NEJM EMR Overview


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Resource for physicians considering EMR/PM solutions

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NEJM EMR Overview

  1. 1. The NEW ENGLA ND JOURNAL of MEDICINE Perspective The “Meaningful Use” Regulation for Electronic Health Records David Blumenthal, M.D., M.P.P., and Marilyn Tavenner, R.N., M.H.A. T he widespread use of electronic health records (EHRs) in the United States is inevitable. EHRs will improve caregivers’ decisions and patients’ $44,000 (through Medicare) and $63,750 (through Medicaid) per clinician. This funding will pro- vide important support to achieve outcomes. Once patients experience the benefits of liftoff for the creation of a na- tionwide system of EHRs. this technology, they will demand the health care community with Equally important, HITECH’s nothing less from their provid- a transformational opportunity to goal is not adoption alone but ers. Hundreds of thousands of break through the barriers to “meaningful use” of EHRs — physicians have already seen progress. The Health Information that is, their use by providers to these benefits in their clinical Technology for Economic and achieve significant improvements practice. Clinical Health Act (HITECH) in care. The legislation ties pay- But inevitability does not mean authorized incentive payments ments specifically to the achieve- easy transition. We have years of through Medicare and Medicaid ment of advances in health care professional agreement and bi- to clinicians and hospitals when processes and outcomes. partisan consensus regarding the they use EHRs privately and se- HITECH calls on the secretary potential value of EHRs. Yet we curely to achieve specified im- of health and human services to have not moved significantly to provements in care delivery. develop specific “meaningful use” extend the availability of EHRs Through HITECH, the federal objectives. With the Centers for from a few large institutions to government will commit unprec- Medicare and Medicaid Services the smaller clinics and practices edented resources to supporting (CMS) in the lead, the Department where most Americans receive the adoption and use of EHRs. It of Health and Human Services their health care. will make available incentive pay- (DHHS) has used an inclusive and Last year, Congress and the ments totaling up to $27 billion open process to develop these cri- Obama administration provided over 10 years, or as much as teria, providing an extensive op- 10.1056/nejmp1006114 1 Downloaded from on July 14, 2010 . For personal use only. No other uses without permission. Copyright © 2010 Massachusetts Medical Society. All rights reserved.
  2. 2. PERSPECTIVE The “Meaningful Use” Regulation for Electronic Health Records Summary Overview of Meaningful Use Objectives.* Objective Measure Core set† Record patient demographics (sex, race, ethnicity, date of birth, More than 50% of patients’ demographic data recorded as struc- preferred language, and in the case of hospitals, date and pre- tured data liminary cause of death in the event of mortality) Record vital signs and chart changes (height, weight, blood pres- More than 50% of patients 2 years of age or older have height, sure, body-mass index, growth charts for children) weight, and blood pressure recorded as structured data Maintain up-to-date problem list of current and active diagnoses More than 80% of patients have at least one entry recorded as struc- tured data Maintain active medication list More than 80% of patients have at least one entry recorded as struc- tured data Maintain active medication allergy list More than 80% of patients have at least one entry recorded as struc- tured data Record smoking status for patients 13 years of age or older More than 50% of patients 13 years of age or older have smoking status recorded as structured data For individual professionals, provide patients with clinical summa- Clinical summaries provided to patients for more than 50% of all of- ries for each office visit; for hospitals, provide an electronic fice visits within 3 business days; more than 50% of all patients copy of hospital discharge instructions on request who are discharged from the inpatient department or emergency department of an eligible hospital or critical access hospital and who request an electronic copy of their discharge instructions are provided with it On request, provide patients with an electronic copy of their health More than 50% of requesting patients receive electronic copy within information (including diagnostic test results, problem list, 3 business days medication lists, medication allergies, and for hospitals, dis- charge summary and procedures) Generate and transmit permissible prescriptions electronically More than 40% are transmitted electronically using certified EHR (does not apply to hospitals) technology Computer provider order entry (CPOE) for medication orders More than 30% of patients with at least one medication in their med- ication list have at least one medication ordered through CPOE Implement drug–drug and drug–allergy interaction checks Functionality is enabled for these checks for the entire reporting period Implement capability to electronically exchange key clinical infor- Perform at least one test of EHR’s capacity to electronically exchange mation among providers and patient-authorized entities information Implement one clinical decision support rule and ability to track One clinical decision support rule implemented compliance with the rule Implement systems to protect privacy and security of patient data Conduct or review a security risk analysis, implement security up- in the EHR dates as necessary, and correct identified security deficiencies Report clinical quality measures to CMS or states For 2011, provide aggregate numerator and denominator through at- testation; for 2012, electronically submit measures Menu set‡ Implement drug formulary checks Drug formulary check system is implemented and has access to at least one internal or external drug formulary for the entire report- ing period Incorporate clinical laboratory test results into EHRs as structured More than 40% of clinical laboratory test results whose results are in data positive/negative or numerical format are incorporated into EHRs as structured data Generate lists of patients by specific conditions to use for quality Generate at least one listing of patients with a specific condition improvement, reduction of disparities, research, or outreach Use EHR technology to identify patient-specific education resourc- More than 10% of patients are provided patient-specific education es and provide those to the patient as appropriate resources Perform medication reconciliation between care settings Medication reconciliation is performed for more than 50% of transi- tions of care 2 10.1056/nejmp1006114 Downloaded from on July 14, 2010 . For personal use only. No other uses without permission. Copyright © 2010 Massachusetts Medical Society. All rights reserved.
  3. 3. PERSPECTIVE The “Meaningful Use” Regulation for Electronic Health Records Summary Overview of Meaningful Use Objectives (Continued.) Provide summary of care record for patients referred or transitioned Summary of care record is provided for more than 50% of patient to another provider or setting transitions or referrals Submit electronic immunization data to immunization registries or Perform at least one test of data submission and follow-up sub- immunization information systems mission (where registries can accept electronic submissions) Submit electronic syndromic surveillance data to public health agen- Perform at least one test of data submission and follow-up submis- cies sion (where public health agencies can accept electronic data) Additional choices for hospitals and critical access hospitals Record advance directives for patients 65 years of age or older More than 50% of patients 65 years of age or older have an indica- tion of an advance directive status recorded Submit of electronic data on reportable laboratory results to pub- Perform at least one test of data submission and follow-up sub- lic health agencies mission (where public health agencies can accept electronic data) Additional choices for eligible professionals Send reminders to patients (per patient preference) for preven- More than 20% or patients 65 years of age or older or 5 years of tive and follow-up care age or younger are sent appropriate reminders Provide patients with timely electronic access to their health in- More than 10% of patients are provided electronic access to infor- formation (including laboratory results, problem list, medica- mation within 4 days of its being updated in the EHR tion lists, medication allergies) * This overview is meant to provide a reference tool indicating the key elements of meaningful use of health information technology. It does not provide sufficient information for providers to document and demonstrate meaningful use in order to obtain financial incentives from the Centers for Medicare and Medicaid Services. The regulations and filing requirements that must be fulfilled to qualify for the Health IT financial incentive program are detailed at † These objectives are to be achieved by all eligible professionals, hospitals, and critical access hospitals in order to qualify for incentive pay- ments. ‡ Eligible professionals, hospitals, and critical access hospitals may select any five choices from the menu set. portunity for public and profes- qualify for incentive payments in activities from which providers sional input. The department the first 2 years of the program. will choose several to implement published proposed meaningful The most important part of in the first 2 years (see table). use requirements on January 16, this regulation is what it says Core objectives comprise ba- 2010. The proposal prompted some hospitals and clinicians must do sic functions that enable EHRs 2000 comments. This week, the with EHRs to be considered to support improved health care. DHHS is releasing a final regu- meaningful users in 2011 and As a start, these include the lation for the first 2 years (2011 2012. In the original proposal, tasks essential to creating any and 2012) of this multiyear in- we identified a broad set of ob- medical record, including the centive program. Subsequent rules jectives, all of which would need entry of basic data: patients’ vi- will govern later phases. to be met. This included 23 ob- tal signs and demographics, ac- Although the intent of our jectives for hospitals and 25 for tive medications and allergies, January proposals has been re- clinicians. The DHHS received up-to-date problem lists of cur- tained and indeed affirmed many comments that this ap- rent and active diagnoses, and through the rule-making process, proach was too demanding and smoking status. the final regulation also incorpo- inflexible, an all-or-nothing test Other core objectives include rates significant changes — a re- that too few providers would be using several software applica- sponse to the comments and ex- likely to pass. tions that begin to realize the perience that diverse stakeholders In the final regulation, we true potential of EHRs to im- shared with us. In particular, con- have divided these elements into prove the safety, quality, and ef- cerns about the pace and scope two groups: a set of core objec- ficiency of care. These features of implementation of meaningful tives that constitute an essential help clinicians to make better use led us to adopt a two-track ap- starting point for meaningful clinical decisions — and avoid proach regarding the objectives that use of EHRs and a separate preventable errors. To qualify allow practices and hospitals to menu of additional important for incentive payments, clini- 10.1056/nejmp1006114 3 Downloaded from on July 14, 2010 . For personal use only. No other uses without permission. Copyright © 2010 Massachusetts Medical Society. All rights reserved.
  4. 4. PERSPECTIVE The “Meaningful Use” Regulation for Electronic Health Records cians must start employing such care — but are also achievable strikes a balance between ac- clinical decision support tools. by average practices and provid- knowledging the urgency of They must also start using the ers in the early years. adopting EHRs to improve our capability that undergirds much The HITECH legislation fur- health care system and recogniz- of the value of EHRs: using rec- ther requires that meaningful ing the challenges that adoption ords to enter clinical orders and, use include electronic reporting will pose to health care provid- in particular, medication pre- of data on the quality of care. In ers. The regulation must be both scriptions. Only when providers the final regulation, we have ambitious and achievable. Like enter orders electronically can simplified the January proposals an escalator, HITECH attempts the computer help improve deci- for quality reporting, while still to move the health system up- sions by applying clinical logic building toward a robust report- ward toward improved quality to those choices in light of all ing capability that will inform and effectiveness in health care. the recorded patient data. And providers about their own perfor- But the speed of ascent must be to begin extending the benefits mance and will eventually inform calibrated to reflect both the ca- of EHRs to patients themselves, the public as well. Clinicians will pacities of providers who face a the meaningful use require- have to report data on three core multitude of real-world challeng- ments will include providing pa- quality measures in 2011 and es and the maturity of the tech- tients with electronic versions of 2012: blood-pressure level, tobac- nology itself. their health information. co status, and adult weight As part of this process, the In addition to the core ele- screening and follow-up (or alter- DHHS is establishing a nation- ments, the rule creates a second nates if these do not apply). Cli- wide network of Regional Exten- group: a menu of 10 additional nicians must also choose three sion Centers to assist providers tasks, from which providers can other measures from lists of met- in adopting qualified EHRs and choose any 5 to implement in rics that are ready for incorpora- making meaningful use of them. 2011–2012. This gives providers tion into electronic records. The DHHS is committed to the latitude to pick their own path The meaningful use rule is support, collaboration, and on- toward full EHR implementation part of a coordinated set of reg- going learning that will mark and meaningful use. ulations to help create a private our progress toward electroni- For example, the menu in- and secure 21st-century elec- cally connected, information- cludes capacities to perform tronic health information sys- driven medical care. We hope drug-formulary checks, incorpo- tem. On June 18, 2010, the that providers and consumers rate clinical laboratory results DHHS issued a rule that laid out will now join us in the effort to into EHRs, provide reminders to a process for the certification of assure that we make the best patients for needed care, identi- electronic health records, so that possible use of our most precious fy and provide patient-specific providers can be assured they health care resource: information health education resources, and are capable of meaningful use. about the patients we serve. employ EHRs to support the pa- The department has also issued Disclosure forms provided by the au- thors are available with the full text of this tient’s transitions between care still another regulation that lays article at settings or personnel. out the standards and certifica- For most of the core and tion criteria that EHRs must Dr. Blumenthal is the national coordinator menu items, the regulation also meet in order to be certified. Fi- for health information technology at the Department of Health and Human Ser- specifies the rates at which pro- nally, realizing that the privacy vices, and Ms. Tavenner is the principal viders will have to use particular and security of EHRs are vital, deputy administrator of the Centers for functions to be considered the DHHS has been working Medicare and Medicaid Services — both in Washington, DC. meaningful users. Reflecting hard to safeguard privacy and the views and experiences shared security by implementing new This article (10.1056/NEJMp1006114) was during the comment period, protections contained in the published on July 13, 2010, at these rates will enable signifi- HITECH legislation. Copyright © 2010 Massachusetts Medical Society. cant progress toward improving The meaningful use rule 4 10.1056/nejmp1006114 Downloaded from on July 14, 2010 . For personal use only. No other uses without permission. Copyright © 2010 Massachusetts Medical Society. All rights reserved.