HITECH ?Meaningful Use? More About Improving Patient Care Than Tech Itself

Dr. David Blumenthal, the national health IT coordinator, is responsible for doling out government grants to reimburse health care organizations that implement electronic records technology. According to the HITECH section of the American Recovery and Reinvestment Act, nearly $22 billion in federal funds has been set aside to “advance the use of health information technology.” A significant portion of that amount will take the form of grants to those health care organizations that can demonstrate “meaningful use” of such IT.

However, what exactly “meaningful use” will entail has been unclear. HHS is expected to release a definition in December, InformationWeek blogger Mitch Wagner says. But those who attended the Medical Informatics Association’s symposium got a “heads up” from Blumenthal on what that definition will focus on.

FierceEMR’s Neil Versel quotes Blumenthal this way:

The meaningful use framework will be about the goals of care, not the technology.

It’s a matter of using technology to improve patient care, not just installing the technology to say you have it. Versel speculates that the goal is to make electronic recordkeeping a best practice, the EMR system a standard medical tool, just as stethoscopes and examination tables are standard now.

Take, for instance, my own experience. I visited the local immediate care center over the weekend when I got tired of a wrenched neck muscle making my life miserable.I filled out the initial paperwork, listed my maintenance prescriptions, gave them the name of my primary care physician, the date of my last visit to her office, insurance information and all the rest. When they called me back, I gave my primary doctor’s name and listed all my meds and my medication allergies (again) for the nurse who took my temperature and blood pressure.

Then, guess what? The doctor came in, looked at my chart, asked again who my primary care physician was and what kinds of anti-inflammatory and muscle spasm medications had worked for me in the past, which ones irritated my stomach and which ones didn’t. After a little over an hour, I was out of there, prescriptions in hand, confident that the pain in my neck was about to go away.

All in all, it was a good experience — especially considering I would have waited at least twice that long if I had gone to the emergency room. But, I was reminded how helpful health IT will be. If the immediate care center and my primary care office had EMR systems that allowed easy sharing of patient information — with my consent, of course — then my visit would have been even quicker. I wouldn’t have had to go through the litany of information three times, and the doctor who treated me would have had my medication history at her fingertips, allowing her to make better informed decisions.

Blumenthal: Meaningful use must result in quality improvement, more time at bedside, less duplication

HHS’ definition of meaningful use will include an organization’s ability to use health IT to improve quality and “inform clinical decisions at the point of care,” David Blumenthal, national coordinator for health information technology, wrote in an Oct. 1 letter to the industry.

CMS is expected to publish its formal definition of meaningful use by the end of the year. Expect it to require providers to use HIT to “reduce the amount of time spent on duplicative paperwork” so they can spend more time with patients, Blumenthal wrote.

“The concept of meaningful use is simple and inspiring, but we recognize that it becomes significantly more complex at a policy and regulatory level,” he added. “As a result, we expect that any formal definition of ‘meaningful use’ must include specific activities healthcare providers need to undertake to qualify for incentives from the federal government.”

EMR likely to boom throughout 2013

We’re in an unprecedented boom in health IT, thanks mostly to growth in the EMR/EHR sector.

A new report from Scientia Advisors says health IT is the fastest-growing segment of what the Cambridge, Mass., management advisory company calls a $1 trillion global healthcare products marketplace. Health IT currently is growing at an 11 percent annual rate, and solid growth should continue at least through 2013, which would be the third year of the federal EMR stimulus program here in the States, the Scientia report forecasts. In that time frame, health IT will increase its market share by a quarter, to 5 percent of global healthcare products sales from the current 4 percent.

In the U.S., according to Scientia, the bulk of the spending will come from inpatient and outpatient EMRs, thanks to the American Recovery and Reinvestment Act. “Clinical decision support systems (CDSS) will likely have a profound impact on clinical diagnostics and therapeutics,” the report says, according to InformationWeek. Some of the growth likely will be at the expense of specialty and departmental systems, however.

Established EMR vendors should benefit most from the increased spending. “Leading players with large installed bases, proven products, and streamlined routes to meaningful use of EHRs are likely to gain share,” Scientia says. However, the research firm says “disruptive innovations” like open-source software and new applications of software-as-a-service could drive down prices, as might new competition from emerging markets in Asia and elsewhere.

EMRs, PHRs, HIE necessary to support patient-centered medical home

Without EMRs, PHRs and health information exchange, the patient-centered medical home may not be bound to fail, but it certainly is difficult to establish and maintain. “IT is really the key to supporting the doctor/patient relationship and making it more efficient, safer and more effective,” Dr. Paul Grundy, president of the Patient-Centered Primary Care Collaborative, tells Health Data Management. The Washington-based organization advocates the medical home, under which a primary-care physician manages and coordinates care on behalf of patients, with an eye toward prevention and management of chronic diseases.

It may be a challenge to implement the medical-home model under current reimbursement systems, but until payers start rewarding physicians for keeping patients healthy, IT may be the best avenue. EMRs with clinical decision support, PHRs that help patients monitor their own conditions and health information exchange to support care coordination all can help establish a team approach to care and treatment, HDM reports.

“This is simply about restructuring the way healthcare is delivered to catch the efficiency of technology,” adds Grundy, who also is director of heathcare transformation at IBM.

Hospitals and EMRs: Stimulating a connection

Changes in Stark laws allow hospitals to offer EMR-implementation subsidies to physicians. Physicians can also tap into federal stimulus money for EMRs. How will the two funding options converge?

By Pamela Lewis Dolan, amednews staff.

Availability of government stimulus money, combined with hospitals being allowed to finance portions of physicians’ electronic medical record systems, could make EMR adoption a veritable bargain. Or the stimulus money could make hospital systems less eager to help pay for your EMR, figuring that government funds will instead.

Either way, the possibility of combining two avenues of EMR funding has added a twist to the economic picture for physicians deciding what, when and whether to buy.

Doctors can get a maximum of $44,000 in funds from the federal economic stimulus package for adopting a certified EMR system that meets the government’s “meaningful use” standards. How much physicians get in stimulus funds will be based on the percentage of their practice that is made up of Medicare or Medicaid patients. Hospitals can get their own share of stimulus funds, but the amount depends on how they’re connected with physicians.

“There’s a lot of activity going on,” said Amy Leopard, health care attorney and partner at Walter & Haverfield in Cleveland. “Incentive payments have spurred that dialogue.”

Some hospital systems are making their offers to physicians more generous; others are figuring out the role subsidies should play in light of the stimulus money.

“I have seen a variety of directions, and even within different hospitals, they are providing a menu of resources for physicians,” Leopard said.

More help for doctors

North Shore-Long Island [N.Y.] Jewish Health System started talking about helping affiliated physicians pay for their EMR systems about nine months before the American Recovery and Reinvestment Act, or federal stimulus package, passed in February.

After the bill was enacted, North Shore continued its plan to offer subsidies of up to $40,000 per physician. That, combined with stimulus funds, could give affiliated practices up to $84,000 per doctor for EMRs.

“To support the highest quality of care that comes with electronic medical records, an offering to make it easier was warranted,” said Michael Oppenheim, MD, medical information officer for North Shore.

The health system is offering two tiers of subsidies. Any affiliated physician can get up to 60% of the purchase price of an EMR. Physicians who agree to share data can get up to 85% of the purchase price — the highest percentage allowed under Stark laws. Neither offer can exceed $40,000.

Dr. Oppenheim said North Shore already had started setting up a regional health information exchange that would help the hospital system qualify for the data-exchange incentive offered by the stimulus act.

Hospitals “have to show the ability to share data to improve quality of care. So if the hospital doesn’t have anyone to share with, they will have a hard time demonstrating that,” said Amy Fehn, a health care attorney for Wachler and Associates in Royal Oak, Mich.

But some hospitals, especially those in rural areas, may find their only chance to qualify for these incentives come from offering subsidies so physicians get EMRs, expert say.

Stimulus money is spread over five years and won’t arrive until after an EMR system is purchased, Fehn said. So physicians still should talk to hospitals about help with upfront costs.

“What I’ve heard … is that the small amount [of stimulus money] won’t make a huge dent in the cost of an EMR, so I would expect that [physicians] will still be looking toward the hospitals for some assistance,” Fehn said.

To qualify for stimulus money, physicians must adopt systems that are interoperable with other hospital systems, Fehn said. “That’s the other catch.”

Attorney Mary Jean Geroulo of the Dallas firm Stewart Stimmel agreed the stimulus money alone might not be enough for some physicians, and the Stark exceptions are important for the health care industry to meet the government’s goal of digitizing all patient files.

“If hospitals have the ability to get affiliated physicians up to speed, we will have made huge strides,” she said. And the Stark deadline — scheduled to expire in 2013, before the stimulus incentives for EMR use turn into penalties for disuse — could be extended if there’s a demonstrated need.

“Hospitals will be taking advantage of this if they haven’t already,” Geroulo said.

For nephrologist Simon Prince, MD, North Shore medical staff president, the subsidy from the health system meant the difference between getting an inexpensive model or getting a pricier, higher quality system. If all they had was the stimulus incentive money, “A lot of people probably would have picked cheaper vendors,” he said.

The hospital’s offer was just one more factor pushing physicians toward adoption, Dr. Prince said.

“It’s the stimulus money, it’s the Stark exemptions, it’s the North Shore Health System. All of these things are playing a role, and it’s all allowing the enthusiasm to bubble up here. Everyone, I think, is getting on board.”

Reconsidering the subsidy

Tufts Medical Center began offering subsidies more than a year ago. It saw them as a good business strategy, as “the community physicians’ role is very important to our success at a larger level,” said Bill Shickolovich, Tufts vice president and chief information officer.

Shickolovich sees Tufts’ contributions in two parts — to defray costs and to show good faith that the medical center was “committed to making this work, together.”

Tufts is still committed to getting its affiliated physicians connected, he said. But “because the stimulus funding has not yet started, we at Tufts Medical Center have not yet decided how to balance any stimulus opportunities with our subsidies.”

Possible scenarios some hospitals are considering include having affiliated physicians share subsidies with the sponsoring hospitals or even repay the entire subsidized amount. But those possibilities raise legal questions, which is why many hospitals haven’t decided what to do yet.

After the stimulus bill was passed, Leopard said, several of her hospital clients said they were glad they hadn’t yet offered subsidies. But the ones that did haven’t discussed “backing up the truck and taking them away.” Some are thinking of other approaches, outside of the Stark exemptions, that would provide assistance without footing the bill, she added.

“I think it’s very dynamic, and a lot of different, creative approaches are being discussed,” Leopard said. But whatever the source of funding, doctors still need to weigh the options before adopting any EMR system.

One possibility is an application service provider EMR, Leopard said. Hospital and physician practices can access an ASP-model EMR online, which means neither group has to invest in the expense of an on-site server. The systems are hosted remotely and accessible via the Internet for both the hospital and affiliated physicians.

Hospitals also could act as vendors and sell licenses to doctors who want to connect. Or hospitals can negotiate with vendors for discounts for affiliated practices.

But affordability shouldn’t be the only consideration in choosing an EMR. It’s crucial, experts say, that the system makes sense for the practice. Having to switch systems later could create major problems, Leopard warned.

Doctors should study any offer’s conditions and not assume that a hospital system will meet the meaningful use criteria and qualify them for incentive money. “It’s going to be a bad scene if [physicians] spend all this money and don’t get the [incentive] funds. They need to proceed cautiously,” Fehn said.

There are cautions for hospitals as well. Hospitals that previously offered the maximum subsidy allowed under the Stark exceptions might consider lowering that amount for physicians who haven’t yet accepted their offers. But, attorneys warn, if this is perceived as favoritism to practices that make more referrals, it’s an antitrust violation.

Attorneys advise physicians to ask sponsoring hospitals about previous offers. Physicians also should get any new offers in writing, with an expiration date.

Before accepting any hospital subsidy, Michigan health care attorney Fehn warns, physicians should “put some thought into it and not just jump on the first bandwagon that comes along.”

Health IT panel to heed calls for simpler EHR standards

By Mary Mosquera

A panel advising the Office of the National Coordinator of Health IT (ONC) said it will heed the overwhelming consensus it has received in recent public comments to develop the simplest possible certification standards for accelerating health IT adoption.

The Health IT Standards Committee’s implementation workgroup reported today that it distilled the testimony of industry organizations within and outside healthcare, as well as contributors to its public blog. The participants provided details of their experiences with adopting standards.

On the blog, physicians and practices have reported that they have difficulty improving quality and productivity with their existing electronic health record systems. As a result, they are looking for the standards to provide a “pathway to success.” The blog will remain live until Dec. 1.

Under the health IT stimulus plan, health care providers will be entitled to receive federal incentive payments only if they purchase electronic health record certified to meet standards for interoperability and other features now being worked out by the committee.

Dr. David Blumenthal, the national health IT coordinator, emphasized that “experience in the field” embodied in the comments will inform how ONC will craft the health IT certification standards that ONC will release later this year.

ONC is expected to publish in late December an interim final rule on certification standards and a notice of proposed rulemaking for the certification process. The standards rule will detail standards for what constitutes a certified EHR.

Dr. John Halamka, vice chairman of the committee, said any refinements to the standards would likely be applied to standards for 2013 and beyond than for 2011, the first year in which providers will be eligible to receive incentive payments under the stimulus plan. In 2011, providers must adopt standards to share medication lists, medical problems, allergies and laboratory reports.

“I think we have a basic set of requirements, and there may be some polish done to them based on the comments and principles. We’re just beginning the directional cycle for 2013 and 2015,” he said.

Physician and industry comments received by the panel overwhelmingly asked that the simplest standards be put forward to provide business value and rapid adoption.

“Our posts have led to conversations with committee members here who have taken them to their constituents,” said Aneesh Chopra, the administration’s chief technology officer and chairman of the committee’s implementation work group.

Among its guiding principles, the committee should concentrate on getting buy-in from physicians for standards required in 2011 to share medication lists, medical problems, allergies and labs before moving to more complex objectives, he said.

Halamka suggested that the committee continue to gather comments about 2011 information exchanges to determine if there are ways to improve testing platforms and implementation guidance.

Another guiding principle recommends that the committee separate content standards, such as those for continuity of care documents, from transmission standards, as well as separate the network layer standards from application layer standards.

Electronic health records for 2010

Some challenges still remain, but government says it will implement integrated health information systems next year.

By Audra Mahlong, Journalist

The start-up phase for its national electronic health record system will finally begin in 2010, says the Department of Health.

While progress has been slow on the implementation of the system, the department says it will be ready to implement the system next year.

It says all the relevant documentation for the start-up phase of the project has been finalised with the State IT Agency (SITA) and the SITA board. It also reports that consultations with all stakeholders in the private and public sectors have been completed.

SA has embarked on a process of developing a national electronic health record (EHR) for all patients in public hospitals. An EHR is a database of patient health information, which will include demographics, vital signs, medical history, medications, procedures, laboratory data and radiology reports.

SITA and the department were tasked with establishing the requirements for implementing an electronic record system.

The department is also creating an e-health strategy, which will guide all its ICT projects. While noting that existing challenges include adequate ICT infrastructure, bandwidth capacity and meeting approved standards, it says the electronic record is still paramount.

Health minister Aaron Motsoaledi previously stated the current fragmented health information systems and sub-systems would be integrated into a single, national system. The focus of the department would be to establish an integrated national data warehouse for all data sources and tracking of human resources equipment, physical status of facilities and expenditure.

The collection, organisation, reporting, storage and use of data for planning, management and healthcare services would strengthen existing health programmes and help the department achieve its priorities, it notes.

Privacy and confidentiality of individuals’ health records will be secured before embarking on the implementation of the system, adds the department. Approved standards, by a recognised body that provides rules and guidelines, would also be in place before the start-up phase.

This would help the department to achieve its priorities and strengthen health programmes through the development of a nationwide integrated system.

CMS to allow EHR reporting for PQRI, e-prescribing bonuses in 2010

The new Medicare Part B fee schedule for 2010 is encouraging doctors to adopt EHRs by, for the first time, allowing practices to use real clinical data from EHRs and e-prescribing systems to report quality measures for the Physician Quality Reporting Initiative (PQRI) and e-prescribing incentive programs. The change, according to CMS, is “to promote adoption and use of electronic health records and to provide both eligible professionals and CMS with experience on EHR-based reporting,” Government Health IT reports.

Whether the incentive payments are large enough to spur many practices to switch to EHRs ahead of the 2011 debut of the federal stimulus program is uncertain, however. PQRI participants can earn 2 percent on top of their total Medicare Part B fees for reporting quality data in 2010, and another 2 percent for writing electronic prescriptions. The e-prescribing bonus drops to 1 percent in 2011 and penalties for not e-prescribing begin in 2012. CMS is trying to simplify reporting of e-prescribing by requiring a single code to be eligible for the bonus next year.

To learn more about the PQRI and e-prescribing aspects of the 2010 fee schedule:

CMS encourages EHR use for Medicare quality reporting

Healthcare providers will have the option to use electronic health record systems to report Medicare quality and electronic prescribing measures to CMS in some of its pay-for-performance programs next year, according to an announcement by the Centers for Medicare and Medicaid Services.

The revisions are designed “to promote adoption and use of electronic health records and to provide both eligible professionals and CMS with experience on EHR-based reporting,” CMS said in the Oct. 30 announcement.

They run parallel to efforts by the Office of the National Coordinator for Health IT to set up additional incentives for providers to measure and submit data measuring the quality of their treatments.

According to CMS, providers could use EHRs to submit information for the CMS’s Physician Quality Reporting Initiative (PQRI) program, which pays an incentive to eligible physicians and other healthcare professionals who report on specific quality measures for care for Medicare patients.

Providers also will be able to report e-prescribing usage through qualified EHR systems or registries, according to CMS. Currently, providers’ reports about e-prescribing are based on patient medical claims.

Under the fee schedule rule, providers for the first time will be able to count quality data submitted through electronic health record systems toward their eligibility for a PQRI incentive payment, CMS said.

Next year, those payments will be equal to 2 percent of their total estimated allowed charges for the reporting periods, CMS said. The final rule will appear in the Nov. 25 Federal Register.

The rule also streamlines reporting of e-prescribing and focuses on the actual use of e-prescribing by the provider. In 2010, providers will use one code for e-prescribing, but they “need to report this code at least 25 times during the reporting period to be considered a successful electronic prescriber,” CMS said.

The Medicare fee schedule puts into practice provisions of the Medicare Improvement for Patients and Providers Act of 2008, which established a program for incentive payments for e-prescribing over five years. In 2012, CMS will impose penalties on providers who are not “successful e-prescribers.”

Once CMS publishes the rule, it said it will accept comments on designated provisions of the final rule until Dec. 29. The policies become effective Jan. 1, 2010.

First Look at ?Meaningful Use?

The meaningful use workgroup of the HIT Policy Committee has released its initial recommendations for a definition of “meaningful use” of electronic health records. The definition is important because under the economic stimulus law, providers must “meaningfully use” EHRs to receive financial incentives from Medicare and Medicaid.

These initial recommendations do not include a formal definition of meaningful use. But they are the initial recommendation of the functionalities that will be required by 2011 when incentives start. “This is the beginning of a conversation that will continue for some time,” said David Blumenthal, M.D., the national coordinator for health information technology, during a meeting of the HIT Policy Committee, a public-private advisory group. Blumenthal added that “there is a long way to go” before a final definition of meaningful use is achieved.

The workgroup’s initial recommendations include 22 objectives–most covering inpatient and outpatient care–for EHRs in 2011. These include, among others:

* Use CPOE for all order types including medications;
* Implement drug-drug, drug-allergy and drug-formulary checks;
* Maintain an up-to-date problem list;
* Generate and transmit permissible prescriptions electronically;
* Maintain an active medication allergy list;
* Send reminders to patients per their preference for preventive and follow-up care;
* Document a progress note for each encounter;
* Provide patients with an electronic copy or electronic access to clinical information such as lab results, problem list, medication lists and allergies;
* Provide clinical summaries for patients for each encounter;
* Exchange key clinical information among providers of care;
* Perform medication reconciliation at relevant encounters;
* Submit electronic data to immunization registries where required and accepted;
* Provide electronic submissions of reportable lab results to public health agencies;
* Provide electronic surveillance data to public health agencies according to applicable law and practice; and

* Comply with federal and state privacy/security laws and the fair data sharing practices in HHS’ Nationwide Privacy and Security Framework, released in December 2008.

The HIT Policy Committee will make the final recommendations on meaningful use definitions to the Department of Health and Human Services and the Centers for Medicare and Medicaid Services.

HHS is mandated to publish an interim final rule for standards, implementation specifications and certification criteria of EHRs that qualify for financial incentives by the end of 2009. CMS will develop the formal definition of meaningful use to support the incentive programs. CMS will go through the full administrative rules process with a proposed rule, public comment period and a final rule. A timetable was not given.

The recommendations from the meaningful use workgroup include a matrix of objectives for 2011, plus enhanced objectives for 2013 and 2015. The workgroup will refine the initial recommendations for 2011 and 2013 within three months.

The meaningful use workgroup also has laid out an “achievable vision” for benefits to be realized by 2015. These include reductions in heart attacks, medical errors, and preventable hospitalizations.

For more information, click here. Scroll down and click on “meaningful use preamble” and “meaningful use matrix.” Updates from certification/adoption and information exchange workgroups also are available.