Idea #67 For April 26th 2009: Not Shooting Ourselves in the Foot or The Meaning of Meaningful Use

On April 28th and 29th, the National Committee on Vital and Health Statistics (NCVHS) will be conducting hearings to collect information on the meaning of “Meaningful Use.” “Meaningful Use” is a 20 billion dollar buzzword these days because those facilities putting an EMR to “Meaningful Use” can get the incentives under ARRA/Hi-Tech, but without “Meaningful Use” you can’t. NCVHS is YAGAYNHO (Yet another government agency you never heard of) but is playing an absolutely crucial role in the practical aspects of final rule-making which will determine how the $20 billion in possible incentives gets doled out. I am quite heartened to see Fred Trotter scheduled to provide testimony and provide some general representation of Open Source systems, which now represent almost 10%-15% of the market (in patient terms), but have had little direct and public inclusion in the healthcare reform so far. Momentum is clearly building.

Historically in government policy making and in certifications like CCHIT, I think there are some significant problems that hopefully will be addressed more elegantly in this round:

  • The government is not typically in the business of intentionally granting monopolies through rule-making but often indirectly does this in healthcare. If “Meaningfule Use” ends up requiring the American Medical Association’s Current Procedure Terminology (CPT), proprietary editions of ICD9/ICD10 codes, direct electronic transmittal of prescriptions (after the RXHUB/SureScripts merger only one company provides this), then they are precluding a completely Open Source offering for healthcare. If from a medical standpoint, relevant parties deem any of these absolute requirements, then there should also be a requirement that those datasets and services be available without royalty or a non-disclore agreement, both of which make it impossible for completely Open Source systems to comply. The SNOMED codeset, while not truly open, has a US national “site license” that, while not ideal, offers a good compromise between Open Source and commercial interests. I think evidence strongly suggests that is what has given SNOMED such a large base of activity and what has positioned it as the major influence on ICD10.
  • There are 250,000 medical practices in the US, only about 10,000 of which have unbiased and clear representation in Washington DC. Experience tells us that there is a huge disparity between the sites that are represented in DC and most of the sites in the country. The “Meaningful Use” bar shouldn’t be too low, but if it is too high, most of the practices in the country won’t be able to meet the standard and the incentives will again be squandered. Common sense needs to come into play here and is notoriously absent in rule-making. Unless the goal is to exterminate single doctor practices, the realities of their business cases need to be considered.
  • What is a good minimum starting point for meaningful use? How about digital data for patient demographics, lab requests and test results, prescriptions (not necessarily direct electronic transmittal) with optional refill requests and  history (which both require SureScripts today), scanning or data entry of critical history/clinical documents (perhaps taxonomied with a document type), a coding history, and some kind of electronic problem list. I think shooting much beyond that simple base puts it out of the reach of the majority of practices (who are still 100% paper) in the short term. Having a complete digital clinical record is a tremendously high bar for those same practices to accomplish in 2 or 3 years. Paper isn’t completely the enemy — which is somewhat against my self-interest to say — the goal here is to reduce costs and improve outcomes, and we should work backward from that. Most communications between practices don’t require the entire chart, but just a much smaller subset of information, and having that digitally available is a fantastic start.
  • You can only move practices that are 100% paper today so far, so fast with a particular budget. To move to a complete digital work-flow from paper in 2-3 years would require another zero on the current incentive amount. It is much more important to solve the numerous “low fruit” problems and build clear momentum for the next ten years than it is to try and force in something for the sake of technology.
  • What is “Meaningful Use” without solid Information Technology to begin with? At least 70% of all practices lack this basic foundation of modern desktops, networking, connectivity and printing. Much more focus needs to be put on general IT at health sites; health sites need to have spending in line with other industries utilizing digital workflows, which spend 5-10% of gross on IT and do not view IT purely as a cost center.  Most practices today spend under 2% of gross on IT. This needs to be reconciled with “Meaningful Use” requirements if they are going to be sustained over the long haul.
  • How can we reconcile the awkward problem of patient healthiness and practice revenue? Practices that improve outcomes measurably because of “Meaningful Use” are potentially threatened because of related revenue decline. Current outcome incentives of 1% or 2% were a good experiment, but they won’t work nationally. Something much more favorable, such as outcome incentives of 5%-20% will be needed to really change habits and change entrenched but less-than-optimal best practices. Only wholesale changes will dramatically improve outcomes and reduce overall cost. The way improved outcomes are measured is perhaps the next and much more controversial battle, and “Meaningful Use” is a way to assist that debate with a common sense approach and solid starting point.

The government has a phenomenal opportunity here to express clear, concise and common sense definitions and goals that apply to, and are attainable by, 75% of practices. But if they take a major wrong turn with standards too high or too low, three years from now we will be right back here with a $20 billion sense of deja vu.

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2 responses to “Idea #67 For April 26th 2009: Not Shooting Ourselves in the Foot or The Meaning of Meaningful Use

  1. Very interesting and actual article, I completely agree with it, thanks.

  2. Pingback: Fred Trotter » NCVHS Testimony on Meaningful Use

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