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August 2, 2010

And So It Is Written…
For The Record
Vol. 22. No 14 P. 20

Industry experts offer their opinions on the 864-page meaningful use edict.

After decades in the making—OK, it only felt like it was that long—the federal government last month presented the healthcare community with the final meaningful use (MU) guidelines for EMRs. For The Record (FTR) gathered reaction from the following thought leaders:

• Margret Amatayakul, MBA, RHIA, CHPS, CPHIT, CPEHR, CPHIE, FHIMSS, of Margret\A Consulting, LLC;

• Edmund Billings, MD, chief medical officer for Medsphere Systems Corporation;

• Rita Bowen, MA, RHIA, CHPS, SSGB, AHIMA president;

• Robert Connely, senior vice president at Medicity Inc;

• Janet Dillione, executive vice president and general manager at Nuance Healthcare;

• Larry Gerdes, CEO of Transcend;

• Heather Haugen, PhD, corporate vice president of research for HIT consulting firm The Breakaway Group, and Jeffrey R. Woodside, MD, former executive vice president and chief medical officer for UT Medical Group, Inc;

• Charlie Jarvis, vice president of healthcare services and government relations for NextGen Healthcare; and

• Ken Rubin, general manager of healthcare at Iron Mountain.

Any surprises in the final rule?

Gerdes: The meaningful use definition is noticeably void of the inclusion of dictation when over 90% of physicians will say it is critical for both productivity and rich content.

FTR: How will the changes affect HIM departments?

Bowen: Fortunately for some individuals working in HIM, their organizations have become electronic or are working toward that goal. Others may not have taken that step toward the adoption and implementation of EHRs, which will prove to be a challenge. The provisions of the regulation outline some activities that organizations are currently engaged in, and this will assist in keeping the reporting burden from increasing exponentially.

Some of the measures, such as providing patients with an electronic copy of their health information, providing patients with an electronic copy of their discharge instructions, and providing patients with timely access to their health information, will indeed impact HIM departments. HIM may be required to redefine their workflow and release-of-information processes and policies. Privacy and security practices and policies must be revisited and possibly modified to reflect meeting the required thresholds.

Defining roles and responsibilities for meeting the requirements is necessary, as there may be an increased need for collaboration and coordination with other departments.

Organizations that may be mostly paper based and are migrating to EHRs could pose challenges for the workforce and its ability to “change with the times.” You may be required to conduct training or hire individuals with some information technology, data analytics, and other skills or shift responsibilities within the department to support those changes. Evaluating the HIM department skill sets is something to consider as this transformation occurs.

Despite the challenges, this regulation presents a significant opportunity to those HIM professionals working in the provider and hospital setting.

Amatayakul: It is conceivable that as more EHR technology supports the production of the continuity-of-care document from structured data within the record, the HIM department could find that other departments, such as nursing and ED (the emergency department), will be producing these either in paper or electronic format to give patients right on discharge. HIM departments need to help these departments perform these functions in appropriate ways and document that such access was provided. I am a very firm believer that HIM departments must evolve to become “departments without walls” and able to support other departments in these activities directly.

FTR: Did the final rule affect the timely access requirement?

Bowen: The final regulation modified this measure slightly in that it shifts this measure from the “core set” of measure reporting to the “menu set,” which allows for some flexibility for eligible professionals (EP) to select from an assortment of measures to report. EPs may or may not select this measure to report on.

The final regulation changes the time frame in which patients are provided timely access to their health information. The proposed regulation specified a time period of allowing access within 96 hours of the information being available, and the final regulation has modified the time frame to allow for some flexibility by allowing access to the information within four business days. CMS (the Centers for Medicare & Medicaid Services) realized that most EPs do not operate under a 24/7 schedule, thus understanding the original time frame would be too burdensome.

The measure threshold for this objective has also been modified slightly. The proposed regulation stated that “at least 10% of all unique patients” would be allowed timely access to their health information. The final regulation has changed the measure to reflect “more than 10%” of all unique patients are provided timely access to their information and allows for some discretion on behalf of the provider to withhold information.

FTR: Will HIM departments have trouble meeting the timely access challenge?

Amatayakul: HIM departments need to work closely with IT on the technical side to be able to generate applicable summaries on a timely basis and with physicians to complete records on a timely basis to produce such summaries.

FTR: Were the rules relaxed too much?

Jarvis: From our initial review of the ruling, it appears several of the criteria were relaxed. However, the bar still remains relatively high, so it is important that providers move forward with EHR product selection as soon as possible. Physicians and hospitals that may have been hesitant in the past should be able to move ahead with confidence as they make their EHR selections and work to meet the MU requirements.

Billings: We do not feel the rules were too relaxed and support the government’s efforts to adjust the criteria so more providers can meet the guidelines and qualify for funding.

Rubin: Time will tell if the rules were too relaxed, borne out by the overall success of EMR implementation. Regardless of whether the rules were too relaxed or not, the reality is that providers will be living in a world of hybrid records for years to come. More than 40 states require 10-plus years of retention of the medical record, and more than 50% of hospitals keep records forever. Consequently, providers need to include in their plans provisions for integrating paper and electronic systems and converting paper records to bridge the gap between paper and digital so that care is delivered on the strength of a complete patient record. With new processes in place, providers should be able to save money by eliminating/reducing legacy costs and redundancies.

Haugen and Woodside: Although CMS reduced the number of meaningful use requirements and reporting thresholds outlined in the proposed rule, the criteria remain challenging and comprehensive. Based on our experience with current clients and research, many organizations will be challenged to meet the minimum requirements for the first payment year.

Dillione: The rulemakers did what they said they would do: They listened. They asked for comments and saw a significant response from the industry. They internalized the feedback and were able to react to what they heard. I don’t think the rules were relaxed too much. I agree with Dr. [David] Blumenthal: It is important for these rules to be set at a level where it is possible for every willing provider to have a good shot at meeting meaningful use.

However, the biggest challenges for providers still remain. It’s not just the meaningful use regulations; it’s the clinical processes themselves that need to be refined in order to migrate toward achieving meaningful use. Despite some relaxation in the rules, there is still a significant amount of work and investment that is needed.

Bowen: We (the AHIMA) would not say that the rules were relaxed too much; however we were pleased to see that CMS modified the clinical quality measures to reflect only those that had electronic specifications, which aligns with the industry moving toward using EHRs and leveraging EHRs for reporting purposes. This reduces the burden for reporting and waiting for the technical specifications to be released at a later date. By providing the technical specifications now, the industry can begin or continue working on becoming a meaningful user of EHRs.

The stage 1 meaningful use objectives and measures remained firm, and we support the use of EHRs for quality measurement. We believe the requirements are aggressive; however we do appreciate the reductions or modifications in thresholds for the measures as well as some flexibility provided in the menu set of objectives and measures for stage 1. These requirements will push industry toward adopting and implementing EHRs but are also attainable. We would also like to emphasize that this program is an incentive program to voluntarily adopt and implement EHRs.
FTR: What was the most significant change?

Jarvis: The reduction in the number of criteria needed to qualify as a meaningful user.

Billings: We are very happy that flexibility is part of the equation. We appreciate that ONC [the Office of the National Coordinator] and HHS [Health and Human Services] are “giving providers the flexibility to find their own paths.”

Dillione: The flexibility introduced for achieving meaningful use is the most salient adjustment. Clearly, this is an indication that the government wants to recognize those who are on the path to improved patient care through the use of electronic records.

Haugen and Woodside: The proposed ruling required all eligible providers, hospitals, and critical access hospitals to achieve stage 3 meaningful use by 2015. Many in our industry felt this was unrealistic considering the criteria for stage 3 and the time frame. The final ruling does not include stage 3 criteria or the time frame for this stage. CMS indicated that “due to many comments and our plan to engage in additional rounds of rulemaking, we are removing discussion of actual alignment between the first payment year of an eligible provider, hospital, or critical access hospital and the stage of meaningful use they will be expected to meet in all years after 2014. Our policies for 2015 and subsequent years will be determined through future rulemaking.”

Klimek: There were several significant changes, mostly related to thresholds being reduced:

• e-prescribing requirements reduced from 75% required to 40%; and

• CPOE (computerized physician order entry) had a threshold of 80% of orders for eligible professionals and 10% of orders for hospitals.  The language in the final rule focuses on order entry of medications and requires that 30% of patients with medication orders to have at least one medication order entered electronically. This requirement applies to both eligible professionals and hospitals.

Bowen: AHIMA was encouraged to see that the final measures for the EP clinical quality measures were limited to those for which electronic specifications are available and a preference for National Quality Forum (NQF) endorsement. We believe this aligns with the intent of the regulation to move away from paper records and manual calculations toward the use of EHRs to collect data and use for a variety of purpose with a priority being meaningful use. We also believe the increased flexibility of selecting from an assorted group of measures in addition to the core measure group enables EPs to select the most appropriate measure for their setting.

This belief also holds true for the eligible hospital set of measures where there was a significant reduction in the total measures from the proposed regulation to only those that have electronic specifications and NQF endorsement.

FTR: Is there a requirement that stayed as is that you thought would have been tweaked?

Jarvis: Lowering the floors on the criteria that still require 89% compliance.

Connely: Quality reporting was a requirement in the interim rule that seemed like it should have been moved to stage 2 or listed as a menu set item. For providers not currently participating in PQRI (Physician Quality Reporting Initiative), this could be a significant hurdle. 

Dillione: I was surprised not to see more clarity surrounding the physician narrative (or the progress note). EHRs are only as valuable as the information that is captured within them, and this includes both structured and unstructured components of patients’ medical records. These two documentation components are critical to enable an environment conducive to analytics, reporting, and to the quality measurement that is absolutely so important to improving patient care.

Bowen: Viewing this question from the other direction, AHIMA had recommended in our comment letter to CMS that they should develop and describe an infrastructure to support a review and appeals process and provide assistance to providers through a traditional help desk method. CMS noted these suggestions and responded they will consider these recommendations in future guidance.

Klimek: It seems to me that there is still some ambiguity as it relates to the section on providing patients their healthcare information and in what format. ONC stated in their final rule, “We believe that more options give the EP needed flexibility.  The EP could choose any of the listed means from the proposed rule of PHR, patient portal on a website, secure e-mail, electronic media such as CD or USB fob, or printed copy.  If the EP chooses an electronic media, they would be required to provide the patient a paper copy upon request.  Both forms can be and should be produced by certified EHR technology.” Allowing all these different options seems to imply the EPs can continue to supply EHR and PHR data via paper or electronically for an extended period of time. We would hope that this would be only for the interim.

FTR: What were the best and worst modifications?

Billings: The decision to offer choice and flexibility for hospitals and physicians to achieve meaningful use demonstrates ONC’s and HHS’ recognition that providers need standards that are able to be adjusted to the specific needs of their facility, practice, and patients. This flexibility drives innovation and interoperability applicable to each healthcare setting. We feel that ONC and HHS have found a good balance between properly encouraging the adoption of EHRs while keeping the requirements relaxed enough to allow them to qualify for federal stimulus funding by achieving meaningful use.

Connely: The best change was the elimination of claims and eligibility requirements, which had little or nothing to do with meaningfully using an EHR. It’s a minor point, but keeping the need to transmit 40% of prescriptions electronically as a core set, instead of menu set item, was probably the worst modification.

Dillione: The best modification was the relaxation of the requirement standards. By stretching the goals over a longer time frame, meaningful use has become more achievable and will not cause as much of a shock to the existing healthcare system.

The worst modification, or nonmodification, is a lack of clear guidance on what should be done with physicians’ unstructured clinical notes, the narrative. We work with thousands of doctors, and time and again we hear concerns about “losing the physician narrative.” Our customers—and we do, too—believe there should be standards surrounding unstructured notes and that the physician narrative should be considered an essential and integral part of any useful, meaningful clinical record.

FTR: How will the changes affect EHR vendors?

Jarvis: The most important next step for EHR vendors is to complete a thorough review of the final criteria and make sure their clients have the tools and resources they need to reach meaningful use. … Also, vendors need to seek certification as soon as the temporary certifying bodies are named.

Billings: The final rules will enable EHR vendors to be more responsive to the specific needs of hospitals and physician practices.

Rubin: With the ambiguity removed, EHR vendors and companies like us that enable meaningful use have a clear mission. The focus can be on achieving an understood definition of meaningful use rather than merely a systems deployment. As such, we can help providers not only implement an EHR but also ensure adoption by comprehensively addressing implementation and providing for the prudent conversion from old to new systems.

Dillione: EHR vendors that deliver healthcare organizations with solutions that clearly align with the meaningful use requirements will undoubtedly see an uptick in their business. … In tandem with the meaningful use rules, it is critical for vendors to support the actual “use” of these systems.
FTR: Can you estimate how many organizations already meet the new criteria?

Haugen and Woodside: This is very difficult to estimate. We can only make estimations based on what we know about the organizations we have been working with to improve EHR adoption. We use a rigorous methodology that allows organizations to measure adoption at the level of end users, which is critical to achieving the meaningful use criteria.  In organizations where users have adopted the system, meaning they are using it according to best practices and policies established in the organization, achieving the stage 1 criteria in 2011 is realistic. However, even for organizations that have reached a high level of adoption, they must have the ability to report on the criteria. In the final ruling, CMS indicates that certified EHRs will automatically calculate the required quality measures. From what we have seen, many organizations will need to upgrade their systems to be in on a certified product.

FTR: How will the new rules affect adoption strategies?

Haugen and Woodside: For several years, we have been encouraging organizations to develop and adhere to research-based strategies for adoption. We often find organizations focusing on implementation or the installation of an application rather than the long-term clinical and financial outcomes they seek from the application. This focus on implementation is not congruent with meaningful use and will slow adoption. Based on our research and experience with clients, there are four critical components to achieving adoption and meaningful use. Organizations must begin with engaged leaders, ensure end users are proficient by role in the EHR, measure and track clinical and financial outcomes, and develop a plan for sustaining adoption over the life of the EHR.