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A primer on meaningful use of electronic health records, and what it will mean for emergency medicine

You may not have realized it, but in recent months there has been a fundamental reordering of the way hospitals are regarding electronic health records (EHR), thanks to what some are calling the single most potent federal effort to change health care delivery in decades (Jha 2010). Remember the stimulus package (officially, the American Recovery and Reinvestment Act)? Inside was something called HITECH – The Health Information Technology for Economic and Clinical Health Act – which stipulated big incentives for hospitals and providers that demonstrated meaningful use of EHR. How big? After ARRA’s passage, while the exact definition of meaningful use was being hammered out, it was clear hospitals would stand to gain as much as $10 million dollars over five years. Eligible providers could gain as much as $44,000.

Sure, implementing an EHR in a hospital or clinic is considerably more expensive than either of these government incentives. But HITECH jump-started provider and hospital consideration of EHRs for a variety of reasons, not the least of which was the fact that these carrots are set to become sticks in a few years, in the form of decreased Medicare and Medicaid reimbursements.

After decades of anemic adoption of electronic systems, the provisions of HITECH seemed likely to bring US healthcare into the connected, computerized world. But the exact criteria by which “meaningful use” of EHRs would be determined was left to HHS Secretary Kathleen Sebelius and delegated to the Office of the National Coordinator for Health Information Technology (ONCHIT), helmed by Dr. David Blumenthal. Over an intense but very open period of activity, with a lot of public (and vocal) input from physicians, informaticists, and industry, a rule was proposed last winter and, this summer, finalized.

The EP in Meaningful Use
For a while it seemed like emergency medicine would sit on the sidelines during this upheaval. The proposed rule had a lot of stringent requirements for hospitals. If they wanted the incentives, for instance, they’d have to have a huge fraction of inpatients receiving CPOE (computerized physician order entry), e-prescribing, and up-to-date problem lists and medication lists. But EPs got short shrift. The proposed rule lumped EPs with anesthesiologists and pathologists as hospital-based personnel, ineligible for the incentives geared towards outpatient providers, and not contributing to the inpatient-centered metrics. (If you looked at the rule, you might think it’s all about EPs – but in fact, when it comes to Meaningful Use, “EP” doesn’t stand for “emergency physician” but rather, “eligible professional.”)

ACEP’s Informatics section, with past presidents Brian Keaton and Angela Gardner, weighed in. A statement was issued, noting that excluding ED patients actually creates disincentives for hospitals to invest in electronic records for the ED. And since so many inpatients come from the ED, some of the metrics that applied to inpatients (like computerized order entry) ought to at least apply to admitted ED patients.

The M.U. workgroup listened and, in the final rule, emergency medicine was well-represented. In fact, EHR usage for ED patients can play a role in nine of the 14 core measures to satisfy meaningful use, and three of the 10 menu measures (only five menu measures need be implemented for FY2011).

The 10 “Menu” Measures*
Five can be deferred, one public health measure must be selected
1. Drug-formulary checks
2. Record advanced directives for patients 65 years or older
3. Incorporate clinical lab test results as structured data
4. Generate lists of patients by specific conditions
5. Use certified EHR technology to identify patient-specific education resources and provide to patient, if appropriate
6. Medication reconciliation
7. Summary of care record for each transition of care/referrals
8. Capability to submit electronic data to immunization registries/systems*
9. Capability to provide electronic submission of reportable lab results to public health agencies*
10. Capability to provide electronic syndromic surveillance data to public health agencies*

 

Even though the calculation for incentive payments is still based on inpatient discharges, the inclusion of the ED in the final rule means expanding the denominator for qualifying for MU objectives. This ought to be sufficient to assure the ED information system won’t be an afterthought for a hospital looking to qualify for meaningful use, but rather an integral component to hospital strategy.

A New Hope for ED Boarding?
The National Coordinator for Health Information Technology has said meaningful users of EHR should be able to calculate clinical quality measures (CQM) of interest – and naturally, they’ve enumerated 15 CQMs that must be made available on the CMS web site. They include a lot of familiar inpatient measures such as VTE prophylaxis within 24 hours of admission, platelet monitoring for patients on heparin, etc. Readers will be happy to note that there’s no new time-to-antibiotics rules. Instead, they’ve included two ED throughput measures: median length-of-stay data on admitted patients (specifically, time to ED departure minus time to arrival) and time-to-decision for admitted patients. (See Sidebar).

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Think about that. Any patient, from the diabetic with some mild chest tightness to a liver transplant patient with a fever, can hop online and see how long they’d be waiting for a bed if they got admitted in your ED (if they qualified for M.U.).

It’s difficult to predict what kind of effect collecting and publicizing these numbers will have on ED boarding and crowding. For those of us who have been collecting and showing these numbers to hospital administrators for years, the prospect of posting them online is hard to wrap our heads around. Simply put, online reporting of these CQM measures may provide the breakthrough in ED throughput that years of academic papers and consensus statements have failed to achieve.

The Future is Now
We’re already in FY2011, and hospitals can register with CMS to be considered as meaningful users of EHR starting on the first of January. It’s generally agreed that EHR implementations take time, thought, process redesign, and lots of testing and training. If enterprise-wide efforts are not already well underway, it’s doubtful your hospital will make it in time qualify for Stage 1 incentives. But here’s the thing: every year, the bar for meaningful use will be raised. What was optional one year will be required the next, and new requirements will be added each year. So even if you don’t qualify for all the incentives, starting as soon as possible may help you avoid some of the penalties slated to kick in down the road. Even a well-planned, coordinated EHR implementation is prone to pitfalls. Here are some of the scenarios that are keeping (or should be keeping) your department’s IT liaisons up at night:

  • Ill-conceived or rushed implementation gets the ED saddled with a cumbersome, inpatient-style information system that slows down clinician documentation and order entry.
  • Say M.U. data on from 2011 is submitted in a timely fashion, but upon review by CMS in early 2012 it’s discovered M.U. goals at your hospital weren’t met. . Just fixing this would be expensive and time-consuming, but since the M.U. bar has already been raised again, next year’s (2012) incentives would now be jeopardized.
  • Rather than buoy the inpatient numbers, inclusion of ED data prevents a hospital from achieving meaningful use, and leads to the forfeiture of millions of CMS dollars.
  • Publicly reported ED throughput measures backfire, and rather than listening to the ED’s proposed remedies for boarding (such as reorganizing inpatient procedures around busy ED days, and sending patients to hallway spots while their beds are being cleaned) the hospital decides to clean house and sign a contract with a new group.
  • You’ve just invested in a new scribe program – it’s not that expensive, your docs are thrilled, patients-per-hour is up, and everyone seems happy.
  • But to qualify for the CPOE M.U. metric, orders must be entered into the computer by licensed providers. Are scribes DOA?

In the coming months, EPM will be looking at efforts to get EDs on board with meaningful use. We’ll look at how some departments are navigating these pitfalls, different approaches that can be employed to satisfy the M.U. requirements, and hopefully, some success stories to emulate. Our focus will always remain with you, the ED physician who wants to learn why their workspace is changing and what forces are guiding its future.



 

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