Finding the Meaning in “Meaningful Use”

The 30,000-foot view and the nitty gritty details of working with electronic health data

Ever wonder what the heck “meaningful use” really means? By now, you’ve probably heard it come up in discussions of healthcare data. You might even know that it specifically pertains to electronic health records (EHRs). But what is it really about, and why should you care?

If you’ve ever had to carry a large folder of paper between specialists, or fill out the same medical history form in different offices over and over—with whatever details you happen to remember off the top of your head that day—then you already have some idea of why EHRs are a desirable thing. The idea is that EHRs will lead to better care—and better research data—through more complete and accurate record-keeping, and will eventually become part of health information exchanges (HIEs) with features like trend analysis and push-notifications. However, the mere installation of EHR software isn’t enough; we need not just cursory use but meaningful use of EHRs, and we need to ensure that the software being used meets certain standards of efficiency and security.

To oversee this process and make the transition worth the while for care providers, the Office of the National Coordinator of Health Information Technology (or ONC) has set up an incentive program (well, actually two programs: one through Medicare and one through Medicade) that pays cash to eligible providers and hospitals who complete a certain checklist of EHR-related tasks through a series of three stages.

Meaningful Use pumpkin

Samantha Sawdon used this perfect illustration.

This program is not new: the EHR incentive program was introduced by the HITECH Act in 2009; Stage 1 began in 2011. As Fred Trotter pointed out then, data geeks should love this program, because it’s all about measuring whether healthcare is actually improving.

Now, in 2014, we are entering Stage 2, and healthcare providers of all kinds are trying to keep up with the rules. I had the opportunity to go to a Health Innovators meetup in Cambridge, MA, last week, where Donald Berwick and Samantha Sawdon both gave excellent talks on meaningful use: Berwick covered the big picture and why we should care, and Sawdon addressed the implementation details. What I learned is that, while there are a lot of details, it’s really not so complicated. And this is something we should all care about, especially data geeks and IT folks (hint: standards, metrics, and interoperability are all key factors here).

Don Berwick focused a lot on the overall healthcare system and the long-terms goal of developing a system that is proactive rather than reactive—of moving health care out of hospitals and reducing costs by preventing catastrophic events in the first place. And he sees this ONC incentive program as a necessary step in getting there: “The only way to think about meaningful use is to think of it as a pillar—an element of what healthcare needs to become.”

He also pointed out that EHRs, when used properly, are not just used to help the system run more smoothly, but to put information and decision-making power back in the hands of the patient. Indeed, as Sawdon later underscored, giving patients a report of their own visit within a short period of time (3 days or less, depending on the stage) is one of the checkboxes on the list. Patient empowerment is key to making the system proactive, and certainly no one I know will complain about having access to their own data.

Berwick specifically recommended that technically-minded folks take a look at the Nuka system of care, an integrated, home-based, holistic approach being used in Alaska, and one he held up as an example of what we should strive for as a country. “The last thing Nuka wants to use is a hospital bed,” Berwick said. (You may remember seeing an interview of Berwick by my fellow StrataRx chair, Colin Hill, last year; their conversation included some discussion of Nuka as well. See Andy Oram’s excellent annotation of that interview for more.)

Samantha Sawdon provided a very thorough and knowledgable tour through the three program stages and the lists of criteria in each one. I highly recommend that you download her slides [PPTX] if you’re interested in the specifics. But essentially, Stage 1 involves a list of 25 checkboxes for providers (24 for hospitals) that are divided into 15 required “core” criteria and 10 “menu” criteria of which at least 5 must be selected and completed. In Stage 2, which we are entering this year, the core list gets longer and the menu list gets shorter.

The checklist items are really pretty basic. Some examples of core items include things doctors are already used to tracking, such as a medication list, allergy list, and vital signs. So it’s not exactly rocket science. Still, many doctors are complaining that the requirements will add to their workload and distract them from their interactions with patients. As the New York Times reports, some doctors are now employing full-time scribes to follow them around and enter patient data into the EHRs. But Sawdon nicely illustrated how each of the core requirements can fit into providers’ existing office workflow, with many tasks taken up by staff and only a fraction of checklist items falling to doctors themselves.

One of the major challenges of the program is the software itself. To qualify for incentive payments, eligible providers and hospitals must use EHR software from an approved vendor—software that has met certain open standards and specifications. But as we progress through time and stages, trying to guess which software is going to be well-enough maintained that it will progress through the stages with you can be a bit of a gamble; if you lose, your only option is to convert all your records to a new vendor.

See below for the video of Don Berwick’s full talk, and the first few minutes of Samantha Sawdon’s talk (unfortunately, I think the memory card in the meetup’s camera filled up partway through, but you can download her detailed slides here [PPTX]). There are lots of specifics to be aware of, but the general outlines are not that difficult to understand.

In the end, meaningful use is about pairing metrics and incentives to make better, more effective, and more affordable care as American as pumpkin pie.

If you want to know more about meaningful use, check out Hacking Healthcare: A Guide to Standards, Workflows, and Meaningful Use (O’Reilly 2011) by Fred Trotter and David Uhlman.

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