Continuing with the discussion of health information technology (HIT) and specifically for electronic health records (EHR), the below will serve as an introduction to some of the “meaningful use” requirements doctors and hospitals must meet to get incentive payments from Medicare and Medicaid.
Under the HITECH portion of the American Recovery and Reinvestment Act (ARRA; aka the stimulus act), incentives would be given to Medicaid and Medicare providers not just for adopting EHRs, but for meaningful use of these EHRs – realizing that just having EHRs did not actually equate to efficiencies and better health outcomes. To demonstrate meaningful use, providers must then meet specific objectives in the use of EHRs such entering information into an EHR in a strutured format, exchanging information, checking for security, and using Computerized Provider Order Entry to make medical orders. These objectives will be released in three stages by the Office of the National Coordinator for Health Information Technology (ONC) – with the first stage released last year and the second stage proposed rules released last month. Below I’ll discuss objectives for Stage 1 and in another post I’ll discuss objectives for Stage 2 and looking ahead to Stage 3.
As I said in the last post, barriers included costs and implementation, particularly for smaller practices. In discussing the following, consider, given the requirements providers must meet, whether these stated barriers are really excuses or truly justified by the challenge of adopting these EHRs.
In Stage 1, providers must meet a core set of 15 objectives (14 for hospitals) and 5 objectives from a list of 10 in the “menu set.”
- Computerized Provider Order Entry (CPOE) – directly enter medication orders from a computer for more than 30% of patients
- Drug Interaction Checks – implement drug-drug and drug-allergy interaction checks in the EHR
- Problem List – maintain problem list including current diagnoses for 80% of all patients
- e-Prescribe – generate and transmit prescriptions electronically
- Medication List – maintain active medication list for 80% of patients
- Medication Allergy List – maintain active medication allergy list for 80% of patients
- Record Demographics – for more than 50% of patients, record preferred language, gender, race, ethnicity, and date of birth
- Record Vital Signs – for more than 50% of patients, record and chart heigh, weight, blood pressure, body mass index, and growth chargs for children 2-20 years old
- Record Smoking Status – for 50% of patients 13 years or older
- Clinical Quality Measures (CQMs) – report ambulatory ambulatory CQMs selected by the Centers for Medicare and Medicaid Services (e.g. – identifying poor control in diabetics by reporting the percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent hemoglobin A1c greater than 9.0%)
- Clinical Decision Support – implement one clinical decision support rule which builds on the EHR to provide providers with general and person-specific information, intelligently filtered and organized, to enhance health. (e.g. – automated data interpretation that helps a provider determine whether a fluctuation in readings is within or outside a typical range for that patient.
- Electronic Copy of Health Information – provide patients with an electronic copy of their health information (including test results, medication lists, medication allergies) upon request for 50% of patients who request them and with in 3 business days.
- Clinical Summaries – provide clinical summaries for each office visit 50% of patients who request.
- Electronic Exchange of Clinical Information – must perform one test of EHR’s capacity to electronically exchange key clinical information such as problem lists, medication lists, medication allergies, lab results.
- Protect Electronic Health Information – conduct a review of security risk analysis, implement security updates, and correct security deficiencies.
Menu Set Measures (of which providers must choose 5):
- Drug Formulary Checks – provider has access to at least one external or internal formulary – a list of prescription medications that a drug plan will pay for.
- Clinical Lab Test Results – inputting clinical lab test results as structured data into EHRs for at least 40% of patients.
- Patient Lists – generate at least one report listing patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach.
- Patient Reminders – send reminders to patients to 20% of patients 65 years or older or 5 years or younger.
- Patient Electronic Access – provide patients with timely electronic access to their health information within 4 business days of that information being available to the provider for at least 10% of patients.
- Patient-Specific Education Resources – use EHRs to identify patient-specific education resources and provide them to 10% of patients.
- Medication Reconciliation – reconcile medications for 50% of patients that the provider receives from another provider.
- Transition of Care Summary – providers who transition or refer their patient to another provider supply summary of the care record, for 50% of transitions.
- Immunization Registries Data Submission – capability to submit electronic data to immunization registries.
- Syndromic Surveillance Data Submission – capability to submit electronic syndromic surveillance data to public health agencies.
So that seems like quite a lot to do. And not being an IT professional myself, I am not quite sure how difficult it is to incorporate these functions into computer software that can easily be used by doctors and hospitals to meet the requirement. In essence, the requirements are both on providers and the software vendors (who will have to undergo their own certification), but providers must learn how to access them and use them to ensure they get the incentive payments.
Still, many of the objectives seem like things providers should be (and probably many are) doing already. For instance, maintaining lists of medications, allergies, and diagnoses should be easy enough and if a doctor is worth his salt, he already has these lists already. Recording demographics, vital signs, and smoking status should also be easy to check off the list of requirements. And of note, the requirements don’t expect the providers to do this for all of their patients at this stage, though it should easily be completed for all of them.
Other objectives may be more difficult, like clinical decision supports, providing copies of health information (especially for bigger files), and exchanging information. These are much more technical attributes of EHRs that might take some time to work out. Overall though, these Stage 1 requirements do not seem to me to be overly burdensome or ambitious. Perhaps I overestimate the technological capabilities or the or providers ability to use EHRs? However, I think these standards are reasonable. The transition from paper to computer should not take too long once the technology is available as long as providers are dedicated to the change. Then the benefits will likely catch on quickly including convenience and efficiency.
Again, HIT and EHRs will change our health care systems incalculably (again cliche – like facebook and twitter changed how we get information) providing information to providers to improve care and to patients who can then be more involved in their care. Beyond the health care system, technology sectors and education are already changing – developing innovative computer programs, schools offering HIT courses or related specialties, and educating an entire professional field to work with the technology. Job candidates with IT experience are highly sought after these days to work in healthcare IT, and the demand will likely continue as HIT expands. (I keep telling those I know in the IT industry to consider opportunities in health IT for the promise that it offers those with pioneering ideas but they have yet to listen to my meager input.)
The possibilities before us in this field are endless and exciting (though filled with many technicalities that may be less exciting).
I’ll save a bit on this topic for another time.