http://meaningfuluse.orgRSS feeds for MeaningfulUse.org60http://meaningfuluse.org/Opinions/ArticleDetail/tabid/62/articleType/ArticleView/articleId/58/Why-the-Digital-Divide-is-Likely-to-Expand-under-ARRA.aspx#Comments90http://meaningfuluse.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=62&ModuleID=377&ArticleID=58http://meaningfuluse.org/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=58&PortalID=0&TabID=62http://meaningfuluse.org/Opinions/ArticleDetail/tabid/62/articleType/ArticleView/articleId/58/Why-the-Digital-Divide-is-Likely-to-Expand-under-ARRA.aspxRecently, a study funded by the Robert Wood Johnson Foundation and the Office of the National Coordinator for HIT found that hospitals that serve a disproportionate share of poor patients are lagging behind other hospitals in adopting Electronic Health Records.   According to the study:    “Data from a national survey indicate early evidence of an emerging digital divide: U.S. hospitals that provide care to large numbers of poor patients also had minimal use of EHRs. These same hospitals lagged others in quality performance as well, but those with EHR systems seemed to have eliminated the quality gap. These findings suggest that adopting EHRs should be a major policy goal of health reform measures targeting hospitals that serve large populations of poor patients.”[1]   These disproportionate-share hospitals (DSHs) now join the ranks of rural and critical access hospitals (CAHs), which have also been shown to have major EHR adoption disparities compared to other hospitals.[2]   John Glaser, Advisor to the National Coordinator for HIT, responded to the study’s release with the following commentary: “The president’s goal is to have everyone in this country benefit from the improvements in care that can result from the meaningful use of electronic health records. Everyone.   “EHR adoption data has indicated the potential formation of a digital divide between the providers that have and the providers that have not. A primary goal of the federal EHR strategy is ensuring that that divide does not form and that all providers (and all patients) realize the value of the technology.   “Medicare and Medicaid incentive funds provided need capital. Extension center activities to support providers are targeted to critical access hospitals and physicians in small practices. The grants directed to the states carry with them the obligation of state government to help ensure that no providers and no patients are left behind.   “An EHR digital divide is something that none of us will accept.”[3]   While I applaud the imperative articulated in Mr. Glaser’s last line, it seems clear that unless action is taken, ARRA and its associated regulations will in fact significantly expand the already prominent digital divide. It will do so for the following reasons:   1. ARRA provides Critical Access Hospitals, which have the lowest EMR adoption rates of any hospitals surveyed by HIMSS Analytics, with a fraction of the incentives that Prospective Payment System hospitals will receive.    2. The “meaningful EHR use” standards (as recommended by the HIT Policy Committee) have been designed for hospitals already far along with their EHR adoption efforts. Many experts believe that if the standards are implemented as written, hospitals at early stages of adoption will simply not have a reasonable amount of time to become meaningful users and attain incentives.    3. Contrary to Mr. Glaser’s assertion, Regional Extension Center activities are not targeted to critical access hospitals or, indeed, any hospitals. In its REC grant guidance, ONC redefined the term “prioritized provider” to exclude hospitals, even though ARRA language originally included them, so hospitals in need of technical assistance will not be able to receive it, at least through the REC program.    4. A key EHR implementation barrier for providers on the wrong end of the digital divide is access to capital. The one ARRA provision that might have helped was a loan program through the states.  It currently appears that ONC will not act to establish this much needed program.  The Small Business Financing and Investment Act contains an HIT loan program, but it has no provisions to help hospitals.   By Louis Wenzlow, CIO of Rural Wisconsin Health Cooperative Blog address: http://www.worh.org/hit/2009/11/why-the-digital-divide-is-likely-to-expand-under-arra/   [1] Ashish K. Jha, et al [Health Aff (Millwood). 2009;28(6):w1160–70 (published online 26 October 2009;10.1377/hlthaff.28.6.w1160)] [2] HIMSS Analytics:  http://www.himssanalytics.org/hc_providers/emr_adoption.asp [3] John Glaser, CHIME’s Healthcare CIO SmartBrief, 10/30/2009  louiswenzlowSat, 14 Nov 2009 10:28:00 GMTf1397696-738c-4295-afcd-943feb885714:58http://meaningfuluse.org/Opinions/ArticleDetail/tabid/62/articleType/ArticleView/articleId/57/In-what-form-will-incentive-payments-for-meaningful-use-come.aspx#Comments179http://meaningfuluse.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=62&ModuleID=377&ArticleID=57http://meaningfuluse.org/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=57&PortalID=0&TabID=62http://meaningfuluse.org/Opinions/ArticleDetail/tabid/62/articleType/ArticleView/articleId/57/In-what-form-will-incentive-payments-for-meaningful-use-come.aspxI am a physician in a 110 physician multispecialty group.  We are part of a 400+ physician health system.  I've been assigned the job of getting the clinic to a level of usage of our EMR (that we have had for 9 years) that will qualify for the incentive payments.  I would like to be able to use this promise of financial reward to get the physicians in the clinic to make better usage of the EMR.  However, my concern is that even if we get to a level of usage that will qualify for the money, the physicians will never get the money.  This is because our pay from the health system is based on fair market value for our production based on RVU's.  This probably isn't unlike many other clinics in the country.  I think I can safely assume that the extra reimbursement for services rendered to Medicare and Medicaid patients won't be tied to extra RVU's for the services.  If that is the case the physicians will never see the money and the health system will keep it to avoid paying the doctors more than fair market value.  If, however, the money is sent separately with it earmarked as incentive pay it will likely flow through to the doctors. My question is, does any one know in what form the payments will be made?  Will the money that comes into the institution or health system be  clearly designated as a payment to the physician separate from the reimbursement for CPT codes? Doug Duncan MD Springfield, MOdduncanWed, 07 Oct 2009 18:24:00 GMTf1397696-738c-4295-afcd-943feb885714:57http://meaningfuluse.org/Opinions/ArticleDetail/tabid/62/articleType/ArticleView/articleId/55/AMDIS-response-to-Blumenthal-on-meaningful-use-definitions-62609.aspx#Comments3http://meaningfuluse.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=62&ModuleID=377&ArticleID=55http://meaningfuluse.org/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=55&PortalID=0&TabID=62http://meaningfuluse.org/Opinions/ArticleDetail/tabid/62/articleType/ArticleView/articleId/55/AMDIS-response-to-Blumenthal-on-meaningful-use-definitions-62609.aspxJune 26, 2009   David Blumenthal, M.D., M.P.P   National Coordinator for Health Information Technology U.S. Department of Health and Human Services Office of the National Coordinator for Health Information Technology 200 Independence Ave, SW Suite 729D Washington, DC 20201   Re: HIT Policy Committee Meaningful Use Response   Dear Dr. Blumenthal:   On behalf of the Association of Medical Directors of Information Systems (AMDIS), thank you for the opportunity to respond to the ONC Meaningful Use definition proposal. AMDIS was founded in 1997 as the premier professional organization of physicians responsible for healthcare information technology. Our members are physician leaders dedicated and experienced in the integration of information technology in large, medium and small healthcare settings throughout the United States. Two thousand members strong, AMDIS physicians are the “front line” of applied clinical informatics, experienced in the transformation and enhancement of healthcare via the application of health information technology (HIT). We have been waiting and hoping for the advent of Meaningful Use for a long time. Furthermore we applaud the vision and goals of ONC in defining Meaningful Use. AMDIS believes it is essential to achieve momentum in the introduction of HIT in America and that the benefits of transformation will enable a new era of healthcare quality, safety and cost-effectiveness. Therefore, our focus in this response will be on the bigger picture and broad themes rather than detailed item-by-item feedback on each objective and measure. Our recommendations are based on ONC’s specific interest in receiving feedback on the aggressiveness of proposed requirement timelines and how best to frame these measures. RECOMMENDATION 1: Meaningful use “as seen through the patient’s eyes” should specifically inform objectives and measures. . .  muadminFri, 26 Jun 2009 17:25:00 GMTf1397696-738c-4295-afcd-943feb885714:55http://meaningfuluse.org/Opinions/ArticleDetail/tabid/62/articleType/ArticleView/articleId/53/Meaningful-Use-A-Brief-History.aspx#Comments338http://meaningfuluse.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=62&ModuleID=377&ArticleID=53http://meaningfuluse.org/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=53&PortalID=0&TabID=62http://meaningfuluse.org/Opinions/ArticleDetail/tabid/62/articleType/ArticleView/articleId/53/Meaningful-Use-A-Brief-History.aspxA humorous look back at medical history from a "meaningful use" perspective to kill time until the Feds release the official definition.jus10Fri, 12 Jun 2009 20:24:00 GMTf1397696-738c-4295-afcd-943feb885714:53http://meaningfuluse.org/Opinions/ArticleDetail/tabid/62/articleType/ArticleView/articleId/52/A-Historic-Opportunity-Wedding-Health-Information-Technology-to-Care.aspx#Comments39http://meaningfuluse.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=62&ModuleID=377&ArticleID=52http://meaningfuluse.org/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=52&PortalID=0&TabID=62http://meaningfuluse.org/Opinions/ArticleDetail/tabid/62/articleType/ArticleView/articleId/52/A-Historic-Opportunity-Wedding-Health-Information-Technology-to-Care.aspx     By Todd Park and Peter Basch May 2009   The $19 billion health information technology investment authorized under the American Recovery and Reinvestment Act’s HITECH program resents a landmark opportunity to catalyze improvement of our nation’s health care system. This key piece of President Obama’s policy agenda encourages doctors and hospitals to embrace health IT solutions in order to strengthen and modernize the infrastructure upon which our health care system runs. This critical health IT investment program will fail, however, if it is treated as a pure technology implementation program. Indeed, failure is effectively guaranteed if the HITECH program embraces technology adoption for the sake of adoption. But if this new health IT investment program is wedded to a strong commitment to provider payment reform in forthcoming health care reform legislation and implemented specifically as an accelerator of health care delivery innovation and payment reform, then the investment program can help transform U.S. health care as we know it.  pbasch1Wed, 10 Jun 2009 20:10:00 GMTf1397696-738c-4295-afcd-943feb885714:52http://meaningfuluse.org/Opinions/ArticleDetail/tabid/62/articleType/ArticleView/articleId/51/Consensus-from-Contradiction-An-Emerging-Case-for-Healthcare-Payment-Reform-plus-Health-IT.aspx#Comments5http://meaningfuluse.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=62&ModuleID=377&ArticleID=51http://meaningfuluse.org/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=51&PortalID=0&TabID=62http://meaningfuluse.org/Opinions/ArticleDetail/tabid/62/articleType/ArticleView/articleId/51/Consensus-from-Contradiction-An-Emerging-Case-for-Healthcare-Payment-Reform-plus-Health-IT.aspxBy Peter Basch, MD, FACP   The verdict on the value of health IT has always been divided and increased attention to the issue has done little to narrow that divide.  Indeed, the entrance of a new administration committed to including health IT in its healthcare agenda has produced a near daily barrage of reports and commentary on the value of health IT – with their verdicts increasingly disparate.   How should the Obama administration read this “scatter-gram” of recommendations? Should it conclude that health IT is so immature and unreliable that each study has legitimately arrived at a very different conclusion? Should President Obama modify his vision of moving all Americans to electronic health records from a horizon of 5 years to something considerably longer?   I think not. I believe that a careful read and “read between the lines” of most studies reveal these common threads: ·         Health IT is not fully mature, and does not yet contain all of the features that are necessary for it to serve as the infrastructure of 21st century healthcare; however, it is mature enough in most settings for use today; ·         Health IT per se is quality, safety, and effectiveness neutral and in some settings will show worsening of care, in some will show no effect, and in some will show improvements to care; ·         Adoption of health IT alone will not and cannot result in healthcare reform; however meaningful healthcare reform is not possible without near universal adoption of advanced health IT; ·         Health IT implemented in a dysfunctional and fragmented healthcare delivery and payment system will always show suboptimal and inconsistent results; this inconsistency will always be present, until the variables of healthcare processes and incentives are controlled; ·         Adoption of health IT without healthcare delivery and payment reform is not enough and all but guarantees that the time, effort, and dollars expended will disappoint the IT purchasers. It will certainly not give patients what they need and deserve – which is a better, safer, and more value-laden healthcare system. A Matter of Maturity   Not all electronic health records (EHRs) are alike, some are much better than others, and none are fully mature.  That said, does that mean that the better EHRs do not provide value now, or that any EHR can’t be modified or enhanced to result in further value? Even less-than-fully-functional EHRs can and do produce improvements in care.   In fact, there is evidence to suggest that even mediocre health IT can lead to care improvement, when implemented well and implemented in a “defragmented” care delivery environment. That does not mean that health IT shouldn’t be improved, of course it should. However, policy makers need to be aware, as I believe the Obama team is, that improved health IT without dedicating resources to an expansion of trained informaticists and implementers will lead to less than ideal results.   The question of why health IT is not more mature is contentious, with some blaming vendors and others faulting the core technology. In my view the answer is neither, but rather lack of a demand. As someone who has  encouraged vendors to develop more advanced EHRs that help to facilitate care coordination, proactive care, and non-visit based care, the response has been consistent and predictable, “… aside from you, who else would buy it?” And, “…doctors are already complaining about how difficult it is to use an EHR. You are suggesting we make it even harder.”  I can’t disagree; without a sustainable business case for health information management and quality (meaning that a significant percentage of physician income is based on management and quality) physicians are not looking for these features, and vendors will not build them. Contrast that with coding support for billing, a feature that is entirely without value to patient care and quality, but built into almost every EHR.   Not Magic, Just a Tool   Even if health IT were fully mature, it is at best an enabling infrastructure. It can do no more than support the business processes of the health system.  If the healthcare system contains fully aligned incentives such that all participants “do well by doing good,” health IT may fully realize its potential. If however, health IT is implemented in the context of the misaligned US healthcare system where “efficiency” for one stakeholder means built-in inefficiency for others, and where providing the most cost effective treatment is not a goal shared by all stakeholders – then we all but guarantee that the integration of health IT will not be fully optimal.   Policymakers tend to have it backwards. For example, former Senator Bill Frist (R-Tenn.) gave a keynote address at a major health IT conference during which he showed a very effective graphical representation of our fragmented healthcare system. Instead of then setting out a plan for fixing it, he turned to the audience of many thousands of IT professionals, and explained that health IT will unscramble and defragment healthcare. That is not possible as health IT is not magic.  Simply digitizing our existing system no matter how sophisticated the technology, will just make bad and/or competing processes happen more quickly. To see mediocre or hopefully better health IT optimize quality, safety, and effectiveness, health IT has to be implemented in a healthcare system that is far less broken than the one we have today.   Health IT Alone Won't Result in Reform   Implementation of health IT can result in new or changed situations that call for new policy, but health IT adoption is obviously not synonymous with healthcare reform. We can have universal health IT adoption and still have the same dysfunctional healthcare system we have now. However, healthcare reform that is shaped around the Institute of Medicine’s laudable vision of 21st century healthcare cannot be realized without widespread adoption of advanced health IT.   Not only have prior studies of health IT implementations shown suboptimal and inconsistent results, but all future studies will do the same– as long as the studies are conducted in an environment of fragmentation and reimbursement toxicity. A recent study from Texas looked at incremental value from health IT systems where the variable was not what health IT system was in place, but rather how much it was used. And to no one’s surprise, the more the advanced features of the system were used, the more care improvements were seen.    The inherent value of health IT is to improve health information management and coordination. Translating this to provision of services, health IT can dramatically improve care coordination, chronic care management, proactive care, and non-visit based care (eCare). But, with the exception of demonstrations and pilot projects, none of these services are currently reimbursed.  Perversely, the more a physician uses a health IT system for optimal benefit, the worse the business case. For example, if my general internal medicine practice were to significantly reduce its volume of reimbursed office visits s in order to optimize time spent on unreimbursed care coordination, chronic care management, proactive care, and non-visit based care, we would go bankrupt in a matter of weeks.  Fix the misaligned reimbursement system, and even with our good (but not perfect) EHR, we could demonstrate consistently enhanced care delivery.    Advanced health IT adoption is necessary but not sufficient for practicing higher quality and safer medicine. Advanced health IT is complex, expensive, and difficult to implement and maintain. The cost and pain of implementation are so great, that unless healthcare and payment reform are part of the broader agenda (though not necessarily simultaneous), health IT adoption is probably not worth doing.   A Time for Optimism   While most readers are intently focused on the outcome of the economic stimulus / recovery package legislation (and where those billions of dollars are going), I would ask that we look instead toward where the new administration is going to take healthcare. Yes, dollars in the stimulus package are important, and can help to incent adoption of health IT and necessary infrastructure (such as broadband in rural areas); but whether or not that health IT is used to enhance care will be determined by what happens next.      About Peter Basch Basch, an early adopter of health IT, is a practicing physician and clinical leader for EHR implementation at MedStar Health in the Baltimore/Washington D.C. area. A version of this piece was first published in February 2009 at www.iHealthBeat.org pbasch1Wed, 10 Jun 2009 20:05:00 GMTf1397696-738c-4295-afcd-943feb885714:51http://meaningfuluse.org/Opinions/ArticleDetail/tabid/62/articleType/ArticleView/articleId/40/Recommendation-for-Meaningful-Use-Definition-from-Rural-Wisconsin-Health-Cooperative.aspx#Comments77http://meaningfuluse.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=62&ModuleID=377&ArticleID=40http://meaningfuluse.org/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=40&PortalID=0&TabID=62http://meaningfuluse.org/Opinions/ArticleDetail/tabid/62/articleType/ArticleView/articleId/40/Recommendation-for-Meaningful-Use-Definition-from-Rural-Wisconsin-Health-Cooperative.aspxRural Wisconsin Health Cooperative   “Meaningful EHR Use,” “Certified EHR,” And “Open Source” Recommendations   The American Recovery and Reinvestment Act of 2009 (ARRA) provides for Medicare incentive payments to hospitals that can demonstrate “meaningful use” of “certified EHR technology,” including for information exchange and for the submission of clinical quality measures, with definitions of these terms to be finalized by the Secretary of Health and Human Services (HHS). This paper provides a summary of published “Meaningful EHR User” definition recommendations, as well as the Rural Wisconsin Health Cooperative’s (RWHC) perspective on the issues. We also address the question of whether open source EHRs are necessarily the right fit for small rural hospitals. RWHC is a cooperative of 35 rural hospitals (including 28 Critical Access Hospitals) that promotes regional collaboration for health and health care services on behalf of rural communities.   Highlights from Other Associations’ “Meaningful EHR User” Recommendations:   College of Healthcare Information Management Executives (CHIME):   ·         Meaningful use must focus on outcomes and not mandate specific functionalities ·         Phase in requirements without setting the bar too high, too early, but raise the bar over time ·         Given existing obstacles, explore ways to initially exchange information other than through an HIE   The Markle Foundation:   ·         Primary goals need to be improving healthcare quality, reducing growth in costs, stimulating innovation, and protecting privacy; not the installation of hardware and software alone ·         In the first years of implementation, meaningful use definition must optimize achievability for providers and benefits to patients and consumers, and the definition should expand over time ·         Processes for certification should embed the capability for hospitals to attain meaningful use, to meet reporting requirements, and comply with security requirements ·         Metrics should allow for a broad range of providers to participate ·         Consumers, patients, and their families should benefit from HIT through improved and secure access   Healthcare Information and Management Systems Society (HIMSS):   ·         Recognize CCHIT as the certifying body for EHRs, and include Open Source and Best of Breed systems ·         Publish data standards for output of EMR data, so interoperability requirements can be achieved ·         Phase in criteria for meaningful use so there is reasonable time to manage the change o        Phase 1 (2 years commencing 2011) §         Ancillary department systems (lab, pharmacy, radiology) and a clinical data repository are in use and interfaced to the patient accounting system. Electronic documentation of a variety of clinical information. CPOE and physician documentation are optional. §         Adoption of a combination of compliance metrics, including core measures, AHRQ quality outcomes and others §         Hospitals electronically exchange information via scanned/text documents, or XML  o        Phase 2 (2 years commencing 2013) §         51% of orders entered electronically by physicians via CPOE. Electronic prescribing beyond the bounds of the hospital to external pharmacies for discharge medications §         Hospitals electronically exchange info with external entities using HITSP standards §         Additional QI metrics. Transmissions submitted in standardized, discrete data elements and transactions via the Continuity of Care Document (CCD) o        Phase 3 (2 years commencing 2015) §         85% of orders entered electronically by physicians via CPOE. Closed-loop medication administration at the point of care. Clinical decision support via evidence based order sets and core measures reminders. Analysis of pharmacokinetic outcomes §         Hospitals electronically exchange information with public health entities and HIEs which are connected at least at the state level §         Additional QI metrics. Components of health information, as specified in the CCD standard, are electronically exchanged as discrete data elements    RWHC’s “Meaningful EHR User” Definition Recommendations   1.       CCHIT should be at least one of the certifying entities for EHRs, and certification should ensure that the certified product has the capabilities to allow hospitals to attain “Meaningful EHR User” designation:   ·         Rural and small hospitals have and will continue to rely on a certifying body to help assure that they have selected a vendor with appropriate capabilities. Since CCHIT establishment, many rural hospitals have selected CCHIT certified vendors with the understanding that such certification will be required to meet future regulations. Whether or not other certification mechanisms are established, the implicit commitment that CCHIT certification is meaningful should be upheld. Rural facilities cannot afford to completely reinvest in software, hardware, installation, and training costs based on shifting conceptions of what makes an appropriate certification body.   ·         CCHIT has so far struck a balance between large-hospital focused vendors and small-hospital focused vendors, with 4 of the 9 inpatient certified vendors commonly used by CAHs and other small hospitals   ·         To the extent that CCHIT certification standards do not force the vendors to provide capabilities that allow hospitals to attain “Meaningful EHR User” status, such standards should be added, and CCHIT should drive increasingly higher levels of capability in coordination with “Meaningful EHR User” definition phases, including for decision support, interoperability, reporting, and security. This concept is consistent with CCHIT’s current mission.    2.  The information exchange requirement should be attainable by hospitals that are in states that do not have health information exchanges, and the cost and complexity of meeting the requirement should not be overly burdensome for small rural hospitals, which generally do not have any integration or interface expertise in house. Consistent with HIMSS recommendations, standards for output and input of EMR data, along with implementation guides, should be developed. Continuity of Care Document (CCD) exchange may be a good focus for this requirement. Vendor capability to produce the CCD should be driven through the CCHIT certification process.   3.  Quality reporting metrics should be designed to maintain existing data submission efforts and to add those metrics that are relevant to quality and patient safety. Vendor capability to automatically capture and report on relevant statistics should be driven through the CCHIT certification process; but it should be understood that certain data, such as scanned documents or the data captured in physician dictations, will not be machine readable, so automated data capture and reporting will be initially limited.  Automated quality submission statistics should be designed with a clear understanding of what will be machine readable after hospitals meet reasonable capability requirements of “meaningful use.” (See Section 5). The collection of non-machine readable relevant data should continue through the current abstraction and upload process.        4.  The primary goals of achieving meaningful use should be improvements in quality and efficiency; however, it should be understood that sometimes quality comes at a higher cost, especially in smaller facilities where there is a lower and sometimes negative return on investment for clinical systems. While we agree that the installation of hardware and software alone is not the primary goal of achieving meaningful use, the migration from paper-based systems to digital systems that allow for decision support and better data collection is in our opinion a required step toward improved quality, as well as for healthcare reform. The critical issue here is to provide enough time for hospitals to phase in certified electronic systems so the hospitals’ existing workflow, quality, and efficiency challenges are mitigated as a result of the implementations.   5.  Meaningful use capabilities should be clearly defined and phased in over time so they are reasonably attainable and so hospitals can appropriately address vendor selection, preparation, and the workflow and quality challenges discussed above. It should be understood that “critical access hospitals” (CAHs) and, separately, “rural” hospitals have a median adoption score of 1.1 on the HIMSS EMR adoption model, whereas “general medical surgical” hospitals have a median adoption score of 2.3. Given this, it seems likely to us that if the meaningful use capability thresholds are the same for CAHs and other small rural hospitals as they are for larger hospitals, far fewer small rural hospitals will attain meaningful use and qualify for incentive benefits.   This will likely exasperate the existing EHR adoption disparity between large and small hospitals. Also, if small rural hospitals are held to the same threshold standards, it is likely that they will have less time to devote to the workflow and quality aspects and will therefore have a higher rate of failed implementations. To address these issues, we recommend that “meaningful use” thresholds for CAHs and all other small rural hospitals be defined separately from thresholds for hospitals with more than 100 beds. Using the HIMSS phasing recommendation as a template, we recommend the following thresholds for CAHs and all other small rural hospitals with fewer than 100 beds:   §         Phase 1 (2 years commencing 2011)   o        Ancillary department systems (lab, pharmacy, radiology) and a clinical data repository are in use and interfaced to the patient accounting system. Orders and results are available online.   o        A starter set of relevant core measures and other patient safety indicators to become incentivized rather than optional (as they currently are for CAHs). Since most data will still be paper based, continue QI data submissions through the current abstraction and upload process, but allow for automated reporting for the data that is available in machine readable form. o        Information exchange that is attainable without the need for significant increase in integration and interface expertise in house   §         Phase 2 (2 years commencing 2013)   o        Bedside electronic documentation of a variety of clinical information (allergies, care plans, vital signs, flow sheets, inputs and outputs, medication lists, etc.), such as through a electronic nurse documentation system. CPOE and physician documentation are optional. o        Expansion of relevant core measures and other patient safety indicators. Incentivized participation in staff and patient perception tools (such as H-CAHPS), which are currently optional for CAHs. With nurse documentation implemented, expand automation of reporting from the EHR. o        Information exchange that is attainable without the need for significant increase in integration and interface expertise in house   §         Phase 3 (2 years commencing 2015): Important to note that CAH benefit payments phase out after 2014, so this phase is only to avoid penalties. PPS hospitals that are meaningful users starting in 2013 will be receiving incentive payments through 2016.   o        EMAR and clinical decision support, including through medication contraindication alerts, with CPOE and physician documentation still optional. o        Demonstration and reporting of quality improvements relating to the selected indicators, and expansion of indicators to achieve additional patient safety goals. o        Information exchange that is attainable without the need for significant increase in integration and interface expertise in house   By phasing in reasonable and achievable requirements, we believe that five years from now it will be possible to look back and see significant improvement relating to both EHR adoption and quality for the vast majority of small rural hospitals. If standards are set unreasonably high, without accounting for the current EHR adoption disparity between large and small hospitals, we believe the result will be that a minority of small rural hospitals will achieve the “meaningful use” standards and earn their incentives, while the majority of small rural hospitals will effectively be left behind in the HIT revolution that ARRA represents.         RWHC’s “Certified EHR Cost” Definition Recommendations   Unlike PPS hospitals, CAHs get their bonus reimbursement based on what they spend on “Certified EHR.” We have not seen many weigh in on this definition, no doubt largely because bonuses for PPS hospitals do not depend on what they spend or the category of their expenditure.   We believe that for the CAH bonus (which is an expanded and immediately depreciable Medicare Share reimbursement for undepreciated and new certified EHR expenditures made by meaningful users between 2011 and 2014) to have much value, the definition of “Certified EHR Cost” should include software, implementation, hardware (server, desktop, laptops, tablets, carts for nurse documentation, etc.), infrastructure (such as networking equipment, including wireless), training, and other costs associated with building a successful, secure, and available EHR environment.   We also believe that the cost for PACS and other systems that are clearly part of the EHR and lead down the road to a paperless environment, should apply to the incentive bonus, even if they are not required for “meaningful use.” This will allow early adopter CAHs to innovate (beyond what is reasonable for most CAHs) and to get some benefit from the CAH incentive, just as PPS hospital early adopters will benefit through their incentive structure.   Our concern is that most of the categories of EHR cost identified above do not and likely will not have “certification” programs. Our recommendation therefore is that the concept “Certified EHR Cost” should be interpreted to mean “costs associated with developing a fully functional EHR environment that uses certified vendors in all those categories of cost where certification programs exist.”        RWHC’s Position Regarding “Open Source” Solutions for Rural Hospitals   We recommend a careful and deliberate approach to address the open source issue. Many advocates of open source (specifically OpenVista) are claiming that it is the right solution for small rural hospitals, primarily because it is assumed that OpenVista is a lower cost solution than commercial vendor solutions and because it has worked well at the VA. It is difficult to test these assumptions, since as far as we know OpenVista has never been fully implemented in an independent critical access hospital environment. Concerns regarding OpenVista in small hospitals include: (1) it was developed for a large hospital VA environment; how will that translate to the small independent hospital environment? (2) integrated financial applications are not available with OpenVista, as they are with commercial vendors; (3) the cost of installation and support may not scale to the very small CAH environment; (4) small hospitals do not have programmers that can take advantage of the open source nature of OpenVista; and (5) OpenVista is not CCHIT certified, even as four small hospital-focused commercial vendors are. Before significant dollars are spent to create a federal OpenVista offering, we recommend that the questions embedded in these concerns be answered through a thorough case study in which the costs, challenges, and benefits of OpenVista (in an independent CAH environment) are documented and compared to the costs, challenges and benefits of CCHIT certified small hospital-focused commercial vendor products.     lwenzlowThu, 14 May 2009 13:16:00 GMTf1397696-738c-4295-afcd-943feb885714:40http://meaningfuluse.org/Opinions/ArticleDetail/tabid/62/articleType/ArticleView/articleId/28/Somewhere-Over-the-Rainbow.aspx#Comments4http://meaningfuluse.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=62&ModuleID=377&ArticleID=28http://meaningfuluse.org/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=28&PortalID=0&TabID=62http://meaningfuluse.org/Opinions/ArticleDetail/tabid/62/articleType/ArticleView/articleId/28/Somewhere-Over-the-Rainbow.aspxJustin Graham, MD MS   Congress left a $19 billion treasure trove for physicians and hospitals in the HITECH provisions of the recent ARRA stimulus package. This particular pot of gold, however, lies at the other end of a magical rainbow labeled “meaningful use of certified electronic health record (EHR) technology.” Like all rainbows, the definition of “meaningful use” is a glittery, insubstantial thing that shifts as one’s perspective changes and encompasses a wide spectrum of colorful views; but, even to experts, it remains unclear if the rainbow can become a bridge across the quality chasm that defines American healthcare. While we wait for a final determination from Washington, the healthcare community has been witness to a panoply of colorful attempts to define and re-define “meaningful use.”   HIMSS, the Markle Foundation, CHIME, AMIA, and other titans of healthcare information technology have added their voices to the spectrum of viewpoints. Largely absent from this debate have been those most likely to be profoundly affected by the HITECH incentives: front-line, practicing physicians, and their patients. “Meaningful” is in the eye of the beholder; unfortunately our fragmented healthcare delivery “system” has more eyes than a potato. “Meaningful use” to a patient might imply a reduction in risk of a life-threatening drug interaction or less paperwork or shorter waits at the doctor’s office. In contrast, “meaningful use” to a physician in a small practice might mean better reimbursement, more leverage against strong-arm insurer tactics, or just getting out of the office before 7pm every night. Certainly, insurers and payers might like to see EHRs improve the quality of care, but they clearly have a vested interest in seeing that improved quality results in greatly reduced costs. And, of course, a whole host of vendors, foundations, and public and private HIT organizations have their own agendas, including explicit or tacit support for standards or technology they are fully invested in. I’ve spent more than 10 years working with healthcare information technology, including spearheading EHR efforts in settings as large as Kaiser and as small as the solo practice, rural physician office. After all this experience, I don’t think I can conclusively create a global definition for “meaningful use” for an EHR any better than I could do it for an automobile or a screwdriver. In the right hands, an EHR is an incredibly powerful tool to create dramatic changes in healthcare delivery and quality. But, in the end, it is only a tool, a means to an end, which has no more value to an unready healthcare provider than a car does to New Yorker who has taken the subway his entire life. The last thing we want from this grand, national experiment in subsidized information technology is “meaningless use,” which might be a bit easier for us to define. After all, a vandalized and stripped car by the side of the road is fairly easy to deem “useless.”   How would we universally define “meaningless use” of an EHR? Here are some suggestions: ·        EHR implementations that lead to unambiguously worse outcomes for patients without hope of improvement. For instance, increased deaths in ICUs when computerized order entry malfunctions. ·        A series of highly visible failed implementations that scare providers (and even patients) from adoption of HIT over the next decade. ·        Cynical use of HIT solely to support higher salaries for providers or reduced costs to insurance companies without concomitant improvements in quality of care ·        Widespread adoption of technological “dead-ends” that lock providers into proprietary data models and interfaces, eliminating the possibility of future innovation and improvement of the healthcare delivery model Like most others in my field, I passionately believe that information technology can dramatic transform healthcare for the better and improve the lives of our patients, providers, and staff while reducing costs. But what will ultimately differentiate “meaningful” from “meaningless” use will not be the technology itself, but rather competent leadership, change management, efficient processes, and a relentless focus on the patient before everything else.   Those who believe they can reach the pot of gold by walking on a rainbow are fooling themselves; the surest way to get there is step by muddy step across the solid ground.jus10Mon, 11 May 2009 13:26:00 GMTf1397696-738c-4295-afcd-943feb885714:28http://meaningfuluse.org/Opinions/ArticleDetail/tabid/62/articleType/ArticleView/articleId/27/What-is-Meaningful-for-Physicians-office.aspx#Comments88http://meaningfuluse.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=62&ModuleID=377&ArticleID=27http://meaningfuluse.org/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=27&PortalID=0&TabID=62http://meaningfuluse.org/Opinions/ArticleDetail/tabid/62/articleType/ArticleView/articleId/27/What-is-Meaningful-for-Physicians-office.aspxHoward Landa, MD   What is “Meaningful” for Physician’s office?   Over a decade and a half of HIMSS (Healthcare Information Management Systems Society) meetings, many are identified in my mind with “catch phrases” and mnemonics. We had “Patient safety;” “to err is human;” and “interoperability." There were RHIOs and CHINs; CPOE and CDS to prevent ADEs as part of EMRs, and EHRs; and these were hotly debated by CIOs, CMIOs, and CEOs, all looking for ROI.   At the end of 2008, I thought that HIMSS 2009 would be a much quieter meeting than in the past. The downturn in the economy had cut everyone's travel budget as well as their ability to make capital investments. But then along came the mnemonic and catchphrase of 2009; ARRA (the American Recovery and Reinvestment Act or Stimulus package), and the phrase “meaningful use.” And HIMSS 2009 came alive! The ARRA promises to provide a great deal of money to physician offices and healthcare organizations that can show “meaningful use” of electronic health record. There is no question in my mind that implementing efficient, effective, well thought out EHRs in ambulatory care has the potential to dramatically improve the quality and efficiency of medical care. As has oft times been said, however, “The devil . . .  hlandaMon, 11 May 2009 06:50:00 GMTf1397696-738c-4295-afcd-943feb885714:27http://meaningfuluse.org/Opinions/ArticleDetail/tabid/62/articleType/ArticleView/articleId/2/Why-Meaningful-Use-is-so-important-to-AMDIS-and-America.aspx#Comments37http://meaningfuluse.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=62&ModuleID=377&ArticleID=2http://meaningfuluse.org/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=2&PortalID=0&TabID=62http://meaningfuluse.org/Opinions/ArticleDetail/tabid/62/articleType/ArticleView/articleId/2/Why-Meaningful-Use-is-so-important-to-AMDIS-and-America.aspxThe Association of Medical Directors of Information Systems is a 2000 member organization dedicated to the integration of information technology into the practice of medicine for the improvement of the safety and quality of the care of our patients. Our organization is differentiated from other medical informatics organizations in that we are composed of individuals with not only the responsibility for successfully introducing and demonstrating the value of information technology in medicine, but who have actually accomplished those goals. It is because of this applied aspect of AMDIS that the Obama administration's agenda for accomplishing the introduction of the Electronic Health Record (EHR) throughout America is of such intense interest and we strongly support this effort. An early aspect of this agenda has been the stimulus of $20 billion dollars to acquire and implement EHRs throughout the United States AND to apply those dollars where "meaningful use" of EHRs is demonstrated. Therefore, at this very early stage of the introduction of the HIT stimulus package, the definition of "meaningful use" has both captured the attention and imagination of the US medical informatics community in a way that is entirely unprecedented. For AMDIS, the definition of "meaningful use" holds the promise of either incentivizing  our common vision of the improvement in the safety and quality of the care delivered to each and every American, or could be squandered in simply providing enhanced administrative control over clinical decision making. We are dedicated to the former and the communication to not only our medical colleagues but our patients and the general public of what, in fact is at stake. We believe and as a result of our experience, KNOW that this time can define a new golden era of medicine in this country. This website will act as a forum for communication between AMDIS, our medical colleagues as well as the general American public in the belief that by sharing our experience and passion for the vision of a better American healthcare system we can benefit our patients, our children and ourselves. Please join us in this vital dialog.   William F. Bria MD CMIO, Shriners Hospitals for Children AMDIS Board PresidenthostThu, 07 May 2009 01:17:00 GMTf1397696-738c-4295-afcd-943feb885714:2