Defining Meaningful Use

A brief overview of CMS' proposed rule

Research by Matthew Weinstock

Now is when the rubber meets the road. For most of 2009, vendors, hospital leaders, consultants and other industry experts professed to know what it will take to achieve meaningful use of electronic health records. But then the Centers for Medicare & Medicaid Services in December issued its proposed rule. As IT experts read through the 500-plus pages, it became clear where the federal government was setting the bar and how far providers had to climb.

Rick Pollack, executive vice president at the American Hospital Association, says the proposal creates a "stringent definition of meaningful use that doesn't recognize" the work hospitals and physicians have already done to deploy information technology and improve quality and safety. Other trade groups, professional societies and the vendor community expressed concerns about the proposal as well. The AHA plans to file comments with CMSÂ in hopes of creating a more flexible final rule; one that "would reward the progress hospitals and physicians already have made toward adopting EHRs," Pollack says.

Although much could change by the time a final rule comes out this spring, hospital officials at least have a roadmap to follow. Importantly, it is not just about IT deployment, says Pam Arlotto, president and CEO, Maestro Strategies, a consulting firm in Roswell, Ga. There is a strong quality focus in the proposed rule.

"What you should do first is say, 'What is our goal here? Are we trying to install IT or are we trying to improve care?'" says G. Daniel Martich, chief medical information officer at the University of Pittsburgh Medical Center. The answer should be the latter and if that's the case, he says, a lot of work needs to be done before flipping the switch on an EHR: standardizing order sets, creating more efficient work processes, and more. "If you automate bad processes, you are not going to get better," he says.

This gatefold provides a broad overview of CMS' proposed rule. H&HN will provide more coverage in the coming months.

A Snapshot: Defining Meaningful Use

Assess Yourself

Now that the flurry of activity surrounding the late December release of the meaningful use proposed rules and an interim final rule on EHR certification has eased a bit, it is time for hospital executives to step back and evaluate their organization's IT status. That's not to say this is a time to rest. CMS' final rule will come out in the spring and the compliance clock starts ticking in October. But before hospitals can think about applying for the enhanced reimbursement, officials need to know where they are and where they are going, experts contend. Maestro Strategies' Arlotto says the assessment must go beyond the ITÂ department. "This is not just an implementation roadmap; it is bigger than that," she says. "It will change your overall strategic plan and your investment strategy. Most organizations don't have the budget or plans to invest in what it is going to be required to take this on." Linda Reed, R.N., vice-president and CIO at Atlantic Health, adds that a thorough assessment will help hospitals figure out when they'll be ready to reach Stage 1 and apply for an incentive. For those that are at the very early stages of IT rollouts, an assessment will help identify key gaps that need to be addressed and avoid the penalties that start in fiscal 2015.

An enterprisewide assessment should include several factors, such as:

Create an ARRA project office with a project manager.
The office should reach across IT, quality
and other impacted areas.
Assess EHR deployment
on the organization's strategic and investment plans.
Assess the impact on other IT projects.
Do you need to re-prioritize?
Do you need to set new expectations with leaders?
Understand your vendors' readiness
and stay in constant contact as they move to certification.
Assess the gap between current capabilities
and the proposed rule and your ability to catch up.
Determine if it is more prudent for your organization
to undertake a rapid rollout so you can apply for incentives
versus taking more time with an eye toward avoiding penalties.
Educate your board, C-suite and physician leaders
on the rapid changes ahead.

Setting the Stage

Rather than require hospitals to meet meaningful use criteria by specific dates, CMS proposes a three-phase approach. The proposed rule issued last December addresses Stage 1; rules for Stages 2 and 3 are forthcoming. While the push is for hospitals to become meaningful users as rapidly as possible, CMS officials say the phased approach recognizes that there is a wide range of IT deployment levels. A variety of reports and studies were issued in the days immediately after the proposed rule came out suggesting that providers are not very far along in meeting the CMS criteria.

STAGE 1
Electronically capture health information in a coded format, track key clinical conditions and communicate outcomes for care coordination, implement clinical decision support tools to facilitate disease and medication management, and report outcomes for public health purposes.

Key Stage 1 requirements for eligible hospitals:

Use of a certified EHR and meeting 23 proposed criteria; 17 objectives require attestation by the provider, the rest will require that information be submitted to CMS.
Hospitals are eligible for Medicare and Medicaid incentives if they meet volume thresholds; physicians must choose between the programs.

STAGE 2
Will expand on Stage 1 to focus on continuous quality improvement at the point of care, greater use of CPOE likely, more robust exchange of health information.

STAGE 3
Will focus on "promoting improvements in quality, safety and efficiency" with an emphasis on decision support, patient access to self-management tools, access to comprehensive patient data and improving population health.

Source: Centers for Medicare & Medicaid notice of proposed rulemaking, Dec. 30, 2009

Top 10 Challenges

Daniel Stewart, partner at health care consultancy CSC Healthcare Group, identifies 10 areas for hospital leaders to focus on:

Do CPOE right the first time.
Help physicians transition to becoming competent, willing users.
Integrate the right clinical decision support into CPOE.
Start the inpatient record in the emergency department.
Manage new types of electronic patient information.
Capture data for quality measures.
Bring clinical data analytics up to par.
Share data with patients and other providers electronically.
Meet new privacy and security requirements.
Deal with transition to ICD-10 at the same time.

An Incentive for Early Adoption

Despite the staged approach, the enhanced Medicare and Medicaid reimbursements are clearly designed to encourage providers to roll out EHRs sooner rather than later. Under the proposal, eligible hospitals could begin to apply for the incentive in fiscal 2011 if they meet Stage 1 requirements and fulfill them continuously for any 90-day period during the fiscal year. Meaningful use would have to be achieved year-round in successive years. Hospitals can wait until 2012 or even 2014 to achieve Stage 1, but the amount of the incentive will shrink and there will be less time to meet Stage 2 and 3 requirements. For instance, a hospital achieving Stage 1 in fiscal 2011 has two years to achieve Stage 2 and four years to reach Stage 3. A hospital waiting until 2013 to get to Stage 1 would have only one year to reach Stage 2 and two years to reach Stage 3.

Certification, Privacy, Security and More

CMS' 500-plus-page proposed rule addresses several other areas of meaningful use that aren't discussed in this foldout. Some of the issues include:

Hospital-based physicians: A physician who provides 90 percent of his or her services in a hospital-based setting (inpatient, outpatient or ED) would not be eligible for incentive payments or subject to penalties.
Medicaid:While CMS proposes that Medicare and Medicaid be aligned, states may have the flexibility to add requirements.
Privacy: CMS appears to defer to HIPAA rather than EHR certification as the place to regulate privacy and security.

Certification:
The Office of the National Coordinator's interim final rule on EHR certification provides some flexibility. Providers can pick either a complete—and certified—EHR product or piece together various modules. If providers go the latter route, each component needs to be certified. ONC still plans to issue a proposed rule on the exact certification process, including how many entities will be given the authority to certify products.

H&HN will provide ongoing coverage of these important issues throughout 2010.

Do You Meet the Criteria of a Meaningful User?

CMS proposes that hospitals meet 23 objectives to be deemed a meaningful user of an EHR. The agency's proposed rule organizes the criteria around five broad policy objectives that apply to Stage 1 implementation. Here's a sampling of what CMS proposes.

The full list can be found in the notice of proposed rulemaking.

A) Quality Reports to the Federal Government

The HITECH Act requires that providers electronically submit data on clinical quality to the federal government. CMS' proposed rule identifies 35 clinical measures for hospitals to collect and report on. All 35 measures have been endorsed by the National Quality Forum; 25 have been adopted by the Hospital Quality Alliance; however, hospital officials note that just nine are currently used in the government's pay-for-reporting program. Experts say that this will be among the most difficult criterion to meet. "Most organizations do it manually right now," says Maestro Strategies' Arlotto. She says IT and quality departments will have to work together to define data sources and figure out where the applicable information is collected in the medical record. "We'll have to map back to fields in our databases and it will be more difficult than expected," adds Atlantic Health's Reed, R.N. Being successful at this also will entail some workflow changes, suggests Tom Smith, CIO at NorthShore University HealthSystem. The Evanston, Ill., system launched its EHR in 2003 and has been reporting on Hospital Quality Alliance measures for several years. When they wanted to track smoking cessation counseling for heart attack patients, Smith's team added a field to the flow sheet, where information such as the patient's temperature is recorded. Previously, doctors recorded the information in the notes section. "That was fine. He documented that he did it, but it was impossible to pick up as a data element from notes," Smith says. Clinicians had to be trained to record the information in a different section of the medical record. Not all changes will be as easy, Smith points out. Beyond the hospital requirements, there are specific measures for medical specialties. Here are some of the hospital quality measures proposed by CMS; the full list can be found in the notice of proposed rulemaking.

Condition	Measure
Acute myocardial infarction/heart attack	Aspirin at discharge Beta-blocker at discharge 30-day hospital-specific readmission rate (risk adjusted and non-risk adjusted)
Emergency department throughput	Median time from ED arrival to ED departure for admitted patients Median time from ED arrival to ED departure for discharged patients
Heart failure	30-day hospital-specific readmission rate (risk adjusted and non-risk adjusted)
Health care-associated infections	Ventilator bundle Central-line compliance Ventilator-associated pneumonia rate for ICU and high-risk nursery patients
Pneumonia	Blood culture performed prior to administration of first antibiotic

Source: Centers for Medicare & Medicaid Services notice of proposed rulemaking, Dec. 30, 2009

B) Have Record, Will Travel

Patients at NorthShore University Health System, Evanston, Ill., have for the past few years been able to access their medical records via a patient portal. More than 100,000 patients have signed on to the service. In mid-December 2009, the health system sent patients an e-mail letting them know that they can now download a summary of the medical record in a password-protected PDF format and save it to a portable flash drive. "It's simple, secure and it fits in the palm of your hand," the e-mail says.

NorthShore officials weren't necessarily thinking about meaningful use when they made the announcement. "We have a lot of patients who are older and leave for the winter," Smith says. "They can take this with them and feel comfortable that they have a summary of their record with them."

Physicians helped identify the essential information they'd like to have in a summary. When a patient goes to the NorthShore portal and clicks on her history, the record is automatically updated with the most recent data.

"We are pushing data out to patients faster and faster," says UPMC's Martich. "We use to have a very paternalistic view that all data had to be viewed before it was given to a patient." Now, most data is released to patients 24 hours after it is delivered to the physician. "First it was a week embargo, then five days, then 72 hours," Martich explains. "It's an effort to keep the patient at the center."

CPOE: Getting it Right

While deploying CPOE is viewed as a major step toward improving patient safety and quality of care, there's a concern that the proposed meaningful use rule will cause hospitals to skip the building blocks that need to be in place first. Five years ago, officials at Atlantic Health targeted CPOE as an organizational goal. The intent was to achieve safer care with better outcomes, says Reed. At the time, there were many horror stories about failed CPOE deployments at major medical centers. "So when we started looking at it with the end in mind, we didn't want to start with CPOE," she says. Atlantic Health set the goal of having a closed loop process. The organization took a phased approach to deploying new technologies:

Reed cautions hospitals from rushing too quickly into CPOE. "Take your time to look at the pharmacy and make sure it is robust," she says. "Really consider what you are doing when you are putting CPOE in place. If you haven't fixed the pieces in the background, you will slam up against the wall."

This article 1st appeared in the February 2010 issue of HHN Magazine.

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