This document summarizes the key events and policies that led to the adoption of electronic health records (EHRs) in the United States. It describes landmark reports in the 1990s and 2000s that highlighted medical errors and the need for health IT. The HITECH Act of 2009 provided billions in funding and created the "meaningful use" program to incentivize EHR adoption. Meaningful use had 3 stages that set requirements for EHR use to qualify for incentives. While adoption of EHRs increased significantly, the program was critiqued for being too ambitious, inflexible, and not focusing enough on usability and interoperability. Lessons for other countries emphasize the need for clear goals, leadership

1. Meaningful Use of EHRs:
A U.S. Public Policy Case Study
Nawanan Theera-Ampornpunt, M.D., Ph.D.
Department of Community Medicine
Faculty of Medicine Ramathibodi Hospital
November 8, 2015
SlideShare.net/Nawanan nawanan.the@mahidol.ac.th
Except where referred
to or copied from
other works

2. 1991: IOM’s CPR Report published
1996: HIPAA enacted
2000-2001: IOM’s To Err Is Human &
Crossing the Quality Chasm published
2004: George W. Bush’s Executive Order
establishing ONCHIT (ONC)
2009-2010: ARRA/HITECH Act &
“Meaningful Use” regulations
U.S. Public Policy Related to eHealth

3. (IOM, 2001)(IOM, 2000) (IOM, 2011)
Landmark IOM Reports

4. • To Err is Human (IOM, 2000) reported that:
– 44,000 to 98,000 people die in U.S. hospitals each year
as a result of preventable medical mistakes
– Mistakes cost U.S. hospitals $17 billion to $29 billion
yearly
– Individual errors are not the main problem
– Faulty systems, processes, and other conditions lead to
preventable errors
Health IT Workforce Curriculum Version
3.0/Spring 2012 Introduction to Healthcare and Public Health in the US: Regulating Healthcare - Lecture d
Patient Safety

5. • Humans are not perfect and are bound to make
errors
• Highlight problems in U.S. health care system
that systematically contributes to medical errors
and poor quality
• Recommends reform
• Health IT plays a role in improving patient
safety
Landmark IOM Reports: Summary

6. “...We will make wider use of electronic records and other
health information technology, to help control costs and reduce
dangerous medical errors.”
Source: Wikisource.org Image Source: Wikipedia.org
President George W. Bush
Sixth State of the Union Address
January 31, 2006
?
Political Support Behind Health IT

7. U.S. Adoption of Health IT
• U.S. lags behind other Western countries
(Schoen et al, 2006;Jha et al, 2008)
• Money and misalignment of benefits is the biggest reason
Ambulatory (Hsiao et al, 2009) Hospitals (Jha et al, 2009)
Basic EHRs w/ notes 7.6%
Comprehensive EHRs 1.5%
CPOE 17%

8. American Recovery & Reinvestment Act (ARRA)
• Economic Stimulus Legislation
• Contains HITECH Act (Health Information Technology for
Economic and Clinical Health Act)
• ~ 20 billion dollars for Health IT investments
Goals:
1. Boost economy (economic health)
2. Widespread adoption of Health IT (clinical health)
Quality Patient Safety Costs

9. President Obama Backs Health IT
“...Our recovery plan will invest in
electronic health records and new technology
that will reduce errors, bring down costs,
ensure privacy, and save lives.”
President Barack Obama
Address to Joint Session of Congress
February 24, 2009Source: WhiteHouse.gov

10. U.S. National Leadership on Health IT
David Blumenthal, MD, MPP
National Coordinator for
Health Information Technology
(2009 - 2011)
Farzad Mostashari, MD, ScM
National Coordinator for
Health Information Technology
(2011 - 2013)
Robert Kolodner, MD
National Coordinator for
Health Information Technology
(2006 - 2009)
David Brailer, MD, PhD
National Coordinator for
Health Information Technology
(2004 - 2007)
Office of the National Coordinator for Health Information Technology
(ONC -- formerly ONCHIT)
Photos courtesy of U.S. Department of Health & Human Services
Karen B. DeSalvo, MD, MPH, MSc
National Coordinator for
Health Information Technology
(2014)

11. HITECH Act &
“Meaningful Use”
of EHRs

12. Blumenthal D. Launching HITECH. N Engl J Med. 2010 Feb 4;362(5):382-5.
HITECH Act

13. “Meaningful Use” of EHRs
• Use of “Certified EHR Technology” (CEHRT) by
providers (eligible professionals, eligible hospitals
& critical access hospitals) to achieve significant
improvements in care
• Financial incentives & penalties

14. Incentives for Eligible Professionals (Doctors)
• Medicaid incentives for eligible professionals
– Maximum $63,750 over 6 years beginning in 2011
• Medicare payments for eligible professionals
– Maximum $44,000 over 5 years

15. Incentives for Eligible Hospitals
http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/MLN_TipSheet_MedicareHospitals.pdf

16. “Meaningful Use” of A Pumpkin
“Meaningful Use”
of a Pumpkin
Pumpkin
Image Source & Idea Courtesy of Pat Wise at HIMSS, Oct. 2009

17. Meaningful Use of EHRs: ONC’s 3-Stage Approach
Stage 1
- Electronic capture of
health information
- Information sharing
- Data reporting
Stage 2
Use of EHRs
to improve
processes of
care
Stage 3
Use of
EHRs to
improve
outcomes
Better
Health
Blumenthal D, 2010

18. Components of Meaningful Use Regulations
• Medicare & Medicaid Incentives for Meaningful Use of EHRs
– Centers for Medicare and Medicaid Services (CMS)
• Rule on Standards, Implementation Specifications &
Certification Criteria
• Certification Programs
– Office of the National Coordinator for Health IT (ONC)

19. Meaningful Use Incentives: Stage 1
Proposed Rule
(Jan. 2010)
• 23 Criteria for Hospitals to Pass
• 25 Criteria for Professionals (Clinics) to Pass
Public Hearing
• Pace & Scope: too ambitious, demanding, inflexible
• Few providers would likely qualify -> Little adoption
Final Rule (2011)
• Core Objectives (14 criteria for Hospitals, 15 for Professionals, required)
• Menu Set (10 criteria, pick 5)
Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010;363(6):501-4.

20. Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010;363(6):501-4.
Meaningful Use Stage 1 Criteria

21. Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010;363(6):501-4.
Meaningful Use Stage 1 Criteria

22. Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010;363(6):501-4.
Meaningful Use Stage 1 Criteria

23. Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010;363(6):501-4.
Meaningful Use Stage 1 Criteria

24. Some Selected Meaningful Use Stage 1 Final Rule:
Core Objectives
• Electronic capture of information
– Demographics
– Vital signs
– Medication list
– Allergies
– Problem list
– Smoking
• Medication order entry
• Drug-allergy & drug-drug interaction checks
• Patient access to/copy of health information

25. Some Selected Meaningful Use Stage 1 Final Rule:
Menu Set
• Drug formulary checks
• Lab results incorporation into EHRs
• Generate lists of patients by specific conditions
• Medication reconciliation
• Electronic reporting to governmental agencies
• Advanced directives for elderly patients
• Patient reminders for certain services (for clinics)
• Patient access to health information (for clinics)

26. Final Rule on Standards & Certification Criteria (Selected)
• Content Exchange Standards
– HL7 CDA Release 2 & CCD
– NCPDP SCRIPT
• Vocabularies
• SNOMED CT
– LOINC®
– RxNorm®
• Security
– NIST-certified encryption algorithms
• Etc.

27. http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2Overview_Tipsheet.pdf
Stages & Timeline of Meaningful Use

28. Evolution of Meaningful Use Objectives in Each Stage
• 2011 Definition Stage 1:
– 14 Core Objectives for Hospitals
– 15 Core Objectives for Professionals
– Pick 5 of 10 Menu Set Objectives
• 2013 Definition Stage 1:
– 12 Core Objectives for Hospitals
– 13 Core Objectives for Professionals
– Pick 5 of 10 Menu Set Objectives

29. Evolution of Meaningful Use Objectives in Each Stage
• 2014 Definition Stage 1:
– 11 Core Objectives for Hospitals
– 13 Core Objectives for Professionals
– Pick 5 of 10 Menu Set Objectives for Hospitals
– Pick 5 of 9 Menu Set Objectives for Professionals
• 2014 Definition Stage 2:
– 16 Core Objectives for Hospitals
– 17 Core Objectives for Professionals
– Pick 3 of 6 Menu Set Objectives

30. Meaningful Use Stage 2 Objectives (2014)
for Eligible Professionals
http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2Overview_Tipsheet.pdf

31. Meaningful Use Stage 2 Objectives (2014)
for Eligible Professionals
http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2Overview_Tipsheet.pdf

32. Meaningful Use Stage 2 Objectives (2014) for Hospitals
http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2Overview_Tipsheet.pdf

33. Meaningful Use Stage 2 Objectives (2014) for Hospitals
http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2Overview_Tipsheet.pdf

34. Critique:
Lessons for Thailand
Disclaimer: Personal opinions of the speaker

35. Lesson #1
Clear aim toward improved quality &
efficiency of health care.

36. Lesson #2
Large health IT initiatives require
leadership from the highest level
of government.

37. Lesson #3
To achieve widespread health IT
adoption, substantial financial
investment is necessary.

38. Lesson #4
Leadership from a national
organization with health informatics
expertise is vital to success.

39. Lesson #5
Criteria for “Meaningful Use” should
be evidence-based
to the extent possible.

40. Lesson #6
Criteria for incentives should be
realistic and flexible.

41. Lesson #7
Criteria for incentives should be
evolutionary.

42. Lesson #8
Accept local diversity in technologies
& requirements.
Don’t aim for homogeneous
environment.

43. Lesson #9
Leverage existing standards
to the extent possible.
Don’t reinvent the wheel.

44. Lesson #10
Acknowledge that more than one
level of interoperability needs to be
achieved.

45. Lesson #11
A policy that attempts to move too
fast or be too dynamic will greatly
burden providers

46. Lesson #12
“Meaningful Use” focuses too much
on functionality, with questions on
true interoperability, and with little
attention on usability, ease of use &
provider acceptance of technology

47. Take Home Message
• Adoption of health IT still work in progress, even
in developed countries
• We can learn something from other countries
• We need to do something, soon.
• Don’t forget to build the workforce!!

48. Useful Online Resources
• www.healthit.gov
• www.cms.gov/Regulations-and-
Guidance/Legislation/EHRIncentivePrograms/index.html
• www.himss.org/EconomicStimulus/
• www.amia.org/public-policy/testimony-comments-reports
• www.nejm.org/doi/full/10.1056/NEJMp0912825
• www.nejm.org/doi/full/10.1056/NEJMp1006114

49. References
• Blumenthal D. Launching HITECH. N Engl J Med. 2010 Feb 4;362(5):382-5.
• Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J
Med. 2010 Aug 5;363(6):501-4.
• Hsiao C, Beatty PC, Hing ES, Woodwell DA. Electronic medical record/electronic health record use
by office-based physicians: United States, 2008 and preliminary 2009 [Internet]. 2009 [cited 2010
Apr 12]; Available from: http://www.cdc.gov/nchs/data/hestat/emr_ehr/emr_ehr.pdf
• Jha AK, DesRoches CM, Campbell EG, Donelan K, Rao SR, Ferris TG, Shields A, Rosenbaum S,
Blumenthal D. Use of electronic health records in U.S. hospitals. N Engl J Med. 2009;360(16):1628-
38.
• Jha AK, Doolan D, Grandt D, Scott T, Bates DW. The use of health information technology in seven
nations. Int J Med Inform. 2008;77(12):848-54.
• Schoen C, Osborn R, Huynh PT, Doty M, Puegh J, Zapert K. On the front lines of care: primary care
doctors’ office systems, experiences, and views in seven countries. Health Aff (Millwood).
2006;25(6):w555-71.