EHR Stimulus Meaningful Use

The Final Meaningful Use Rule: Overview of Changes and Clarifications to Meaningful Use

The final rule for meaningful use incentives for 2011 and 2012 was released on July 13, 2010. The basic shape of the meaningful use rule is unchanged from the draft released in January, but significant flexibility has been added that will make the transition to EHRs more feasible for
many providers.

• CMS received over 2,000 comments on the proposed rule.
  
• For 2011 and 2012, the requirements for meaningful use incentives are divided into core requirements that are mandatory and a menu of ten additional requirements of which
  five need to be met.
  
• Two new optional requirements have been added.
  
• The requirements for electronic eligibility checking and claims submission have been eliminated (but will be required under the health reform law).
  
• The percentage of patients that are required to qualify as a meaningful user have been lowered for many (but not all) criteria.
• The quality reporting requirements have been scaled back.

Introduction
The HITECH provisions of the American Recovery and Reinvestment Act of 2009
provide billions of dollars in incentives for the adoption and use of Health
Information Technology (HIT) by Medicare and Medicaid providers over the
next 10 years.

To receive the financial incentives, eligible professionals and hospitals must achieve
“Meaningful Use” of an electronic health record (EHR). On July 13, 2010, the
Centers for Medicare & Medicaid Services (CMS) released the final rule defining
the requirements for meaningful use in 2011 and 2012. The requirements are
substantially the same as those proposed in January, but only 15 core requirements
are now mandatory for eligible providers and 14 are mandatory for hospitals.
Five additional requirements must be selected from a “menu” of ten additional
requirements. (In the previous version, eligible providers had 25 mandatory
requirements and hospitals had 23, so the number of requirements has
decreased and the flexibility increased.) Many of the targets for the percentage
of patients that must meet the requirements have also been lowered. Two
additional “menu” requirements have been added. To qualify for incentives,
hospitals and eligible providers must be using certified systems — and to be
certified the systems must be capable of meeting all the final requirements.
Therefore, the requirements for vendor products have increased slightly.

The final rule that was released on July 13 only covers Stage 1 requirements for
2011 and 2012. To get the maximum Medicare payments, eligible providers need to
qualify by CY 2012 and hospitals by FY 2013. More details related to qualification
and payments are provided in the companion white paper Update on Incentives.
Industry Impact

The financial incentives in the stimulus bill provide a landmark opportunity for
eligible organizations and professionals who desire a fully integrated EHR, but
struggle with funding and with barriers to sharing information effectively. We believe
that there are four key requirements to achieve the right outcomes from an EHR:

1. Setting the right EHR goals
2. Purchasing the right EHR product
3. The right implementation of the EHR
4. The right use of the EHR by caregivers

The Right Goals
The goal in implementing an EHR is to improve patient care. This is a major
undertaking involving massive changes that will touch everyone in the organization.
Busy providers will rally around the cause of safer, more efficient care. At best,
they are willing to “go along with” a change that provides an extra payment to the
hospital. This is especially true of community physicians who need to take time
away from their practice (and their income) to lead the change, receive training
and optimize use.

The Right Product
Purchasing the right EHR product is an essential requirement for achieving
meaningful use. First, the product must be certified as providing the capabilities
and complying with the standards for meaningful use. The final rule on certification
was issued in June, and the Office of the National Coordinator (ONC) expects to
have organizations ready to certify products in a few months. (See our Update
on Certification white paper for more details.) The requirements will increase
every two years, with updates currently scheduled to go into effect in 2013 and
2015. It is important to evaluate the future development plans of each vendor to
help ensure that they will remain certified in the future. It is also important to
keep in mind that the final rule for meaningful use establishes the minimum
requirements, and purchasers may want to go beyond these requirements to
maximize the value from their EHR systems. For example, even though not
required in Stage 1, if an EHR does not provide the capability to check orders for
the right dose based on renal function, then use of computerized physician order
entry (CPOE) will not address one of the top ten causes of preventable adverse
drug events. Although use of bar-coded medication administration checking is
also not required in Stage 1, it is important to close the loop for medication
safety because this is the last chance to catch an error before it reaches the
patient. Note also that certification ensures that the capabilities will be available,
but the user must still evaluate if they are integrated and can be used efficiently.
If drug-drug alerts are turned off because they “over-alert,” users will not qualify
for incentive payments; and obviously, if the system is not used because it
creates inefficiencies, no benefits will accrue.

The Stage 1 Capabilities for 2011 and 2012
The final requirements for qualifying as a meaningful user of an EHR in 2011
and 2012 are summarized in the table below. Changes from the proposed rule
are included under the notes column. Each requirement has an associated
measure. The percentages indicated apply to all patients — not just Medicare
and Medicaid patients. In 2011, all meaningful use requirements will be
demonstrated by attestation; in 2012, in addition to attestation, quality data
will be required to be submitted electronically. Also note that in many cases
data must be coded according to standards released by ONC in February 2010.
The final rule has 15 core (mandatory) requirements for eligible providers and
14 mandatory requirements for hospitals. There are ten additional “menu”
requirements for hospitals and eligible providers; meaningful users must meet
at least five of the menu/optional requirements.

Electronic eligibility checking and submitting claims electronically were
eliminated from the requirements that had been proposed in January. These are
typically functions of a practice management system and not the EHR. However,
the health reform law passed earlier this year (The Affordable Care Act of 2010)
will require electronic eligibility checking and electronic claims submission.

Right Implementation

Organizations satisfying meaningful use requirements must implement qualified
EHRs in such a way that the staff can make full use of its capabilities.

The right implementation involves setting goals for benefits and adjusting processes
and organizational governance to achieve those goals. It is essential to recognize
that achieving meaningful use of an EHR system is a large-scale clinical change
project involving significant changes in care delivery that must be clinician-led.

Right Use
To meet the meaningful use requirements, all organizations must implement
an EHR so that it is incorporated into the routine care process. We recommend
that the “right use” of a qualified EHR is demonstrated by the following levels
of adoption:

• Equal to or greater than 90 percent of care-related electronic tasks are
  completed by clinical professionals utilizing the EHR (e.g., entering
  medication orders and/or documenting problems and allergies).
  
• Direct evidence of role-based use by clinicians (e.g., physician order entry, e
  prescribing, registered nurses documenting medication administration,
  pharmacist electronically sending pharmacy alerts to physician team,
  respiratory therapist electronically entering and reporting ventilator bundle
  checks each shift, etc.).
  
• All quality reporting fed by electronic clinical documentation.
  
• Integration with the revenue cycle process (e.g., appropriate interfaces must
  be established and documentation should feed charge capture rather than
  requiring a separate electronic step in the charging process).
  
• Monitoring evidence of benefit (e.g., the number of alerts that result in a
  change in orders, the number of nursing hours spent in compiling quality
  data, the number of chronic care patients that meet the criteria for
  appropriate care).
  Recommendations
  
• Most hospitals and some physician practices have developed and started to
  implement plans to demonstrate meaningful use and qualify for incentive
  payments. Some were waiting for the final rule to be released. Now is the
  time to redouble efforts to meet the criteria in 2011 and 2012. There are
  several reasons for qualifying early. First, hospitals need to qualify by 2013,
  and physicians need to qualify by 2012 to get the maximum payments. Since
  about 70 percent of the incentive dollars are paid in the first two years,
  early qualification means earlier availability of money to invest in future
  requirements. Finally, the Stage 1 requirements have been relaxed and made
  more flexible for 2011 and 2012; however, there is no guarantee that these
  same changes will apply if qualifying against Stage 1 criteria at a later date.
  
• If you have not yet implemented CPOE, start now. This is a large-scale
  change project that has to be done right and will take time.
  
• Independent of the meaningful use requirements, implement CPOE with
  evidence-based order sets and meaningful decision support at the point
  of care from the start. Order sets greatly reduce the time for ordering and
  reinforce evidence-based practice. Without meaningful decision support, the
  physician will be acting as transcriber and not perceive any added value
  from CPOE.
  
• The basis for meaningful use is a certified system. Certification against Stage
  1 criteria will be available soon, and the standards for systems have already
  been published. Make sure the vendors you plan to use to meet meaningful
  use have definite plans to get their product certified and that their schedule
  meets your needs.
  

Note: this early release summary is based largely on: “The “Meaningful Use”
Regulations for Electronic Health Records” by David Blumenthal M.D., M.P.P. and
Marilyn Tavenner, available online at www.nejm.org