New and Improved Meaningful Use

The long anticipated final rule on Meaningful Use was unveiled yesterday with much pomp and circumstance in a rather unusual ceremony which, interestingly, also marked the first public appearance of Dr. Berwick as CMS Administrator. The Final Rule is contained in an 846 page document. Accompanying the CMS ruling is the 228 pages final EHR certification rule issued simultaneously by ONC. Fortunately for all of us scrambling to figure out what has changed, Dr. Blumenthal released a synopsis in NEJM (recommended). Already many articles and disertations have appeared and indubitably many, many more will be written in the next few days and weeks analyzing every change and every nuance of the new, and now binding, Meaningful Use. For those who don’t care much about nuances, preferring a bigger and lower resolution picture, here are the major changes to the old version of Meaningful Use.

The Good

• By far the biggest relaxation was to divide the original 25 measures (23 for hospitals) into two groups – 15 mandatory measures and 10 optional measures of which only 5 need to be fulfilled, per provider choice. This is in effect a 20% reduction of the Meaningful Use burden.
• They added back a requirement for hospitals to record advanced directives. It is listed in the optional group, which means that some hospitals could choose not to implement it, but one must be grateful for having it back on the list.
• Although CPOE is not optional, it has been scaled back to medication orders only.
• The bewildering array of quality measures has been trimmed to 3 simple core measures (weight, BP, smoking) and only 3 more per provider’s choice.
• Another relief for providers is that EHRs will be required to automatically perform all the calculations of nominators and denominators for all measures that involve percentages, and there are many of those. These calculations were initially supposed to be performed manually by the practice or hospital.
• Several measures which required tracking and reporting, such as CDS alerts, now only require attestation that the functionality is turned on.
• If you are a physician with a nice little EHR that will surely be certified, but has no online PHR, there’s no need to despair. PHRs, Patient Portals or the need to provide online medical records is now optional. Even providing electronic clinical summaries for transitions of care is purely optional.
• You don’t have to rush to the office on weekends to give patients copies of their records. Everything is now measured in business days instead of hours from patient request.

The Bad

• In the ONC certification rule, Immunizations have been removed, along with procedures, from the minimum requirements for data elements to be shared with patients and other providers. For Pediatricians and all parents of young children, particularly this time of year, this is not welcome news. Hopefully vendors will go above the minimum here, since it is rather trivial to provide immunization histories to any interested party.
• The two Administrative requirements of submitting claims electronically and verifying eligibility with payers have been removed. On the surface this makes sense when talking about the use of EHRs. However, the vast majority of providers, hospitals and private practices, already meet both criteria since Medicare and Medicaid require electronic submission of claims, not to mention the potential cost savings from automating such process. 

The Inconsequential

• For most measures, the minimum percentage for compliance has been dropped to about 50% or less. This gives the impression of further concessions, however it is rather meaningless. If you are going to manage medications in the EHR, you will do that for all patients, not just a select 30%. Not to mention that if you use electronic prescribing for some allowed prescriptions and not for others, you will end up with a reconciliation nightmare when electronic renewal requests start flowing in from pharmacies for all your paper scripts. Anyway, placing the bar lower is a friendly gesture from CMS
• Many previously required standards for terminology and data exchange have been relaxed in the ONC document, particularly for labs and medications. While completely irrelevant to physician users, this is a huge win for vendors whose efforts to retool their EHRs are now postponed by a couple of years.

All in all, the new Meaningful Use is a bit more flexible than the old version and what was bound to become a typically painful bureaucratic attestation for physicians, is now a rather straightforward process. Other than that, you still have to buy a certified EHR, install it and meaningfully use it by October 1st 2011. If you’re considering hopping on the bandwagon, call your Regional Extension Center and see if you can get some free services to get the ball rolling. Meaningful Use has been officially declared the Law of the HIT Land and there is no turning back now.