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The Mechanics of Meaningful Use
By David Yeager

On December 30, 2009, Health and Human Services (HHS) took another step toward defining the meaningful use of EMR systems. Following months of discussion, the Centers for Medicare & Medicaid Services issued a notice of proposed rulemaking, known as the meaningful use rule, that outlines the criteria for healthcare organizations to qualify for meaningful use incentive payments. Now in the public comment period, the rule could become official as early as this spring. Not surprisingly, the proposal has generated plenty of talk in HIT circles.

The meaningful use rule lays out three stages that medical providers must complete to achieve meaningful use. Stage 1 focuses on the capture and coding of medical information to track certain clinical conditions and communicate that information for care purposes, as well as the development of clinical decision-support tools and the reporting of quality measures. Stage 2 refines these initiatives and expands their scope to include computerized physician order entry (CPOE). Stage 3 mandates decision support for national high-priority conditions, patient access to self-management tools, and access to comprehensive patient data with an eye toward improving health outcomes. Medical providers and vendors have been waiting for the ruling to be issued but, according to Erica Drazen, ScD, head of the emerging practices group for technology vendor CSC Health Services, there were no real surprises.

“There were tweaks, but there weren’t major changes,” says Drazen. “There have been lots of opportunities to comment [throughout this process], so I doubt we’ll see major changes [in the final rule]. The only area where [HHS] really said they didn’t like what they had published and wished it could be changed was in the area of whether or not physicians that practice exclusively in hospitals will be eligible for meaningful use payments. And they clearly didn’t want to exclude primary care providers in those settings. But the way it’s currently set up, if you practice more than 90% exclusively within the hospital, even if it’s in an ambulatory setting most of the time, you’re not eligible for the incentive payments. So that, I think, is the most likely thing that will change.”

One of the biggest differences between the meaningful use rule and what had previously been discussed is the amount of time medical providers will have to begin achieving meaningful use. The target date for Stage 3, 2015, remains unchanged, but there is more time allotted to reach Stage 1.

“They were concerned that if you missed the Stage 1 window, which was then called the 2011/2012 window, you had no opportunity to catch up because, in the original proposal, if you started in 2013, you had to meet what’s now called the Stage 2 requirement,” says Drazen. “And in the first year, you only have to demonstrate meaningful use for three months rather than the full 12.”

But even with the extra time, Ron Wince, president and CEO of Guidon Performance Solutions, a management consulting firm that works with healthcare organizations to improve operational efficiency, sees it as a major hurdle for those who wish to qualify. He thinks the timelines may be extended further.

“I wouldn’t be surprised to see them extended a couple of times,” says Wince. “I think they’ll probably move it again and maybe once more. But what you might see are piecemeal changes. For example, the simple requirement of having an electronic medical record will not move, but harder things like using it as a clinical support tool or something like that where you’re changing processes that people follow will move. A lot of folks aren’t ready for that kind of stuff. I think the places where it’s harder to comply will be the places where [HHS] will be forgiving on the dates.”

Drazen notes that the extra time will allow more organizations to gain access to a small pool of IT vendors who may not have been available with a shorter timeline. However, the extra time isn’t a cure-all. “All that’s done is move crunch time from the beginning of the period to the end of the period because you still have to get there by 2015 to avoid the penalty,” she says. “People who started last summer are not going to be disappointed.”

Wince adds that small organizations in particular will have to scramble to get the work done. “The people with the smallest projects and the least amount of money and who are latest to the party are going to get whatever’s left over,” he says. “I think we’re going to have a crunch in the amount of resources available from outside the organizations to support what’s going on in the practices and the smaller healthcare organizations.”

He says small practices will also face other difficulties. “For the smaller folks, when you don’t take into account the magnitude of what’s going to have to happen within their organizations—finding the right vendor, meeting the requirements, getting the capital available to do it, freeing up the resources within the organization—in many ways it’s creating a perfect storm for any of the organizations that have not already had some familiarity with EMRs. I think it’s going to be a boon for the software and consulting groups that do EMR implementations.”

Drazen says other challenges that practices of all sizes will need to meet include capturing quality data, sharing information with patients, getting doctor buy-in for documentation, CPOE, clinical information exchange, and ICD-10-CM coding. All things considered, though, she believes the rule provides clarity and levels the playing field.

But Wince isn’t quite as optimistic. “The fact that in basically 12 months or 18 months we’ve gotten to the point where we are doesn’t necessarily mean that the industry can move that quickly, especially considering the fact that healthcare in general has not kept up with the pace of information technology as well as a lot of other industries,” he says.

“I think without that perspective we’re putting some pretty heavy pressure on some of these organizations who are going to find it pretty hard to meet all the requirements.”
One thing they both agree on is that patients will benefit from the improved communication. “I do think there will be some impact on the patient side where we’re going to have better information available,” says Wince.

“The winners are the patients,” says Drazen. “If you look at where this is all headed, it’s headed toward greater openness, greater safety, and more standard procedures.”
It remains to be seen, however, how long it will be before patients reap those benefits.

— David Yeager is a freelance writer and editor based in Royersford, Pa.

Centers for Medicare & Medicaid Services’ Proposed Rule: http://edocket.access.gpo.gov/2010/pdf/E9-31217.pdf

Health and Human Services’ Interim Final Rule: http://edocket.access.gpo.gov/2010/pdf/e9-31216.pdf