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16 CITATIONS • SEPTEMBER 2010WHAT’S THE MEANING OF “MEANINGFUL USE?”By Karen Darnall“To err is human, but to really foul things upyou need a computer.” - Paul EhrlichEarly this year when healthcare reform wasthe subject of noisy town hall meetings, thefederal government was quietly promulgatinglaws to promote electronic health records(EHR). Little-known rules (that havenothing to do with healthcare coverage) willforever shape the way clinical data is collectedand the way doctors relate to their patients.The Department of Health and HumanServices (HHS) has devised a carrot-and-stickstrategy to motivate doctors to put downtheir note pads and use computer keyboardsinstead.What Is the Carrot?Last year Congress passed the AmericanRecovery and Reinvestment Act of 2009.Better known as the Stimulus Act, it authorizeda budget of $27 billion to improve “healthcare, quality, safety and efficiency” throughthe Health Information Technology forEconomic and Clinical Health (HITECH)Act (Title VIII).On July 28th, 2010, HHS publishedmeaningful use (MU) rules to help eligibleprofessionals (mostly hospitals and doctors)purchase new EHR systems.Next year Medicare will start paying bonuses of$44,000 (spread over 5 years) to MU-qualifieddoctors. Medi-Cal providers will get $21,250to purchase EHR systems plus $8,500 peryear up to $63,750 over six years. Hospitalincentive payments are based on the volumeof Medicare, Medi-Cal and charity patientsplus other factors. Mid-size hospitals mayqualify for $6-7 million and large hospitalsmay receive up to $11 million.Health-IT vendors expect to profit from theHITECH Act and are eagerly waiting forHHS to publish Certification rules for EHRModules.What Is the Stick?After 2015, professionals who decline MUsystems will see their Medicare reimbursementsincrementally reduced. The penalty for nonadoptersstarts at 1 percent and rises 1 percenteach year to a maximum 5 percent penaltyin 2019. Hospitalist and Medi-Cal doctorsare not subject to reductions in Medi-Calreimbursement but they will be subject toreductions in Medicare reimbursements.Rural areas may lack important resources suchas IT consultants and sufficient bandwidthto support MU compliance. Some countrydoctors have already sold their practicesto hospital groups as a prelude to earlyretirement. HHS has authority to exemptnoncompliant providers for hardship, ona case-by-case basis, but the exemption issubject to annual renewal and is limited to5 years.What Does MU Require?Last January when HHS published initialrules, hundreds of stakeholders complainedthat MU would be unachievable for mostproviders. Consequently, HHS relaxed therules and took a gradual, three-stage approachto meeting its goals. Stage I specifies 15 Coreobjectives, plus each provider must chooseanother 5 procedures from a Menu set of 10objectives specified by Medicare.Stage I Core objectives requires doctors to usecomputerized provider order entry (CPOE)systems and e-prescribing systems; they mustenter specific data required by CMS andstate agencies; they must be able to providecopies of EHR to patients upon request andrecord clinical summaries for each officevisit and send alerts for drug interactionsand be capable of up dating problem lists,diagnoses, medication lists, allergy lists andchanges in vital signs (including automaticcalculation of BMI); they must recorddemographic data and smoking status; theymust be able to incorporate lab results andbe able to designate clinical data to exchangewith medical providers (and other patientauthorizedentities). Also, each EHR systemmust be able to implement “at least oneclinical decision support rule” and be able toprotect electronic health information.What Does MU Mean to Patients?Some people are troubled by HHS’s decisionto calculate everyone’s body mass index (BMI)because it smacks of government meddling.But collecting such data is probably not acivil rights violation. Calculations are whatcomputers do best. Besides, MU rules donot specify how often patients must getweighed.Some people are annoyed by questions abouttheir smoking status. But knowing that fewerthan 100 cigarettes in one’s lifetime is the MUrule that defines a person who never smoked— could help some people report their statustruthfully.Some people are already accustomed to seeingEHR data entered on laptops during officevisits. A few tech-savvy doctors already uselarge-screen monitors to display radiologicimages to patients.Some doctors have purchased iPads toshow patients how to browse the web forappropriate information on their condition.EHR has instructional value (especially forcomputer geeks).Large medical groups like Kaiser, and manypharmacies, are already emailing messages totheir patients. Some facilities allow patientsto view lab results on line.What About Confidentially?Creating rules for exchanging EHR betweenproviders and entities will be very trickyindeed. HITECH has budgeted $564million to help states “rapidly build capacityfor exchanging EHR.” But California,unfortunately, is a lumbering giant.For 30 years, California’s Confidentiality ofMedical Information Act (CMIA) has allowedproviders and health plans to disclose certainhealth information without obtaining signedconsent. Since 2003, state lawmakers havemade an effort to harmonize CMIA withthe federal HIPAA Privacy Act but this jobis unfinished. Adding HITECH objectivesto the mix will increase uncertainty aboutfederal pre-emption.HHS has designated a Tiger Team torecommend policies to protect privacy andsecurity. Patient consent for disclosingsensitive information (such as HIV statusand substance abuse treatment) is a currenttopic of debate. Chairman Deven McGraw

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