Meaningful Meaningful Use?

Why Health Care IT Lags

CIO Unplugged — Tue, 17 Nov 2009 18:38:10 GMT

The views and opinions expressed in this blog are mine personally, and are not necessarily representative

The Politicalization of Health Information Technology

CIO Unplugged — Tue, 22 Sep 2009 20:39:25 GMT

The views and opinions expressed in this blog are mine personally, and are not necessarily representative

re: Meaningful Meaningful Use?

Jim Jones — Mon, 20 Jul 2009 10:49:19 GMT

I would like to add two or three additional comments to this thread. The first has to do with legacy incentives. All of us have seen, read, and participated in discussions, over the years, in regards to the value of access to consolidated, accurate, and electronically available data. It is not like the idea behind meaningful use(namely the ability to use data is predicated on the idea you "have and can access accurate and complete data) is new. Those of us who have been around either have authored or read white papers 20 years ago descrbing the quality to be achieved with the meaninful use environment, now described.

I would ask the question and argue that we have "known" for years this type of health information should have been available in interoperable formats long ago. Those of us who stayed and then participated in the Dr. Brailer round tables on interoperability and standards to create reports and direction documents on Connected Communities reinforced the urgency of raising the bar. Again, well publicized, bell ringing Paul Revere type notification for the industry to get moving.

Now it is here and, regardless of its strength-today, or over time, there remain facets of achieving this that continue to be overlooked by Congress and the market as a whole. One of these is that the mandates and curricula for medical schools, requirements for July 1st residents and interns to be exposed to only CPOE environments, and attention to additional care/incentives for physician practice adoption, remain, in my opinion, way behind.

Some academic medical centers started a few years ago, putting applying residents on notice that educational classes were available which had certifications required before they set foot "on campus" in July for employment. Those who did not arrive with certifications, ready for duty in July, were not approved for work. Similarly physicians not compliant with greater than a significant CPOE per cent usage, were also shown the door. The meaningful use direction is headed in the same direction.

The challenge in all of this, and therefore the different dimensions/or prisms required to look at this, again in my opinion, are that regardless of the strength of the coffee, having finally mandates, with accountability for all, could accelerate adoption in ways and against schedules that we would all welcome.

History shows that encouragement, cajoling, white papers showing the advantages, and individual institutional incentives have only gone so far. Giving the market time, as one blogger has suggested, could accomodate those who either don't have the money or have a number of phases to adopt, over the burn in period to complete compliance. At the same time, there is speculation in D.C. that consolidation of services-triggered by HIE initiatives, reshuffling of community care, based on reimbursement, will surface new business and care strategies.

All in all, the debate, under these new rules, will have visible and trackable progress against goals, on a national and local basis, (The final dimension) which will allow all of us to see where progress is being made because we will, for the first time, really have data that can be used to reinforce local programs and educational support for adoption techniques.

I suspect that the visual which emerges will be a mosaic, not dissimilar to projects we all have, that (if you use them) change colors as progress is made in each cell, over time.

In the end, I come down on the side of cheering for finally getting some goals on the board, but, at the same time, sensitive to individual struggles by organizations who are not starting at the same place.

re: Meaningful Meaningful Use?

Bill Spooner — Sun, 19 Jul 2009 02:23:44 GMT

Well-stated, Ed. Using the Starbucks analogy, the July 16 release of round #2 of meaningful use requires you to add food coloring and call it coffee.

We HIT professionals have been advocating for years the profound influence that accelerated EHR adoption, in the form of CPOE, evidence-based decisonmaking, and information exchange can have on the quality, cost and availabilty of healthcare. I wish I could count the number of conference presentations and published case studies I have seen highlighting the many success stories resulting from our initiatives. We have been proud of our many achievements.

Now Congress has appropriated significant dollars intended to advance our successes, and we appear to be viewing the opportunity as an entitlement or simiulus rather than an incenitve opportunity. I know we can do better than that.

We need to rise to this occasion and not be branded as another industry seeking a bailout. It is itme to show the nation what we can do, and not be labelled General Medical (GM) seekking a bailout.

re: Meaningful Meaningful Use?

Louis Wenzlow — Sun, 05 Jul 2009 14:51:20 GMT

Nobody is making the point that standards should be watered down so institutions can "pretend" to meet standards. The point being made is that those institutions that are at the early stages of EHR adoption will be effectively excluded from participating and "left behind" if their bar is set so high that it is practically impossible for them to reach it. Don't water down; make the standards meaty but achievable.

Issue I ask you to focus on is "what is achievable for those starting at early stages?" If you know hospital IT, then you must have some sense of how long it takes to go from HIMSS stage 0 (having no ancillary systems in place) to HIMSS stage 1 (lab, radiology, and pharmacy in place), to stage 2 (ancillaries feeding CDR for physician access and controlled medical vocabulary), to stage 3 (nurse documentation, 1st level clinical decision support, and PACS), to stage 4 (CPOE).

Is anyone really arguing that all this can be done in 1 to 2 years? Consider the fact that rushed implementations will lead to more medication errors, diminished patient safety and satisfaction, lower efficiency, and in general a higher rate of implementation failures. See any case study of successful clinical implementations to assure yourself of this.

Most important: Ask yourself how it is possible that an institution starting at stage 0 can reach the same milestone as an institution starting at stage 3. If you seek to stretch the stage 3 institutions you are inevitably leaving behind the stage 0 institutions. If you seek to stretch the stage 0 institutions, you are making it too easy for the stage 3 institutions. Is this issue, which seems to me very straightforward, really so hard for people to understand?

Why can't we get behind the concept that all providers should have a reasonable shot at the ARRA incentives if they meet reasonable yet aggressive implementation requirements? If we agree on that principle, I think we will inevitably come to the conclusion that we need more than one meaningful use matrix, and then the issue will simply (-: be how to design these so we can effectively accomplish our common goals.

Again, let's get beyond the political sound bites ("social promotion???") and into the details of how to move all providers along the HIT adoption spectrum.

re: Meaningful Meaningful Use?

Satish Nagarajan — Thu, 25 Jun 2009 19:58:20 GMT

The reason we want these high standards is because the current state is not sustainable or even acceptable in many cases. So I have little sympathy for the point of view that standards should be watered down so the "disadvantaged institutions" can continue to perform lower and pretend they are meeting the standard.%0d%0a%0d%0aIf an organization is behind this should be treated as a call for all hands on deck. To borrow a different quote we need this to become "no health care provider left behind". The health care equivalent of "social promotion" is no longer acceptable.

re: Meaningful Meaningful Use?

edward marx — Wed, 17 Jun 2009 22:49:27 GMT

From Blogger. I can see how the second to last paragraph could be misinterpreted. I am not suggesting that the majority of hospitals have already achieved Stage 4 adoption levels. I am concerned that the definitions may be watered down to a level where a majority of hospitals would immediately qualify, thus retarding adoption. If the bar were raised higher, there would be increased motivation. Somewhere there is a balance and I hope we get it right. Too high of standards and many won't make it. Not high enough and we miss the opportunity for transformation. My experience has been the greater the stretch, the greater the accomplishment.

re: Meaningful Meaningful Use?

Louis Wenzlow — Wed, 17 Jun 2009 15:16:18 GMT

It's not accurate to say the CPOE or second level decision support has been achieved by the majority of hospitals today. These applications correspond with stage 4 of the HIMSS EMR adoption model. The median general medical surgical hospital is at stage 2.5, and the median rural and critical access hospitals are at stage 1.3. CPOE is an application that is usually (and for good reason) implemented as a capstone application after dozens of other applications (the ancillary systems that feed the data repository, physician EMR portals, and eMARs, among others) are implemented. I think any reasonable CIO would concede that moving from stage 1 to stage 4 on the HIMSS adoption scale will take at least 3 to 5 years, even with an extremely aggressive strategy. The time is required to perform appropriate vendor selection, workflow revision, education, file building, and various other implementation activities. If the time were not taken, we would see a high rate of failed implementations.

The position that meaningful use requirements should be so stringent that rural and small hospitals are effectively excluded from receiving any benefit is in my opinion bad policy. Most everyone agrees that we want to stretch folks but still make the requirements attainable. If tertiary center and teaching hospital representatives (those making the decisions on meaningful use), most of whom are already at stage 4 or 5 or 6, win the day by setting the requirements so high that only they can reach them, then they will create a national landscape of HIT haves and have-nots. Good to be king I guess, but my sense is that they should be looking beyond their own interests. Do they really want to structure an incentive that stretches some hospitals, but effectively excludes other? In other words, how can you stretch a hospital that is at stage 4 without excluding a hospital that is at stage 1? Perhaps we need distinctive meaningful use requirements based on category of provider.

Let's find a way to use the ARRA incentives to move every provider up the continuum of HIT adoption, whether they are starting at stage 4 or stage 0.