Meaningful Use and the Path to Population Health and Quality in a Transforming Healthcare System

PHYTEL | WHITEPAPER

Population Health

Meaningful Use and the Path to Population
Health and Quality in a Transforming
Healthcare System

Contents
The Challenge
The U.S. healthcare system is on the verge of a major
transformation that has the potential to achieve several
national priorities

Incentive Structure
government Incentives

Three-Stage Process
Meaningful Use in Stage 1
A Graphical Timeline

Major Barriers to Meaningful Use
Adjunctive Technologies
Achieving Meaningful Use

Conclusion

Appendix

The Challenge: The U.S. healthcare system is on the verge of a major
transformation that has the potential to achieve several national priorities.
At the highest level, these priorities focus on expanding access to care, improving the quality of care, and reducing
cost growth to a sustainable level. More specifically, the agenda set forth in the federal reform legislation and the
HITECH provisions of the 2009 American Recovery and Reinvestment Act (ARRA) has these goals:

• Improve quality, safety, efficiency and reduce health disparities

• Engage patients and their families in their health care

• Improve care coordination

• Improve population health

• Ensure privacy and confidentiality for personal health information

In a previous paper, we discussed the importance and the role of population health management (PHM) in healthcare transformation.1 While PHM
is still largely confined to some large healthcare organizations and governmental systems, several elements of the Affordable Care Act (ACA)
that affect Medicare are driving the healthcare system in this direction. Among them are pilots of or incentives for care coordination, value-based
purchasing, accountable care organizations, and payment bundling.2 In addition, the “meaningful use” requirements of the HITECH Act are
designed to steer healthcare toward PHM.

The HITECH Act stipulates that physicians must show “meaningful use” of certified EHRs or EHR technology to qualify for government incentives.3
While the legislation instructs the Department of Health and Human Services (HHS) to fill in the details, it does specify that electronic prescribing,
health information exchange, and quality data reporting—all key to quality improvement--must be among the requirements.4 The Notice of
Proposed Rulemaking (NPRM) on the meaningful use regulations, issued in December 2009, went several steps further in laying out a framework
for population health management (PHM).5 The final regulations, which HHS released in July 2010, retain most of that framework, although they
make some PHM-related requirements optional or postpone them to a later stage of meaningful use.6 So, while the HITECH Act is primarily
designed to accelerate EHR adoption, the meaningful use rules turn the government incentives into a vehicle for launching transformational
initiatives.

1. Richard Hodach, “The Promise of Population Health Management,” White Paper, July 2010, accessed at xxxx
2 David Cutler, “How Health Care Reform Must Bend The Cost Curve,” Health Affairs, June 2010, 1131-1135.

PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | phytel.com ©2011 Phytel All rights reserved. 3

Incentive Structure: To be eligible for government incentives, physicians
must not practice primarily in a hospital setting, although they may be
employed by hospitals or healthcare systems.
Both Medicare and Medicaid will provide do not have EHRs or do not use them
subsidies, but an eligible professional (EP) meaningfully by 2015 will lose 1 percent of
can receive incentives from only one of Medicare reimbursement that year. They
these programs in a given year. To receive will give up 2 percent in 2016, and their
Medicaid incentives, physicians must derive reimbursement will drop 3 percent in 2017
30% or more of their income from Medicaid and each subsequent year.8
(20 percent for pediatricians). Other providers Medicaid incentives are structured a bit
may also be eligible for Medicaid subsidies, differently. According to the Centers for
including dentists, certified nurse-midwives, Medicare and Medicaid Services (CMS),
nurse practitioners, and physician assistants “Eligible professionals may receive up to
who are practicing in Federally Qualified 85 percent of the net average allowable
Health Centers (FQHCs) or Rural Health costs for certified EHR technology, including
Clinics (RHCs) led by a physician assistant.7 support and training (determined on the
An eligible professional who can show basis of studies that the Secretary will
meaningful use of a “qualified” EHR—one undertake), up to a maximum level, and
that has been certified by an HHS-approved incentive payments are available for no more
certifying body--may obtain incentives of up than a 6-year period.”9
to $44,000 from Medicare or nearly $64,000
from Medicaid. The Medicare incentives
will be paid over a five-year period, starting
in 2011. A physician who applies for a
Medicare incentive in 2011 or 2012 can get

1%
$18,000 the first year, followed by annual
payments of $12,000, $8,000, $4,000, and
$2,000. Those who apply in 2013 and 2014
will receive less, and anyone who applies
lower Medicare reimbursement
after that will get nothing. Physicians who
that are not meaningfully using an
EHR by 2015.

3. Centers for Medicare and Medicaid Services (CMS), “Medicare and Medicaid Health Information Technology: Title IV of the American Recovery and Reinvestment Act,” Fact Sheet, June
16, 2009, accessed at https://www.cms.gov/apps/media/press/factsheet.asp?Counter=3466&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&src
hData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date.
4. Ibid.
5. HHS (Department of Health and Human Services)/CMS, “Medicare and Medicaid Programs; Electronic Health Record Program; Proposed Rule,” aka “Notice of Proposed Rulemaking,”
Federal Register, 42 CFR Parts 412, 413, 422 and 495.
6. HHS (Department of Health and Human Services)/CMS, “Medicare and Medicaid Programs; Electronic Health Record Program; Final Rule, Federal Register, 42 CFR Parts 412, 413, 422,
and 495.
7. HHS/CMS, NPRM, 1930.
8. Ken Terry, “The EHR Stimulus: A Complete Primer,” Physicians Practice, July/August 2009
9. CMS Fact Sheet, op. cit.


Three-Stage Process
The process of showing meaningful use will be divided into three stages, each more difficult than the last. The Stage 1 criteria, the subject of this
paper, focus on electronically capturing health information in a coded format; using that data to track key clinical conditions; communicating that
information for purposes of care coordination; implementing clinical decision support tools; and reporting clinical quality measures and public
health information.In Stage 2, the requirements for EPs and hospitals will be expanded “to encourage the use of health IT for continuous quality
improvement at the point of care and the exchange of information in the most structured format possible, such as the electronic transmission of
orders entered using computerized provider order entry (CPOE) and the electronic transmission of diagnostic test results.”

The Stage 3 criteria will “focus on promoting improvements in quality, safety and efficiency, focusing on decision support for national high priority
conditions, patient access to self management tools, access to comprehensive patient data, and improving population health [emphasis added].”10
The details of Stage 2 and 3 will be defined at a later stage, after policy makers have had some experience with Stage 1.

Meaningful Use in Stage 1
On Dec. 30, 2009, HHS published a Notice of Proposed Rulemaking (NPRM) that presented the draft
regulations governing meaningful use.11 That document was accompanied by an Interim Final Rule that covered
the standards for EHR certification and interoperability.12 On July 13, 2010, HHS issued final rules with regard to
both meaningful use and EHR certification.13

Physician and hospital associations pushed back strongly against the draft regulations, saying that the
timeline was too short and that the requirements were too rigid and too difficult to meet.14 The Medical Group
Management Association said that, taken as a whole, the criteria were “onerous” and would result in reduced
physician productivity.15

The final rule on meaningful use showed that HHS had listened carefully to the complaints and had responded
to most of them. In place of the 23 criteria that eligible providers had to meet and the 25 required of hospitals
in the NPRM, the final rule stipulated 15 “core” requirements for eligible providers and 14 for hospitals.
Providers may choose any five of 10 additional criteria on an optional menu and have until the end of 2012 to
meet them. (One of the optional criteria has to be a public health measure--either immunizations or syndromic
surveillance.)16

The measures for both the core and optional requirements have been substantially revised. In some core
categories, such as patient demographics, vital signs, and smoking status recorded in the EHR, the required
percentage of the population has been reduced from 80 percent to 50 percent. Physicians need send only
40 percent of their prescriptions online to pharmacies, compared to 80 percent in the original draft. The
requirement that practices import 50 percent of lab results into their EHRs as searchable data has been

10. HHS/CMS, NPRM, 1852.
11. HHS/CMS, NPRM, op. cit.
12. Department of Health and Human Services, “Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health
Record Technology; Interim Final Rule,” Federal Register, 45 CFR Part 170.
13. HHS/CMS, Final R ule, op. cit.
14. Chris Silva, “EMR Meaningful Use Rules Need to Be More Flexible, Doctor Groups Say,” American Medical News, March 22, 2010.
15. MGMA letter to Dr. David Blumenthal, re: “Proposed Establishment of Certification for Health Information Technology,” April 8, 2010, accessed at http://www.mgma.com/WorkArea/
DownloadAsset.aspx?id=33320.
16. David Blumenthal and Marilyn Tavenner, “The ‘Meaningful Use’ Regulation for Electronic Health Records,” New England Journal of Medicine, July 13, 2010, accessed at http://
healthcarereform.nejm.org/?p=3732&query=home.


transferred to the optional menu, and the However, HHS has made it clear that all of
threshold for meaningful use is now 40 the original meaningful use criteria that have
percent of results. Also, the number of quality been scaled back or made optional will be
measures on which physicians must report requirements in stage 2 or stage 3. At a
data has been reduced to six; three are press conference, David Blumenthal, MD,
mandatory and the rest must be selected National Coordinator of Health Information
from a list of 38 measures. 17
Technology, said that the criteria that involve

The final rule on EHR certification and electronic connectivity have been relaxed

standards allows the certification of modular temporarily until the nation’s health IT

components of EHRs that can qualify for infrastructure is equal to the task. But, at

meaningful use. This allows the certification that conference and in later Congressional

of various non-traditional EHRs and testimony, Blumenthal noted that those

supplemental technologies that can aid criteria would become more stringent in the

physicians in improving quality and obtaining later stages.20

government incentives. While the later requirements have yet to be
drawn up, the final rule for stage 1 shows

The AMA, praised the increased flexibility in the meaningful use criteria, the
changes in the quality reporting mandate, and the elimination of requirements
related to claims submission and eligibility checking.

Industry reaction to these changes has
that HHS remains on course to deploy
been generally positive. The AMA, for
meaningful use as a lever to get physicians
example, praised the increased flexibility
to use EHRs for quality improvement and
in the meaningful use criteria, the changes
population health management. So, in
in the quality reporting mandate, and the
devising strategies to meet these criteria,
elimination of requirements related to claims
physician groups and healthcare systems
submission and eligibility checking.18 And the
must keep the government’s ultimate goals
MGMA lauded HHS’ willingness to address
in mind.
industry concerns about the regulations.19

17. Ibid.
18. AMA press release, “AMA Pleased With Improvements to EHR Meaningful Use Requirements, But Challenges Remain to Widespread Adoption,” July 21, 2010.
19. MGMA press release, “MGMA Responds to ‘Meaningful Use’ Final Rule,” July 13, 2010.
20. iHealthBeat, “Administration Officials Defend ‘Meaningful Use’ Before Congress,” July 21, 2010.


The timeline for showing meaningful use in Stage 1 is as follows:

Registration for the Medicare program begins.
January 2011 For Medicaid providers, states may launch their programs if they choose.

April 2011 Attestation of meaningful use begins, using data from previous three months.

May 2011 EHR incentive payments begin.

November 2011 Last day for eligible hospitals to register and attest to receive incentives for 2011.

February 2012 Last day for eligible professionals to register and attest to receive an incentive payment for 2011.

Major Barriers to Meaningful Use
Although the final rule on EHR certification covers the technical standards required to support the meaningful
use regulations, it does not describe how EHRs will be certified; but final temporary certification criteria have
been established so that meaningful use can be accomplished in 2011. HHS and the certification entities it
chooses will determine that. EHR vendors, naturally, are working overtime to upgrade their software to meet the
requirements, and many have promised customers and potential buyers that they will able to show meaningful
use. Unfortunately, that will not be true for most existing EHRs, unless they’re supplemented by adjunctive
technologies.


Part of the problem is that today’s EMRs were outside of office visits, because only a subset physician practice decides to avoid the more
not designed for quality improvement or for of patients register on these portals and/or difficult requirements on the optional menu in
managing the health of populations.21 For provide their e-mail addresses. stage 1, the practice will eventually be forced
example, one of the optional requirements Other meaningful use areas in which to comply with them to show meaningful use.
stipulates that eligible providers send alerts many EHRs fall short include the ability to
about needed care to 20 percent of their generate lists of patients with specific chronic
patients who are 65 or older and five or conditions or preventive-care needs; the
younger. The EHR that a particular physician ability to collect and report quality data; and
uses might be able to generate these reports the ability to generate condition-specific
on patients who have come into the office in educational materials for patients.
recent months. But it will not be able to help
Each EHR has its own strengths and
the doctor identify the patients for whom
weaknesses, of course, and the ways in
he does not have this data. Nor will it be
which it is used in the office environment
able to identify patients who are overdue for
will dictate how many of the meaningful use
preventive and chronic care services without
criteria physicians can meet. In addition, as
a fair amount of customization.22
discussed below, there are problems with
Smaller practices are simply not set up bad data, missing data, and non-discrete
to send alerts to patients who don’t visit, data that will prevent doctors from achieving
because it is too time-consuming and meaningful use, no matter what kind of
difficult to track their population.23 Less technology they use.
than half of larger groups are “engaged in
EHR vendors will adapt their software to
substantial activity in the quality and safety
satisfy the meaningful use requirements,
By combining EHRs
domains focused on the patient (patient
educators, sending patient reminders,
but most of them will offer the plain-vanilla with these automated
administering health risk assessments, and
versions of the required functionality in order
approaches, physicians
to meet the competition. That might not be
health promotion programs).”24 Regardless
good enough to achieve the government’s can show meaningful
of practice size, use of patient portals alone
cannot ensure that patients receive alerts
goals in stages 2 and 3. And, even if a use

21. Paul A. Nutting, William L. Miller, Benjamin F. Crabtree, Carlos Robert Jaen, Elizabeth E. Stewart, Kurt C. Stange. Initial Lessons From the First National Demonstration Project on
Practice Transformation to a Patient-Centered Medical Home.” Ann Fam Med 2009;7:254-260.
22. Rushika Fernandopulle and Neil Patel, “How The Electronic Health Record Did Not Measure Up To The Demands of Our Medical Home Practice,” Health Affairs, April 2010, 622-628.
23. Robert A. Berenson, Terry Hammons, David N. Gans, Stephen Zuckerman, Katie Merrell, William S. Underwood, and Aimee F. Williams, “A House Is Not a Home: Keeping Patients at
The Center of Practice Redesign,” Health Affairs, September/October 2008, 1219-1230.
24. Diane R. Rittenhouse, Lawrence P. Casalino, Robin R. Gillies, Stephen M. Shortell, and Bernard Lau, “Measuring The Medical Home Infrastructure in Large Groups,” Health Affairs,
Health Affairs 27, no. 5 (2008): 1246–1258.


To achieve meaningful use consistently over the five years of the incentives and
to advance toward quality and population health management, physicians will
have to use supplemental technologies in conjunction with their EHRs

Adjunctive Technologies medical homes and PHM, can then use this
information to prepare doctors and nurses
To achieve meaningful use consistently
for patient visits. Between visits, they can
over the five years of the incentives and to
use the population health improvement
advance toward quality and population health
technology to make sure that patients get
management, physicians will have to use
their needs addressed and come back for
supplemental technologies in conjunction
follow-ups. The technology solution does
with their EHRs. These may include
the heavy lifting, increasing care managers’
electronic registries; multiple outreach and
productivity and allowing practices to do
communications methods; and software that
more with fewer personnel.
can calculate the metrics required for quality
reporting. By combining EHRs with these automated
approaches, physicians can show meaningful
What all of these methodologies have in
use, qualify for medical home certification,
common—aside from the analytic software—is
obtain pay for performance incentives, and
that they automate the work of monitoring,
prepare themselves for the value-based
educating and maintaining contact with the
reimbursement systems that are down the
patient population. Especially at a time when
road. At the same time, these adjunctive
primary-care providers are in short supply
technologies enable physicians to gather
and stretched thin, it is essential to provide
the quality data they will need to report to
this level of automation so that the routine,
Medicare and private payers in an automated
repetitive work can be done in the background,
manner. And by giving care teams real-time
rather than taking up the valuable time of
data on the services that patients need
doctors and nurses.
when they’re in the office, these methods
Information on the care gaps of specific
empower physicians and other clinicians to
patients can be automatically generated
improve quality and engage in productive
and provided to care coordinators and care
conversations with patients about how they
managers within practices. These clinical
can maintain or restore their health.
staffers, who are key to both patient-centered


Supplemental PHM programs have the capability to clean up data and
identify opportunities for improving information quality.

Like any computerized approach, information data will undermine the effectiveness of menu require identification of conditions
technology designed for population health an electronic registry or another adjunctive using multiple forms of discrete data,
improvement depends on the quality and technology. including medications, labs, and diagnoses.
consistency of the data it uses. And the data Analytic support may also be required to
For these reasons, supplemental PHM
in some EHRs is seriously flawed for a variety provide positive identification.
programs should have the capability to
of reasons. First, some older EHRs allow clean up data and identify opportunities for To attest that a physician has gathered
anybody in a physician practice to create improving information quality. They should data on at least six of the quality measures,
new data fields, leading to inconsistent and also be able to define subpopulations with practices will have to identify the numerator
improper use of the system. The information chronic conditions, identify gaps in care, and the denominator on each metric. For
may also contain errors because of faulty and report on key quality indicators for the example, if smoking cessation advice is
data entry. Also, information that comes into leading chronic diseases. the measure, an organization must be able
an office in the form of paper documents to identify the number of smokers in the
is scanned into the system, rather than Achieving Meaningful Use practice and what percentage of those
being entered as discrete data. And in patients received physician counseling.
Despite the changes in the meaningful
many practices with EHRs, some or all of Analytic support that is not available in an
use criteria, it will still be very difficult for
the physicians still dictate much of their EHR may be required to collect this data.
many physicians, especially those in small
notes, restricting the amount of discrete
practices, to show meaningful use within
data available for quality improvement and
the short time frame specified to receive full
reporting.
incentives. But supplemental technologies
Bad or limited data can directly affect a can help in some very specific ways.
physician’s ability to show meaningful use.
For instance, of the 15 core measures in the
For example, EHR users are required to
final rules, six require discrete, searchable
prove that they documented blood pressure
data on the percentage of patients who meet
and body-mass index for 80 percent of their
the objectives. This may be difficult to obtain
patients over 2 years old. If they don’t have
because the data is missing or has been
correct demographic data on all of their
patients, or if one medical assistant enters
entered in non-standard ways, as explained
Limited data can
earlier. To strengthen the data enough to
blood pressure readings or BMI in a different
present fairly accurate reports, practices can directly affect a
way than other clinicians in the practice do,
it will be impossible for physicians to show
run registry reports and ferret out the bad or physician’s ability to
incomplete data.
they met these criteria. In addition, bad EHR show meaningful use.
Similarly, the patient alerts on the optional


Conclusion

The overarching goal of the meaningful use requirements of ARRA is to facilitate the transition to
real quality improvement and population health management. For most physician practices, this
will be very difficult to do, even if they have top-of-the-line EHRs. They will need supplemental
information technology that automates the basic tasks of identifying, contacting, and tracking
patients who need preventive and chronic care services, coupled with reports that care teams can
use for quality improvement and reporting. By using this technology in conjunction with EHRs,
physicians should be able to attain the goals of meaningful use.


Appendix: What follows are some examples of how a particular type
of population health management software can help EHR users show
meaningful use in Stage 1.
Core Measure Support

At least 50 percent of all unique patients seen by the EP have A general registry report shows the demographic data on all
demographics recorded as structured data patients who have been seen.
For at least 50 percent of all unique patients age 2 and over seen A registry can show how many patients in those age categories
by the EP, record height, weight, and blood pressure. have recorded blood pressure and other vital signs, including body
mass index.
Record smoking status for at least 50 percent of all unique patients Use general registry and condition reports generated from EHR
who are 13 or older. data and online health risk assessments.
Report ambulatory quality data to CMS or to the states. A quality report can be generated by applying evidence-based
protocols to registry data on the entire population and on specific
subpopulations.
Implement one clinical decision support rule relevant to the clinical Generate reports showing care gaps for all patients who have a
quality metrics that the EP is responsible for. condition such as diabetes. Send messages to patients alerting
them to contact their doctor. Show results of these efforts in
the quarterly quality reports. A pending orders report prompts a
specific care manager action to close a particular care gap.
Measure on Optional Menu Support
Generate at least one report listing all unique patients who have a Use condition-specific reports from the registry.
specific health condition.
Optional Measure Support
Reminders are sent to at least 20 percent of all unique patients Evidence-based clinical protocols use registry data (including
seen by the EP who are 65 or older and five or young. problem lists) to trigger outbound messaging to patients by phone,
secure email, text messages, etc.
Summary of care record is provided for more than 50 percent of Patient clinical summary that includes preventive care gaps,
patient transitions or referrals. lab results for chronic conditions, and health risk information is
available to care teams and can be shared with patients.
More than 10 percent of patients are provided patient specific Web-based, multimedia educational materials tailored to chronic
educational resources. conditions and individual risk factors.


Meaningful Use and the Path to Population Health and Quality in a Transforming Healthcare System

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (20)

Similar to Meaningful Use and the Path to Population Health and Quality in a Transforming Healthcare System

Similar to Meaningful Use and the Path to Population Health and Quality in a Transforming Healthcare System (20)

Recently uploaded

Recently uploaded (20)

Meaningful Use and the Path to Population Health and Quality in a Transforming Healthcare System