Note: This article was written before the implementation of the Meaningful Use rule that was a gate to obtaining funding for EHRs through the HITECH Act. It provides some contextual background on the evolution in our use of EHRs.
A short three years ago, the Office of the National Coordinator for Health Information Technology (ONC) was funded at a level of less than $150 million. Today, thanks to the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH)—part of the American Recovery and Reinvestment Act (ARRA)—the ONC received a budget of over $2 billion. In addition, no less than an additional $19 billion is set aside to facilitate the adoption of electronic medical records over the next decade.
For both industry and government, budgets provide a more reliable picture of strategy than do policy statements. Therefore, there is little doubt that the current administration expects health information technology to play an important role in reducing healthcare costs while improving quality, safety, and access, a high priority of the president.
To accomplish this goal, adoption of technology is not enough. These new tools must be utilized effectively to achieve desirable and measurable results. Therefore, almost all of the incentive funding available to providers for the adoption of health information technology is tied to the “meaningful use” of that technology. David Blumenthal, MD, the current national coordinator for health information technology released a statement on October 1, 2009:
We recognize that better health care does not come solely from the adoption of technology itself, but through the exchange and use of health information to best inform clinical decisions at the point of care.
So what is “meaningful use?” Perhaps former Supreme Court Justice Potter Stewart provides some guidance. In a 1964 opinion on an obscenity case (Jacobellis v. Ohio) the late Justice Stewart described hard-core pornography as follows:
It is hard to define, but I know it when I see it.
In spite of the work performed by many ONC committees to date, many working in healthcare believe the ONC is taking the same approach to defining “meaningful use.”
With so much money at stake, this fluid and vague definition presents great problems for those who consider purchasing health information technology products. This uncertainty “freezes” the market for both buyers and vendors of these tools. For buyers, there is no guarantee that an investment in a particular EMR will satisfy meaningful use criteria, and therefore trigger the payment of health information technology incentives. For vendors, the unclear definition does not allow the development and testing of modules that can be used to meet the definition of meaningful use. Although planning is ongoing, both stakeholders are taking a “wait and see” attitude.
Final rule in late Q1, 2010
To its credit, the ONC is working to offer providers a hard and fast definition of meaningful use backed up by exactly defined, collectable measures. Although the definition is in flux, the process is clear. The HIT Standards Committee provided its recommendations to the HIT Policy Committee, which then forwarded its recommendations to the ONC this past July. The ONC will review the recommendations and deliver its position to the secretary of Health and Human Services (HHS). By statute, the secretary has until December 31, 2009, to issue an interim rule on meaningful use. As the rule must go out for comment for a minimum period of time, a final rule is not expected until late Q1, 2010.
With all this attention on the meaning of meaningful use, there is less focus on the overriding goal of implementing EMRs and other health information technology—to improve quality, safety, access, and efficiency. Setting goals and minimum standards often drives change toward delivering high scores based on narrow criteria while ignoring more broad and impactful objectives. Therefore, adherence to the final meaningful use rule does not guarantee successful meaningful use. The “meaningful” in meaningful use depends upon an organization’s strategic goals and objectives. What can be accomplished is determined by the existing infrastructure, resources at hand, and corporate culture. Without a guiding vision of how health information technology tools can transform an organization, senior management cannot expect to achieve significant improvements in quality, safety, access, or efficiency, irrespective of whether they satisfy the definition of meaningful use.
So, how do we get there?
The availability of health information technology funds provided by ARRA provides healthcare leaders an opportunity to transform their organizations into 21st century healthcare delivery institutions that effectively leverage these tools. The administration understands that mandating rigid software applications, functionality, and processes could prove problematic as one solution cannot fit every organization. Flexibility is necessary to account for the difference in capabilities, culture, and communities. That said, our government cannot provide funds to institutions without some degree of oversight. This reality brought us all this fun we are having with defining meaningful use.
Perhaps the administration did not know what impact EMRs were going to have on healthcare beyond providing a foundation where “meaningful change” could occur. EMRs without process and workflow changes do little if anything to improve quality, safety, and efficiency. In some cases they make all this worse. Nevertheless, we do know that health information technology is a tool, that when properly deployed, can dramatically and positively impact healthcare delivery. Information technology helped most every other industry improve, and there is no reason the same cannot be expected for the healthcare industry. Unfortunately our challenges are great, and change is difficult.
EMRs serve two masters
For example, if EMRs were solely designed to facilitate patient care, their user interface and embedded workflow would be dramatically different than what we see today. Unfortunately, EMRs serve two masters. One is to facilitate healthcare delivery, as already noted. The other is to document physician activities to generate billing codes for reimbursement. These two purposes clash, producing EMR applications that fail to excel in either area. The resulting workflows frustrate physicians and patients while falling short of their goal to improve care delivery. Until our reimbursement method is changed, EMRs will continue to struggle, trying to please these two masters. Perhaps healthcare reform will ease this burden. Only time will tell.
Therefore, the responsibility to make meaningful use meaningful rests on our shoulders. It is no longer acceptable to assume an implementation is deemed successful by the number of boxes checked on a requirements list. It is time for each of us to figure out the configuration, the processes, the clinical decision support, and the workflows that can achieve meaningful use for our organizations.
Dr. Blumenthal essentially said this himself in a statement released on October 1, 2009:
Meaningful use, in the long term, is when EHRs are used by health care providers to improve patient care, safety, and quality.
Right you are, sir!
- Justice Stewart Potter quotation from Oyez, Supreme Court Media (http://www.oyez.org/justices/potter_stewart/), as cited in Wikipedia.
- Timmerman, A. (2009, July 7). What hospitals need to know about the ARRA and the HIPAA updates. Becker’s Hospital Review. Available at http://www.hospitalreviewmagazine.com/news-and-analysis/legal-and-regulatory/what-hospitals-need-to-know-about-the-arra-and-the-hipaa-updates.html
- Christensen SM. ARRA health IT incentives – Uncertainties about “meaningful use.” www.martindale.com, 09/08/2009
- ARRA incentives for acute care PPS hospitals. Available at http://cpsinet.com/stimulus/ARRA_Acute_Care_Incentives.pdf
Excerpt from “Making Meaningful Use ‘Meaningful'” published in Patient Safety and Quality Healthcare