Health IT Czar, CMS Official On Meaningful Use

Following the U.S. Dept. of Health and Human Services public release on Tuesday of its long-awaited final rules for the meaningful use of e-health record incentives plan of the HITECH Act, Dr. David Blumenthal, national coordinator for health IT, and Tony Trenkle, director of Centers for Medicare and Medicaid Services ehealth standards and services, spoke with InformationWeek senior writer Marianne Kolbasuk McGee about the significance of changes made to the final "meaningful use" rule compared to the original proposed rules released in January.

InformationWeek: It seems flexibility was important in what's in the final meaningful use rules, keeping the final rules having the same kind of ambitious goals set out in the proposed rule, but making them more achievable for healthcare providers. Are there one or two themes in sort of the changes made to final rules that address the main hurdles healthcare providers expressed in their public comments to the interim rules?

Blumenthal: Use of a menu [of achievable goals] is a major way to get flexibility. [We] increased achievability by reducing the requirements of Stage One from 25 to 20 for eligible professionals [such as doctor practices] and from 23 to 19 for hospitals, that's about a 20% reduction for meaningful users.

Then we looked at each of the thresholds and tried to put ourselves in the position of the individual institutions trying to get to meaningful use. We thought about what would be possible and what wasn't. We looked at each of the objectives on its own merits. CPOE [computerized physician order entry] was an area where we did a lot of work.

If you recall CPOE in the interim rule, eligible providers had to enter 80% of all orders [including lab tests, referrals, drugs and more] and hospitals had to enter 10% of all orders. We thought about that and said we want to get CPOE started but we don't want to force a person too fast.

What we knew from the literature was that ordering medication with CPOE really reduces medication errors. There is really strong evidence of that. We thought it was not appropriate not to act on that evidence, so we focused on medications and we said, 'let's get them started on putting in an electronic order for a third of their patients to start.

So basically, for 30% of patients, doctors and nurses offices and hospitals need to at least order one drug through CPOE. We believe once they start ordering medications that way, they'll start doing it for almost all medication orders and for all patients, but 30% to start is achievable.

InformationWeek: Being that the first wave of incentives start in 2011, and it's already 2010, was time a factor in the decision to add this kind of flexibility to the final rules?

Blumenthal: All the original requirement of the interim rule we think are very likely to be required in 2013. So you can see it as a deferral of 20% of the requirements to the later stages.

InformationWeek: So, what that really means is that when healthcare providers get to the next stages, they'll just have more work to do?

Blumenthal: Keep in mind that we also reduced thresholds, so if you think of it as the first step on an escalator, it's going at a slightly slower pace and on a slightly smaller step, but you still have to get on and move with it.

Trenkle: Another thing I want to point out too is that over the next few years the work being done by CMS and ONC is building the infrastructure which should allow us to raise up some of the thresholds and some of the requirements for later stages. For instance, the health information exchanges and other areas where there isn't quite the infrastructure to support some of the requirements at this point, but there will be there in Stages Two and Three.

InformationWeek: Healthcare providers were waiting for the meaningful use final rules to come out, and now they're out, but now is the burden now on vendors to make sure their products are certified?

Blumenthal: As of today, we're ready for take-off. We've been putting in place piece by piece, block by block a foundation. We've put out grant programs, we've put out a certification regulation, we've put out interim rules and today we've finalized those rules.

We now have certification criteria, a certification process, we have a set of goals in the form of meaningful use objectives, technical assistance in the form of regional extension centers, and the makings of health information exchanges by empowering state and encouraging them to be leaders.

We have a workforce training program to help all those programs get out and running. We laid out the framework and now it's the private sector's job to take the guidance and the rules we've created and resources we've put out there and try to make it work. InformationWeek: So there are no more excuses to procrastinate.

Trenkle: Right. And it's been an open and transparent process with plenty of opportunity for stakeholders to weigh in. The HIT Policy and Standards committees have had public hearings to discuss the requirements.

ONC through its programs has laid out a foundation that's been very open and transparent. So I think over the last year and half, we've sent out a lot of signals to community to indicate of the directions where we were going. So the vendors should be well prepared to support these programs as they stand now with the final rule.

InformationWeek: Stage Two and Three, when will they be worked on and addressed?

Blumenthal: It will be like this process, and it will also be an open process. We'll have a lot of discussions in the federal advisory committees about what's appropriate and necessary in Stage Two.

Some of those discussions will occur leading up to the achievement of Stage One. So some will be more theoretical, but we hope later on it will be informed by experience of Stage One, as well as with progress in the industry as the industry innovates.