Meaningful Use: Safety and Quality of Care

For nearly a year and a half following the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act, the medical community had one question on its mind: What constitutes meaningful use? The HITECH legislation stresses that in order to receive stimulus funding for health IT, providers must prove meaningful use of that technology. On July 13, 2010, meaningful use was defined—or, rather, the stage 1 requirements for achieving it were spelled out, almost 17 months after the HITECH Act’s enactment. On August 4, Jonathan Teich, MD, PhD, CMIO of Elsevier Health Sciences, led a webinar sponsored by the Healthcare Information and Management Systems Society (HIMSS), parsing meaningful-use requirements as they relate to the stated DHHS goal of improving the safety and quality of care.

“It’s striking a balance between the overall goal, using EHRs to improve quality, while encouraging widespread adoption and avoiding an excessive work burden on physicians. While not fulfilling every quality metric that the policy committee would like, you’re gaining the capability to do that.”

— Jonathan Teich, MD, PhD, CMIO of Elsevier Health Sciences

Teich began with a brief historical overview of the meaningful-use concept. A proposed rule released in January of this year garnered over 2,000 comments, Teich notes, some in support of the rule and most requesting changes. “If I had to summarize the most common comments, number one was the concern that this was an all-or-nothing proposition,” Teich says. “There was a general sense of inflexibility. Because practices are so different, it was difficult to understand how a variety of them would pass this.”Key Changes in the Final RuleTo address this concern, the final rule, which applies to eligible professionals as well as eligible hospitals and critical-access centers, includes both core tasks—measures that must be fulfilled to qualify a professional or facility as a meaningful user—and menu-set tasks, from which facilities can select measures that most readily apply to them. This, Teich notes, was a direct response to comments about inflexibility; instead of a laundry list of tasks that every user must complete, users now “must do some and can choose from others,” he says. Thresholds for many of the tasks were also rolled back, making it easier for users to acclimate themselves to new and unfamiliar IT systems. For instance, the proposed rule stated that eligible users would have to transmit 75% of prescriptions electronically, but that number has been reduced to 40%; it also required use of computerized provider order entry (CPOE) 80% of the time. This threshold has been drastically scaled back to include only medication orders, for 30% of patients. Several calculations have been simplified. In the proposed rule, many calculations were based on the number of encounters; in the final rule, these are based on the number of patients instead. The requirement for manual chart review has also been excised. “All information can now be captured through the electronic health record (EHR) itself,” Teich says. Because there will be three stages of requirements for meaningful use, Teich says that the philosophy behind the first stage is to be as inclusive as possible. “It’s striking a balance between the overall goal, using EHRs to improve quality, while encouraging widespread adoption and avoiding an excessive work burden on physicians,” he says. “While not fulfilling every quality metric that the policy committee would like, you’re gaining the capability to do that.” He adds that many of the criteria removed from the proposed rule will reappear after 2013, in the following two stages.Tasks and MeasuresThat’s not to suggest that stage 1 tasks and objectives won’t be a challenge for first-time users of health IT to meet. Core-task categories, which everyone must manage on a per-patient (not per-encounter) basis in order to qualify as performing meaningful use, include:

• demographics;
• vital signs, body-mass index, and growth;
• problem lists;
• medication lists;
• allergy lists;
• smoking status;
• clinical-encounter summaries;
• health summaries;
• transmission of prescriptions;
• CPOE for medication orders;
• drug–drug and drug–allergy interaction checks;
• tests of ability to exchange clinical information;
• security-risk analysis;
• reporting of quality measures; and
• creating and tracking one clinical decision support rule.

For the last item, Teich notes, “Users must implement one clinical decision support rule relevant to their specialty or a high clinical priority, along with the ability to track compliance for that rule, so I need to design a rule such as, ‘Patients over this age are eligible for a mammogram,’ and track whether I am following it.” Quality measures change depending on whether the provider is an eligible professional or an eligible hospital. Eligible hospitals must fulfill all 15 core measures, while eligible providers will work with both core and menu-set measures to work. For eligible hospitals, measures deal with emergency-department throughput for admitted patients, stroke, and venous thromboembolism; for eligible physicians, core measures include hypertension management, tobacco-use assessment and tobacco-cessation intervention, and adult weight screening and follow-up action. Alternatives are available for practices to which these measures don’t apply, such as pediatric practices.Looking ForwardProviders will be able to register for the program beginning in January 2011, and for the first year, they will only have to demonstrate fulfillment of tasks and measures for a single 90-day period. Until stage 2 begins, providers will be able to attest manually, using a form, instead of transmitting attestation from their EHRs. “Later on, there will be mechanisms to submit through a registry or through your EHR into your health information exchange,” Teich says, noting that the full rules for the next stage are to be posted by April 1, 2011. CMS has stressed that most of the measures and tasks removed from the first stage are likely to reappear in the second and third, and Teich says he would not be surprised to see a few additional tasks added to the mix. “One explicit number we’ve seen is that the CPOE usage requirement will rise to 60% of patients, and other thresholds are likely to increase,” he says. “What you’ve got here is a two-year respite.” Stated goals for the second stage (2013) include disease management, clinical decision support, medication management, patient access to health information, transitions in care, quality measurement, and communication to/from public health organizations. Stated goals for the third stage (2015) are improvements in quality, safety, and efficiency; clinical decision support for national high-priority conditions; patient self-management tools; access to comprehensive patient data; and population health outcomes. “There’s been no explicit statement that any of these items will show up in particular tasks,” Teich notes. “This is more about philosophy.” Teich concludes that the first stage of meaningful use will be about “making the computer your friend before we make it your taskmaster. It makes sense to have everyone walk,” he says, before running. “I’m glad to see an emphasis on adoption and getting your foundation ready for doing this quality work,” he adds.Cat Vasko is editor of ImagingBiz.com and associate editor of Radiology Business Journal.