Provider groups raise a clamor over 'meaningful use'

Health providers and IT policymakers returned from the holiday weekend on Monday having had just enough time sort through the administration’s “meaningful use” proposal, its 700-page incentive plan designed to spur hospitals and physicians to pursue digital make-overs of their practices.

Their first impression: That the administration’s hugely ambitious, carefully crafted, $20 billion incentive plan may provide too much stick for the carrot.

The Medical Group Management Association, which represents a primary target group for the plan – small and medium-sized health practices – said the rules were “overly complex,” warning they would present group practices with “significant challenges” in meeting the requirements.

Dr. William Jessee, the association’s president and CEO, called for simplifying the criteria for how providers are to earn plan’s incentive payments, saying the “overly burdensome requirements” would “discourage physician participation in the program and the implementation of EHRs.”

Among the barriers MGMA underlined were “unreasonable thresholds” for qualifying as meaningful users, including computerized physician order entry, electronic claim submission and the requirement that physicians provide patients electronic copies of medical records within several days of a request.

The American Hospital Association, whose 5,000 member hospitals represent the single largest group of potential beneficiaries of the plan, took a different tack, saying that hospitals should be rewarded for the work they have already  accomplished in digitizing their health records.

The proposed rules, AHA said, “create a stringent definition of meaningful use that don’t recognize these important efforts and would unfairly penalize many hospitals.”

AHA executive vice president Rick Pollack urged the Health and Human Services Department to make “significant changes” to the plan or it will be “unlikely that the vast majority of hospitals can meet the proposed standards, making them ineligible for this important funding.”

The proposed definition of "meaningful use" is a worthy goal, he added, “but it should be a destination point, not a starting point.”

ONC's balancing act

Other observers noted the Office of the National Coordinator and the Centers for Medicare and Medicaid Services had to set up a delicate balance in designing the incentives – making them challenging enough to have a lasting impact on health outcomes but not so burdensome as to stall adoption.

“ONC and CMS are between a rock and a hard place,” said Dr. John Loonsk, the former director of interoperability for ONC and now chief medical officer for CGI Federal Inc., an IT services firm.

The challenge they faced, he said, is to “thread the needle with enough requirements and specifications to create a viable, secure electronic infrastructure without, in doing so, making the adoption of electronic medical records less attractive to the providers they want to adopt them.”

Meaningful use planners were trying to create a balance between spurring adoption and achieving an infrastructure with enough “technical rigor” to mobilize data in ways needed to improve health outcomes, Loonsk argued.

“It would have been appealing if (the HITECH Act which funded the incentive program) focused more on these data needs,” said Loonsk, “but ONC and CMS are now trying to find the right balance to make HITECH work.”

'Transparency on steroids'

Other experts emphasized the challenges providers will have applying the standards for achieving meaningful use. Dr. Mark Frisse, director of regional informatics programs at Vanderbilt University’s Center for Better Health, described the ONC interim final rule on standards and certification as “demanding,” “precise,” and “artfully crafted.”

Frisse praised the emphasis the standards appear to place on the role of the electronic health record as a “means of communication among providers, patients and other care givers,” rather than as “a static repository of electronic health information.”

“The rule carries this clinical tradition through almost four decades of research on clinical decision support, e-prescribing, human factors, and outcomes measurement,” Frisse said in an email message. “Undoubtedly, this interim final rule is focused on the well-being of the individual receiving care first and foremost.”

Even so, the standards must solve for enormous business challenges, Frisse noted. One of them is the requirement for medications prescribed by multiple providers to be integrated into a single medication list.

In this area, “there are great discrepancies among the prescription medication list in an EHR, what many claims-based systems report having been dispensed, what retail pharmacy systems report as dispensed, and the intent of the prescriber,” Frisse wrote.

“Reconciling these lists is challenging when one must “electronically complete medication reconciliation of two or more medications lists (compare and merge) into a single medication list that can be electronically displayed in real time.”

However, the regulation offers immediate benefits for consumers. Frisse noted. Among the most powerful “game changers” in the rules may be the requirement that physicians provide patients with electronic assess to their health information within 96 hours of the information being available to the physician. The information includes lab results, problem list medication lists and allergies.

“This is transparency on steroids,” Frisse said.

Glass half full

Other health IT industry organizations also saw the glass as half full. The Healthcare Information and Management Systems Society, which represents health IT industry organizations and is the publisher of Government Health IT, said the proposal included “much more to applaud than criticize.

“We now have clarity of what technology functions constitute a qualified electronic health record,” said Steve Lieber, HIMSS president and CEO.  In respect to market forces, ONC “refrained” from establishing single standards, even in places where they should be established.

“Such restraint will have ramifications, as will the necessary establishment of initial provider performance requirements that will ultimately drive quality improvements,” Lieber said. As a result, the goal of meaningful use may take longer and cost more.

“This foundational work, while required, will likely result in provider uncertainty about which IT products to adopt, costs through adoption of ever-maturing IT over time, higher costs associated with a need to support multiple standards, and somewhat delay improvements in patient outcomes and costs,” he said.

Dr. John Halamka, co-chairman of the federal advisory Health IT Standards Panel, said in a Jan. 4 blog posting that he expected that “many will be stressed by meaningful use.”

Halamka counseled providers is to be practical. “My advice is to approach it stepwise, breaking it down into discrete projects which are doable,” he said. Halamka offered a 25-step plan adopted by Beth Israel Deaconess Medical Center, where he is chief information officer, but the steps are applicable to other providers.