Many reviewers of a draft set of recommendations on the so-called “meaningful use” standards for the government's electronic health-record subsidy program say that providers are being asked to do too much too soon to qualify for billions of dollars in federal health information technology payments.
In a sample of the responses to an HHS call for public comments on an initial release of recommendations, virtually all respondents began by lauding the broader IT goals of the government and the general approach of the work group of the HIT Policy Committee.
The work group made public its draft definitions of meaningful use on June 16. HHS then opened a 10-day comment period. Virtually all who responded followed up their praise with criticism or sometimes lengthy suggested modifications to the work group's proposed "meaningful use" definitions.
“We applaud the overall framing of the vision for meaningful use in the context of the National Priorities Partnership, convened by the National Quality Form,” and the “significant work” that went into it, according to the Consumer Partnership for e-Health. The coalition is composed of 17 organizations, including the AARP, Consumers Union, the National Partnership for Women & Families and the Service Employees International Union.
The coalition weighed in with a five-page response, plus a four-page appendix despite the government's request to limit comments to 2,000 words. As one might expect, the coalition suggested a number of consumer-health oriented changes to the meaningful-use criteria, including that each of the work group requirements have a “patient engagement” goal, “in addition to the establishment of a separate patient-engagement goal.”
The Federation of American Hospitals had a more pithy, three-page response. Samantha Burch, the FAH's director of healthcare policy and research, said the work group, “really did right” when it “acknowledged there needs to be a staged approach to implementing meaningful use and there is a balance that needs to be reached” between the status quo and “moving this along.”
“That's a very delicate balance, and we really appreciate that the work group did recognize that,” Burch said. But the FAH—among several other reviewers—also criticized the work group for recommending early use of computerized physician order entry, or CPOE, a subsystem of an EHR that has extremely low implementation rates, particularly in hospitals. It also has low rates of full physician use even in hospitals with fairly advanced IT programs, including some that have electronic order-entry systems.
The American Hospital Association expressed “serious concerns” about the first draft definition, saying that the work group's targets, based on the National Priorities Partnership goals, were “laudable, but not achievable in the time frames proposed.” The work group's initial schedule for adoption of EHR functionality “is overly aggressive and unrealistic” for most hospitals, the AHA said, noting that a study published in the New England Journal of Medicine found that just 1.5% of hospitals use a “comprehensive EHR” while between 8% and 12% of hospitals, depending on the definition, have even a basic EHR.
The American Medical Association joined 81 medical specialty associations and state medical societies in commenting in a letter to David Blumenthal, head of the Office of the National Coordinator for Health Information Technology at HHS. Blumenthal chairs the HIT Policy Committee.
“In general, we support the committee's objectives and vision as outlined in the proposed matrix released by your office,” the AMA-led coalition said. Yet it said the work group's timeline “is too aggressive given that we continue to lack the necessary infrastructure, standards and systems.”
The work group's report was the first official stab at further defining "meaningful use" beyond those expressed requirements in the law. The work group is reviewing the yield of responses from the public-comment period that closed June 26. It is expected to present a second-round of recommendations to Blumenthal at the next HIT Policy Committee meeting July 16. Ultimately, the CMS is tasked with drafting a proposed final rule on meaningful use. That's due by fall. After public comments to the proposed rule, the CMS is expected to publish an interim final rule by early next year, according to the CMS.
The work group, citing the profound influence of CPOE as a key quality improvement and patient-safety tool, called for its installation and use to be a meaningful-use standard at the start of the program in 2011.
The AHA, however, noted that some hospitals have spent “millions of dollars to achieve relatively advanced EHR systems,” but have yet to roll out CPOE.
“Because successful CPOE implementation depends on other EHR components, requires significant cultural changes and entails significant costs, CPOE should not be required until 2015 or beyond,” the AHA said, adding a warning that “rushing to adopt could compromise patient safety and the success of this effort.”
The FAH said that it, too, wanted the CPOE requirement pushed back, at least to 2013.
The Association of Medical Directors of Information Systems, whose 2,000 physician members typically champion IT programs at their practices and hospitals, said in its comments that AMDIS members “have been waiting and hoping for the advent of meaningful use for a long time.”
But AMDIS warned that there needs to be a “crawl-walk-jog-run” progression to EHR adoption. “These cycles cannot be skipped or condensed … without risking failure to ‘go the distance' in the marathon that is HIT-powered healthcare transformation,” the association said.
Thus the group also recommended any CPOE requirement should be deferred until 2013 “or beyond,” warning CPOE implementations are “fraught with potential unintended negative consequences if done too quickly or incorrectly.”
“Even in the hands of our most experienced members working in organizations with EHR systems that are already up and running successfully, implementing robust CPOE functionality is generally a challenging, multiyear undertaking that requires careful planning and execution,” AMDIS said.
AMDIS President William Bria said currently CPOE is “the dominant activity of our membership.” Bria, the chief medical information officer at the Shriners Hospitals for Children system, based in Tampa, Fla., said that he appreciates the work group's targeting of CPOE, agreeing that it is important to improving quality of care. Still, Bria said, “Everybody would like to have a beach body, but you've got to go through all of the strain and sweating and exercising and cutting out a crazy diet it takes to get there.”
In addition, experience has shown that the clinical leaders, not the “geek” doctors, at a hospital or practice, catalyze IT adoption, Bria said. That's particularly true for something as disruptive to a physician's workflow as CPOE. Bringing those clinical leaders around to the new technology not only takes time, but also the time required differs by location, he said.
“The idea of saying, ‘Whatever the size, in two years, you have to get it done,' that's a bad idea,” Bria said. “We're so strongly in favor of the directions this meaningful-use discussion is all about, but we're also so mindful, based on our experience, that we know you have to allow the proper time.”
The American Health Information Management Association also worried about the timeline, particularly over what is included in the initial 2011 measures. It also called for more specificity in determining what quality reporting measures will be needed with “precise data element level definitions and reporting guidelines.”
“We just want to ensure there is a consistency in the approach to the use and requirement of measures,” said Allison Viola, director of federal relations for AHIMA. “As variability increases, the administrative burden for organizations that have to report on these measures increases as well.”
AHIMA also asked for more specificity on meaningful-use requirements for CPOE by referencing the certification criteria for CPOE functions in EHRs developed by the Certification Commission for Healthcare Information Technology and standards for clinical-care summaries specified in the Clinical Care Document standard.
“We're encouraging them to evaluate what's out there and these are just examples of organizations that have already done the good work and to leverage that as much as possible,” Viola said.
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