Meaningful Use

Meaningful use is using certified electronic health record (EHR) technology to: Improve quality, safety, efficiency, and reduce health disparities. Engage patients and family. Improve care coordination, and population and public health.

Meaningful use, which CMS changed to "advancing care information" and rolled out under the Medicare Merit-based Incentive Payment System, will now be called "promoting interoperability."

OMB Reviewing Proposed Rule for Stage 3 of Meaningful Use

Last week, the Office of Management and Budget received the proposed rule for Stage 3 of the meaningful use program, Politico's "Morning eHealth" reports.

In addition, OMB received a proposed rule from the Office of the National Coordinator for Health IT that would adjust the EHR certification program to "make it more broadly applicable to other types of health IT health care settings" (Gold, "Morning eHealth," Politico, 1/5).

OMB review is one of the last steps before rules are published in the Federal Register (iHealthBeat, 9/16/13).


Under the 2009 federal economic stimulus package, health care providers who demonstrate meaningful use of certified electronic health record systems can qualify for Medicaid and Medicare incentive payments.

In March 2014, the Health IT Policy Committee voted to approve recommendations from its meaningful use workgroup for new objectives for Stage 3 of the meaningful use program (iHealthBeat, 3/11/14). The Policy Committee in its recommendations aimed to tighten the focus of Stage 3, which begins in 2017, and relieve some of the burden on stakeholders (Slabodkin, Health Data Management, 1/6).

The approved recommendations were sent to CMS to develop a proposed rule (iHealthBeat, 3/11/14).

Stage 3 Proposed Rule Details

In the submission to OMB, HHS states that the proposed rule for Stage 3 focuses on improving health outcomes and furthering interoperability. The proposed rule also explains the criteria eligible professionals and eligible hospitals must meet to demonstrate meaningful use under the program.

In addition, HHS said that Stage 3 proposed rule includes changes to the meaningful use program's:

  • Reporting period;
  • Structure; and
  • Timelines.

For example, it would provide a single definition of meaningful use.

HHS said it will work with CMS and the Office of the National Coordinator for Health IT to "ensure that the Stage 3 meaningful use definition coordinates with the standards and certification requirements being proposed and that there is sufficient time to upgrade and implement these changes."

Next Steps

Both proposed rules will be posted in the Federal Register upon completion of OMB's review (Health Data Management, 1/6). ONC expects the proposals to be approved by OMB sometime this winter ("Morning eHealth," Politico, 1/5).

Source: iHealthBeat, Tuesday, January 6, 2015

BMC Med Informatics Study: Physicians More Pessimistic on Meaningful Use Than Staff

Compared with other ambulatory practice staff, physicians are more pessimistic about whether their practices will be able to address challenges related to the implementation of electronic health records under the meaningful use program, according to a study published in BMC Medical Informatics & Decision Making, EHR Intelligence reports. Physicians also expressed less willingness to change their work habits to meet the requirements of the program.

Under the 2009 federal economic stimulus package, health care providers who demonstrate meaningful use of certified EHRs can qualify for Medicaid and Medicare incentive payments (Bresnick, EHR Intelligence, 12/31/14).

Details of Study

For the study, researchers surveyed 400 providers and staff from 47 ambulatory practices within an integrated delivery system (Slabodkin, Health Data Management, 1/2).

Researchers found that 57.9% of physicians said they were willing to change their work practices in response to the meaningful use program, compared with about 83% of advanced-practice providers and nursing staff.

In addition, a minority of respondents believed their organization was prepared to address challenges related to attesting to Stage 1 of the meaningful use program. Specifically:

  • 28.4% of physicians said their organization was prepared for such challenges; and
  • About 45% of advanced-practice providers and nurses said their organization was prepared for such challenges (EHR Intelligence, 12/31/14).

Meanwhile, the study found that 12.6% of providers or staff  in specialty care settings said they thought the meaningful use program would divert attention from other priorities for patient care, compared with 4.4% of providers or staff in primary care settings (Shea et al., BMC Medical Informatics & Decision Making, 12/14/14).

Further, the study found that the belief that the meaningful use program aligns with department goals was associated with providers and staff being more willing to alter their work practices. (Health Data Management, 1/2).


The authors wrote that the "results suggest that leaders of health care organizations should pay attention to the perceptions that providers and clinical staff have about [meaningful use] appropriateness and management support for" meaningful use.

Specifically, the authors recommended that leaders of health care organizations:

  • Document measures and proficiency required for Stage 1 attestation to reduce staff concerns;
  • Form a clear framework for meaningful use implementation to help improve the chances of attestation success; and
  • Provide further opportunities for demonstrations, guidance and trainings for staff on EHR (EHR Intelligence, 12/31/14).
Source: iHealthBeat, Monday, January 5, 2015

AMA Urges CMS To Better Align Meaningful Use, Two Other Programs

The American Medical Association has sent a letter to CMS urging the agency to align the meaningful use program, the Physician Quality Reporting System and the Value-Based Payment Modifier so that providers can avoid penalties under the initiatives, EHR Intelligence reports.

Under the 2009 federal economic stimulus package, health care providers who demonstrate meaningful use of EHR systems can qualify for Medicaid and Medicare incentive payments.

Details of Letter

In the letter to CMS Administrator Marilyn Tavenner, AMA Executive Vice President and CEO James Madara  wrote that the "programs, with often incomprehensible, conflicting requirements and flawed implementation processes, are all entering their penalty phases and pose a risk to the stability of the Medicare program that many policymakers do not seem to appreciate."

The group noted that because the programs were created through separate legislative processes, policymakers do not understand the "cumulative effect of a set of penalties that, when combined with a 2% payment sequester reduction, would total 11% in 2017 and grow to 13% by the end of the decade."

Further, AMA wrote that the penalties' timings could threaten providers' efforts to comply with ICD-10 standards by Oct. 1, 2015. U.S. health care organizations are working to transition from ICD-9 to ICD-10 code sets to accommodate codes for new diseases and procedures. The switch means that health care providers and insurers will have to change out about 13,000 codes for about 68,000 codes.

In addition to better aligning the programs, AMA called for the reversal of a proposed 10% increase in penalties (Murphy, EHR Intelligence, 10/23).

Overall, AMA President Robert Wah said that if providers "meet the protocol and standards for one quality program, they should be deemed successful for all."


In order to better align the programs, AMA recommended that CMS:

  • Stop using an "all-or-nothing approach" to the meaningful use program and instead make standards that challenged providers optional, while also reducing the 2015 reporting period;
  • Release 2013 PQRS and VBM aggregate data that will help providers and others to assess the program in a more timely manner and develop a formal appeals process to allow providers more than 30 days to correct inaccurate data; and
  • Curb VBM implementation if Congress and the Obama administration seek to impose it on all physicians instead of repealing the measure, and allow providers more time to assess its effect before levying penalties if it is not repealed (AMA release, 10/21).
Source: iHealthBeat, Friday, October 24, 2014

EHRs: Expecting Too Much, Too Soon?

In 2014, health care record-keeping and communication are finally emerging from the Stone Age and entering the 21st century, moving away from the pen-and-paper processes abandoned by the rest of the modern world decades ago.

This revolution is driven primarily by the HITECH Act and accompanying meaningful use program. These initiatives drove greater adoption of electronic health records by doctors and hospitals in the last five years than in the previous 40. According to one estimate, EHR adoption by physician practices rose from 17% in 2008 to 48% in 2013 and hospital EHR adoption increased from 13% to 70% during the same time period. These EHRs will play a central role in the move to accountable care and population health management.

A principal HITECH objective was to improve patient care, but a number of recent publications challenge the program's success and EHRs' value -- from both the perspectives of physicians using EHRs and researchers who are decrying a high level of patient safety events across the industry. One article points out that a substantial minority of physicians are dissatisfied with the effect of the EHR on office operations; others suggest EHRs are failing to live up to their promise of reducing patient harm.

Should we be disappointed that this technological revolution hasn't yielded all the anticipated benefits? We think this would be premature. Here's why -- and who's doing it right.

Managing Expectations for the EHR

EHRs can facilitate patient care improvements through three basic mechanisms:

  • Better information capture and documentation;
  • Better sharing of information across settings; and
  • Most importantly, application of computerized clinical decision support (CDS) and data analysis.

The early literature supporting the value of CDS -- on which the meaningful use criteria were largely based -- was derived mostly from a handful of academic institutions with custom-built EHRs that they had constructed and tuned over decades.

It is unreasonable to expect that the majority of organizations that have implemented commercial EHR products in recent years will achieve the kinds of care improvements in a short period of time (two to five years, or "overnight," in health care industry terms) that took the early academic centers many years to achieve.

While in recent years we have learned more about how to design and implement effective CDS, most organizations have neither the staff expertise nor the budgets to commit to drive changes of this magnitude in a short time. Commercial EHR products are equipped with many of the ingredients needed to support clinical workflows and build robust CDS, but they bring with them their own inherent constraints.

Perhaps more importantly, we know that driving rapid technologic and workflow change in organizations is both difficult and hazardous. One way hazards can manifest is through unintended consequences of computerization. Sometimes problems arise from improperly designed or coded software containing errors; however the great majority of unintended consequences arise from the gap between vision for the system as designed and the reality of the system as used. It is virtually impossible to anticipate the full spectrum of individual human and workflow interactions with the system and the resulting manner in which the system gets used.

Implementation Challenges

Problems may manifest during implementation -- for example, during the switch from manual to automated processes. In another common scenario, designers underestimate the amount of time required by physicians to complete their documentation and ordering tasks, resulting in increased physician workload. Quality of documentation may suffer through efforts to replace narrative text with structured templates. Workflows can be disrupted in dangerous ways and new kinds of errors can be introduced.

It takes painstaking planning and rapid response during and after implementation to avoid these problems and resolve those that inevitably occur. It usually takes years for organizations to overcome these challenges and settle into the routine use of a new EHR system. Only then is it possible to truly take advantage of the system's more sophisticated tools and capabilities to affect lasting improvements in patient care processes and patient safety.

So, Who Got It Right?

While success is less newsworthy than failure, an increasing number of organizations have weathered these trials and succeeded in demonstrating genuine benefits from computerization.

Sentara Healthcare

Sentara Healthcare in Virginia reported operational and financial benefits from EHR use, such as length of stay reductions, reduced IT maintenance costs, lower medical records staffing and lower paper costs. It also reported improvements in clinical processes, including faster order execution (e.g., 80% reduction in medication delivery times), increased nursing efficiency (e.g., one hour increase in direct patient care time per nurse, per shift) and more rapid patient transfer times (e.g., 40% reduction in the time it takes to transfer a patient from one unit to another).

Most significantly, it also reported substantial outcome improvements, such as a 50% reduction in hospital mortality ratios (actual/expected deaths) and a reduction of more than 100,000 potential medication errors annually.

Texas Health Resources

Texas Health Resources in Dallas reported EHR-related improvements in its compliance with its CMS Core Indicator bundles, increasing from 65% to 90% compliance to 90% to 95% compliance for all items in the bundle. The organization also achieved a more than 50% reduction in adverse drug event incidence at several targeted hospitals within one year of EHR implementation.

They measured more than 40 minutes of net time savings per nurse, per shift in three of four studied nursing units. And the average time from order writing to computer input for non-stat orders fell from 118 minutes to zero, resulting in more rapid order execution and the more timely delivery of needed care to patients.

Geisinger Medical Center

Geisinger Medical Center in Pennsylvania reduced average hospital length of stay for coronary artery bypass cases by 16% through its evidence-based care program. Geisinger's EHR system helps ensure that 40 critical steps are followed for every patient in the program through the use of checklists, default documentation templates, health maintenance gap reminders and automated order sets; the EHR identifies gaps in care so they can be completed in a timely manner (e.g., before surgery).

Geisinger's pre- and post-implementation analysis showed that 100% of program patients received all 40 care elements included in the bundle, compared with just 59% of those in the conventional care group. Average total hospital length of stay was 5.3 days in the program group, compared with 6.3 days in the conventional care group, and hospital readmission rates were substantially lower for the program patients.

EHRs Are 'Far From Perfect,' but 'Essential'

Today's EHRs are far from perfect. Physician documentation often requires more time than it used to, at least initially. And it takes time and expertise to build out the programmatic and application structures needed to realize significant benefits in safety and quality.

But EHRs are nonetheless essential, and we should thank the federal program that's forcing health care to finally join the 21st century. We are obligated to move forward -- to use modern tools to improve medical decision making, to document legibly and to share information quickly and accurately with our colleagues, as well as our patients. We cannot return to the Neolithic era.

Source: iHealthBeat, Tuesday, September 2, 2014