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Is EHR 'meaningful use' a floor or a ceiling?

Is the federal "meaningful use" standard a floor or a ceiling for electronic health records?

That was the question put to the closing panel at WTN Media's ninth annual Digital Healthcare Conference in Madison last week by conference chair Dr. Barry Chaiken. There was no consensus, but plenty of lively discussion about the $27 billion Medicare and Medicaid incentive program for embracing EHRs in order to improve the quality and efficiency of patient care.

"Meaningful use is not the floor," said Gartner health IT analyst Vi Shaffer, who expressed frustration that so many healthcare organizations still have not met performance measures set by the National Quality Forum as long as 12 years ago. "All the existing quality measures that have been out there so long should be considered the floor."

Another panelist, Judy Murphy, vice president of information services at Aurora Health Care in Milwaukee, respectfully disagreed on this point. "For the majority of the criteria [in Stage 1 of meaningful use], it's a floor," she said.

Murphy pointed to the requirement that providers employ computerized physician order entry (CPOE) technology for at least one medication order for a minimum of 30 percent of patients. "No one would go into an implementation shooting so low," she said.
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Proposed rules from late 2009 set the CPOE threshold at 10 percent for hospitals but 80 percent for physicians, but the final requirement, published in July 2010 in response to public criticism of the discrepancy, is 30 percent for both.

Judy Faulkner
(Murphy and the other participant in the panel discussion, Epic Systems CEO Judith Faulkner, actually had hands in shaping the Stage 1 standards as part of advisory boards to the U.S. Department of Health and Human Services. The Murphy is a member of the Health IT Policy Committee and Faulkner is on the Health IT Policy Committee; the Aurora executive also sits on the Health IT Policy Committee's Meaningful Use Workgroup.)

Shaffer did allow that electronic documentation and clinical decision support functions of EHRs are often underused, and usage can vary quite a bit from hospital to hospital, even within health systems. Organizations tend to implement a few CDS rules at a time or concentrate on electronic documentation in certain departments or disease states, generally wherever clinician "champions" of EHRs practice, Shaffer said.

According to Shaffer, the idea behind meaningful use is to "lift people up," particularly when it comes to safety-net providers like critical-access hospitals. Shaffer, who had traveled from Centreville, Va., for the event, said policymakers didn’t want to see "oligopolies" in local markets because smaller providers were forced to merge with large health systems because of EHR requirements.

(Although a lot of small physician practices have joined up with group practices or sold to integrated delivery networks in recent years, consolidation was underway prior to passage of the American Recovery and Reinvestment Act in 2009. That legislation authorized the EHR incentive program.)

Faulkner didn't explicitly state whether she thought meaningful use was a ceiling or a floor, but noted that the Verona-based EHR vendor shows a simpler version of its core product in foreign markets than it does in the U.S. That's because Epic has had to add a number of functions to its domestic EHR to help customers meet regulatory requirements or protect themselves from malpractice liability.

Murphy said that Stage 1 meaningful use has caused Aurora to alter its own IT plans by activating a patient portal and moving more toward interoperability sooner than intended. “We wouldn’t have decided to give electronic copies of clinical summaries at discharge [without meaningful use],” Murphy said.

Chaiken, chief medical officer at Docs Network, the Boston-based consultancy that he runs, and a former chair of the Healthcare Information and Management Systems Society (HIMSS), said he believes health IT will raise the norm for all providers and “lock in” better behaviors, suggesting that in some ways, meaningful use could be a floor.

Right now, Stage 2 of meaningful use, looks more like a ceiling for a lot of providers. For one thing, the second of three levels is scheduled to start in 2013 for hospitals and doctors meeting meaningful use in 2011, but Murphy noted that the rules for Stage 2 will not be final until June 2012. Since Medicare Part A—inpatient care—is tied to the federal fiscal year of Oct. 1, that would give hospitals less than four months to upgrade their EHR systems and meet the new standards, a task made even more difficult by the fact that EHRs must be certified to have all the functionality required for each stage and providers must be using a certified version for the entire reporting period.

But HHS seems to be taking steps to address this timeline that Murphy called "impossible." A day after the WTN Media conference, Faulkner and Murphy were in Washington, D.C., for a Health IT Policy Committee meeting. There, the Meaningful Use Workgroup formally asked HHS to give anyone attaining Stage 1 meaningful use in 2011 three years to get to Stage 2.

Whether HHS does eventually allow this delay, Murphy believes acceptance of EHRs will come rapidly and the floor/ceiling debate will become moot. "I think in 2015, we’re gonna look and say, 'How did we even have healthcare without computers?'" Murphy said.

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