Meaningful Use of EHRs

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The Final Rule for Electronic Health Records (EHR) Incentive Program (published July 28, 2010 in the Federal Register) has added flexibility and will increase the feasibility of qualifying for Stage 1 meaningful use incentive payments. The requirements are no longer "all or nothing." For hospitals, there are now 14 mandatory requirements, and for eligible professionals there are 15 mandatory requirements. Both hospitals and eligible professionals have a list of 10 additional requirements; only half of these need to be met in Stage 1. Thresholds for some of the measures have also been reduced. The final rule for incentives (often referred to as the Meaningful Use Rule) is focused on what is required. A companion rule on Standards, Implementation Specifications and Certification Criteria (the Standards Rule) details how the EHR systems must operate to meet the requirements.

What are the Standards, Certification and Meaningful Use Incentive Requirements and how do they relate?
Qualifying for EHR incentives requires meaningful use of a certified system. There are four interrelated components to meeting this requirement. First, the system must be certified that it provides the right capabilities and meets standards. The Final Criteria and Standards Rule were published on July 28. In the middle of August the National Institute of Standards and Technology (NIST) released the test scripts that will be used in testing systems and in late August the first two certifying agencies were authorized. Now all the components needed to qualify for meaningful use incentives are in place.

 While the requirements to be a meaningful user were relaxed in the final rule, the certification requirements for EHR technology were not. A certified system still needs to support all the mandatory and additional requirements of meaningful use in Stage 1. To receive payments the meaningful use must be accomplished with a system that is currently certified independent of the stage of meaningful use that is being demonstrated. This means that in 2013 meaningful use requires a system certified against Stage 2 requirements.

To really understand the requirements, it is important to read the final incentive program rule and the final standards rule. For example, meaningful use requires that smoking status be recorded for more than 50 percent of patients over age 13. The standards rule says the system used to accomplish that must "Enable a user to electronically record, modify and retrieve the smoking status of a patient. Smoking status types must include: current every day smoker; current someday smoker; former smoker; never smoker; smoker, current status unknown; and unknown if ever smoked."

What is new in the final rules and what is unchanged?
The final incentive rule has one major change: for eligible hospitals to receive incentive payments the hospital must meet meaningful use criteria for the most critical patients treated in the emergency department (ED) as well as in the inpatient service areas.  ED patients who are later admitted and those who are held for observation count toward meeting meaningful use criteria.   

Other significant changes in the final rule include:

• Medication reconciliation (which was considered to be a major challenge) has become optional.
• The threshold criteria for the percentage of patients who must meet the requirement have been substantially lowered for: e-prescribing, recording demographics, recording vital signs, recoding smoking status, proving clinical summaries and discharge instructions, sending reminders and performing medication reconciliation.
• However, the requirements for maintaining active problem, medication and medication allergy list have not changed. They still must be met for 80 percent of patients; this means that 80 percent of a hospital's ED patients held for observation and inpatients and 80 percent of an outpatient provider's practice must have their records maintained on the EHR to qualify for incentive payments.
• The rules related to use of computerized physician order entry (CPOE) has changed to only include medication orders and to be based on the percentage of patients with at least one CPOE order, rather than based on the percentage of orders.
• The number of required quality measures that must be reported has been reduced.
• The requirements for electronic eligibility checking and claims submission have been deferred to Stage 2.
• The final rule also extended the timeline to the qualifying under Stage 1 until 2014.
• The final rule clarified that certified systems must be able to generate all the required measures of performance for reporting on meaningful use.

Here are a few examples. Storing laboratory data in coded form within the EHR is an optional, not a mandatory requirement; however, if an eligible provider chooses not to capture the laboratory data in the EHR, they will not be able to report many of the quality measures that require laboratory information. Similarly, for inpatients, there is no meaningful use requirement that medication administration records are electronic, yet many quality measures are based on medications administered to patients. The rules make it clear that measures for quality reporting must be calculated and reported from certified EHR technology.           

Many people were relieved to see that reconciliation of medications is an optional requirement for Stage 1 of meaningful use; however, it remains a Joint Commission on the Accreditation of Health Care Organizations (JCAHO) national safety goal.

The new CPOE requirement is that more than 30 percent of patients must have one medication entered directly into the EHR using CPOE to receive incentives for Meaningful Use Stage 1. However, it is difficult to imagine how you could safely meet this requirement. Would nurses look two places to make sure they were aware of new medication orders? If a patient comes into the ED and has medications from home entered into the system using CPOE, but new medications were on paper in the ED, if that patient went to surgery or was admitted, how would providers know the complete set of medications the patient was receiving? How would the CPOE system be able to check for all drug interactions?

It is easy to see how this type of "solution" would not support the goal of optimizing patient safety. Having two sources of orders also would require two different processes for filing those orders in the pharmacy, which will definitely create inefficiencies, and may also create safety issues. The goal should be implementation of an EHR system that improves access to care, patient safety and transparency. The incentive payments are a huge bonus, but they should not be the driver of the implementation.

This is clearly a very complicated process, with many potential pitfalls and a very short timeline. The good news is there are now many examples of success and resources on how to become meaningful users of EHR technology, including an online support community established by CSC (https://community.csc.com/community/meaningful_use for providers to ask questions and exchange ideas around meaningful use of EHR technology.

To remain competitive, providers need to start laying the foundation for a new environment and take a bigger picture view of where they need to be in 5 years as they work toward meaningful use. Preparing for the future realities of healthcare will be a long and resource-intensive process, and achieving meaningful use is just the first step on the way to maximizing meaningful value from IT.

Peggy Congin is senior/manager and Erica Drazen is the managing partner of the Emerging Practices Group, both in the Health Care Sector Group at CSC.