Monday, May 7, 2012

Meaningful Use Stage 1 - Redux

Escher - Relativity, 1953
The public comments for the proposed rules for Meaningful Use Stage 2 are closing now. After reading the public submissions of several organizations, I decided not to comment, since what I wanted to say was covered by much better heeled organizations, and I am not convinced that individuals can influence government in any shape or form nowadays. Instead, I thought that this would be a good time to look back at Meaningful Use Stage 1 and see if there are any lessons to be learned, something that CMS did not deem necessary to do before moving up the escalator to Stage 2. This is a bit peculiar considering that only 5% of physicians were able to attain Meaningful Use so far, and according to a new study published in Health Affairs, less than 14% of physicians said that their EHR has all the bells and whistles necessary for Meaningful Use Stage 1. Since Meaningful Use Stage 2 is largely an amplified version of Stage 1, it may be useful to look back and identify the most troublesome aspects, prior to significantly increasing their magnitude.

Computerized Physician Order Entry (CPOE) – On the surface, asking that 30% of prescriptions be entered in the EHR seems like an almost trivial task. Where else would you enter them? A closer look reveals that there is some complexity in the definition of the denominator for this measure, and the requirement is that 30% of patients who have at least one active medication on their medication list should be prescribed at least one item using CPOE. Does this mean that the doctor must prescribe something for a third of patients seen? While this may make sense for a primary care doctor with an elderly panel, it does not make sense for other specialties, where patients have most of their medications prescribed elsewhere. And the exclusion for those who write less than 100 scripts per reporting period, which is now one full year, is not an adequate answer either. Perhaps a better measure would be to require a much higher percentage of all prescriptions written, to be entered through the CPOE module, regardless of whether the patients come in with existing meds or not. This is not an easy thing to measure though, but it could be done if EHRs were required to have the prescriber identified in the medication list.

Clinical Summaries – Probably one of the most confusing measures for both patients and physicians requires that 50% of patients be given a visit summary within 3 days of the encounter. This is reasonable and even a bit lax if you have at least 50% of patients using your patient portal. If not, and if you are actually handing out printed summaries, the measure makes little sense. First, the 3 days period is completely contrived. You either give people a summary when they walk out the door, or you don’t. How many patients do you know who will return in the next couple of days to the office to pick up their visit summary? Or how many patients would hang around the office waiting a couple of hours to get that summary? Zero. You either print the thing out before patients check out, or the patient will leave without it. Printing summaries at the end of the visit means that all components have been updated in the EHR during the visit. If you still dictate most of your note, or if you finish notes at the end of the day, or between patients, your summaries may not be accurate. The second problem with this measure is that not all patients want a summary, but Meaningful Use is not making any allowances for patient preferences. So what do people do? They either print all summaries on paper and shred the ones left behind, or print them to electronic file (to trigger the EHR count) and only generate paper if the patient wants a summary. A much more realistic measure would require that summaries be given to 100% of patients who request one during the visit and 100% of summaries are made available on the portal within 48 hours of the encounter. Click fewer boxes, kill fewer trees.

Electronic Copy of Medical Records – This most peculiar measure requires that half of all patients requesting medical records are accommodated within 4 business days. Why only half? HIPAA guarantees the right of all patients to obtain copies of their medical records. Meaningful Use requires an electronic option. If the EHR is capable of packaging a chart in electronic format, why would you only give a copy to half of the people who want it? How does CMS know who wants a copy of their records? There is a checkbox of course, and if there’s that checkbox, and if you clicked it, chances are very good that you will also click the button to generate a chart export, which should give you a perfect 100% score, which should have been a requirement to meet this measure.

Public Health Reporting – There are two public health measures to choose from in Stage 1, immunizations data and syndromic data, and only a test of capability was required, even a failed test was just fine. Should have been a slam-dunk, but it was not. Most public health entities were not ready to receive electronic data and most certified EHRs were incapable of transmitting anything in spite of being certified to that capability. I have no suggestions for how to improve these measures other than refraining from requiring nonexistent things and ensuring that EHR certification is slightly more than fee-for-rubber-stamping.

Medications Reconciliation – This action is required to occur for 50% of care transitions. Since certified EHRs are not required to provide true electronic reconciliation of two datasets and since one almost never has a structured second medication list from an outside source, the best case scenario consists of clicking on two boxes – one at the front desk, designating the visit as a “transition of care”, and one during the visit, validating that the physician (or assistant) opened the medication list page. This measure should have been postponed until the ability to measure, and the tools to actually perform reconciliation, become available.

Security Risk Review – Nobody knows what that is. It is, however, a wonderful opportunity for IT guys to relieve small practices of anything between $2,000 and $5,000, and suggest that the server should reside in a cabinet and that the virus protection software should be updated. Why is CMS getting itself involved with HIPAA and security is a mystery to me, considering that these things are under the purview of the Office of Civil Rights (OCR), which is actively pursuing the matter independently of Meaningful Use. This measure should not have existed.

Clinical Quality Measures – Much has been written about the inadequacy of the chosen quality measures for anything but primary care. Also the seemingly multiple choices of measures are largely theoretical because certified EHRs are not required to certify for all measures and users are basically stuck with whatever the EHR vendor chose to certify, whether the certified measures are applicable to the practice or not. For example, one very popular EHR only has diabetic menu measures available. If you are, say, a dermatologist, you will have to report weight management as part of the core and also dismal measures for your ongoing management of HbA1c. The other major problem with clinical quality measures is their hidden complexity and the not immediately obvious data elements required to calculate the measure and particularly the exclusion of patients from a given measure. A very interesting example of how some EHRs deal with such complexity is the new and fairly common checkbox next to any given diagnosis to mark the condition as terminal in less than 6 months, since this is an exclusion to the weight management core measure. Seriously? And this should be made available on the patient portal too? Clinical quality measures should be carefully reconsidered and dialed back to a sensible set that is truly meaningful.

Meaningful Use Stage 1 created a lot of confusion amongst providers trying in earnest to meet the measures and gobbled up scarce resources in organizations big and small. Many of the measures are being attested to with very little confidence in accuracy, definition and meaningfulness. It would have probably been a very good idea for CMS to go out there and survey its existing and potential meaningful users to seek some authentic guidance, instead of relying on professional advocates (and occasional testimony from carefully selected users), before putting in place the next theoretical step on the now famous escalator.