Comments on Meaningful Use Based on Experience

Now that we have accumulated some experience with the criteria for the EHR Incentive Program (Meaningful Use), we can see where some of the pain points are. When the Office of the National Coordinator (ONC) set up the criteria for demonstrating Meaningful Use, it was the result of a long, open, and deliberative process, which most everyone applauded. At the same time, it was based on speculation as to what could easily be achieved as a “minimum threshold” for Stage 1 – we now have some experience with which to comment on that initial speculation.

Unlike in the past, where the focus of the EHR industry was on making sure that commercially available products had a specified set of features, Meaningful Use ushered in a new era – simply having features in an EHR was not enough; one needed to demonstrate that one is actually using the EHR in day-to-day clinical practice.

Common myths
Despite considerable talk and interaction, a number of misunderstandings are still prevalent about Meaningful Use. Colleagues of mine have been given some of their misinformation by their billers. Except for Practice Fusion users, where very active support comes from the vendor, actual vendor support around Meaningful Use from most other widely-held EHRs is minimal – usually simply pointing out where, in their product, the reports are located in order to fill out Attestation. Where it exists, most Meaningful Use support comes from organizations that host EHRs (like medical groups, IPAs, hospitals and their affiliated community practices, etc.).

Myth #1: Meaningful Use is only about Medicare patients. This is false. The whole purpose of the EHR Incentive Program is to encourage Eligible Professionals to use EHRs in their whole practice. CMS is the funding pipeline for Meaningful Use, but the criteria apply to all the patients in the practice, regardless of payer. Medicare patients, private insurance patients, HMO patients, cash-paying patients are all part of the numerators and denominators for Meaningful Use. This is significantly different from other federal incentive programs – the e-prescribing (MIPAA) incentive is only about Medicare patients; and PQRS (formerly PQRI) is only about Medicare patients. But Meaningful Use is about everyone.

Myth #2: Clinical Quality Measures (the 3 menu ones) can be from any of the 35 options listed. This is not exactly true either. Meaningful Use requires that you report CQM only on elements that the EHR is Certified for. Very few EHRs are Certified for all the CQM measures – most are Certified for only 3 (or so) of the menu items. This is true as well for Practice Fusion, which is Certified to report on diabetic eye exams, foot exams and blood pressure control. The Stage 1 Meaningful Use CQM bar is fairly low – the numerators can all be zero, in fact. What is intended is to get Eligible Professionals used to reporting CQM measures – there is no minimum performance threshold for this. Now, of course, down the road, organizations like ACOs and Medical Homes will use CQM performance as “report cards” that will allow them to compete based on quality measures. But that comes later.

Roadblocks to successful Meaningful Use now better understood
Now that we are able to look at actual performance “in the field” of Eligible Professionals with respect to each of the Meaningful Use criteria, we can see where the pain points are.

Many clinicians are already achieving most of the core Meaningful Use measures – and if not, they are close, and can get to the performance thresholds without too much difficulty. There are two criteria, however, that we have seen significantly very low scoring.

One measure for which there is low utilization is providing patients with Health Education – menu measure #6. However, this is a menu (optional) measure, and the performance threshold is 10% – in other words, 10% of all patients seen in the 90-day measure period need to be given patient-specific education resources at least once. This item, given that it is optional, and given that the threshold is 10%, is one that can be achieved with some deliberate effort, even in the remaining time this year.

The most significant problem area is Clinical Summaries – core measure #13. This item is a core element, which means that failure to achieve this blocks access to EHR Incentive money via Medicare altogether. The only exception is professionals who have no office visits during the 90 day period (e.g. home-visit practices, etc.). Most professionals trying to achieve Meaningful Use, however, are office-based, and will need to report on this.

The challenge is that 50% of all visits need to have a Clinical Summary provided to patients during the Measure Period (not just Medicare patients, but all patients) within 3 days of the visit. This is a very high bar to achieve – it might not have seemed so onerous when policy-making was looking at this, but now that we have some experience, this is likely the single-most-problematic of all the Meaningful Use measures.

There are 2 ways of generating Clinical Summaries: (1) print out a Summary for each visit and give it to the patient within 3 days, or (2) enroll the patient in a linked PHR that updates automatically with each visit from the associated EHR.

The first method results in something operationally unrealistic. If a typical practitioner sees 20-30 patients a day in the office, and if there are 2-3 practitioners in that office, and if a Summary takes up 1-2 pages of printout, then you are looking at going through a full ream of paper every 1-2 days on this alone! This ream-of-paper-a-day as a result of moving from a paper-based environment to an EHR is an unintended consequence of such a Meaningful Use measure.

More practically, enrolling patients in a PHR is a more feasible solution. Even so, this is a huge challenge. A full 50% of all patients seen need to be enrolled in the PHR (Kaiser – a fully integrated delivery system – only has achieved 30-40% enrollment). This is not just a Practice Fusion issue – informal conversations with colleagues working for other EHR companies face the same challenge.

To help our users achieve this difficult hurdle – one that is a sine qua non for receiving Meaningful Use money – we have focused significant efforts on helping our users. For reference, refer to the step-by-step guide we have published here.

Policy considerations
This experience “in the field” highlights some policy challenges that are becoming apparent after-the-fact. Most of the Meaningful Use requirements are fine, and achievable, and reflect the active use of an EHR by Eligible Professionals. However, the Clinical Summaries (core requirement #13) represents a roadblock that can make access to EHR Incentive funds nearly impossible to achieve.

The 50% threshold is part of the problem. The requirement to generate such a Summary for every visit (not just for every patient, but for every visit) – and not just for patients who ask for it, but for everyone regardless of whether they want it – is also part of the problem.

It is a bit late for CMS or the ONC to revise this requirement for 2011 (although, re-consideration would be widely welcomed). However, either (1) reducing the threshold of performance to some level below 50% – for example, 10%, in line with other measures – or (2) revising the criteria to pertain only to patients to ask for a Summary (rather than everyone, regardless) would be two appropriate ways of making this measure more realistic.

Hopefully, CMS will take a good look at the experience coming “from the field.” For our part, we will do everything we can to help our users achieve this single high hurdle.