The Centers for Medicare & Medicaid Services' (CMS) proposed definition of a "meaningful user" of electronic health records (EHR) is a well-intentioned but overly ambitious attempt to move hospitals into a fully digital world, say hospital information technology (IT) leaders. Some fear it would lead to an expanding "digital divide" within the field.
The CMS proposal was released on December 30, along with the Office of the National Coordinator for Health Information Technology's (ONC) interim final rule on standards, specifications and certification criteria for EHR technology. The rules set EHR adoption requirements that hospitals and physicians must meet under the 2009 "American Recovery and Reinvestment Act."
Under the act, providers would be eligible for billions of additional dollars in Medicare and Medicaid payments beginning in 2011 to help reimburse them for the costs of purchasing and operating EHR systems. To receive the IT funds, they must demonstrate that they are meaningful users of the technology. Otherwise, they will incur significant payment penalties beginning in 2015.
Hospital IT leaders say CMS and ONC may be trying to accomplish too much, too soon.
"I am concerned about the pace of change required by the meaningful user requirements," says Marc Probst, Intermountain HealthCare's chief information officer in Salt Lake City, UT, and a member of the Health Information Technology Policy Committee, which contributed recommendations to CMS and ONC last year on defining meaningful use. "There are many hospitals, clinics and physician practices that may not be capable of achieving meaningful use" as defined by the proposed rule.
Unless hospitals are "well on their way to implementing an EHR solution, many may struggle with the technical and operational requirements," he says.
"It would have been nice if the standards addressed the different situations that organizations face, rather than a one approach for all," says Marc Gibbs, Crouse Hospital's chief information officer in Syracuse, NY. He observes that "these tight standards are being issued at a time when hospitals face major state and federal cutbacks in funding & and have little available funds to implement the changes these regulations were intended to achieve."
EHR payments can only be made to those providers who use in a "meaningful manner" EHR that has been "certified" by an organization recognized by ONC. The only exception to the meaningful user requirement is for eligible providers receiving initial EHR payments under Medicaid. Those Medicaid providers don't have to demonstrate meaningful use in the first year, but do in subsequent years.
CMS proposes three increasingly stringent stages of meaningful use criteria, with details of the first of the three stages covered by the regulations issued on Dec. 30. Stage 1 for 2011 and 2012 focuses on electronically capturing health information in a coded format, using that information to track clinical conditions and communicating that information for care coordination. It also calls for implementing clinical decision-support tools to facilitate disease and medication management and reporting clinical quality measures and public health information. There are 23 Stage 1 criteria for hospitals.
Under the proposed rule, hospitals are required to measure and attest that 10% of all orders placed by physicians, nurses and other authorized providers are entered into a computerized physician order entry (CPOE) system by 2011. The AHA notes that only about 30% of hospitals have implemented CPOE in at least one department. Hospitals also are required to count how many paper and electronic orders they process, which means setting up new and cumbersome collection systems, according to hospital IT officials.
Rural hospital leaders worry that the EHR rules will lead to a digital divide. "The bar has been set too high," says Louis Wenzlow, the Rural Wisconsin Health Cooperative's director of health information technology. The Wisconsin cooperative represents 35 rural hospitals, including 28 critical access hospitals.
"Disadvantaged providers at low stages of [EHR] adoption who especially need assistance will be much less likely to get help," says Wenzlow, adding that "CMS and ONC have structured the program in a way that will dramatically expand the digital divide between our country's EHR haves and have nots."
Others, like Cristina Thomas, Catholic Health Initiative's (CHI) vice president of clinical IT strategy in Denver, CO, are encouraged by the work done thus far. But she, too, cautions that the rules are "very ambitious, especially for an organization of the size, scope and complexity of CHI."
March 15 is the deadline to comment on the CMS and ONC rules, which were published in the Jan. 13 Federal Register.
The AHA has expressed concern that the regulations would seriously limit hospitals' access to federal heath IT funds, and plans to recommend a number of policy changes in its comments to CMS and ONC.
