Yesterday, the HIT Policy Committee’s Workgroup on Meaningful Use released initial recommendations on the definition of “meaningful use” of certified electronic health records (EHRs). Because “meaningful use” is an important criterion for Medicare and Medicaid incentive payments created as part of the American Recovery and Reinvestment Act, this early read on the definition has been much anticipated. Having attended the committee hearing in Washington, D.C., yesterday, I endeavor today to share early reflections on the implications for hospitals and health systems.

Four months ago, President Obama signed into law the American Recovery and Reinvestment Act, allocating over $19 billion to accelerate the adoption of electronic health record (EHR) technologies and to facilitate nationwide health information exchanges (HIEs) to improve the quality and coordination of care between health care providers. The law’s HITECH ACT section provides Medicare and Medicaid incentive payments, commencing in 2011, to eligible hospitals and physicians for demonstrating “meaningful use” of certified EHRs but did not define the criteria for “meaningful use,” leaving that task to HHS and two federal advisory committees—the HIT Policy Committee and the HIT Standards Committee.

After incorporating diverse stakeholder opinions gathered at the National Committee on Vital and Health Statistics (NCVHS) hearing on meaningful use in April 2009, and balancing the ambitious goals of the HITECH ACT against the short time frame for hospitals to demonstrate “meaningful use” to be eligible for the incentive payments, the HIT Policy Committee’s Workgroup on Meaningful Use yesterday released initial recommendations on the definition of “meaningful use” of health IT. The highlights are summarized below.

The most important aspect of yesterday’s announcement is the three-phased approach to the definition, which proposes a different focus for assessing meaningful use during each phase:

• 2011: Data Capture and Sharing
• 2013: Advanced Clinical Processes
• 2015: Improved Outcomes

The Committee also articulated an ultimate vision for meaningful use of EHRs, as well as overarching goals common to all three phases of the meaningful use definition. The vision for meaningful use is to enable significant and measurable improvements in population health through a transformed health care delivery system. The overarching goals are as follows:

• Improve quality, safety, and efficiency
• Engage patients and their families
• Improve care coordination
• Improve population and public health, and reduce disparities in care
• Ensure privacy and security protections

• Eligibility criteria increasingly complex at each phase—initial phase of definition starts with a simpler performance measurement focus; definition progresses to demonstrating improved outcomes in the final phase.
• Outcomes measured broadly—definition prioritizes not only individual care but also population health outcomes, requiring hospitals to initially submit relevant data to registries and eventually establishing two-way data sharing to inform care delivery in real time.
• A focus on health outcomes, not specific technologies—to foster continuous innovation, definition does not mandate specific technologies but rather encourages entities to focus on achieving favorable health outcomes through improvements in key care processes.
• Patient engagement in health care a priority—recognizing the importance of engaging patients in their own health care, definition requires hospitals to share relevant clinical information with patients as well as to educate them on their specific conditions, all while respecting patients’ preferences for accessing and receiving information.
• HIPAA integral part of definition—definition precludes hospitals failing to comply with HIPAA rules and National Privacy and Security Framework from being deemed meaningful users of health IT.

The proposed meaningful use definition recommends a phased-in approach, with a simpler performance measurement focus in the initial phase (2011) moving to a more complex set of eligibility criteria focused on improving outcomes in the final phase (2015). Interestingly, the incentive payments are richer in the initial years (2011-2012) and decline in the outlining years (2013 onwards). Given this escalating scale of requirements and declining incentive payments, hospitals must make every effort to meet meaningful use in the initial years to maximize their incentive collections.

Use of Computerized Physician Order Entry (CPOE) is foundational to achieving the health IT goals of the stimulus bill—improving the quality of care through reductions in medication errors. The newly proposed meaningful use definition requires use of CPOE for all orders, including medications, by 2011 in order to collect the Medicare and Medicaid incentives. Furthermore, implementation alone is not enough—the definition proposes a certain percentage of all orders to be electronically submitted by physicians in order for the hospital to meet the meaningful use criteria. IT executives should work closely with Chief Medical Officers and informaticists to adequately plan, design, implement, and train physicians on CPOE in a timely manner.

The proposed definition requires the HIT quality metrics to be generated from data stored in clinical systems as opposed to the current reporting based on administrative and claims data. Furthermore, the data for the quality metrics must be electronically captured and automatically reported through the clinical systems. This new focus on clinical data reporting will require hospitals to audit existing clinical systems to assess current data capture completeness and accuracy; subsequent work will likely be required to create fields necessary for data capture and to train clinicians on capturing new data elements. Moreover, future IT implementations will also need to comply with data capture requirements.

The proposed definition for meaningful use requires hospitals to share relevant care information with physicians and patients in an electronic format. Many of these required information sets (problem list, medication list, allergies) are not always electronically documented in current processes. Furthermore, in many hospitals, critical lab and test results are also unavailable in the EHR. To provide care providers and patients with the relevant clinical information, hospitals will need to ensure that all sources of data are adequately interfaced to inform clinicians during care delivery. The final phase of meaningful use recommends providing patients their information in a personal health record (PHR) that can be managed by the patient. This next step to eligibility will not only require electronic data but will call for additional interfaces to be built between existing clinical systems and the PHR.

The original HITECH Act listed compliance with the expanded federal patient privacy and security laws as one of the four health IT provisions of the stimulus bill. Recognizing the importance of securing patient data in this increasingly electronic world of data capture and information sharing, the HIT Policy Committee decided to include HIPAA compliance as part of each of the eligibility criteria for collecting incentive payments (meaningful use, certified EHRs, participation in HIEs). As a result, each phase of the meaningful use definition lays out more stringent privacy and security requirements. This means any entity under investigation for HIPAA violation cannot earn the incentives associated with demonstrating meaningful use until the entity is cleared. To avoid losing incentive payments to potential HIPAA violations, hospitals must revisit their HIPAA policies, update them to reflect the expanded federal patient privacy and security laws, and subsequently educate employees on the violation penalties and incentive losses associated with failure to comply with the HIPAA rules.

In order to be eligible for the Medicare and Medicaid incentives, hospitals and physicians must meet the meaningful use criteria associated with the year in which the provider applies for the incentive, regardless of where the provider falls in the EHR implementation cycle. The proposed three-phased definition for meaningful use is very detailed for the first phase starting in 2011 and grows less specific for the subsequent phases (2013 and 2015). That said, each phase is defined by clear objectives and discrete measures within each of the five goals. Outlined below are the key objectives associated with each phase of the meaningful use definition, categorized by the five overarching goals

Phase 1: 2011 – Data Capture and Sharing

Improve Quality, Safety, Efficiency

• Capture data, such as current problem list, active medication list, active medication allergy list, vital signs, patient characteristics, in coded format
• Update problem lists and other relevant patient information at each encounter
• Incorporate lab/test results into EHR
• Document progress notes for each encounter (outpatient only)
• Use CPOE for all order types, including medications
  • Generate and transmit permissible prescriptions electronically
  • Implement drug-drug, drug-allergy, drug-formulary checks
• Manage populations
  • Generate list of patients by specific conditions (outpatient only)
  • Send patient reminders for preventative and follow-up care based on patient preference

Engage Patients and Families

• Provide patients with electronic copy of or electronic access to clinical information, based on patient preference
  • Include labs, problem list, medication list, allergy information
• Provide access to patient-specific educational resources
• Provide clinical summaries to patients for each encounter

Improve Care Coordination

• Exchange key clinical information among providers of care
  • Include problems, medications, allergies, test results
• Perform medication reconciliation at relevant encounters

Improve Population and Public Health

• Submit electronic data to immunization registries where required and can be expected
• Submit electronic reportable lab results to public health agencies
• Submit electronic syndrome surveillance data to public health agencies according to applicable law and practice

Ensure Privacy and Security

• Compliance with HIPAA Rules and state laws
• Compliance with fair data sharing practices set forth in the Nation Privacy and Security Framework

Phase 2: 2013 – Advanced Clinical Processes

Improve Quality, Safety, Efficiency

• Evidence based order sets
• Clinical documentation recorded (inpatient)
• Clinical decision support at point of care
• Manage chronic conditions using patient lists and decision support
• Report to external disease registry

Engage Patients and Families

• Offer secure patient-provider messaging
• Access to patient-specific educational resources
• Record patient preferences
• Documentation of family medical history
• Upload data from home monitoring devices

Improve Care Coordination

• Medication reconciliation at each transition of care
• Produce electronic summary of care at each transition
• Retrieve and act on electronic prescription fill data

Improve Population and Public Health

• Receive immunization histories from registries
• Receive public health alerts
• Electronic syndromic surveillance data sent to public health agencies

Ensure Privacy and Security

• Use summary or de-identified data when reporting data for population health purposes

Phase 3: 2015 – Improved Outcomes

Improve Quality, Safety, Efficiency

• Achieve minimal levels of performance on quality, safety, and efficiency measures
• Implement clinical decision support for national high priority conditions
• Achieve medical device interoperability
• Provide multimedia support (e.g., x-rays)

Engage Patients and Families

• Provide access for all patients to PHR populated in real time with data from HER
• Provide patients with access to self-management tools
• Capture electronic reporting on patient’s care experience

Improve Care Coordination

• Access comprehensive patient data from all available sources

Improve Population and Public Health

• Use epidemiologic data derived from EHRs
• Automate real time surveillance
• Provide clinical dashboards
• Generate dynamic and ad hoc quality reports

Ensure Privacy and Security

• Provide patients with accounting of treatment, payment, and health care operations disclosures
• Protect sensitive health information

For a detailed view of each of these objectives and the metrics associated with them, by each of the three phases of meaningful use, please see the Meaningful Use Matrix in the appendix.

The Workgroup’s proposed three-phased definition is only the first step to finalizing meaningful use. Health care executives wishing to comment on this proposed definition can do so by going to http://healthit.hhs.gov. The public comment period will be open through the close of business on Friday, June 26, 2009. Following this public comment period, the workgroup will modify the proposed definition to incorporate the various opinions and comments received and make their final proposal to the HIT Policy Committee which will then approve and recommend the definition to ONCHIT/HHS. The final definition will be proposed by CMS and will follow the typical rule making process –a proposed rule, followed by a 60-day public comment period, and a final definition scheduled for sometime in early 2010.

Department of Health and Human Services, “Meaningful Use: A Definition: Recommendations to the Health IT Policy Committee from the Meaningful Use Workgroup,” June 16, 2009.

Department of Health and Human Services, “Meaningful Use Matrix,” available at http://tiny.cc/xYCjp.

The Advisory Board Company, “Health IT Implications of the Stimulus Bill”, available at http://www.advisory.com.

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About Protima Advani
Protima Advani is the practice manager for the IT Insights program at the Advisory Board Company. She has authored best practice studies on IT governance, data analytics and selecting IT metrics for effective dashboards. You may contact Protima at AdvaniP@advisory.com.