Article Summary: The Meaningful Use Workgroup of the Office of National Coordinator’s HIT Policy Committee presented its initial draft of “meaningful use” at the Committee’s June 16, 2009 HIT Policy Committee meeting. As the National Coordinator and Chair of the HIT Policy Committee, David Blumenthal, M.D., M.P.P., reminded the meeting’s participants: “This is an initial draft, which has a long way to go.”  Health reform clearly is a cornerstone of the Meaningful Use criteria. The Committee established five key Meaningful Use goals with criteria that will be stengthened every two years based on that year’s specific objective.

Wow, what a meeting on Meaningful Use. The Office of National Coordinator’s HIT Policy Committee’s Meaningful Use Workgroup, which presented its initial draft at the June 16, 2009 HIT Policy Committee meeting, clearly worked hard these past few weeks.  The National Coordinator and Chair of the HIT Policy Committee, David Blumenthal, M.D., M.P.P., commented that the meaning of “weekend” may have to be redefined for the Workgroup’s members.  I commend these folks and their organizations for volunteering their time to the arduous task of defining Meaningful Use.

John Chilmark’s Twitter entry expressed my exact sentiments: “So many angles to meaningful use, difficult post to write today.” I too have so many thoughts about what I heard about the first draft of Meaningful Use, I have decided to let some of them gel. I will focus this blog entry on my initial thoughts and comments, and post more later.

The Initial Draft.

As promised, we do have a start at a definition for Meaningful Use.  It’s important to keep in mind that today’s release was never meant to be even close to final.  As Dr. Blumenthal reminded today’s participants: This is an initial draft, which has a long way to go.

The Workgroup emphasized that it is absolutely essential for us to have a sense of the ultimate vision, which is: “To enable significant and measurable improvements in population health through a transformed health care delivery system.” HIT is envisioned as laying the foundation for health reform and affordability. In fact, health reform clearly is a cornerstone of the Meaningful Use criteria.

Five key goals of Meaningful Use were articulated:

1. Improve quality, safety & efficiency
2. Engage patients & their families
3. Improve care coordination
4. Improve population and public health; reduce disparities
5. Ensure privacy and security protections

Per the Workgroup presentation, “These goals can be achieved only through the effective use of information to support better decision-making and more effective care processes that improve health outcomes and reduce cost growth.”

The Workgroup first established an “achievable vision for 2015” with goals that would evidence Meaningful Use. It then worked back from 2015 to establish the 2013 and 2011 goals. In doing so, the result is that Meaningful Use would progress to a full slate of more stringent requirements in 2015, from data capture in 2011 to ultimately improved outcome measures in 2015. The objective for the Meaningful Use requirements would progress every two years as follows:

• 2011: Capture and share data
• 2013: Advance care processes with decision support
• 2015: Improved Outcomes

With this progression laying the foundation, the Workgroup set out Meaningful Use criteria for each of the five goals for 2011, 2013 and 2015.   The measures in 2011 are more developed while most of the measures in 2015 are more broadly stated with a note that they are TBD (“to be determined”). The complete Meaningful Use Matrix setting out the objectives and measures for 2011, 2013 and 2015, can be reviewed on the HIT Policy Committee webpage.

Who Has Yet to Weigh In?

On the one hand, I marveled at the impressive work product and effort put forth by the Meaningful Use Workgroup.  Their knowledge and thoughtfulness only made me fear that the aggressive deadlines Congress passed may cause America to shortchange itself in regard to what the Workgroup and others can contribute if only we had more time. The Workgroup’s time is especially short because the HITECH Act requires its product to also be deliberated on by the members of both HIT Committees, as well as the ONC, in consultation with the Secretary for Health & Human Services (HHS), which will undoubtedly rely on the Centers for Medicare and Medicaid (CMS).

And the National Quality Forum also will need to weigh in on the Meaningful Use definition, especially as concerns “eligible professionals.”  The HITECH Act requires, with regard to any reporting measures that are adopted as part of Meaningful Use for eligible professionals, that the Secretary give preference to clinical quality measures that have been “endorsed by the entity with a contract with the Secretary under section 1890(a).” This entity so far has been the National Quality Forum, which is the consensus-based entity designated via Section 1890(a) of the Social Security Act, to make recommendations on integrated national strategy and priorities for health care performance measurement in all applicable settings. (For example, the 2011 Measures include multiple reporting measures such as % diabetics with A1c under control and % of smokers offered smoking cessation counseling.)  When and how will the requisite endorsement be obtained and reflected in this process?

The states, conceptually, also should be weighing in on Meaningful Use, given that each state will play a critical role in the interoperable network of EHRs; however, there is no specific process for state input under the HITECH Act.  (States are responsible for establishing their own definition of Meaningful Use, subject to CMS approval, for the Medicaid incentives but I would expect that they will look to the Medicare definition for initial guidance.)  Other groups were suggested today as having valuable knowledge and insight in regard to the development of HIT that involves quality measures, but will there be time for their input?  Are we, as a country, taking advantage of all the resources at our disposal before we rush to adopt some form of meaningful use of EHRs?

Finally, the public can weigh in on this initial draft. However, time is limited. To submit comments on the draft, go to the HIT Policy Committee homepage and click on the link at the top of the page directing readers to Meaningful Use Comment Instructions.  Public comments are due by June 26, 2009.

The HITECH Act Requirements Pose Challenges for Adoption.

As we worked through the initial draft and the comments today, it became clear that the time constraints and incentive schedule under the HITECH Act may actually work against achieving the quality goals of HIT. Several participants suggested that providers might be induced by the Meaningful Use schedule to adopt early merely to get the larger incentive payment while the Meaningful Use standards were still fairly achievable. These early adopters might not apply for the later, lower incentive payments as the Meaningful Use standards increase in later years.  In fact, the HITECH Act may require later EHR adopters to face what is effectively a double penalty: a) lower incentive payments; and b) tougher Meaningful Use standards in the very first year of use. It was suggested today that this fact combined with the lower incentive payments may be a disincentive.  Although these providers may still adopt EHRs in the long-run, they may opt out of the incentive payments fearing that the resources required to meet the higher standards may not be worth the lower financial reward.  (Many rural or small providers will rely on HITECH loans; such providers will have to produce certain quality data, but whether this will be the same as Meaningful Use was not discussed today.)

The Workgroup acknowledged some of the difficulties inherent in complying with the HITECH Act’s timelines. The Workgroup expressed that it wanted the Meaningful Use definition to be sensitive to small practices, stating that small practices face special issues in dealing with financial capital and human resources necessary to implement Meaningful Use of EHR.  It becomes a time versus money tradeoff. The HITECH Act says 2011 is the boarding year and front loads the incentives and decreases them over time. This obviously is to encourage early adoption. So the issue becomes how much to load into the Meaningful Use standard as soon as possible yet be sensitive to the constraints on smaller providers. The Workgroup struggled with balancing a sense of reform against the time it takes to get the job done under the law’s current requirements.

HIEs and RHIOs relying on their states to set up HITECH Act grant or loan programs may be at an even greater disadvantage depending on the state they are in.  Take a state like Kentucky, currently in a “special session” to address a nearly $1 billion budget shortfall. I hardly expect that the Governor or Lt. Governor are thinking about HIT at the moment when the state is doing good to keep the Medicaid program and teachers salaries funded.  Speaking of varying state budgets and priorities, just how many small and rural providers will be left out in the cold across America due to lack of focus, resources or attention within a particular state on aggressively competing for available HITECH Act funds to establish grant and loan programs?

Another significant consideration is the applicability of the reporting measures to all physicians who may have hoped to apply for the incentive money. If you are a specialist who is  not a general practitioner or internist, meeting many of the quality, efficiency and patient disparity measures in this initial draft appear either impossible or entirely irrelevant.  Consider such 2011 quality reporting measures as % hypertensive patients with BP under control, % of patients at high-risk for cardiac events on aspirin prophylaxis, % of patients who received flu vaccine, or % of females over 50 receiving annual mammogram, just to name a few. Although such measures may have relevance from time to time to a specialist, they will not be the types of measures that many specialists, such as an ophthalmologist, orthopedic surgeon, or pediatrician, would want to add to their patient care checklist.

All in all, if enough providers in all categories are not applying for the incentives because qualifying is too burdensome or because they cannot obtain sufficient financing or are facing other barriers, the HITECH Act’s goal of improving quality of care for all Americans will not be achieved.

We Need More Time.

I believe that there is nothing we Americans cannot do, at least with a little time. After listening to the June 16, 2009 meeting, however, I fear that time is not on our side.  There is so much work yet to do, including coordination of Meaningful Use with development of the certification standard, and so little time between when the standards will be finalized and the practical time it will take to choose, invest, adopt, implement and train for EHR use.  Many observers thought it was mind-bogglingly, aggressive when first unveiled. Today’s meeting seemed to emphasize this.

Will the healthcare industry, possibly even including ONC and HHS, ultimately prevail upon Congress to act to amend the incentive schedule to be more reasonable? Even if Congress has to fix certain faulty elements of the HITECH Act in order to give it a more meaningful chance to effectively accomplish its goal for the Meaningful Use of interoperable HIT, America nonetheless will be closer to having an interoperable EHR than we would have been without ARRA of 2009.  So, maybe all will not be lost.

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