After the American Recovery and Reinvestment Act of 2009 was passed, I crafted the following memo to help prepare our hospital clients for the implications of Meaningful Use as it relates to IT planning.

Memo

The recent healthcare information technology provisions (known as Health Information Technology for Economic and Clinical Health, or HITECH) included in the American Reinvestment and Recovery Act (ARRA) of 2009 have garnered a great deal of attention from stakeholders throughout the healthcare industry. You are positioned to take advantage of the incentives being offered to hospitals of your size (and avoid penalties associated with lack of compliance), but a number of regulations must be met beforehand. Most notably among these regulations is meaningful use of certified electronic health records.

Specifics of Meaningful Use
The definition of meaningful use was finalized by the Health Information Technology Policy Council in a set of recommendations presented to the Office of the National Coordinator for Healthcare Information Technology (ONCHIT) in August. I would like to set the stage for the information in this memo by noting “the primary goal of HITECH is to improve the care of individuals and the health status of the American population”("Observations on “Meaningful Use” of Health Information Technology," 2009). It should be focused on the results, not the specific technology used to achieve those results.

Meaningful use implies attention to how an Electronic Health Record (EHR) is implemented and used for patient care and health promotion (Anderson & Goedert, 2009). The defining components are outlined in the following heath outcome policy priorities:

• Improve quality, safety, efficiency, and reduce health disparities
• Engage patients and families
• Improve care coordination
• Improve population and public health, and
• Ensure adequate privacy and security protections for personal health information ("Health IT Policy Council Recommendations to National Coordinator for Defining Meaningful Use," 2009).

The objectives and measures for achieving these outcomes will start at reasonable levels, and will move from “measuring performance to constantly improving outcomes. (Merrill, 2009)” The metrics will be made increasingly stringent at two year intervals (Definition of Meaningful Use of Certified EHR Technology for Hospitals, 2009).

By 2011, medical providers should meet and be able to report on the following objectives:
(Note: These definitions are taken from "Health IT Policy Council Recommendations to National Coordinator for Defining Meaningful Use" published in August, 2009. You can access the full matrix of objectives and measures, including 2013 and 2015 objectives here.)

Objectives Related to Improving Quality, Safety, Efficiency, and Reducing Health Disparities

• Capture patient demographics including preferred language type, gender, insurance information race, and ethnicity
• Capture advance directives and vital signs
• Enter 10% of all orders through Computerized Physician Order Entry (CPOE). This applies to any type of order entered by an authorized provider (an MD, DO, RN, PA, or NP)
• Maintain drug-drug, drug-allergy, and drug-formulary checks
• Maintain active medication and medication allergy list
• Incorporate lab test results as structured data
• Generate lists of patients by specific conditions
• Capture hospital quality measures (and report them to CMS)
• Verify insurance eligibility and submit claims
• Begin implementation of clinical decision support by implementing one clinical decision rule related to a high priority hospital condition

Objectives Related to Engaging Patients and Their Families

• Provide patients with an electronic copy of
  • their health information (including lab results, problem list, medication lists, allergies, discharge summary, and procedures) upon request
  • discharge instructions
  • patient-specific education resources

Objectives Related to Improving Care Coordination

• Exchange key clinical information among providers of care (our ambulatory clinic and community clinics, among others) and patient authorized entities
• Perform medication reconciliation at relevant encounters and each transition of care

Objectives Related to Improving Population and Public Health

• Provide electronic data on immunizations, reportable lab results, and syndromic surveillance data to public health agencies

Objectives Related to Ensuring Adequate Privacy and Security Protection for Personal Health Information

• Comply with HIPAA Privacy and Security rules
• Comply with fair data sharing practices

Incentives

Hospitals and clinics are eligible for incentives under HITECH. Incentives start in 2011 for hospitals that demonstrate meaningful use by that time. The greatest incentives available for those who start early, and they decrease over time. Hospitals forfeit their right to incentives and actually face penalties if meaningful use is not achieved by 2015.

Analysis by Price Waterhouse Coopers shows that an average 500-bed hospital would receive an average of $6.1 million in incentives, assuming it demonstrates meaningful use of healthcare IT by 2011 (Rock and a Hard Place: An analysis of the $36 billion impact from Health IT stimulus funding, 2009). Conversely, the same hospital could lose up to $3.2 million in Medicare funding by the time the penalties are fully phased in 2017 (Rock and a Hard Place: An analysis of the $36 billion impact from Health IT stimulus funding, 2009).

Incentives are based on Medicare and Medicaid case load, as well as volume of charity care a hospital produces each year. Your incentives may be different from the example cited by PWC.

Although analysis shows that the stimulus incentives do not come near to compensating overall costs (Rock and a Hard Place: An analysis of the $36 billion impact from Health IT stimulus funding, 2009), you should consider installation of a certified EHR as essential to doing business and caring for patients in the future. As such, we should embrace the potential incentives, even if we are not ready by 2011, rather than wait and face penalties.

Timing

The clock is already ticking for implementation of EHR technology to achieve the objectives and measures set forth by HITECH. In fact, those entities that already have EHRs or have begin planning are ahead of the game and are likely to reap the most rewards. Vendors reported to the National Committee on Vital Health Statistics that they need as much as 18-24 months to create and roll out product enhancements, and providers often take 18-24 months to implement new technology ("Observations on “Meaningful Use” of Health Information Technology," 2009). You will need to move quickly in order to qualify for incentives in 2011 or, at least, 2013.

Certification

The objectives and measures outlined for meaningful use must be achieved through en EHR that is certified. Certification criteria are not yet determined, but by December 31, 2009, ONCHIT will “adopt an initial set of standards, implementation specifications, and certification criteria” for electronic health records ("American Recovery and Reinvestment Act of 2009," 2009). There is still some question about how selective these certification criteria will be, and if they will be able to balance standardization with a diverse offering of best of breed and innovative solutions, in addition to major market players in the EHR space.

Interoperability

EHRs must be able to communicate with other internal systems and with outside providers to achieve meaningful use. Interoperability is an underpinning of meaningful use and is essential to realizing improved healthcare in America (Rosenfeld, Siler, Rubin, & Glaudemans, 2009). Selection of an EHR product that is compatible with the Continuity of Care (CCR) standard and other applicable standards is essential.

Differing Needs Throughout the Enterprise

The Markle Foundation has identified that HIT needs of an integrated delivery network and smaller ambulatory practices (such as our outpatient clinics and community clinics) may differ greatly (Achieving the Health IT Objectives of the American Recovery and Reinvestment Act: A Framework for Meaningful Use and Certified or Qualified EHR, 2009). We need to consider the needs of our different care facilities, as well as interoperability between them, in choosing an EHR.

Workflow

If chosen carefully and thoughtfully, EHRs can help physicians become more efficient and allow them to focus on caring for patients rather than administrative work (Rishel, 2009). However, incorporating an EHR into clinical practice at a delivery network will inevitably result in the need to adjust and change workflow and work practices. If an organization attempts to implement an EHR without reworking the workflow, the staff will simply “work around” the system, thus rendering the system unlikely to improve efficiency or job satisfaction (Rishel, 2009).

User Experience

Related to workflow and administrative burden is the idea of user experience when working with an EHR. Poor usability is one of the key barriers to adoption of HIT systems and a principal reason for rejection once these systems are installed (Schumacher, Yee, Myers, & Lew, 2009). All medical providers should evaluate user performance criteria for potential systems before purchasing one. Pilots or trials with clinicians followed up with research into ease of use and measurable outputs can be very informative and save the institution from purchasing a system users won’t like.

HIPAA

The HITECH Act includes increased penalties for violation of HIPAA requirements. In the new tiered structure, fines are no longer $100 per violation across the board, but range from $100 to $50,000 per violation, depending on whether or not the violation was due to willful neglect and how quickly it was remedied (Waldren, Kibbe, & Mitchell, 2009). IT solutions that combat and prevent HIPAA violations will be worth their implementation cost if penalties can be avoided.

ICD-10

Clinicians have been mandated to ICD-10 by October, 2013, in a measure separate from ARRA. The new code set offers twice as many diagnoses as ICD-9 and 20 times as many injuries, but represent a challenge to existing workflows in clinical settings (Rishel, 2009). An EHR with the ability to support ICD-10 as well as ICD-9, or allow for seamless expansion to the new code set, should be considered over those without such capability.

Conclusions

As you can see, the HITECH Act beckons a new era of electronic capture, measurement, and sharing. It is not without its challenges, which must be considered carefully. IT choices in an organization have a tremendous impact on clinician and patient satisfaction, quality of care, and fiscal health. Careful and thoughtful consideration of IT solutions will allow us to improve health outcomes for our patients, while garnering incentives as appropriate to help us achieve our goals.

Sources

Achieving the Health IT Objectives of the American Recovery and Reinvestment Act: A Framework for Meaningful Use and Certified or Qualified EHR. (2009). The Markle Foundation Connecting for Health.

American Recovery and Reinvestment Act of 2009. (2009).

Anderson, H., & Goedert, J. (2009). Industry Raises its Voice on 'Meaningful' EHR Use. Health Data Management, 17(7), 8. Retrieved July, 2009, from

Definition of Meaningful Use of Certified EHR Technology for Hospitals. (2009). Healthcare Information and Management Systems Society (HIMSS).

Health IT Policy Council Recommendations to National Coordinator for Defining Meaningful Use. (2009). In H. P. Committee (Ed.).

Merrill, M. (2009). Officials outline criteria for meaningful use. In Healthcare IT News.

Observations on “Meaningful Use” of Health Information Technology. (2009). In N. C. o. V. a. H. Statistics (Ed.).

Rishel, W. (2009). Requirements for Helping U.S. Physicians to Adopt EHRs: Gartner.

Rock and a Hard Place: An analysis of the $36 billion impact from Health IT stimulus funding. (2009). Price Waterhouse Coopers Health Research Institute.

Rosenfeld, S., Siler, S., Rubin, S., & Glaudemans, J. (2009). Interoperability and Meaningful Use: Keys to the Future of Health Information Exchange: The Federation of American Hospitals.

Schumacher, R., Yee, W., Myers, S., & Lew, G. (2009). Supplemental Testimony: Developing a Roadmap for Addressing the Behavioral Aspects of HIT Meaningful Use: User Centric.

Waldren, S., Kibbe, D. C., & Mitchell, J. (2009). Will the Feds Really Buy Me an EHR? Family Practice Management(July/August 2009), 19-23.

Lee Farabaugh
Director of User Experience