Monday, April 12, 2010

Reconciliation of Meaningful Use

The long drawn battle over Health Care reform has concluded with a process that merged together the wants and needs of multiple legislative constituencies. Nobody got exactly what they started out with, but we now have a workable solution. Following the same reasoning, Meaningful Use could benefit from Reconciliation with Reality.

As various provider constituencies analyze the proposed tasks required from a Meaningful User, it appears that Meaningful Use (MU) as defined by CMS is quickly becoming an insurmountable barrier to adoption of EHRs.  The HIT Policy Committee has proposed some relaxation to MU by allowing providers to defer 6 items from the original 25 requirements list (see below). While this proposal is most definitely a step in the right direction, it is not enough. By contrast AMA has proposed retaining only 5 criteria. Now that CMS is poring over the public comments to the proposed MU criteria, which seem to be calling for relaxation, it may be a good time to heed passionate calls as the one made by Dr. David Kibbe on THCB on behalf of the majority of health care professionals who practice in small underfunded settings.

Unlike the ONC IFR for EHR certification criteria which is now final, the CMS MU proposal is only a proposal and, as such, can be altered. Certifying EHR technologies based on the full 25 criteria, per the ONC IFR, is actually a good thing as it ensures available technology as HIT adoption, and meaningful use of it, progresses. However, unless we take on step back on MU, moving forward becomes a very uncertain proposition. We should also keep in mind that the discussion here is limited to MU Stage 1, which can be initiated by physicians as late as ctober 1st 2011, and Stage 2 is slated to begin 15 short months thereafter. There may be a need for considering the general time lines at some point.

An Honest Look at Meaningful Use Criteria

Out of 25 proposed criteria, 9 are either simple or a prerequisite to the business of medicine and there is no question that these should be required. One would be hard pressed to find a provider disputing the necessity of any one item below, except maybe #6 and the charting part of #5, which should be limited by specialty. In reality, most providers already satisfy these requirements in electronic format.

Green Light List – All Clear!

1. Maintain an up-to-date problem list based on ICD-9-CM or SNOMED CT®
2. Maintain active medication list
3. Maintain active medication allergy list
4. Record demographics
5. Record and chart changes in vital signs
6. Record smoking status for patients 13 yearss and older
7. Generate lists of patients by specific conditions to use for outreach
8. Submit claims electronically to public and private payers
9. Provide clinical summaries for patients for each office visit

The second chunk of 7 MU criteria is a bit more complex and will likely require adjustments to current work flows. However, most can be achieved with simple means and all make perfect sense from an immediate patient care perspective. For example, the last three could be achieved simply by adding a Patient Portal to an existing EHR, and the first two could be satisfied by incorporating one of the many standalone electronic prescribing modules available on the market.

Yellow Light List – Proceed with Caution.

10. Generate and transmit permissible prescriptions electronically
11. Implement drug-drug, drug-allergy, drug-formulary checks
12. Send reminders to patients per patient preference for preventive/follow-up care
13. Check insurance eligibility electronically from public and private payers
14. Provide patients with an electronic copy of their health information upon request
15. Provide patients with electronic access to their health information within 96 hours of availability
16. Provide summary care record for each transition of care and referral

The last 9 MU criteria are very difficult to implement and with one exception, #25, there is no immediate benefit to patient care, although CDS (#20), if done correctly, can have immediate benefits for some specialties. Interestingly, three of these criteria are defined as capabilities. Capabilities belong in the vendor Certification realm, not Meaningful Use. Medication reconciliation is utterly useless at this time. I cannot imagine any use case where two medication lists exist in an EHR for a given patient, unless codified exchange of information between providers is actually happening. Therefore, #21 should be defined as a capability and moved into the vendor certification area. The other major offender is #19 (quality measures), which particularly for primary care is bewilderingly complex and has no immediate effect on patient care. CPOE and structured lab results should really go together to be meaningful and there are multiple objective hurdles to implementation. The last item on the list, Privacy & Security, although presenting a huge burden, must be part of any EHR system.

Red Light List – Stop!

17. Use CPOE
18. Incorporate clinical lab-test results into EHR as structured data
19. Report ambulatory quality measures to CMS or the States
20. Implement 5 clinical decision support rules relevant to specialty  and track compliance
21. Perform medication reconciliation at relevant encounters and each transition of care
22. Capability to electronically exchange key clinical information among providers of care and patient-authorized entities
23. Capability to submit electronic data to immunization registries and actual submission where required and accepted
24. Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice
25. Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities

Reconciliation Proposal

A Meaningful User, must attest adherence to all 9 Green Light criteria, at least 3 Yellow Light criteria of their choice and at least 1 Red Light criterion not to exclude item # 25 - Privacy & Security.

This is slightly over 50% of the original MU criteria and it may very well be the optimal place to start, optimal in the sense of encouraging computerization of medical records.

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