Guidelines on EHR meaningful use moving forward

The recommendations, which will help determine who receives federal stimulus funding, have been revised from an initial draft.

By — Posted Aug. 3, 2009

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The Obama administration's national health information technology coordinator has approved recommended definitions for what constitutes "meaningful use" of electronic health records, about a month after asking a key working group to revise its initial recommendations.

The green light from David Blumenthal, MD, means that the recommendations now will be sent to the Dept. of Health and Human Services, which by the end of the year must issue a rule with final definitions. Meaningful use is a key term that ultimately will determine which physicians and hospitals are eligible for billions in federal EHR money made available through the economic stimulus package approved earlier this year.

Recommendations from Dr. Blumenthal and the Health IT Policy Committee provide the first look at a policy framework for the development and adoption of a nationwide health information infrastructure. The committee said it received nearly 800 comments after unveiling a first draft of the recommendations June 16, though policy experts say few major changes were made since then.

"To say Dr. Blumenthal sent the working group back to the drawing board really is inaccurate," said Erica Drazen. a managing partner in the health care group at Computer Sciences Corp., a technology firm in Waltham, Mass. "There weren't really too many surprises or changes made from the initial draft. If anything, it's slightly more aggressive."

Drazen pointed out, for example, how the final recommendations specified that only 10% of all orders entered by an authorizing physician at a hospital must be made via computerized physician order entry. The initial draft did not provide an exact percentage. But the requirement for physician practices remains the same -- they must use CPOE for all orders, according to the final version. Doctors also received several additional recommended standards to meet by 2011.

Some health care policy experts praised the quick work by Dr. Blumenthal, the committee and the working group.

"They have laid out these big, achievable goals that are central and critical, and the way meaningful use needs to be implemented is with an eye toward achieving these objectives," said Carol Diamond, MD, managing director of the health program at the Markle Foundation, a health IT policy organization based in New York. Markle teamed up with two other health care policy organizations -- the Center for American Progress and the Engelberg Center for Health Care Reform at Brookings -- to comment on the working group's report.

The organizations called the measures ambitious but achievable. Dr. Diamond cautioned, however, that HHS should not try to add new goals or tasks for physicians. "Rather than try to expand these even more and add more requirements, there's a real opportunity for HHS to define within these goals how each specific provider group can achieve these measures."

2011 objectives

Despite some revisions, most of the initial recommended requirements for physicians receiving EHR stimulus money remain the same. By 2011, physicians will be considered meaningful EHR users if the practice meets multiple objectives, including:

  • Maintaining an active medication list.
  • Incorporating lab test results into the EHR as structured data.
  • Generating lists of patients by specific conditions to use for quality improvement, reduction of disparities and outreach.
  • Reporting ambulatory quality measures to the Centers for Medicare & Medicaid Services.
  • Sending reminders to patients for preventive and follow-up care.
  • Documenting a patient progress note for each encounter.

The Health IT Policy Committee also recommended objectives for 2013 and 2015.

The medical community has tracked the committee's work and the meaningful-use debate with much interest, as the stimulus package provides approximately $19 billion in net Medicare and Medicaid EHR incentives for physicians, hospitals and others. The incentives begin as bonuses for early adopters but turn into penalties for those who don't adopt quickly enough.

Meaningful users have been defined generally as physicians who have demonstrated to the government that they are using electronic prescribing and that their systems are connected to other entities in a way that provides for the exchange of health data to improve care quality. But the working group was asked to specify exactly what objectives and measures physicians would need to meet for stimulus incentives.

Health IT and policy experts say the recommendations approved by Dr. Blumenthal are a significant benchmark for physicians.

"This is a good time for physicians to check in, because the first wave of the draft was more about moving it out of the political process, and this development certainly moves it toward rule-making," said Jana Skewes, president and CEO of SharedHealth, a provider of health information products and solutions based in Chattanooga, Tenn. "I would say now there are enough signs and pillars of requirements that physicians would be using their time wisely to determine what the requirements are."

Skewes advised doctors who already have EHRs to check with their vendors to see if systems are up to date with the most current recommendations.

Now that the medical community has a pretty good idea of what to expect from the government, Drazen said, practices shouldn't wait to start upgrading or adding EHRs.

"The market has been waiting, and people have been afraid to make investments, because they weren't sure what was required," she said. "But big capital investments shouldn't have to be made to at least get started."

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What makes EHR use "meaningful"?

The Health IT Policy Committee's final meaningful-use recommendations for federal stimulus funding eligibility make several revisions to a working group's draft. The new recommendations break down the objectives according to hospitals and "eligible providers," which include physicians. Among the revisions:

2011 requirements

  • For hospitals, 10% of all orders (medication, laboratory, procedure, diagnostic imaging, immunization, referral) directly entered by an authorizing physician must be made through a computerized physician order entry process. Individual physicians still must use CPOE for all orders, even if electronic interfaces with receiving entities are not available. The initial draft did not specify the required percentage for hospitals and did not address the electronic interface issue.
  • Physicians must be able to check insurance eligibility electronically from public and private payers, when possible, and submit claims electronically. This was not in the initial draft.
  • Patients must receive timely electronic access to their health information, including lab results, medication and problem lists, and allergies. The initial draft did not include the word "timely."
  • Physicians must implement one clinical decision rule relevant to specialty or high clinical priority. This was not in the initial draft.
  • Physicians must record patient smoking status and advance directives. This was not in the initial draft.
  • Physicians must report ambulatory quality measures to CMS. This was not in the initial draft.
  • Physicians must maintain an up-to-date list of current and active diagnoses based on ICD-9 or SNOMED. The initial draft did not specify use of the two classification sets.

2013 requirements

  • Specialists must report to relevant external disease or device registries that are approved by CMS. This was not in the initial draft.
  • Hospitals must conduct closed-loop medication management, including computer-assisted administration. This was not in the initial draft.
  • All patients must have access to a personal health record populated in real time with health data. This was moved up from 2015 in the initial draft.

Additional provisions

  • Patients' access to EHRs may be provided via a number of secure electronic methods, such as personal health records, patient portals, CDs or USB drives.
  • CMS will determine how submitting electronic data to immunization registries applies to Medicare and Medicaid meaningful-use requirements.
  • CMS may withhold federal stimulus payments from any entity that has a confirmed privacy or security violation of the Health Insurance Portability and Accountability Act, but it may reinstate payments once the breach has been resolved.

Source: Health IT Policy Committee

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