In many ways the meaningful use program is well-conceived.


The focus on use that is meaningful shifted the industry from its prior focus on adoption. The number of hospitals that adopt computerized provider order entry is less important than whether those hospitals use CPOE extensively to enter orders.

The focus on meaningful use also stops short of outcomes. This is appropriate. Use must precede outcomes, and while the meaningful use of electronic health records should improve care delivery, major gains in outcomes are likely to be more effectively driven by changes in payment reform than by changes in the degree to which the problem list is maintained. Meaningful use provides the foundation for improvement in outcomes.

However, using EHRs to improve care requires more than a shift in focus. It requires implementation assistance to providers, increased numbers of clinical systems professionals and advancement of standards for interoperability. It also requires quality measures, clear privacy and security requirements, and the furthering of the health information exchange infrastructure. Programs, initiatives, funding and advisory committees have been put in place to ensure that these supporting mechanisms are established.

Reason for Concern

There is no question that the needle has moved as a result of the meaningful use program. As of August 2012, almost 4,000 hospitals and 280,000 providers have registered for the program. The percentage of physicians who use a basic EHR has increased from 48 percent in 2009 to 72 percent in 2012, according to the National Center for Health Statistics.

While acknowledging many of the successes of the meaningful use program, there is reason for concern.

As of October 2012, 19 percent of eligible physicians and 29 percent of hospitals have attested for Stage 1 Medicare meaningful use. These are significant numbers, but they are a minority of providers.

Stage 2 requirements have been defined. These requirements raise the bar significantly for providers. With the specific testing and certification requirements close to completion, providers and their software vendors will have about 18 months to complete development, testing, upgrading and implementing those electronic health record and clinical process changes necessary to begin attestation for Stage 2.

This is an extraordinary amount of change and work. It also coincides with the implementation of ICD-10 and with providers who are undertaking their own local efforts to improve care quality and efficiency through information technology.

One of the more difficult decisions about implementing change in an organization is determining the appropriation ambition and pace of change. The organization may have aspirations that clearly will require significant increases in performance as well as broad and deep changes in processes. If the aspirations are too modest, the organization could fail to achieve what it could have. If the aspirations are too high, the organization could become dispirited and demotivated. Change that is implemented too slowly places the organization at risk of mediocrity. Change that is implemented too fast risks breaking the organization.

Fundamental Risks

The time frame for implementation of Stage 2 is too short, given the aspirations of Stage 2. The requirements pose two fundamental risks for the government's effort to significantly improve care delivery through the meaningful use of electronic health records.

First, providers could blow it off; they could decide not to pursue Stage 2 (and perhaps Stage 3). Hospitals and physician practices can look at the costs and effort required to achieve Stage 2 and decide that it is not worth it. There are too many other things to do, such as the conversion to ICD-10. There are too many other demands on the organization's capital budget. There are too many other tasks claiming managers' and clinical leaders' bandwidth. And meaningful use is voluntary, while other demands are not.

One can tell those organizations that penalties — significant penalties — are coming. One can tell them meaningful use will be a critical capability for addressing the demands of looming payment reform. They will acknowledge all of that. But they face extensive, often crushing demands, today. And to meet the demands of today, they may make a perfectly rational decision to forgo Stage 2.

The percentage of providers attesting that we see today may represent the near peak of participation in meaningful use. No one would view this as success.

Second, given the tight time frames and high energy demands, many providers may hurriedly slam the system in, forgoing many of the necessary process and care delivery changes as they rush to get the Stage 2 payment. Implementing any major application system should be accompanied by the thoughtful reengineering of processes and practices to ensure that the information technology investment generates as much organizational gain as possible.

What can result? Several years from now we could step back and ask if we can see material improvements in the efficiency, quality and safety of care delivery that should have resulted from the meaningful use of EHRs. And we could find that we do not see these improvements or the level of gains that we had expected to see.

Again, no one would view this as success.

Time for a Time-out?

The meaningful use program is a critical contributor to our country's efforts to improve care delivery. There are many thoughtful, well-conceived and well-executed aspects of the program.

However, as we implement it, we should be mindful of the need to calibrate the pace and direction of change. A delay in Stage 2 would be well-advised. Moreover, we should take time to ensure that, as the program progresses, we are seeing evidence that the desired goal of improved outcomes is being achieved. Hence, we should assess the gains in care quality, safety and efficiency by providers that have attested to meaningful use. And we should assess provider ability to perform associated process reengineering and care improvement steps needed to optimize investments in electronic health records.

In a season of many sporting events, we are reminded of the value of a time-out to assess the situation. As with any team in the middle of a football or basketball game, we have worked hard to get here and we have a goal in mind. Let's make sure that we get what we came here to get.

John Glaser, Ph.D., is CEO of Siemens Healthcare's health services business unit in Malvern, Pa. He is also a regular contributor to H&HN Daily.