The widespread use of electronic health records
(EHRs) in the United States is inevitable. EHRs will improve
caregivers' decisions and patients' outcomes. Once patients experience
the benefits of this technology, they will demand nothing less from
their providers. Hundreds of thousands of physicians have already seen
these benefits in their clinical practice.
But inevitability does
not mean easy transition. We have years of professional agreement and
bipartisan consensus regarding the potential value of EHRs. Yet we have
not moved significantly to extend the availability of EHRs from a few
large institutions to the smaller clinics and practices where most
Americans receive their health care.
Last year, Congress and the
Obama administration provided the health care community with a
transformational opportunity to break through the barriers to progress.
The Health Information Technology for Economic and Clinical Health Act
(HITECH) authorized incentive payments through Medicare and Medicaid to
clinicians and hospitals when they use EHRs privately and securely to
achieve specified improvements in care delivery.
Through HITECH,
the federal government will commit unprecedented resources to supporting
the adoption and use of EHRs. It will make available incentive payments
totaling up to $27 billion over 10 years, or as much as $44,000
(through Medicare) and $63,750 (through Medicaid) per clinician. This
funding will provide important support to achieve liftoff for the
creation of a nationwide system of EHRs.
Equally important,
HITECH's goal is not adoption alone but “meaningful use” of EHRs — that
is, their use by providers to achieve significant improvements in care.
The legislation ties payments specifically to the achievement of
advances in health care processes and outcomes.
HITECH calls on
the secretary of health and human services to develop specific
“meaningful use” objectives. With the Centers for Medicare and Medicaid
Services (CMS) in the lead, the Department of Health and Human Services
(DHHS) has used an inclusive and open process to develop these criteria,
providing an extensive opportunity for public and professional input.
The department published proposed meaningful use requirements on January
16, 2010. The proposal prompted some 2000 comments. This week, the DHHS
is releasing a final regulation for the first 2 years (2011 and 2012)
of this multiyear incentive program. Subsequent rules will govern later
phases.
Although the intent of our January proposals has been
retained and indeed affirmed through the rule-making process, the final
regulation also incorporates significant changes — a response to the
comments and experience that diverse stakeholders shared with us. In
particular, concerns about the pace and scope of implementation of
meaningful use led us to adopt a two-track approach regarding the
objectives that allow practices and hospitals to qualify for incentive
payments in the first 2 years of the program.
The most important
part of this regulation is what it says hospitals and clinicians must do
with EHRs to be considered meaningful users in 2011 and 2012. In the
original proposal, we identified a broad set of objectives, all of which
would need to be met. This included 23 objectives for hospitals and 25
for clinicians. The DHHS received many comments that this approach was
too demanding and inflexible, an all-or-nothing test that too few
providers would be likely to pass.
In the final regulation, we
have divided these elements into two groups: a set of core objectives
that constitute an essential starting point for meaningful use of EHRs
and a separate menu of additional important activities from which
providers will choose several to implement in the first 2 years (see table
Summary Overview of Meaningful Use Objectives.).
Summary Overview of Meaningful Use Objectives.).
Core
objectives comprise basic functions that enable EHRs to support
improved health care. As a start, these include the tasks essential to
creating any medical record, including the entry of basic data:
patients' vital signs and demographics, active medications and
allergies, up-to-date problem lists of current and active diagnoses, and
smoking status.
Other core objectives include using several
software applications that begin to realize the true potential of EHRs
to improve the safety, quality, and efficiency of care. These features
help clinicians to make better clinical decisions — and avoid
preventable errors. To qualify for incentive payments, clinicians must
start employing such clinical decision support tools. They must also
start using the capability that undergirds much of the value of EHRs:
using records to enter clinical orders and, in particular, medication
prescriptions. Only when providers enter orders electronically can the
computer help improve decisions by applying clinical logic to those
choices in light of all the recorded patient data. And to begin
extending the benefits of EHRs to patients themselves, the meaningful
use requirements will include providing patients with electronic
versions of their health information.
In addition to the core
elements, the rule creates a second group: a menu of 10 additional
tasks, from which providers can choose any 5 to implement in 2011–2012.
This gives providers latitude to pick their own path toward full EHR
implementation and meaningful use.
For example, the menu includes
capacities to perform drug-formulary checks, incorporate clinical
laboratory results into EHRs, provide reminders to patients for needed
care, identify and provide patient-specific health education resources,
and employ EHRs to support the patient's transitions between care
settings or personnel.
For most of the core and menu items, the
regulation also specifies the rates at which providers will have to use
particular functions to be considered meaningful users. Reflecting the
views and experiences shared during the comment period, these rates will
enable significant progress toward improving care — but are also
achievable by average practices and providers in the early years.
The
HITECH legislation further requires that meaningful use include
electronic reporting of data on the quality of care. In the final
regulation, we have simplified the January proposals for quality
reporting, while still building toward a robust reporting capability
that will inform providers about their own performance and will
eventually inform the public as well. Clinicians will have to report
data on three core quality measures in 2011 and 2012: blood-pressure
level, tobacco status, and adult weight screening and follow-up (or
alternates if these do not apply). Clinicians must also choose three
other measures from lists of metrics that are ready for incorporation
into electronic records.
The meaningful use rule is part of a
coordinated set of regulations to help create a private and secure
21st-century electronic health information system. On June 18, 2010, the
DHHS issued a rule that laid out a process for the certification of
electronic health records, so that providers can be assured they are
capable of meaningful use. The department has also issued still another
regulation that lays out the standards and certification criteria that
EHRs must meet in order to be certified. Finally, realizing that the
privacy and security of EHRs are vital, the DHHS has been working hard
to safeguard privacy and security by implementing new protections
contained in the HITECH legislation.
The meaningful use rule
strikes a balance between acknowledging the urgency of adopting EHRs to
improve our health care system and recognizing the challenges that
adoption will pose to health care providers. The regulation must be both
ambitious and achievable. Like an escalator, HITECH attempts to move
the health system upward toward improved quality and effectiveness in
health care. But the speed of ascent must be calibrated to reflect both
the capacities of providers who face a multitude of real-world
challenges and the maturity of the technology itself.
As part of
this process, the DHHS is establishing a nationwide network of Regional
Extension Centers to assist providers in adopting qualified EHRs and
making meaningful use of them. The DHHS is committed to the support,
collaboration, and ongoing learning that will mark our progress toward
electronically connected, information-driven medical care. We hope that
providers and consumers will now join us in the effort to assure that we
make the best possible use of our most precious health care resource:
information about the patients we serve.