify get the same $18,000 initial payment under Medicare if they start in 2011 or 2012, so having the criteria stay the same for both of those years made sense, Tang said.

Kent Gale, president of Orem, Utah-based market analysis firm KLAS Enterprises, is among those who think having a CPOE requirement so early in the mix may be too much too soon. “I hate to sell American ingenuity short and say we can’t do it,” he said. “Some of the best minds can get together. Maybe we can do it, but it sure doesn’t seem from upfront it’s that doable.”

CPOE, Gale said, “is a major stretch for some organizations, a significant stretch. There are hospitals that have better funding capabilities than others. It’s fair that there is the same bar for everybody, but if you’re in a larger city, the funding and the ability to get there would be greater” than in smaller community or rural hospitals.

Lac Tran, senior vice president and chief information officer at 676-bed Rush University Medical Center in Chicago, said that none of the meaningful use criteria for any of the three time periods, including CPOE, will present a major challenge to Rush. Rush embarked in 2005 on a $60 million inpatient and outpatient clinical IT system installation that was fully implemented this March.

In Sault Ste. Marie, Mich., David Jahn, president and CEO of the 47-bed War Memorial Hospital, said that it is moving forward with an IT plan that already includes installations of a picture archiving and communication system, electronic entry of nursing notes and laboratories. A medication safety program was next, with automated pharmacy cabinets and bar-coded medication administration. Then the stimulus program came along.

“When we saw that CPOE was high up in the list, now we’re looking to get that implemented,” Jahn said. “We’re pretty sure we can get that done by 2011. In a way, we were a bit further ahead than most, but we haven’t been able to do it without help from consultants. Our IT staff isn’t large enough.”

War Memorial currently staffs about 50 beds and is the only U.S. hospital in 60 miles, Jahn said.

For all the uncertainties, Jahn said that War Memorial is better off than some. “There are a lot of facilities out there, especially the real small ones, the crucial access ones, are they in a position to make that investment upfront?”

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