Nine Healthcare Executives Respond to the Meaningful Use Definition

The long-awaited definition of meaningful use is finally here. Just before the New Year, the Centers for Medicare & Medicaid Services and the Office of the National Coordinator released both the definition of "meaningful use" for electronic health records and the standards to improve the efficiency of health information technology.

Hospital and provider group organizations have already offered their criticism of the proposed regulations. Yesterday, my colleague Janice Simmons offered a good evaluation of the American Hospital Association, Medical Group Management Association, and the American Medical Association concerns.

I was curious what individual providers thought of the definition, so I asked physicians, chief information officers, and other industry leaders whether they thought the meaningful use bar was set too high or low, and what they thought was the most significant change to the HIT Policy Committee's recommendations, if any. Many executives are still delving into the 700+ page document, but here are their initial reactions.

---

The ONC and CMS have set the bar at an appropriate level. While everyone does not agree with everything they are doing, it is very clear that the health IT agenda in the United States will be driven by the ONC agenda. There is considerably more health "reform" in the HITECH legislation than is likely to come out of the current healthcare reform debate going on in Washington. This legislation will likely prove to be the biggest and most transformational quality and safety initiative ever launched in this country. A huge national experiment is about to take place, and I am looking forward to being involved in it!

John L. Haughom, MD
Senior vice president, clinical and patient safety
PeaceHealth

---

CMS and ONC have admitted they won't be ready to enforce the rules for 2011 and that answered the biggest question I had regarding how will I report and qualify for the first year. Other items that make the first year easier include relaxed quality measure reporting and the requirement to be ready for a health information exchange but not actually exchanging information. The cost calculation is somewhat low. It states that it should cost a hospital $5 million to meet the requirements, which is really low for most hospitals. The five clinical decision support rules were a surprise and need more definition. Overall, I think the document lifts a good deal of fog that blocked organizations from moving forward.

Jack Kowitt
Chief Information Officer
Parkland Hospital and Health System
Dallas

---

Overall, the criteria are thoughtful and fair. I like that we are not stretching for the stars—100% compliance for [CPOE] for instance—which indicates that the ONC is listening to sites that are live with an EHR and still having problems getting everything working perfectly. Where we might struggle is in creating accurate denominators that include paper or non-EHR processes, because these are notoriously difficult to collect. For example, the denominator for order entry or ePrescribing seems to require that you keep track of all paper orders. This was never done in the past and is not tracked in our EHR. Therefore, it is a new process and we will have to figure out who/how/when this will be done.

Some providers will think the bar is too low. But when you examine the measures, it becomes clear that the low threshold will almost be immediately exceeded by the mere implementation of the functionality. If an organization is going to all the trouble of CPOE, it is hard to envision that they would stop at 10%.

Naturally, the requirements around HIE are the most daunting. I think the ONC is doing the right thing by including them in the requirements, if for no other reason than to continue to put pressure on communities to develop functioning HIEs that will meet the criteria. I don't think HIE would occur naturally otherwise as it is quite laborious and lacks an immediate ROI to make it attractive.

Richard Vaughn, MD
Corporate Vice President Clinical Decision Support and Medical Director, Project Beacon
SSM Health Care
St. Louis, MO

---

We are extremely disappointed that CMS has decided to exclude critical access hospitals from the Medicaid (as opposed to Medicare) portion of the incentives. We are concerned that CAHs still don't have the all the information they need to understand what constitutes an "eligible EHR expense." The objectives have not significantly changed from the HIT Policy Committee's recommendations. The bar has been set much too high for small and rural facilities. The key question for all to consider is how one can set the same bar for providers at early stages of adoption and at advanced stages of adoption. The result of this single-bar strategy is that providers who already have EHRs—and therefore don't need assistance—will get the lion's share of the incentives. Disadvantaged providers at low stages of adoption who especially need the assistance will be much less likely to get help. CMS and ONC have structured the incentive program in a way that will dramatically expand the digital divide between our country's EHR haves and have-nots, large proportions of which are small and rural providers.

Louis Wenzlow
Director of Health Information Technology
Rural Wisconsin Health Cooperative

---

This is the initial analysis of "meaningful use" by the National Rural HIT Coalition's rural hospital user group. This proposed rule builds on concerns we have about how CAHs are rewarded for EHR implementation under ARRA. Although CAHs are significantly behind other general hospitals, their EHR financial incentives are significantly lower than prospective payment system hospitals. CAH incentives require that they purchase rather than lease, meaning CAHs have less flexibility than the other hospitals. In developing their ARRA compliance strategies, CAHs (unlike PPS hospitals) depend on rule makers to articulate exactly what costs are eligible. This delay and resulting uncertainty will prevent many CAHs from reaching meaningful use. CAHs are extremely dependent on the speed with which the certification process takes place, but many applications don't have certification processes in place.

These barriers mean that CAHs must rely on CMS and ONC to issue instructions that are sensitive to the realities of community hospital EHR vendor models, the numerous systems that generally fall outside of the certified EHR vendor offerings, certification organization capabilities, and how all of this impacts CAHs' costs incurred.

Terry J. Hill
Executive Director
Rural Health Resource Center
Duluth, MN

The proposed definition of "meaningful use" will result in the fulfillment of the policy priority of "improving quality, safety, efficiency and reducing health disparities." The proposed definition will also meet the five care goals of the HIT Policy Committee. The objectives in the Stage I criteria of meaningful use are reasonable and appropriate and should not represent a significant challenge for users of Certified EHRs. Southeast Texas Medical Associates is performing all of the measures of Stage I, II and III.

Even though there is a great deal of overlap in national quality measures, the Physician Quality Reporting Initiative and National Quality Forum clinical quality measure sets are too robust for a beginning effort. The extensive quality measure tracking and reporting requirements will result in many excellent groups either not participating, or not succeeding in their participation in the CMS program. A more circumscribed measurement group would be appropriate with gradual increasing of the breath of the requirement.

Caution must be used in the requirement for being able to report patient information electronically between practices, some with different EHRs and some without EHR capability. This interoperability is in development. The rules for participation in the CMS HIT incentive program must not discourage participation, but encourage it.

The promise of EHR and actually of "electronic patient management," is within our reach. The meaningful use requirement is a step in the right direction; it must proceed steadily but not so rapidly as to discourage participation.

James L. Holly, MD
CEO
Southeast Texas Medical Associates

---

The issue of whether CMS is reaching too high really depends on the situation each organization faces. It would have been nice, if the standards addressed the different situations that organizations face rather than a one approach for all. It is also noteworthy that these tight standards are being issued at a time when hospitals face major cutbacks in funding at both the state and federal levels and therefore have little available funds to implement the changes these regulations were intended to achieve. This is particularly true for rural hospitals that will have to decide if they can really take on the risk of taking out loans to pay for system implementations when there is a high risk they will still not achieve "meaningful use".

Marc Gibbs
Chief Information Officer
Crouse Hospital
Syracuse, NY

---

CMS wishes to use the same "meaningful use" definitions for both Medicare and Medicaid. However, each state must create its own administrative program (subject to approval) and can add other "meaningful use" measures. We think these two points will add challenges to reconciling both programs.

Hospitals may participate in both the Medicaid and Medicare programs if they qualify for each. In addition, those hospitals participating in both will not have to meet additional state (Medicaid) meaningful use measures if they meet Medicare's. Physicians, on the other hand, cannot participate in both, and instead would have a onetime option of switching from one program to another. At the very least, these disparities will cause confusion.

CMS did modify some of the objectives recommended by ONC's Policy Committee. Most notably, CMS rejected recording advanced directives. They also rejected the suggestion that providers report quality improvement and public reporting to patient registries.

CMS has chosen a three-stage approach: Stage I (2011-2012) emphasizing "electronically capturing health information in a coded format; using that information to track key clinical conditions and communicating that information for care coordination purposes"; Stage II (2013-2014) encouraging "the use of health IT for continuous quality improvement at the point of care and the exchange of information in the most structured format possible"; Stage III (2015) on "promoting improvements in quality, safety and efficiency, focusing on decision support for national high priority conditions, patient access to self management tools, access to comprehensive patient data and improving population health." Using this staged approach, CMS is proposing a flexible system that allows hospitals and physicians to start adopting over time, where those starting in later years would have to accelerate through the stages to catch up with earlier adopters in order to collect incentives. It's hard to know at this juncture how providers will navigate the many different potential paths to qualifying for incentives or which paths are the most efficient and effective.

Bruce Taffel, MD
Chief Medical Officer
Shared Health
Chattanooga, TN

---

Note: You can sign up to receive HealthLeaders Media IT, a free weekly e-newsletter that features news, commentary and trends about healthcare technology.