As the Obama administration forms its information technology policies also shaped by Congress through the American Recovery and Reinvestment Act of 2009, HHS and its Office of the National Coordinator for Health Information Technology are gathering input from various healthcare industry groups on where to take the federal IT program and, through it, the country.
At the 18th Annual Physician-Computer Connection Symposium hosted by the Association of Medical Directors of Information Systems in Ojai, Calif., Thursday, Robert Warren provided a personal overview of the direction an organization sponsored by the Institute of Medicine advised federal IT leaders to take in the use of electronic health-record systems.
Warren, a physician, is the chief medical information officer of 458-bed Texas Children's Hospital, Houston, and a member of the Institute of Medicine's Electronic Health Record User Innovation Collaborative, which met with ONC head David Blumenthal Monday in Washington.
On Thursday, a work group of the HIT Policy Committee released its second draft of recommendations for the definitions of “meaningful use” under the stimulus law.
Read more on the HIT Policy Committees "meaningful use" draft recommendations.
Under the law, physicians and hospitals must meaningfully use EHRs to receive an estimated $34 billion in federal IT subsidy payments from Medicare and Medicaid. Ultimately, the CMS will write the rules on meaningful use with input from the public. Much of that input is being sought by and funneled through the ONC.
A first draft of a proposed rule on meaningful use is expected this fall, with a final rule completed by the CMS sometime early next year. Provider compliance with the initial round of meaningful-use criteria is to begin in 2011, the first payment year under the stimulus law subsidy program. Under the law, the meaningful-use criteria are to ratchet up in difficulty, with two-year increments between ratchets being the time frame recommended by the HIT Policy Committee work group.
Warren stressed he was giving his personal observations drawn from the IOM committee meeting and was not an official spokesman for the committee, of which he has been a member since January. An official summary of the meeting is expected to be drafted and needed to be in the hands of the ONC in a few days, Warren said.
One component of meaningful use is expected to be a physician and hospital reporting on quality measures through an EHR. Congress, in a sparse outline in the statute of what it wanted to see in any meaningful-use criteria, specifically mentioned quality reporting. Currently, quality reporting takes two forms, with the much easier and more widely achieved reporting of process measures (e.g., was a smoking-cessation program offered to patients who smoke?) and the more difficult capture and reporting of outcomes (e.g., mortality rates 30-day post discharge for patients with a specific diagnosis).
“Process measures, like EHR adoption, are valuable, but Blumenthal said, ‘We're in the business of increasing quality, so utilize true outcome measures as soon as possible,' ” Warren said. But quality measures probably won't come in the first round of meaningful-use criteria in 2011, Warren said.
Blumenthal posed three questions to the IOM group, Warren said.
- What would define a provider invariant core of measures of meaningful use, including specialists, nurse practitioners, physician assistants and dentists?
- What other approaches should be considered for specialists as meaningful users?
- How and what measures could be “scaled” by percentage, increasing over time, and in particular, what should be the initial levels to set the bar for meaningful use in 2011?
“What I really, personally got the impression, listening to Dr. Blumenthal is, what he's really interested in is improving quality of care,” Warren said.
In the HIT Policy Committee work group's “matrix” of recommendations on meaningful-use criteria, over time it goes from basic EHR adoption at the start “to show that outcomes are better” in the later years, he said. And Blumenthal wants those outcomes to be measurable, although he doesn't appear to want those outcome measures that are more difficult to obtain to be forced on providers too early in the stimulus payment process.
According to Warren: “Does he want a percentage? Well, that's what he said. ONC was disappointed in us that we didn't say readmission rates were decreased by some percent and you get paid or not. But I'd be very, very shocked if there are those kinds of measures in 2011.”
Warren said the IOM subcommittee counseled that EHR certification and reporting requirements must not bias toward providers or hospitals with single-vendor EHR systems. The group also recommended multiple specific measures to use as meaningful-use criteria, such as electronic prescribing, computerized physician order entry, electronic note taking, and demonstrating that medical records could be communicated with others. But there was not a consensus among group members on these requirements, Warren said.
The group was most forceful in counseling that Blumenthal and CMS need to try and foresee and then measure the potential unintended consequences of program requirements, Warren said. He added that subcommittee member and clinical computing pioneer G. Octo Barnett memorably counseled that the mere purchase or even the implementation of an EHR doesn't necessarily mean workflow and quality of care are better. For example, Warren said, the program needs to ensure there is value in the data exchanged in health information exchange.
Other members counseled that some medical specialties have developed extensive data-mining programs to improve quality of patient care and recommended these established programs count toward meaningful use. The group also recommended that meaningful use not be limited exclusively to patient-level data, but that “facility information is also critical to care.”
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