The Quest for Meaningful Use

Section 4101 of the American Recovery and Reinvestment Act creates an incentives program for Medicare providers (and a penalty program after 2015 with regards to reimbursement) for EHR adopters.  See this article from June 2009 on “meaningful use.”  See also an earlier blog post on ARRA incentives here.

One of the provisions for receiving incentive payments is that the provider can demonstrate “meaningful use” of the EHR system.  The section also requires that this meaningful use occur on a certified EHR system.  The term “meaningful use” is not defined by the statute, except as follows: “(i) Meaningful Use of Certified EHR technology – The eligible professional demonstrates to the satisfaction of the Secretary, in accordance with subparagraph (C)(i), that during such period the professional is using certified EHR technology in a meaningful manner, which shall include the use of electronic prescribing as determined to be appropriate by the Secretary.”

The phrase is not defined by the statute, but presumably will be defined by the promulgation of a regulation by the Secretary of Health and Human Services.  The thinking today is that meaningful use would be defined by the achievement of certain milestones over time by providers using EHRs.  Initially, the focus would be on actually putting data into the system.  With time, the definition would expand to being able to look at data trends over time and evaluate this data for trends.  And eventually, providers would be required to have an actual impact on patient health outcomes.  There is likely to be a similar movement within the private insurance world for providers, as in a “pay for improved outcomes” model, moving beyond just reducing the number of times someone comes to the doctor’s office (the old, HMO model of quality).

In more practical terms, a provider that wanted to demonstrate meaningful use would need to buy some software, take it out of the box, and actually use it to put some kind of data into it.  Most likely, a more sophisticated system purchaser would give some thought to how that data would be organized within the computer system, with the goal of being able to get it back out again on demand.  In the paper health record world, this is comparable to having a paper note to document the visit, and a separate flowsheet that is maintained to track certain kinds of lab results over time.  The flowsheet is the manually created output which ultimately can be used to evaluate patient outcomes to treatment.  For example, an HIV patient is routinely checked for his or her HIV viral load.  A lower number (or an undetectable viral load count) is better than a higher one.  HIV care providers also keep track of the number of CD4 cells in a given blood sample: a higher CD4 count is better than a lower one.  Over time, these two values are related to each other, and also predict if a patient is doing better or worse with the disease.

An observant provider would educate the patient about these lab results and their implications for health, and demonstrate how close adherence to the schedule for taking HIV medications helps improve the patient’s health over time.  An HIV provider would also be watching for unexpected changes in these values to determine if the patient should be evaluated for resistance of the disease to the current regimen.  HIV is an expensive and high risk disease to manage; but it only gets more expensive if the patient’s condition is not managed appropriately (with lengthy hospital stays, complications and other health issues).  In addition, a patient’s quality of life goes down the tubes with the progression of the illness; usually the side effects of the medications to treat the illness are the lesser evil.

An EHR can help to improve the efficiency of this quality and management process for providers.  A well-designed and implemented system will place relevant lab values onto an electronic flowsheet which can be charted and analyzed over time, avoiding the time spent updating the paper forms and reducing errors in data entry.  In addition, an EHR can present multiple views to the data depending on the patient’s health condition, and can help manage care to accepted standards by reminding providers of tests or actions that are due (such as annual pap smears, 10 year tetanus boosters, quarterly viral load testing, STD screenings, etc.)  EHR’s can also cut down on duplicate tests being ordered (at least within a practice that uses the system) if a patient is seen by more than one provider over time, as all have access to the same information in the same format.

While not yet fully defined, meaningful use will likely lead our nation to more defined care standards, with incentives (and potentially penalties) for better outcomes.  But a word of caution – patients ultimately have to make decisions about their own health.  Not everyone is convinced that having a BMI over 30 is bad enough to warrant exercising an hour every day and cutting calorie intake by 25-50%.  Or consider smoking, which leads to a fair amount of bad health outcomes over time, yet how many Americans still smoke?  Penalizing physicians for the stupid choices that patients make is not fair, even though the health outcomes for these patients will be worse than if the patient had listened to their physician.  Expect the definition for meaningful use to be published soon, but also expect changes over time, particularly on standards for health outcomes.

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Maryland technology attorney and college professor.

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