The thrust of Meaningful Use of Certified Electronic Health Records (EHRs) is actually quite profound. Beyond simply encouraging physicians to capture their day-to-day chart note-taking electronically (instead of on paper), and beyond facilitating physician workflows (like electronic prescribing, review of lab test data, etc.), Meaningful Use also requires the use of Clinical Quality Measures (CQM).
Tying Meaningful Use incentive payments to CQM is actually pretty profound. It elevates the paying-attention-to-clinical-quality-metrics to a new level. As American healthcare moves from a business model that rewards usage of services (the fee-for-service tradition of healthcare reimbursement) towards one that rewards outcomes (the pay-for-performance incentives), knowing what the Quality Measures are, and having tools to report them, are more important than ever.
A variety of pay-for-performance initiatives have been rolled out in a variety of settings over the past decade or so. In California, the Integrated Healthcare Association (IHA) has pulled together HMO insurance plans, hospitals, and medical groups and IPAs that assume risk for capitated HMO populations, and has developed a common set of criteria for statewide pay-for-performance incentives to groups that do well. Medicare has also developed an individual pay-for-performance program (PQRI) that rewards individuals who can demonstrate performance based on a Medicare-centered set of measures (the PQRI measures).
As these efforts to shift the incentives (compensation) from “fee-for-volume” to “pay-for-performance” the issue of creating consensus around which CQM measure set to use becomes important. By defining a set of measures in Meaningful Use, federal policy is trying to establish this consensus. In fact, the Centers for Medicare and Medicaid Services (CMS), who is implementing the payouts of Meaningful Use bonuses, has explicitly stated its intent to coordinate CQM development and reporting between the various national and statewide programs, and result in a single, common list. This becomes de facto the standard of care, from a national policy level.
Under Meaningful Use, clinicians in ambulatory practice (referred to as Eligible Providers, or EPs, in Meaningful Use jargon) must demonstrate use of 3 “core” (or 3 “alternate core”) measures, and any 3 out of 38 other measures. The measures used by CMS here are drawn from National Quality Forum (NQF) measures, which occasionally overlap with PQRI. Hospitals, for their Meaningful Use CQM component, must report on 15 hospital-oriented quality measures.
For EPs, the 3 core measures are (1) measuring blood pressure in patients with hypertension, (2) screening for tobacco usage, and counseling smokers on cessation, and (3) screening adults for obesity (measuring BMI) and counseling those over-weight (or under-weight) on weight management. For practitioners whose type of practice does not cover these kinds of patients (e.g. pediatricians), the alternate core measures are (1) weight measurement and counseling for children and adolescents, (2) influenza vaccination for patients over 50, and (3) childhood immunization status.
Taking a step back from the details, what does this mean for American healthcare? It means that all practitioners everywhere need to be routinely screening for smoking and weight management. Such screening has now become the universal standard-of-care. Given the cost impact of taking care of the health consequences of these conditions (diabetes, chronic lung disease, heart disease), such universal standards make sense. It should be no surprise that measuring blood pressure in hypertensive patients is a national standard-of-care.
From the standpoint of developing EHR tools that can assist practitioners in documenting these screenings, and can prompt when such screenings are due – this has also become the national standard. HHS Certification, which is what is needed from EHRs in order to be eligible for use in access to Meaningful Use bonus money, now requires that every EHR system contain the capacity to do this. It is no longer elective; it is a Certification requirement.
The increasing importance of Clinical Quality Measures in the delivery of healthcare represents a profound change in the status quo. Meaningful Use, as well as other previous separate efforts from private and public payors, have elevated the whole concept that (1) medical quality can be measured, (2) improved outcomes for the American public can be demonstrated as a result of good performance on these measures, and (3) payment methodologies that encourage good performance around these measures should be significant. These are actually rather bold statements that speak to the depth of healthcare delivery transformation envisioned by current national policy.
Robert Rowley, MD
Chief Medical Officer
Practice Fusion EMR
