CIOs, Others React To Meaningful Use Final Rule

Most healthcare stakeholders are reacting positively, so far, to the feds' meaningful use final rule, but not everyone is pleased.

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While CIOs, vendors and other health IT stakeholders are still poring over the 864-page e-health meaningful use final rule released this week by the Dept. of Health and Human Services, reaction so far to the HITECH Act's $20 billion-plus financial incentive program's regulations has been mostly positive.

That's mainly because HHS and its various advisory committees took to heart the gist of many of the approximately 2,000 comments it received from the public -- including hospitals, nurses, doctors, medical associations and patients -- during the crafting processes of the final rule.

The outcome: Compared with HHS' proposed rule released in January, the final rule announced this week is a more flexible, less onerous set of criteria that healthcare providers will need to meet in order to qualify for financial incentives during the meaningful use program's Stage 1, in which reward payments begin in 2011.

HHS essentially dumped its original "all or nothing" approach to the incentive program as written in its proposed rule which required "eligible professionals," such as doctors and nurse practitioners, to meet 25 requirements and hospitals 23, as well as steep "thresholds" of measures in their use of health IT systems.

Under the original proposals, healthcare providers would only qualify for the financial rewards by meeting all those criteria and measures. Success at some or most of the requirements would not be rewarded at all.

However, under the modified final rules, eligible professionals need to meet only 15 core requirements and hospitals 14. In addition, some of the threshold measures in those core requirements were also lowered to make them more easily achievable.

For instance, a previous requirement related to the meaningful use of computerized physician order entry, or CPOE, said that 80% of an eligible professional's orders (for medical tests, referrals, etc.) needed to be done electronically. That was requirement was loosened. Under the new modified rule, eligible professionals must order at least one drug via CPOE for 30% of their patients.

That change makes the CPOE requirement more doable for doctors during Stage 1, while still addressing patient safety and quality of care, which is huge goal of the HITECH programs, said Dr. David Blumenthal, national coordinator for health IT.

"Ordering medication with CPOE really reduces medication error…there is really strong evidence of that," said Blumenthal in an interview this week with InformationWeek. So, rather than require all orders, such as test and referrals to be done electronically in Stage 1, "we focused on medications and said, 'let's get them started on putting in an electronic order for a third of their patients to start,'" he said.

In addition to the core requirements, eligible providers and hospitals also meet five objectives from a menu of 10 objectives. Since hospitals and doctors practices and their specialties aren't all the same, that menu lets healthcare providers focus on areas where they are stronger or can more easily achieve a goal.

According to final rule documents, among the menu of objectives from which healthcare providers can choose to tackle during Stage 1 is "generating lists of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach" and also "incorporating more than 40% clinical lab results in certified e-health records as structured data"

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The flexibility of the Stage 1 rules doesn't necessarily mean the HITECH program goals have been watered down from its original intent. Most of the requirements dropped from the original proposals will be deferred to later stages of meaningful use, Stages 2 and 3.

"All the original requirements 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," Blumenthal said.

In the meantime, "I think a lot of the changes are good," said Dr. Steven Walden, director of the health IT center of the American Academy of Family Physicians, an organization that represents more than 90,000 family practitioners.

"The all or nothing approach was a major concern," said Waldren of the originally proposed rules. "The reductions in thresholds make this more practical," he said.

"Meaningful use is a stepping stone. A lot of doctors will do what's been deferred -- they'll still do it even if it's not required" once they begin to get the hang of new systems and workflows and see the benefits they bring, Walden said.

Vendors of health IT systems and services for the most part so far said they are pleased with the relaxation of some of the requirements.

"All the comments received [by the federal government from the public] were taken quite seriously, and major issues were addressed," said Mark Segal, VP of industry and government affairs at GE Healthcare, a major vendor of e-health record and other clinical information systems to hospitals and doctor practices.

"The menu approach substantially reduces the success thresholds, which makes the requirements more achievable but still challenging," he said.

Still, HHS did not make all the changes some were seeking in the final rule. Among changes HHS did not make, which GE Healthcare had commented on to the government during its public response phase, is a requirement for 80% of patient problem lists, active allergies and medication lists to be documented electronically. "That threshold is still too high," Segal said.

Nonetheless, changes in other areas of requirements will help get healthcare providers moving, he said. "The intent from Congress was to have functions as incentives, but in order to be incentives, they need to be achievable," he said.

"I think [the government] did an excellent job reconciling what was in the interim rule," said Patti Dodgren, CEO of Hielix, a provider of health IT consulting and services to physician offices.

"The interim rule was confusing in some of its specifications and intimidating for small practices," she said. "Smaller practices will be relieved in reducing the thresholds for CPOE and e-prescribing to realistic levels, and picking and choosing from a menu "of discretionary requirements during Stage 1, she said. "No one ever hits the line in lock step," she said.

Also, the relaxed criteria for Stage 1will help fuel the plans of healthcare providers to also comply with Stages 2 and 3once the details of those requirements are worked out, said James Venturella, CIO of hospital and community services division of the University of Pittsburgh Medical Center, which operates a health plan, outpatient facilities and several hospitals in Pennsylvania.

By rolling back some of the measures of Stage 1, healthcare providers have a little more wiggle room to accomplish necessary work to qualify for the first wave of incentives, which begin in 2011. "Even for organization as automated as ours, achieving all the measures is difficult," he said.

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Also, by making the criteria in Stage 1 less difficult and more achievable, providers who qualify and receive those financial incentives could have more money available to fund the next round of work in meeting Stage 2 and 3 requirements, he said.

The final rule was fair compromise to the goals being sought by the U.S. government in the mass adoption of health IT by U.S. healthcare providers, and those providers' realistic ability to get the work done within the timeframe of the HITECH Act, which in addition to awarding financial incentives for "meaningful use" beginning in 2011, also enacts financially penalties for non-compliance beginning in 2015.

"Overall this final rule maintains a balance between the policy objectives sought and the technology changes possible that are achievable now," said John Halamka, who wears dual hats as the CIO of Harvard Medical School and Boston's Beth Israel Deaconess Medical Center.

"There will still be 3 stages of meaningful use and later stages will be more demanding. All the original stage 1 requirements will still be part of meaningful use by stage 2," said Halamka, who is also vice chair of the HIT Standards Committee that advised the Office of National Coordinator during the meaningful use rulemaking period.

"The final rule means Meaningful Use will be achievable by many," Halamka wrote in a posting of his blog.

While the final MU criteria is still being digested and analyzed, and has so far received mostly positively reviews, not all healthcare stakeholders are pleased by the contents of the final regulations.

"The feds gave the health IT industry what they demanded, a few quality, reporting, and data exchange requirements but watered down or eliminated all the new patient protections required in HITECH –like the requirement to give patients an accounting of all disclosures of personal health information for three years," said Dr. Deborah Peel, founder and chair of Patient Privacy Rights, a patient advocacy organization in an email interview with InformationWeek.

"Patients should be able to share information selectively with specific people they trust and prevent data flow to the secret health data mining industries, such as health IT vendors, insurers, data aggregators, big pharma, etc," she said.

"Patients should be able to set advance directives for all routine sharing they want –like send a copy of every health visit and all treatment to my family doc, but send changes in meds and allergies to my allergist and dentist," she said.

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