High Hurdles for HITECH Dollars

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The indefinite path to qualifying for Health Information Technology for Economic and Clinical Health Act funds just came into greater focus, but it’s not to everyone’s liking. At the end of December 2009, HHS released two notices of proposed rule making that specify, in numbing detail, the definitions of terms associated with the meaningful use of health IT, along with the criteria that hospitals, physicians, and other qualified health professionals must meet in order to qualify for nearly $19 billion earmarked for health IT projects. HHS will accept comments on the proposed rules through March 15, but several provider associations have already begun to weigh in on them. Another rule is expected from the Office of the National Coordinator (ONC) for Health Information Technology that will define the process by which the ONC will recognize how health IT products are certified, in addition to naming the certifying organizations. The Medical Group Management Association calls the interim rules overly complex and believes that physicians will have a difficult time meeting program requirements. The response from the Healthcare Information and Management Systems Society was more sanguine, welcoming the clarity provided by the rules, noting that they offer more to applaud than to criticize, and reminding us that the regulations are proposals and that comments are solicited. Meaningful Use While the actual definition of a qualified electronic health record (EHR) is unavailable pending the rule from the ONC (due in late February), the proposed rule for the EHR incentive program goes into great detail on meaningful use and how eligible providers and eligible hospitals will demonstrate that use. Meaningful use will be approached in three phases, which will be further defined in successive rule making. Stage 1 (beginning 2011): Criteria in this initial phase focus on the electronic capture of coded health information to track key clinical conditions and communicate that information for care-coordination purposes in structured format whenever feasible; the implementation of clinical decision support tools to facilitate disease and medication management; and the reporting of clinical quality measures and public-health information. Stage 2 (beginning 2013): Criteria further encourage the exchange of information in the most structured format possible, such as the electronic transmission of orders entered using computerized provider order entry (CPOE) and the electronic transmission of test results, including those from radiology, cardiac-imaging, and nuclear-medicine tests. HHS may extend the criteria more broadly to apply to both inpatient and outpatient hospital settings. Stage 3 (beginning 2015): Criteria will further promote improvements in quality, safety, and efficiency by focusing on decision support for national high-priority conditions, on patient access to self-management tools, on access to comprehensive patient data, and on improving population health. A good deal of money is at stake here: For example, a 250-bed hospital could qualify for almost $6 million, over four years, if it could demonstrate meaningful use beginning in 2011.1 Detailed information on payment methodology, mechanics, and timing can be found at http://edocket.access.gpo.gov/2010/E9-31217.htm. Standards, Specifications, and Criteria HHS also issued an initial set of standards, implementation specifications, and certification criteria for EHR technology, to which it will add through successive rule making. Initial certification criteria establish the capabilities and related standards that certified EHR technology must include in order to meet proposed stage 1 meaningful use. The rule provides definitions for a complete EHR, an EHR module, and a certified EHR. In other words, a provider can patch together three modules to create a qualified EHR or can purchase a complete EHR. A qualified EHR must include patients’ demographic and health information and must have the ability to provide clinical decision support and CPOE, to capture and query information relevant to health-care quality, and to exchange and integrate health information from various sources. Further guidance will be offered in the ONC’s forthcoming Interim Final Rule. The short list of examples of EHR modules cited in the proposed rule includes a clinical decision support rules engine, but providers bear the responsibility of ensuring the interoperability of the modules. The rule defines certified EHR technology as meaning either a complete EHR or a combination of EHR modules (each of which meets the requirements included in the definition of a qualified EHR) that has been tested and certified in accordance with the certification program yet to be established by the ONC as having met all applicable certification criteria adopted by the secretary of the DHHS. The proposed rule’s authors wrote, “We believe that by adding the word ‘technology’ after ‘EHR,’ Congress intended to convey an expectation that rather than adopt a complete, all-in-one solution, eligible professionals and eligible hospitals would likely adopt and implement some number of technological components or EHR Modules to extend the useful life of their legacy EHR technology or other HIT that may not provide all of the capabilities necessary to achieve meaningful use.”2 The list of certification criteria that must be met by eligible providers and eligible hospitals is quite daunting, but particularly so for physician providers, who are likely to have limited (if any) IT support. For instance, in order to support achievement of stage 1 meaningful use, an eligible provider’s complete EHR or EHR module must provide CPOE; must electronically record, store, retrieve, and manage medications, laboratory results, and radiology results; must generate prescriptions electronically; must check insurance eligibility; and must submit claims electronically to public and private payors, in addition to meeting a dozen other requirements. The proposed rules slammed the door shut on radiology practices hoping to acquire PACS on the federal dime, but clearly, referring physicians will require some assistance from radiology providers in connecting PACS to their office-based EHRs. Because the rule cites radiology CPOE, mammography reporting, and radiology quality-measure reporting in the definitions and certification criteria for stage 1 meaningful use, that same door appears to have been left ajar for those hospitals and health systems building a qualified EHR and wishing to add radiology PACS, CPOE, mammography reporting/notification systems, and decision support.