meaningful use - will the end result be meaningful?

Jodi Sperber Quality and Performance Measurement in Health Care

March 31, 2010

Meaningful Use: Will the end result be meaningful?

With the cost of health care in the United States continuously increasing, significant

efforts are being made to make systemic improvements that save on cost without

negatively impacting quality of care. Moreover, the true goal is to contain spending

while at the same time making improvements to quality. This endeavor has

numerous components to be considered, given the complexity of the American

health care system.

Over the past 10 years, health information technology has increasingly been viewed

as a vital factor in health reform efforts. To this end, the American Recovery and

Reinvestment Act (ARRA) of 2009, commonly known as the stimulus bill, included a

provision called the Health Information Technology for Economic and Clinical

Health (HITECH) Act. Provisions of this act involve a number of regulations and

programs aimed to support the improvement of health care systems and, ultimately,

help to increase the health of Americans (Blumenthal, 2010; Centers for Medicare

and Medicaid, 2006; Glaser, 2010; Halamka, 2010b).

Of primary interest within HITECH is the development and utilization of electronic

health records (EHRs) as a normative part of the American health care experience.

As a part of this effort, the federal government is interested in boosting the use of


March 31, 2010

EHRs among providers receiving payments from Medicare and Medicaid in ways

that are considered to be “meaningful.” How meaningful use gets defined is of great

significance, as new financial incentives rest upon providers and hospitals meeting

minimum standards set forth. As of this paper’s writing, no final decisions have

been issued – the initial proposed rule of meaningful use was issued in December

2009, and public comments on the proposed rule were accepted until March 15

(Department of Health & Human Services, 2009; HHS Press Office, 2009). These

comments are currently under review.

For the purposes of studying meaningful use in more detail, it is worth taking a

moment to delineate electronic medical records (EMR) and EHRs, two terms that

are often conflated. Though frequently used interchangeably they are, technically,

distinct. As defined by the recently disbanded National Alliance for Health

Information Technology (NAHIT), EMRs refer to the “electronic record of health-‐

related information on an individual that is created, gathered, managed, and

consulted by licensed clinicians and staff from a single organization who are

involved in the individual's health and care.” EHRs refer to the “aggregate electronic

record of health-‐related information on an individual that is created and gathered

cumulatively across more than one health care organization and is managed and

consulted by licensed clinicians and staff involved in the individual's health and

care” (Neal, 2008).


March 31, 2010

Therefore, while an EMR may be very useful for capturing and organizing

information within a single practice or for a single patient, an EHR can be utilized to

compare commonalities and difference across populations, making it a more robust

mechanism to spot trends, highlight outliers, and support evidence based treatment.

Using these definitions, an EHR can be viewed as an EMR with the capability of

integrating into multiple systems, making it a much more powerful tool for

measuring quality. Thus, the federal government is interested in incentivizing

practitioners who meet EHR standards aimed at improving quality for patients even

as they move around within the larger health care system.

Despite both private and public actions to date, and consensus that the use of health

information technology will likely lead to more efficient, safer, and higher-‐quality

care, the adoption of EHRs in the US has been slow. Lethargy in EHR adoption has

been a topic of discussion amongst researchers, health providers, consumers, and

policy makers for some time. At present, less than 20% of physicians currently use

an electronic records system. Such systems are generally found in larger care

settings including hospitals and large practices, while smaller practices rarely have

such systems in place (DesRoches, et al., 2008; Jha, et al., 2009; Jha, et al., 2006).

Within the federal government, IT modernization efforts are an integral part of the

Health Information Technology Framework. The US Department of Health and

Human Services listed health information technology as a priority for quality


March 31, 2010

measurement and data collection, indicating that interoperable electronic records

should be available “to patients and their doctors anytime, anywhere” (Centers for

Medicare and Medicaid, 2006).

To both ease and encourage the transition to EHRs, the proposed meaningful use

definitions and goals for EHRs are broken into three separate stages, scheduled to

be rolled out in sequence between 2011 and 2015. Each stage builds upon the

previous, with financial incentives available at each new stage. Stage 1, which

begins in 2011, focuses primarily on basic EHR capabilities, naming 25 modules for

eligible professionals (EPs) and 23 modules for eligible hospitals that must be met

to be deemed a meaningful EHR user. Stage 2 expands Stage 1 criteria in the areas

of disease management, clinical decision support, medication management, support

for patient access to their health information, transitions in care, quality

measurement and research, and bi-‐directional communication with public health

agencies. Stage 3 focuses on achieving 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 outcomes (US Department of Health and Human

Services, 2010).


March 31, 2010

Each module within the meaningful use definition contains a specific objective and

measurable goal that must be met for disbursement of the associated financial

incentive. Sample hospital objectives/measures include:

1. Objective: Use of computerized physician order entry (CPOE) for orders (any

type) directly entered by authorizing provider (for example, MD, DO, RN, PA,

NP)

Measure: CPOE is used for at least 10 percent of all orders

2. Objective: Implement drug-‐drug, drug-‐allergy, drug-‐ formulary checks

Measure: The eligible hospital has enabled this functionality

3. Objective: Maintain active medication list.

Measure: At least 80 percent of all unique patients admitted by the eligible

hospital have at least one entry (or an indication of “none” if the patient is

not currently prescribed any medication) recorded as structured data.

4. Objective: Record demographics.

Measure: At least 80 percent of all unique patients admitted to the eligible

hospital have demographics recorded as structured data

5. Objective: Generate lists of patients by specific conditions to use for quality

improvement, reduction of disparities, research, and outreach

Measure: Generate at least one report listing patients of the eligible hospital

with a specific condition.

Similar measures and objectives have been created for providers who do not work

within a hospital system (Beaudoin, 2009a, 2009b). On its face, each module

appears relatively straightforward. However, as evidenced by the lack of EHR

adoption within the US and the lively discussion that is taking place with the initial

definition released, it is clear that there is room for debate on the viability of the

current federal strategy.


March 31, 2010

One would be hard pressed to find a provider who is not interested in providing

quality (however they define the word) care. At the same time, a wide range of

studies have suggested that EHRs are an important factor of quality improvement

strategies (Chen, Garrido, Chock, Okawa, & Liang, 2009; MW Friedberg, et al., 2009;

M Friedberg, et al., 2009; Orszag, 2008). With this in mind, it is reasonable to

inquire why all health care providers have not already embraced meaningful use of

EHRs as an automatic member of the overall care approach.

Research to date, as well as comments from experts in the field, consistently

underscore that it is not the mere presence of an EHR that makes a difference, but

rather the use of the information contained as a decision support device that

improves quality (Dexheimer, Talbot, Sanders, Rosenbloom, & Aronsky, 2008; Ford,

Menachemi, Peterson, & Huerta, 2009; M Friedberg, et al., 2009; Poon, et al., 2010;

Sequist, et al., 2005). This distinction is at the heart of the challenge of universal

EHR adoption; crossing the divide between the presence of an EHR and the proactive

use of an EHR is where strategy, creativity, and technological savvy meet.

This paper does attempt to tackle the myriad facets of EHR creation and adoption; to

do so would require volumes as an entire industry is devoted to this pursuit.

Instead, focus is placed specific elements underlying the possibility of adoption and

widespread use of such tools, with an eye towards the overarching question of


March 31, 2010

whether or not EHRs will in fact impact the quality of health care in the United

States. These elements include design, interoperability, and patient access to data.

The three elements named are at the heart of moving from EHRs being viewed as

impediments to EHRs being seen as tools to positively impact quality of care for all

patients, regardless of geographic location or health status. Justification for slow

adoption rates are complex, involving cost, variability in EHR platforms, culture

within each practice, a lack of incentives, and a lack of resources to install, train, and

maintain such systems.

While the current meaningful use standards and incentives are limited to Medicare

and Medicaid patients, it is important to remember that providers for these patients

are situated within the larger context of the American health care system, which at

its core is based in a competitive business model. The business of EHRs is a part of

this, with a number of individual vendors vying to gain market share. This has only

increased with the possibility of financial incentives from the federal government.

For evidence of this, one needs to look no further than the most recent Healthcare

Information and Management Systems Society (HIMSS) conference that took place

in early March of this year. Per feedback from attendees, there was a surge in

attendance from EMR and EHR vendors, and everyone was talking about meaningful

use (Dillon, 2010; Halamka, 2010a).


March 31, 2010

At present, there is no industry standard on core elements that should be included

within an EMR, and many EHR providers are striving to set the standard (or have

enough market share that they are by default the standard). This means there is a

long list of EHR providers to choose from – a quick web search resulted in over 200

distinct vendors, each offering variations on the general idea of an EHR ("EMR and

EHR Matrix," 2010; John, 2006). For smaller offices, most of who do not have IT staff

knowledgeable about EHRs, the task can seem overwhelming to the point of being

impossible.

It is here that design and interoperability must be carefully considered, as they play

a critical role in the ability to effectively use an EHR. With each company striving to

stand out from the pack, there is a lack of uniformity within current systems. Each

has a unique user interface, meaning there is a learning curve for providers

switching from one vendor to another. Even within vendors, there is variability of

design, as each individual implementation is generally customized based on the

purchaser’s needs. Thus, if a provider has worked with a particular vendor’s system

at Hospital A, there is no guarantee that the same vendor’s EHR will look similar if

the provider takes on a new job at Hospital B. This can be frustrating, and a

deterrent for adoption of the technology.

A frequent concern voiced by physicians is that EHRs are designed to suit the needs

of administrators, rather than reflecting the flow of clinical interactions (Loomis,


March 31, 2010

Ries, Saywell, & Thakker, 2002; McDonald, 1997; Smith & Zastrow, 1994). As a

result, the user interface is not well suited for efficient entry from a clinical

perspective. Similar to the learning curve encountered when learning a new system,

the inability to enter data in an intuitive fashion is seen largely as a deterrent and

inefficient use of time, as opposed to being helpful for patient care.

Customization, while reasonable from an individual practice perspective, also leads

to interoperability challenges, as there is generally more focus on tailoring the

interface than forethought on core elements that should be carried through to other

practices. What is often neglected along the way is attention put towards having a

patient’s medical record live anywhere but the place in which it originates. Thus,

using the same Hospital A/Hospital B/same vendor scenario above, it is possible

that a patient can change providers and not have their record travel electronically

with them, even if both systems utilize an EHR from the same company.

Interoperability is not only of concern for providers, but patients as well. Patients

are increasingly interested in the ability to access their own medical information on

an on demand basis. Personal health records (PHRs) are patient-‐facing interfaces

designed to handle this task, and, like EHRs, come in many different forms. Ideally

PHRs are a subset of EHR data, with the capability of being augmented by the

patient and/or multiple data sources to create a more complete health picture.

Large organizations such as Kaiser Permanente have invested heavily in this type of


March 31, 2010

tool, most recently partnering with Microsoft to transfer data between internal

systems and Microsoft’s HealthVault, and online data platform (Press Release,

2008a, 2008b). Kaiser is unique, however, in having the resources and willingness

to adopt this type of approach.

The ability of patients to access their information from EHRs as an element of

improving quality of care was a topic covered within the public comments on the

meaningful use proposed definition. Notably, Google, Microsoft, and Dossia (a

consortium of Fortune 500 companies striving to aggregate health information into

a web-‐based platform) submitted joint testimony highlighting the significance of

including PHRs in meaningful use criteria. In their joint comments, they requested

that HHS “clarify that patients have the right to direct EPs and eligible hospitals to

electronically transmit such information to a destination of their choice and…

require that at least 80% of all unique patients seen by the EP are provided timely

electronic access to their health information” (Dossia, Google, & Microsoft, 2010).

Even with the aforementioned concerns in mind, there is a strong case to be made

for the federal government’s efforts to define meaningful use and promote adoption

of EHRs via the use of financial incentives. The staged approach was established

intentionally to allow time for debate and development, and incentives are not tied

to quality improvement until the final stage. Still, without establishing core


March 31, 2010

principles early on, it is possible that the efforts will fail to meet the ultimate goal of

quality improvement.

One of the central principles that should be established is the creation of a core set

of data points should be determined for all EHRs, and structured such that these

data elements can be transferred between all EHRs eligible for meaningful use

certification. These data elements could include aspects such as demographics,

allergies, immunizations, and medication lists.

A second, and more controversial, consideration is to allow EHRs utilizing the use of

an open application programming interface (Open API) to qualify for certification

(only EHRs certified by the Certification Commission for Health Information

Technology (CCHIT) are eligible for financial incentives as proposed in the stimulus

package). An Open API entails a set of technologies that enable websites to interact

with one another in a more seamless fashion. This generally presumes web-‐based

applications (in contrast to software installed on a local hard drive), although that is

not required. The benefit of such systems is that it allows for a vast and vibrant

ecosystem of smaller programs to develop and work together to deliver a more

robust overall product. For example, a design specialist could work on a malleable

user interface, while an engineer can implement the back end data elements into

software. It would not be necessary that these two workers be with the same

company. Alternatively, a small company could create a solution to store and track


March 31, 2010

data related to a unique set of conditions, which could then be read within the

patient’s EHR.

At present this approach is highly uncommon, and there is some debate over

whether this is due simply to a lack of lobbying power (Blankenhorn, 2009; Douglas,

2009). However, with cloud computing becoming more prevalent, and with an

increasing shift towards democratizing application development (see the success of

Firefox’s add-‐ons as a challenger to Microsoft Internet Explorer for an example of

this approach) it is likely that certification will have to address the possibility of

Open API in the future.

Overall, the development of meaningful use standards is a step in the right direction.

EHRs, when utilized in a systematic and purposeful fashion, can have a tremendous

impact on quality measures. At present the possibilities are tempered by consensus

on how to best define meaningful use, a lack of core standards across all EHRs, and a

general hesitancy within the provider community. By coupling a transparent and

open process with financial incentives, however, large-‐scale change should be seen

over the next five years. Tremendous opportunity for quality improvement exists if

people can remain patient and persistent throughout the process.


March 31, 2010

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meaningful use - will the end result be meaningful?

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