Meaningful Use: All Stick and No Carrot

The initial reaction to the HIT Policy Committee's recommendations for the definition of "meaningful use" of electronic health records was shock and concern. I overheard phrases like:

• "It's more of a stimulus stick."
• "You have to walk before crawling."
• "It sets the bar so high; it forces us to game the system."
• "It doesn't show how the functionality required furthers quality goals."

Chief information officers were overwhelmed by the list of objectives for EHRs by 2011, which include

• Using computerized physician order entry systems for all order types including prescriptions in both outpatient and inpatient settings.
• Incorporating lab-test results into EHRs in both outpatient and inpatient settings.
• Generating lists of patients by specific condition to use for quality improvement initiatives, reducing disparities, and outreach in outpatient settings.
• Providing patients with an electronic copy of- or electronic access to- clinical information (including lab results, problem list, medication lists, allergies) in both outpatient and inpatient settings i.e. through a personal health record.
• Providing clinical summaries for patients for each encounter in outpatient and inpatient settings.
• Exchanging key clinical information with other care providers, such as problems, medications, allergies, test results in both outpatient and inpatient settings.
• Submitting immunization and laboratory data to public health agencies.
• Complying with HIPAA Privacy and Security Rules and state laws.

These objectives were centered around five desired health outcomes: Improving quality, safety, efficiency, and reducing health disparities; engaging patients and families; improving care coordination; improving population and public health; and ensuring privacy and security for personal health information.

Even though the policy committee was more aggressive in its first draft of recommendations than many healthcare executives expected—perhaps the committee was hoping to generate a lot of public comment—many healthcare leaders still applauded the goals of the committee.

"The healthcare industry is far behind other industries in this country. Therefore, the bar needs to be set very high in order to drive the industry to catch-up and get where we need to be," says Norm Mitry, CEO of Heritage Valley Health Systems, an integrated delivery network in southwestern Pennsylvania.

Peter Basch, MD, the medical director for ambulatory clinical systems at MedStar Health, an eight-hospital system based in Columbia, MD, agrees. "The HIT policy committee has to take a road where an incentive is an incentive," he says, explaining that it should put the goals within reach of early adopters or just outside of reach of average physicians and hospitals adopting HIT. "We don’t what to set the bar too low that the results of this massive investment by American tax payers in healthcare infrastructure goes to naught."

Still there is a real concern that the bar may be out of reach for many providers. "Hospitals will need significant clinical systems already in place to meet the proposed timeframes," says Catherine Bruno, vice president and chief information officer at Eastern Maine Healthcare Systems in Brewer, ME. "Even though these are health information technology objectives, they are really changing clinical practice," she says.

CPOE in 2011—really?
Not surprisingly, the two areas that seemed to cause the most consternation were the CPOE requirement and emphasis on PHRs listed in the 2011. Some hospital executives said that CPOE and medication administration using barcoding, which was listed under the 2013 objectives, should be flipped.

For his part, Basch says that implementing CPOE in the outpatient setting in the 2011 timeframe is a doable goal. The inpatient setting is a different story, however. "For those of us in medical field, we are a little gun shy of pushing CPOE too quickly when we haven't gotten other pieces of the loop complete—medication administration and barcoding—and done sufficient workflow analysis first to make sure there will not be unintended consequences," he says.

MedStar Health, which has been working on an accelerated timeline to have all of their physicians in the outpatient setting up on EHRs, is on target to achieve meaningful use under the proposed recommendations and timeline, Basch says. The organization decided to move on the outpatient setting first because it is "easier, far less expensive to do, and the technology was more shovel ready," says Basch. In the inpatient arena, however, MedStar had barcoding and CPOE flipped in its schedule of adoption. If CPOE stays in the 2011 timeframe, the organization may have to alter its strategy. "We will have to reconsider the impact and size of federal incentives on our existing roadmap and make a decision at the leadership level as to whether we keep to the roadmap or adjust it," says Basch.

Bruno is concerned about implementing this amount of change at all six of EMHS' hospitals under the current timeline. She says their tertiary referral hospital, Eastern Maine Medical Center, will likely be able to meet the 2011 and 2013 objectives because 93% of orders are created using CPOE and they already have most of the other functionality planned. However, the same cannot be said for their smaller hospitals, which do not have CPOE yet. The organization plans to implement CPOE at the other facilities over the next three years. But with the 2013 requirement for barcode medication administration, it will be taxing, Bruno says, because pharmacy expertise is needed for both projects.

"A significant part of CPOE is medication ordering, dose range alerts, allergy alerts, and drug interaction alerts. The barcode medication administration also requires pharmacy expertise," she says. "It will be difficult for all six of our eligible hospitals to meet the 2013 objectives."

PHR surprise
Many healthcare executives were shocked to see the emphasis on personal health records in the 2011 objectives. But Mitry was not one of them. "We are a believer that everyone should have the opportunity to access their personal health record online at anytime of the day or night," he says.

Glen Tullman, CEO of software vendor Allscripts, is also supportive of PHRs being included in the 2011 objectives. "We cannot create an electronic healthcare highway and not have onramp for patients," he says. "Right now PHRs aren’t connected and nobody wants to use it, but who wanted to be the first fax users?"

Basch, however, is not convinced that forcing providers to adopt PHR technology at this point is the right approach given the limited adoption rates. "I’m not saying that having a dimension of meaningful use that includes engaging patients and families is a mistake. I think that is correct," he says. The language should be altered to include "patient portals, PHRs, or some other means of sharing data securely with patient and families," he says.

Do you think the HIT Policy is being too aggressive including CPOE and PHRs in the 2011 goals? Do you think the timeline for other functions and objectives should be altered? These recommendations are just a first draft and you still have time weigh in. Comments are due by June 26, 2009, and should be no more than 2,000 words in length.