Once the definitions are provided, who is responsible for proving it? Is it the vendor - and then health systems just have to prove they have that version of the product that is 'certified;' or will the end user have to prove meaningful use to receive the incentive payments?

I believe this is the crux of the matter. If the user is burdened with proving meaningful use, it would relate to the practice of medicice, if the vendor is permitted to define and prove this, then the ends may just be self-serving way to sell more product. I believe it ought to be that an objective body determine what is expected from 'meaningful use' and then it is up to the vendor to provide the user with a system (or systems) that enable them to accomplish this feat. If left to the vendor, the ability may be in their software, but the feasibility of a user utilizing it may be low.

Meaningful use = a function, an action resulting from the use of a certified / qualified record. Meaningful use has some guidance in the ARRA language (eg performance reporting, etc) but the final details and defiintions will come from the Secretary of HHS, working with ONC (and the HIT Policy Committee). Dr. Blumenthal, the National Coordinator as quoted at the Kaiser website -
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Administration News | HHS Will Release Guidance on 'Meaningful Use' of Health Information Technology This Summer, Blumenthal Says
[May 11, 2009]

HHS soon will issue guidance and specifications on the definition of "meaningful use" of health information technology, National Coordinator for Health IT David Blumenthal said on Friday, CongressDaily reports (Noyes, CongressDaily, 5/8). "Meaningful use is very much on our mind," he said, adding, "We hope to provide a direction and some specifications in the late spring, early summer" (Goldstein, "Health Blog," Wall Street Journal, 5/8).

The recently enacted economic stimulus law included $17 billion in Medicare and Medicaid incentive payments to health care providers who demonstrate meaningful use of health IT, such as electronic health records (Reichard, CQ HealthBeat, 5/8). Beginning in 2015, the law would levy penalties on those that have not yet installed EHR systems (CongressDaily, 5/8). "Those two words [meaningful use] are the key to success in health information technology policy over the next several years," Blumenthal said during a media conference call (CQ HealthBeat, 5/8). He said that the effort to establish a national health IT system is "joined at the hip" with health care reform efforts in Congress (CongressDaily, 5/8).

Blumenthal on Friday also announced appointments to the two advisory committees -- the Health IT Policy Committee and the Health IT Standards Committee -- that were established under the stimulus law and are tasked with making recommendations to Blumenthal on a policy framework for the development and adoption of an interoperable health IT system. The two committees are scheduled to hold their first meetings this week.

Blumenthal did not specify if the Certification Commission for Healthcare IT, which was established under the George W. Bush administration and currently certifies EHR systems now available on the market, will retain its functions along with the two new advisory committees. "The certification process is under review," Blumenthal said, adding, "There was a complicated committee structure in the past" (CQ HealthBeat, 5/8).
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I would assume that vendors would be responsible for providing "certified" systems, but the system only provides tools to allow automated processes. If a provider has a certified system, whatever that will be, they will likely still have to prove or attest to a workflow that results in adherence to the standards that are established for Meaningful Use. For example, just because a system allows for automated prescriptions, a physician can still use the manual method.

Meaningful use should reside with the user because even a great product can be improperly implemented a defeat services conforming to the requirements.

Additionally meaningful use should have two components.

1) The system can capture and report on all the quality/safety data required per the definition of the HIT Policy Committee
2) The system is being used by everyone, doctors included. Some percentage level of used must be incorporated within the definition to satisfy significant use.

I think that ultimately meaningful use will need to be demonstrated by the end users. The only thing vendors could demonstrate is that certain functionality is provided in the software and maybe some stats on who is using it. I question how truly meaningful that is. On the other hand, users can demonstrate not only that clinicians are using the system -- "use" -- but also the benefits realized by their patients -- "meaningful use".

Part of meaningful use, then, could come from showing the effectiveness of the care delivered for the population under care (effectiveness on satisfaction, quality and cost dimensions)

ARRA says:

Certified EHR technology must certify qualified records that include:

QUALIFIED ELECTRONIC HEALTH RECORD- The term `qualified electronic
health record' means an electronic record of health-related information on an individual that—

(A) includes patient demographic and clinical health information, such as medical history and problem lists; and

(B) has the capacity—
(i) to provide clinical decision support;
(ii) to support physician order entry;
(iii) to capture and query information relevant to health care quality; and
(iv) to exchange electronic health information with, and integrate such information from other sources.

Meaningful EHR user --

(i) Meaningful use of certified ehr technology – includes - use of electronic prescribing as determined to be appropriate by the Secretary.

(ii) Information exchange.-- connected in a manner that Provides for the electronic exchange of health information to improve the quality of health care,such as promoting care coordination.

(iii) Reporting on measures using ehr.-- submits information on such clinical quality measures and such other measures as selected by the Secretary under subparagraph. The Secretary shall seek to improve the use of electronic health records and health care quality over time by requiring more stringent measures of meaningful use selected under this paragraph.

At HIMSS I heard a Senator, who seemed to be quite knowledgeable about health IT, say that Congress wasn't sure what to require for "meaningful use". Their expectation is that some agency-CMS, ONC?-will put out a definition. If enough people don't like it and complain to their congressperson, then Congress will tell the agency to change it. This sounds a bit crazy, but is how lots of gevernment rules are decided and evolve. Our only hope is that the agency will specify outcomes, and not specify vendors or technology. CCHIT requires lots of things that are not particularly useful for actually seeing patients. Software can be said to work if a specific click on a button always gets the same result. The problem with the current vendor EHRs is that neither the button nor the result may have any utility to the practitioner.

How about an independent, 3rd party meeting some of the following criteria:

1. Knowledgeable - with verifiable experience - in both clinical and administrative healthcare

2. Not directly affiliated with any provider or vendor who is being 'certified' - at least for a few years.

3. Someone who understands the entire process: from registration through payment posting?

4. Can discretely provide statistical - and not anecdotal or politically influenced - proof of agreed upon metrics?

5. Won't add an unreasonable cost and delay to the overall process

I am a full time practicing physician in a field of medicine that is very data driven (Nephrology). First of all I would like to ask our leaders not to reinvent the wheel when trying to decide what is "meaningful use". Use the work done by the USRDS (renal data systems) over the last 10 years. Over that period of time dialysis facilities have submitted data, had it analyzed and published showing over 11 quality indicators.

Now my brother is a cardiologist, and a really good cardiologist at that. But for all the world I could not prove that fact. On the other hand I am a good nephrologists and I can prove it:

http://www.usrds.org/odr/xrender.phtml

How many of you physicians out there even know you own patients’ mortality rate? How about avg. Albumin or Hospital days? Again for the last 10 years we in the nephrology community have discovered and implemented “meaningful use”. Let’s learn from it.

But Hlanda is correct that the devil is in the details. On a daily basis I work with 4 different EHR systems. (dialysis unit, two different hospitals, office system) My office system (A4/AllScripts) does a great job fulfilling the documentation requirement. I can generate the best looking progress note you could imagine. I can bill a high level using it if I wanted to. But in reality the note is completely lacking thought. The system was clearly designed to document a patient encounter for the soul purpose of billing. The system completely misses the boat when it comes to E&M content of any type. Here is the irony; it is the only system I use that is CCHIT certified. My little study of 4 systems clearly shows me that “meaningful use” has two very different meanings. It could mean a billable note or the ability to fax a Rx to the pharmacy. My hope is though that someday “Meaningful Use” means so much more. I hope we define it to mean true quality improvement for my patients’ lives. Then and only then will EHR vendors and healthcare providers work together to provide a truly remarkable system.


This is an exciting time. Move over Penicillin and X-Rays we are on the cusp of the next medical revolution; The ability to handle, digest and make sense of all the data the previous revolutions have give us. Let’s not screw it up by allowing our leaders and vendors to define meaningful use in some shallow context.
Just my thoughts.

Dr. Andy O’Shaughnessy

Like "awosha", I hope the deciding committees and policy makers build off the infrastructure that already exists. Regarding "wegotthold's" comment that CCHIT has a number of unnecessary things in it, I would agree. But we should build off the CCHIT chassis, and fix the parts of it that are not effective, rather than scrapping it and starting over. Vendor certification is an important part of this, and none of need our vendors having to start over. That would be ridiculous.

Great opinions, based on these I'm still leaning towards at the end of the day the user will probably be responsible.

The user has to prove meaningful use.

The vendor has to provide a certified product that if used according to design it meets the criteria of meaningful use.

The application should also have a way of being measured through certain metrics that can determine whether it is being used in a meaningful way.

The HL7 Guy

I agree with those who have stated that meaningful use must be shown by the user, if this funding is to have anything like the impact that's intended. Especially considering that by some surveys, half of the physician offices which have purchased EMRs have not even implemented them. "zunidoc" in another thread on this site tells just such a tale.

I think Dr. O'Shaughnessy (awosha) hits the nail on the head with regard to true improvement in patient outcomes - exciting times indeed, but we have a long way to go to get there.

Neither vendors nor the government-authorized CCHIT (Certification Commission for Healthcare
Information Technology) are in a position to guide “meaningful use,” in my opinion. Neither actually uses healthcare software in a clinical situation. CCHIT only tests software in the laboratory “in vitro, not in situ” as Dr. Ross Koppel states. Meaningful use will vary depending on specialty. A radiologist will probably never use electronic prescribing. A family practitioner will hardly, if ever, use a pre-surgical scheduling program. A physician specializing in chronic pain will use eRx, but probably only infrequently since hard copy prescriptions are required (at least in my state). And that’s another issue: meaningful use might differ state-by-state.

Users need to step up to the plate here and put forth their needs. I hope the American College of Physicians (I am an internist), the American College of Surgeons, and all other interest groups express their constituents’ needs.

Part of teh funding will require reporting of data to teh government which will be used to measure "meaningful use". For example, the governemnt might require that 80% of prescriptions are filled by eRX vs paper.

The EHR vendors wil need to add provider dashboards so that each provider can see how they are meeting the meaningful use requirements.l

Here is my perspective on the meanngful use 'saga': http://www.revenuexl.com/blog/bid/23970/Physicians-beware-EHR-vendors-can-t-ensure-meaningful-use-Only-you-can.

Ultimately, the burden of proving that the EHR is being pu to meaningful use lies on the end user and not on the vendor.

Cheers,

Alok Prasad
RevenueXL Inc.
alok.prasad@revenuexl.com