Guest commentary
The meaningful use requirements of the HITECH Act are designed to facilitate quality improvement, better care coordination and population health management. Most physician practices and hospitals will find it difficult to meet these goals, even if they have top-of-the-line electronic health records (EHRs). They will likely need supplemental information technology that automates the basic tasks of identifying, engaging and tracking patients who need preventive and chronic care services, coupled with reports that care teams can use for quality improvement and reporting.
The five-year period in which providers can qualify for HITECH incentives is divided into three stages. Under the Department of Health & Human Services (HHS)’ final rule, adopted in July 2010, Stage 1 meaningful use criteria will focus on electronically capturing health information in a coded format; using that data to track key clinical conditions; communicating that information for purposes of care coordination; implementing basic clinical decision support tools; and reporting clinical quality measures and public health information.
The Stage 2 and 3 criteria will be more stringent. In the second phase, eligible professionals and hospitals will have to use health IT for quality improvement and exchange information in a structured format, such as the electronic transmission of test results. Stage 3 will focus on improvements in quality, safety and efficiency, using advanced clinical decision support, patient self-management tools, and population health management techniques.
From the provider viewpoint, HHS’ final rule for Stage 1 is less difficult than the earlier Notice of Proposed Rulemaking (NPRM). In place of the 23 criteria that eligible professionals had to meet and the 25 required of hospitals in the NPRM, the final rule stipulates 15 “core” requirements for eligible providers and 14 for hospitals. Providers may choose any five of 10 additional criteria on an optional menu and have until the end of 2012 to meet them.
Despite these changes, the Stage 1 requirements for meaningful use remain substantial. In some core categories, such as patient demographics, vital signs and smoking status recorded in the EHR, physicians must document this information electronically for 50 percent of their patients. Physicians must send at least 40 percent of their prescriptions online to pharmacies. And if practices choose the electronic receipt of lab results from the optional menu, they must import 40 percent of lab results into their EHRs as searchable data.
While the Stage 2 and 3 requirements have yet to be drawn up, the final rule for Stage 1 shows that HHS remains on course to deploy meaningful use as a lever to get physicians to use EHRs for quality improvement and population health management. So, in devising strategies to meet these criteria, physician groups and healthcare systems must keep the government’s ultimate goals in mind.
Meaningful use will require supplemental technologies
Certified EHRs and combinations of certified EHR modules should enable physicians to show meaningful use in Stage 1, which covers 2011 and 2012. But in later stages, or even for some optional Stage 1 criteria, additional technologies might be required.
Certified EHRs and combinations of certified EHR modules should enable physicians to show meaningful use in Stage 1, which covers 2011 and 2012. But in later stages, or even for some optional Stage 1 criteria, additional technologies might be required.
While EHRs excel at point-of-care patient interactions and decision support, most were not designed for quality reporting and managing population health. For example, one of the optional requirements stipulates that eligible providers send alerts about needed care to 20 percent of their patients who are 65 or older and five or younger. EHRs will be able to generate these reports based on the data in the respective records; but once a list is generated, it will require staff time to contact these patients.
When managing large populations, this effort requires significant resources. Automated technology that can perform outreach with multimodal communications will be needed to accomplish this efficiently.
Smaller practices often are not set up to send alerts to patients who don’t visit because it can be time-consuming and difficult to track their population. And, regardless of practice size, the use of patient portals alone cannot ensure that patients receive alerts outside of office visits because only a subset of patients register on these portals and/or provide their e-mail addresses.
Healthcare organizations and providers will appreciate automated solutions that generate lists of patients with specific chronic conditions or preventive-care needs and reach out to those patients. They will also appreciate the ability to assimilate actionable, population-based reports; to generate quality data for meaningful use purposes; to help providers close care gaps routinely; and to generate condition-specific educational materials for patients.
Supplemental technologies
For all these reasons, physicians will typically need to use supplemental technologies along with their EHRs to show meaningful use consistently over the next five years. These may include electronic registries; multiple outreach and communications methods; software that can calculate the metrics required for quality reporting; and solutions that extend the reach of the provider and the care team to help keep patients engaged in their care.
For all these reasons, physicians will typically need to use supplemental technologies along with their EHRs to show meaningful use consistently over the next five years. These may include electronic registries; multiple outreach and communications methods; software that can calculate the metrics required for quality reporting; and solutions that extend the reach of the provider and the care team to help keep patients engaged in their care.
What all of these methodologies have in common is that they automate the work of monitoring, educating and maintaining contact with the patient population that meaningful use will require. Especially at a time when primary-care providers are in short supply and stretched thin, it is essential to provide this level of automation so that the routine, repetitive work can be done in the background, rather than taking up the valuable time of doctors and nurses.
Information on the care gaps of specific patients can be automatically generated and provided to care coordinators and care managers within practices. These clinical staffers can then use this information to prepare doctors and nurses for patient visits. Between visits, they can use the population health improvement technology to make sure that patients get their needs addressed and come back for follow-ups. The technology solution does the heavy lifting, increasing care managers’ productivity and allowing practices to do more with fewer personnel.
Even in Stage 1, supplemental technologies may be required. For example, the patient alerts on the Stage 1 optional menu for meaningful use require the identification of conditions using multiple forms of discrete data, including medications, labs and diagnoses. Analytic support that goes beyond EHR functionality may also be required to provide positive identification.
To attest that a physician has gathered data on at least six of the 38 quality measures, practices will have to identify the numerator and the denominator on each metric. For example, if smoking cessation advice is the measure, an organization must be able to identify the number of smokers in the practice and what percentage of those patients received physician counseling.
By combining EHRs with these automated approaches, physicians can show meaningful use, qualify for medical home certification, obtain pay-for-performance incentives and prepare themselves for the value-based reimbursement systems that are down the road. At the same time, these adjunctive technologies enable physicians to gather the quality data they will need to report to Medicare and private payers in an automated manner.
And by giving care teams real-time data on the services that patients need when they’re in the office, these methods empower physicians and other clinicians to improve quality and engage in productive conversations with patients about how they can maintain or restore their health.
The meaningful use requirements of the HITECH Act can be met using EHR and supplemental technologies to keep patients engaged and coordinated in their care. Adjunctive technologies and automation that support the overall goals of quality improvement and population health management will also be required.
Richard Hodach, MD, MPH, PhD, is chief medical officer of Phytel.
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