The soon-to-be delivered federal funding for electronic health-record systems subsidize will launch a new era in the widespread adoption of healthcare informatics practices, but Bria reminded his audience of health IT veterans, “We're at the very beginning in so many ways of connecting these tools, these educational environments, to what we do in practice. We need to start to focus, not on the most exotic examples of information sharing, but the more simplistic ones.”
On Tuesday, the CMS released its final rule on the criteria physicians and hospitals must meet to effectively demonstrate that they are using EHR systems in a “meaningful manner” and qualify for federal reimbursement for the purchase and use of an EHR system under the American Recovery and Reinvestment Act of 2009, also known as the stimulus law.
Physician Mike Zaroukian, chief medical information officer at Michigan State University, said in a presentation on the new rule that he spent an “intimate 10 or 12 hours” reading the 800-plus page document to cram for his scheduled presentation, along with Pat Wise, vice president of health information systems at the Healthcare Information and Management Systems Society.
The new rule, like its predecessor—a proposed rule released by the CMS in December—calls for phasing in the meaningful-use criteria in three stages, with the initial set of “Stage 1” guidelines covering the first two years of the EHR subsidy program. The new rule, as did much of the day's discussion, focused on Stage 1 criteria, but Wise said even the Stage 1 criteria will be “a moving target” after the first two years of the program.
“By 2013, we could have another rule that will address the Stage 1 criteria,” Wise said.
Thus, if a provider waits until 2013 to apply for stimulus law funding for an EHR system, the Stage 1 criteria required to qualify for federal reimbursement are likely to different, and possibly more stringent, than those Stage 1 criteria in the recently released rule. But, Wise said, the new rule didn't specify what those future changes to the Stage 1 criteria might be.
HIMSS Analytics, a market research arm of the Chicago-based trade association, has developed an Electronic Medical Record Adoption Model to classify how far along providers are on a continuum of installation and use of health information technology systems. The model has eight adoption stages, zero through seven.
According to the latest HIMSS Analytics data, about 50% of U.S. hospitals are at the third level of the HIMSS adoption model, but Wise said they'll need to reach level four to qualify as meaningful users under the new CMS rule. Only about 10% of hospitals are at level four, and less than 7%, combined, are at the three higher levels of EHR adoption, according to Wise.
In most cases, the new rule relaxed requirements in comparison with the December proposed rule, according to Zaroukian, but there was at least one notable exception.
The Health IT Policy Committee, a federal advisory committee created under the stimulus law, originally recommended including a meaningful-use requirement that hospital EHR systems be able to flag providers of the existence of a patient's advanced directive. That requirement was dropped by the CMS in the December proposed rule, but added back in the newly released final rule. Now, hospitals must demonstrate that for more than half of patients age 65 or over they have an indication in the EHR of whether there is an advance directive recorded.
AMDIS member Peter Basch, commenting on the meaningful use presentation, said it was clear that CMS rule-makers took public comments on the December proposed rule “very, very seriously,” particularly those from users of EHRs already deployed who said “nobody could pass” under those more stringent criteria.
Meeting the new meaningful-use requirements will be “pretty simple for most of us,” said Basch, the medical director for ambulatory clinical systems at MedStar Health, given that most AMDIS members are at organizations that are fairly well along in EHR adoption. But Basch said, “This is a rule that had to be brought down to a certain level, not only for veterans to be able to say, ‘We can do this,' but also so beginners can say, ‘I can do this.'”
For veteran users, “let's aim higher than the floor,” Basch said. “We think we know where payment reform is going. Hospitals will fail if we don't go beyond meaningful use as a rule and go to the core of why we are in this business.”
As did Wise, Jason Hess, general manager of clinical research at KLAS Enterprises, Orem, Utah, a health IT market research firm, presented data during the symposium indicating just how far many providers have to go to get themselves qualify under even the new, more-relaxed meaningful-use guidelines.
The new rule requires hospitals (and office-based physician practices) to use computerized physician order entry systems. For both, practices and hospitals, to qualify, more than 30% of patients with at least one medication recorded must have at least one medication ordered through CPOE systems. Under the earlier proposed rule, practices would have had to run 80% of all orders through CPOE, while hospitals would have been required to have 10% of orders processed through CPOE.
But of 5,010 hospitals KLAS surveyed, just 804 (roughly 16%) have some CPOE use in 2010, according to Hess.
Several vendors of hospital EHR systems have fairly high levels of CPOE use among their customers, but many others do not, Hess said. The implication is that, despite the lowered meaningful-use requirement on CPOE, even hospitals with partial IT systems in place will join what could be the technological equivalent of an Oklahoma land rush to get fully compliant systems in place to meet payment deadlines.
“It's been modified, but it's still a pretty noticeable bar you have to get to,” Hess said. Vendor capacity to handle the customer rush “is certainly a concern,” he said, “especially if you're with one of those vendors that can't boast high CPOE adoption yet.”