"Ambitious but achievable." Only time will tell if David Blumenthal's prognosis of federal rules for meaningful use of health information technology is accurate. The truth is, at this early stage no one really knows, not even Blumenthal himself.

In a recent interview, the national coordinator for HIT said he wasn't sure how many providers would be ready to apply for the $27.3 billion in incentive payments in the 2011-2012 timeframe. But that's not the ultimate goal. The real mark of success, he said, will be if there are gains in quality and safety and if patients show greater trust of electronic health records.

Despite concerns over specific requirements in the final rule, that broader sentiment is being echoed by providers and vendors alike as they now assess how meaningful use impacts them.

"Hospitals are improving health IT to improve patient care," says Chantal Worzala, director of policy, American Hospital Association. "And they shouldn't lose focus on how IT fits into their strategic plan. So, while the incentive programs are in place, hospitals need to ensure that they stay true to their strategic vision. It's important to keep this in perspective: How are you going to use IT to provide the best quality care overall?"

Take computerized provider order entry as an example. The final rule requires that more than 30 percent of patients with at least one medication recorded must have at least one medication ordered through CPOE systems. That's reduced from the January proposal, which suggested that 10 percent of all hospital orders be done through CPOE. What's important, Worzala says, is using CPOE to further the hospital's safety and quality goals, not just trying to meet a specific number.

"I don't know a physician in the world who likes CPOE," adds Stephen Stewart, CIO at Henry County Health Center, a critical access hospital in Mount Pleasant, Iowa. "But if you don't fundamentally believe that it will enhance quality and safety, then why are you doing it?"

Stewart says senior leaders need to take a hard look at their organizations and figure out where they are on the implementation spectrum and what's been holding the organization back. "Has it been funding? Are you fragmented by department?"

The other piece, says David Muntz, senior vice president and CIO, Baylor Health Care System, Dallas, is putting meaningful use in the context of the organization's entire operations. The final rule, for instance, delays some administrative simplification requirements until further rulemaking, but that doesn't mean hospitals should ignore those pieces.

Then there's the impact of reform, which emphasizes data, integration, quality improvements, transparency and more. Understanding how IT fits into that equation will be critical as meaningful use moves into the next two stages, says Philip Pead, president and CEO of IT vendor Eclipsys.

Perhaps the biggest concern for providers is whether vendors have the product and staff in place to meet what's likely to be a dramatic increase in demand.

"Demand is going to be off the charts," says Muntz. "So we'll have to see how quickly the vendors can respond."

What's Meaningful?

Hospitals will have to meet 14 core criteria and select five additional requirements in order to be eligible for incentive payments in 2011-2012.

Core requirements

  • Record patient demographics
  • Record vital signs and chart changes
  • Maintain up-to-date problem list of current and active diagnoses
  • Maintain active medication list
  • Maintain active medication allergy list
  • Record smoking status for patients 13 years of age or older
  • Provide electronic copy of discharge instructions on request
  • On request, provide patients with an electronic copy of their health information
  • Use CPOE for medication orders
  • Implement drug-drug and drug-allergy interaction checks
  • Be capable of electronically exchanging data between providers and patient-authorized entities
  • Implement one clinical decision support rule and track compliance
  • Put privacy and security systems in place
  • Report clinical quality measures to CMS or states

Additional requirements

  • Implement drug formulary checks
  • Incorporate clinical lab test results
  • Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach
  • Use EHR to identify patient-specific education resources
  • Perform medication reconciliation between health care settings
  • Provide summary of care record for patients referred or transferred to another provider
  • Electronically submit immunization data to immunization registries or information systems
  • Submit electronic syndromic surveillance data to public health agencies
  • Record advance directives for patients age 65 or older
  • Submit electronic data on reportable lab results for public health agencies

Source: Centers for Medicare & Medicaid Services notice of proposed rulemaking, Dec. 30, 2009

'Stretching' the Industry

David Blumenthal, M.D., believes that the federal government has set a course for the use of electronic health records that will stretch providers and vendors, but also one that will ultimately improve patient care. The national coordinator for health information technology spoke with Hospitals & Health Networks Senior Editor Matthew Weinstock.

In announcing the rule, you said one objective was to make meaningful use ambitious but achievable. How do you think you've accomplished that? We had a vision of how electronic health records can improve care. That mission is embodied in the pillars of meaningful use—safety, efficiency, quality, disparities, patient coordination, patient and family engagement, public health improvement and privacy....We don't think that Congress wanted us just to reward the adoption of records, they wanted to reward the meaningful use of records. So I think we set a target that will stretch the industry and in the process benefit patients and that, eventually, the entire industry can get to.

What specific measures are really going to stretch the industry? I think that the combination is what will stretch them....I think each individual requirement, if it would be the only thing they had to do, would be pretty easy for them to get to. Frankly, some of them are pretty much basic to electronic records, all the demographics, the medication lists, the problem with allergy recording, a lot of those things that are just sort of bread and butter.

It doesn't appear that you have created a separate path for rural hospitals to go through to meet the meaningful use criteria. Well, we did something to make it easier for rural hospitals. We included them as eligible for incentives under Medicaid and we are providing extra support for them through our regional extension centers. We think that patients in rural hospitals deserve the same level of care and the same quality of care and the same efficiency of care as other patients, and we don't want to build disparities between geographic entities or between population groups into our federal rules.

Most Wired Institutions Chart Gains in Patient Safety

Hospitals & Health Networks' 2010 Most Wired Survey reveals continued progress in such patient safety initiatives as closed-loop medication systems: 57 percent of medication orders are placed electronically by physicians and other authorizing providers at Most Wired hospitals, up from 49 percent last year. Fifty-five percent of Most Wired hospitals match medication orders at the bedside through bar coding or radio-frequency identification, up from 49 percent in 2009 and 23 percent five years ago.

The Most Wired data also show hospitals moving forward in evidence-based order sets and security systems, says Chantal Worzala, director of policy, American Hospital Association. But, she notes, there is a lot of ground still left to cover, especially in coordinating care.

In some instances, the Most Wired are doing well when it comes to sharing information during care transitions. For example, new medication lists are electronically delivered to caregivers and patients 94 percent of the time when a patient is transferred within the hospital, 98 percent at discharge and 86 percent when transferred to another care setting.

On the other hand, electronic medical record functions continue to lag, especially with independent physicians. For the Most Wired, just 43 percent of independent physician practices have electronic clinical documentation, 41 percent have CPOE and 44 percent have decision support.

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For more on the survey, visit www.hhnmag.com.