Monday, April 13, 2009

What is Meaningful Use?

The definition of "Meaningful Use" in ARRA is one of the most critical decision points of the new administration's healthcare IT efforts. That definition will influence the types of products that will be implemented in clinician offices and the types of standards used for healthcare exchange to qualify for stimulus dollars.

For example, if meaningful use is defined as e-prescribing, then standalone products such as Dr. First's Rcopia could be used as part of a clinician's office compliance in lieu of a complete EHR.

If meaningful use is defined as the basics of ordering/viewing labs, then products like 4medica could constitute meaningful use.

If meaningful use requires sophisticated quality measurement, decision support, and workflow redesign to enhance efficiency, then a CCHIT certified comprehensive EHR may be required.

My prediction of meaningful use is that it will focus on quality and efficiency. It will require electronic exchange of quality measures including process and outcome metrics. It will require coordination of care through the transmission of clinical summaries. It will require decision support driven medication management with comprehensive eRx implementation (eligibility, formulary, history, drug/drug interaction, routing, refills).

Each year, the definition of meaningful use will be expanded, setting the bar higher and requiring more features and more data exchange.

Thus, in the short term, meaningful use may be a combination of products or an EHR lite. However, over the longer term, a comprehensive EHR will be the best foundation for meaningful use.

The definition of "certified" is also important. Today, CCHIT includes those criteria that make an EHR capable of supporting an optimal set of functionality. If certification is redefined as a baseline set of functionality, then more basic EHR lites may meet the definition of "certified". If certification is based on the criteria as written today and the likely evolving criteria for usability and interoperability, then a comprehensive EHR will be the best foundation.

There are many stakeholders on both sides of this discussion. Small clinician offices with few resources want stand alone e-prescribing and lightweight EHRs to get them started on e-health. Hospitals, larger practices, population health experts, and researchers favor a more comprehensive EHR.

As background, here's the HIMSS strawman proposal for meaningful use.

The next few months will settle this question once and for all. If you have an opinion about meaningful use, I expect the first recommendations to come from the new HIT Policy Committee and possibly NCVHS, an existing FACA advising HHS. Participation in any call for public comment will be the best opportunity to contribute your opinion.

11 comments:

Evan Steele, CEO SRSsoft said...

This is an insightful blog posting!

In the posting, you mention: "There are many stakeholders on both sides of this discussion. Small clinician offices with few resources want stand alone e-prescribing and lightweight EHRs to get them started on e-health. Hospitals, larger practices, population health experts, and researchers favor a more comprehensive EHR."

The smaller practices to which you refer that don't want a comprehensive ( i.e., CCHIT-certified EHR) make up the lion's share of all ambulatory physicians in the US (75% of ambulatory physicians practice in groups with less than <10 providers). I'd add to the list of those not wanting comprehensive EHR the very large, high-performance, high-volume group practices, like orthopaedics and ophthalmology, where a comprehensive EHR also is not a fit.

Will the voice of the large majority of ambulatory physicians be heard when the meaningful use requirements are created?

PeterNGilbert said...

I can never remember whether the "straw man" is the one without a brain :-)

Regarding the Hospital document: On line 56 and 57 it says

"Clinical documentation by nurses and other clinicians such as pharmacists, but optional for physicians"

Why optional for physicians?

Also, on lines 62 and 63 it says:

"Note that this requires no actual operational, external exchange of health information with another entity."

What's the point? How can you measure "an active process" without actual exchange?

Dr. Joe Kim said...

Isn't it great that such important documents are written with such vague language as "meaningful use?" It must have been written by an attorney!

Arthur said...

By leaving "meaningful use" purposefully vague, this was not tied-up in Congress for months or years. This, in theory, allows more of the impacted stakeholders to have a voice. This has been a frequent technique used in Legislation these days.

Kate said...

The question of meaningful use is key to the success of the ARRA funding. Without a clear concept, the money could be wasted on projects with limited value.

Many ideas are being discussed, such as interoperability, patient outcomes, e-prescribing, and PHR. Those of us who have actually implemented EHR in ambulatory care know that these are goals, not groundwork. You cannot achieve Meaningful Use if you don’t have a decently-implemented EHR.

Most physicians don’t have EHRs, so the ARRA funds should be spent on implementation groundwork, recognizing that long-term goals will be achieved as a result of successful implementation.

If funds are spent on implementation groundwork, what would that actually entail? I propose a three-step approach to implementation. In the first level, Basic EHR Adoption, certain criteria apply. For example, there has to be a stable technical environment that allows end users total accessibility to the application. Also, certain health information must be entered into the EHR as discrete data, such as vital signs, allergies, and Problem List. This approach will enable data-sharing down the road, and also enables certain functionality to be achieved, such as drug/allergy alerts.

The second level is Integrated EHR System, which some ambulatory groups have achieved. They should be rewarded for achieving that level. The rest should be supported over the next two years as they attempt to reach Level One.

Contact me if you would like to see a presentation with the full Three-Step Approach.

Kate Galambos, RN, MSN, CPHIMS
Director if IT Clinical Operations
New England Home Care
kategalambos@gmail.com

Tim said...

Perhaps the real intent of using the term "meaningful use" was to be purposefully 'flexible'. It bothers me that there is a compulsion to have to define how a provider will use technology that, heretofore, has been so dismally adopted. The last thing we want is for the government to tell us what technology is 'best for us'. This paternalistic approach, however well intended, actually inhibits innovation and presumes that all practices and providers are run the same way. Clearly, even factoring in for 'best practices', this is not indicative of reality.

I believe the definition of 'meaningful use' needs to be defined by the user -- and no one else. Incentives should be structured to encourage 'use'. Providers will not use the technology unless it's meaningful to them.

Certainly, I agree that there are some recommendations that should be made along with some requirements (i.e. interoperable, secure) but at the end of the day, the decision about what is 'meaningful' or not should lie with the one who needs to deliver better care at lower cost -- because that is what we all ultimately want as an outcome.

Tim Elwell
VP, Misys Open Source Solutions

Steve Daviss said...

"I believe the definition of 'meaningful use' needs to be defined by the user -- and no one else."

I agree with what Tim Elwell said, but would extend this to the ultimate end-user: the patient. The litmus test for "meaningful use" should be "Does the use of this particular EHR benefit the care of the patient, regardless of where they receive their care."This speaks to interoperability and to usability. Is it "meaningful" to have a hospital EHR where the patient's PCP cannot easily, quickly, and securely access the info with the patient lying on the exam table? If an EHR falls in the forest and noone is there, does it make a meaningful sound?

Eddy said...

How can exchange of quality data be a requirement? I have looked at the CMS indicator requirements for reporting. They are not standardized. The forms change constantly. New indicators are being added continually. Additionally, each state may have their own requirements. A more reasonable requirement is requiring some basic functionality for managing chronic disease patients such as diabetes, heart failure, etc...

Football Matches said...

Many ideas are being discussed, such as interoperability, patient outcomes, e-prescribing, and PHR. Those of us who have actually implemented EHR in ambulatory care know that these are goals, not groundwork. You cannot achieve Meaningful Use if you don’t have a decently-implemented EHR.

Football Matches said...

Many ideas are being discussed, such as interoperability, patient outcomes, e-prescribing, and PHR. Those of us who have actually implemented EHR in ambulatory care know that these are goals, not groundwork. You cannot achieve Meaningful Use if you don’t have a decently-implemented EHR.

Recep Deniz MD

DoktorTR.Net

NCG Medical said...

Thus, in the short term, meaningful use may be a combination of products or an EHR lite. However, over the longer term, a comprehensive EHR will be the best foundation for meaningful use.

It's true that companies may assimilate into using lite, but a lot further down the road full EHR technologies will be the only ones suited for use.