One of the longer and more interesting discussions during Wednesday's meeting of the meaningful-use work group of the Health IT Policy Committee centered on how to handle advance directives in the digital age.
Dancing around directives
Work group members, at the urging of Tony Trenkle, director of CMS’ office of e-health standards and services, tiptoed around what to do about advance directives in future meaningful-use criteria.
All of that sensitivity, it seems, comes in the wake of the "death panel" lunacy that surrounded the healthcare reform debate last fall. As you may recall, that debate centered on a legislative initiative to add end-of-life counseling, including helping patients draft end-of-life directives, to the Medicare reimbursement list.
A small aside is worth introducing here. A few months ago, I had a conversation with then-outgoing CCHIT Chairman Mark Leavitt, now retired. Many healthcare IT veterans remember him as a pioneering developer in the mid-1980s of a notable early EHR called Logician. Leavitt, a physician, said he designed his EHR to handle patient directives because alerting physicians to the existence of an advance directive and providing access to it were important to good, patient-focused care.
Early discussions by the meaningful-use work group members last year followed Leavitt’s logic. That is, they recommended that EHRs deal with advance directives, too.
But that recommendation was dropped in the proposed rule on meaningful use issued by the CMS in January 2010. It was only resurrected, in ghostly form, in the final rule published by CMS in July.
That final rule regarding patient directives says that more than 50% of all patients age 65 and older who have been admitted as an inpatient must have an indication whether an advance directive for them has been recorded.
In other words, in fiscal 2013 and 2014, to be certified as worthy of a federal incentive payment, an EHR doesn’t have to be able to electronically store an advance directive. It only has to be capable of flagging a caregiver that a directive exists, somewhere, in some form. And even that pale shadow of a rule wasn’t made mandatory, being listed as a "menu" item that hospitals could meet or ignore as they see fit.
Trenkle advised the work group members Wednesday that it "would be helpful" if they would pause to "look into it to see what’s feasible," noting there has been some interest in Congress about advance directives and there were "some issues around state statutes as well."
Paul Tang, a physician and chair of the meaningful-use work group and vice chairman of the Health IT Policy Committee, acquiesced but said the issue will be revisited.
"The goal is that we discuss it with patients, and if they have one, it will be recorded," Tang said, "but there is no forcing" anyone to prepare an end-of-life directive. "We’ll do further work on this, but the spirit is we make patient wishes actionable."
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