I posted an EHR stimulus poll a week ago and I thought it would be interesting to post some preliminary results. I really wish a few more people would have participated in the poll. It’s only 2 clicks to add your opinion. I expect over time I’ll get some more responses.

Take a look at the current results for the question: How will your clinic be approaching the EMR Stimulus money made available in the HITECH Act (ARRA)?

What’s surprising to me from the results so far is that such a large percentage of people are either waiting to hear about the EHR stimulus money or are planning on the EHR stimulus money. This poll is a little bit biased since so many of the people visiting EMR and HIPAA these days are coming here to learn about the EHR stimulus money.

Like I’ve said before, there’s no doubt that the $18 billion investment by Obama into electronic health records has increased the interest in EHR software. We’ll have to just wait and see how much of this increased interest in EHR turns into actual EHR purchases.

We’re all still sitting here waiting for the government to finally decide two key terms in regards to gaining access to the $18 billion in stimulus money in the HITECH act (ARRA). I’ve been interested in the subject myself since before it was even settled that we’d call it meaningful use as opposed to meaningful EMR user. From the looks of that post back in February, there was still a lot of confusion about “meaningful use” and “certified EHR.”

Turns out that a few months later, we still have very little clarification about what these two terms mean. Certified EHR discussion has really revolved around CCHIT certification or some other alternative. We’ll try to leave that discussion for other posts. What has been interesting is in just the past week or two there has been a literal flood of people offering their perspective on meaningful use. Sometimes I like to be on the cutting edge of these definitions (like I was in the link above) and other times I like to sit back and let them play out. This time I’ve been letting it play out and it’s really interesting to see the multitude of perspectives.

I’m not planning on writing my own plan for how they should do meaningful use. I may do that at a later time if so inclined. For now, I’ll just focus on highlighting points from what other people have suggested and provide commentary that will hopefully enhance people’s understanding of this complicated mandate (yes, that means this post will be quite long).

I think it’s reasonable to first point you to the NCVHS hearing on “Meaningful Use” of Health Information Technology. This matters, because at the end of the days hearings like these are where most of the information are going to come. Then, with the information from these hearing decisions will be made. The other sources like blogs won’t carry nearly as much weight (although it’s unfortunate that more politicians aren’t listening).

John Chilmark on Meaningful Use
Next, I’ll go to one of my newly found favorite bloggers named John Chilmark (any coincidence we’re both named John). John from Chilmark Research commented that HHS is bringing together the “usual suspects” to discuss “meaningful use. Chilmark also states that the following criteria are what’s required for meaningful use:

1. Electronic Prescribing
2. Quality Metrics Reporting
3. Care Coordination

I’m not sure where he got this list, but this list feels kind of weak if you ask me. In fact, John suggests that these requirements will be simple and straightforward and first and then ratcheted-up in future years. Interesting idea to consider. I hope that they do draft the requirements for meaningful use in a way that it can be changed in the future if it turns out to not be producing the results it should be producing.

John Halamka on Meaningful Use
Next up, the famous John (another John) Halamka, Chief of every Health IT thing (at least in Boston), calls defining “meaningful use” “the most critical decision points of the new administration’s healthcare IT efforts.” He’s dead on here. In fact, it might not be the most critical decision for healthcare IT, but for healthcare in general as well. Here’s John Halamka’s prediction for how “meaningful use” will be defined:

My prediction of meaningful use is that it will focus on quality and efficiency. It will require electronic exchange of quality measures including process and outcome metrics. It will require coordination of care through the transmission of clinical summaries. It will require decision support driven medication management with comprehensive eRx implementation (eligibility, formulary, history, drug/drug interaction, routing, refills).

Basically, he’s predicting inter operable EMR software and ePrescribing with a little decision support sprinkled on top. I won’t be surprised if this is close to the final definition. The only thing missing is the reporting that will be required to the government. The government needs this data to fix Medicare and Medicaid (more on that in another post).

Blumenthal Comment to Government Health IT
Government Health IT has a nice quote from David Blumenthal that says: “The forthcoming definition of the “meaningful use” of health information technology will set the direction of the Obama administration’s strategy for health IT adoption, said David Blumenthal, the new national coordinator for health IT.”

I think there’s little doubt that David Blumenthal has a good idea of the importance of the decisions ahead. What should be interesting is to see how involved Obama is in these very important decisions. I’m guessing Obama won’t do much more than sign a paper to make it happen. I just hope I’m wrong.

HIMSS Definition of Meaningful Use
Here’s a short summary of the HIMSS definition of “meaningful use”

According to HIMSS officials, EHR technology is “meaningful” when it has capabilities including e-prescribing, exchanging electronic health information to improve the quality of care, having the capacity to provide clinical decision support to support practitioner order entry and submitting clinical quality measures – and other measures – as selected by the Secretary of Health and Human Services.

Basically, e-prescribing, interoperability and clinical decision support. Turns out a BNET Healthcare article suggested the same conclusion “The consensus of physician and industry representatives was that meaningful use should include interoperability, the ability to report standard quality measures, and advanced clinical decision-making.”

I think we’re starting to see a bit of a pattern here. I should say that these are all very good things, but the challenge I see is that any requirement needs to be easily and consistently measured. Interoperability and clinical decision support are both very difficult to measure. Just wait until they see the variety of software that tries to do those two things. It’s very difficult to measure it consistently across so many EHR software.

Wow!! I barely even got started on this subject. Instead of belaboring the point, let me just point you to some other interesting readings about the HITECH Act, ARRA, and “meaningful use.”

• Fred Trotter’s Open Source Perspective
• Blackford Middleton’s Comments on “Meaningful Use”
• Steve Beller’s Definition of “Meaningful Use”
• Human Factors and “Meaningful Use”
• AHIMA Comments on “Meaningful Use” (pdf)
• Markle Foundation Framework (PDF)

Please let me know if there are other good sources for perspectives on defining “meaningful use.” This really is a landmark decision for healthcare IT.

I may have missed this somewhere else, but today was the first time I have found one of the major newspapers actually talk about EHR certification possibly being worse than what a competitive EHR marketplace can produce.

You can read the Wall Street Journal opinion article to see what I mean. Here’s the conclusion which describes the problem with certified EHR:

The stimulus hands the Obama Administration the power to define and approve “certified” records, therefore the power to create a health-tech monopoly. With stimulus money being shoveled out as quickly as possible, doctors and hospitals may end up prematurely investing in the costly systems that happen to have the government seal of approval — and in the process freezing out an innovative marketplace.

Granted, this was just in the opinion section of the Wall Street Journal, but I think more people need to stand up and make this opinion known. If you think we have problems now imagine what will happen when the government becomes the “arbiter of health information technology.”

I’ve been really amazed at the number of people I’ve heard talking about the HITECH Act bringing in a “new age of EHR” and other similar phrases. Then, I usually consider who’s been saying it and I realize that their pocketbooks are going to be lined with money from the HITECH Act and EHR adoption. So, I take it with a grain of salt.

Instead, I like to look at examples to help me better understand what might happen with the $18 billion Obama’s planning to spend on EHR adoption. The best example I know of comes from the British National Health System. It’s certainly not a perfect match, but should open our eyes on government funded EHR systems.

The Examiner (San Francisco) provided an interesting editorial on Britain’s National Health Service’s HIT systems implementation:

Britain’s NHS, who have been trying to get their HIT system to work properly for the past 5 years. The cost of NHS’ HIT has escalated to 6 times the original estimate — the U.S. equivalent of $18.4 billion — to serve just 30,000 physicians in 300 state-run hospitals, a fraction of the health care providers in the USA.

HIT is such a mess that Leigh recommended funding alternative systems if matters don’t improve within the next 6 months.

A large 2003-04 study of 1.8 billion ambulatory patients discovered that the use of electronic health records provided no difference in 14 of 17 quality-care indicators, produced significantly better care in just two and worse care in one.

And, a summary of 33 studies done in Europe between 1985 and 2009 found that HIT actually causes a significant number of medical errors.

Definitely cause for concern since Britain has spent $18.4 billion on a MUCH smaller health care system. Looks like Obama should have applied his “down payment” principle to HITECH Act’s $18 billion towards EHR too.

HISTalk did a great job summarizing what this writer found about the new health czar Nancy-Ann DeParle’s ties to healthcare.

According to this writer, new health czar Nancy-Ann DeParle has some deep financial ties to the healthcare industry she’s supposed to reform: (1) she is a managing director for an advisory firm whose affiliate converted a non-profit Idaho hospital to a for-profit; (2) as a Cerner board member, she was paid $195K in stock and cash and held around $1 million of CERN shares at the end of 2007; (3) she was on the board of Triad Hospitals and made $1.4 million on its sale; (4) she’s on the board of medical device maker Boston Scientific, paid $160K and holding $400,000 of stock at the end of 2007; (5) she’s on the board of dialysis vendor Davita, paid $194K and holding $1.8 million in shares in 2007; (6) she was on the board of specialty pharmacy vendor Accredo, now Medco; (6) she made money by selling Guidant shares when it merged with Boston Scientific; (7) she was on the board of Specialty Labs, Inc. and got 38,500 shares, which she sold. Maybe she can reform the system, but so far her talent seems to be in profiting from it. Not exactly the anti-insider that Obama said he wanted all around him.

I should mention that DeParle has resigned from Cerner’s board.  Smart decision.  I’m not really sure what to think of this list.  However, just reading through it gives me that kind of sick feeling that something doesn’t feel right.  Reminds me of my previous post aboutAllScripts CEO as Obama’s Healthcare advisor.

An AP report is announcing that Kathleen Sebelius will be announced as Barack Obams’s new nominee for HHS secretary tomorrow. The article says the following about Kathleen Sebelius as HHS secretary:

Sebelius, 60, is seen as a steady hand, an experienced public official who knows how to work across political lines. As a former state insurance commissioner, she is unfazed by the complexities of health care and insurance issues.

Of course, Sebelius will still have to gain confirmation from the Senate which could be interesting because Sebelius has clashed with abortion opponents in Kansas and the fight might head to Washington.

Another delay in the nomination of the HHS secretary could mean even more delays in the HITECH act and EHR adoption. I for one hope that health care doesn’t have to wait even longer for the HHS secretary to start getting down to business. There’s just far too much to do for us to be without a leader.

UPDATE: It’s now official that Kathleen Sebelius has been named as Obama’s HHS secretary. Check out the Huffington Post report and the Washington Post.

If you’ve read this blog, then I’m sure you know that Tom Daschle withdrew his nomination for HHS secretary. Some people have suggeste Howard Dean to be a nice replacement for Tom Daschle as HHS secretary, but unless I missed something in the midst of the HITECH act mania nothing’s been officially announced by Obama.

All of this means that HHS is without a secretary to implement the HITECH act along with the $2 billion of discretionary funds, choosing an EHR certification criteria, and defining meaningful EHR use.

I can’t imagine the people at HHS are just sitting on their hands, but I sure wonder what impact not having an HHS secretary will have on Obama’s health care reform.

One of my biggest fears about the carrot and stick approach to the HITECH EHR stimulus package is that many doctors are never going to see any of the EHR stimulus package. Not because they aren’t going to implement an EHR, but because they won’t meet the “meaningful use” criteria that HITECH requires.

This isn’t a view that I share alone. Take a look at the following two comments made about HITECH’s inability to actually pay the doctors who participate.

CEOMike’s (CEO of Medscribbler) take on doctor’s qualifying for the EHR stimulus:

Not only is the EMR have to qualify – THE DOCTOR IS GOING TO HAVE TO QUALIFY – the experience with e-prescribing and the incentives programs is a LOT of doctors who thought they would get money didn’t even though their EMR produced the required information – a lot of times the information produced by the EMR proved the doctor did NOT qualify !!!

Remember this is government !!!

Al Borg’s take on past projects similar to the HITECH reimbursement plan:

In past demonstration projects, less than half of physicians or practices ever got any money and those that did got much less than what they thought they would get (the most recent one the 40% which were winners won only $600 on average). Everyone that participated ended up a loser, whether they got paid or not. Are they nuts?

Certainly some people will see the money. The question is whether you’ll be one of them. It’s why I still believe that $18 billion of EHR Stimulus won’t actually be spent.

I love how people are saying that $18 billion will be spent on EHR adoption due to what has been dubbed the HITECH act. My question is how did they come up with the $18 billion number? I guess you could say that it’s the max that the government has permitted to be spent. However, if that’s the case, then shouldn’t people be saying that $18 billion MIGHT be spent to stimulate EHR adoption?

Seriously, what if doctors don’t like any of the certified EHR (whatever that turns out to be) and decide not to implement an EHR? What if Medicaid and Medicare make “meaningful EMR use” so difficult to achieve that most doctors who implement an EHR don’t actual see the stimulus from the government?

I’m not trying to say that the government isn’t going to pay our billions of dollars to those who have implemented an EHR. I have a feeling that billions will be paid out as medicare and medicaid bonuses. However, I don’t know how they got the number of $18 billion. For all we know, it could end up being $2 billion.

Plus, we have to ask ourselves the purpose of the HITECH act. Many have said that it’s to “stimulate EHR adoption.” I have a strong feeling that those existing EHR users will be the ones who benefit most. If $15 billion of the $18 billion allocated goes to existing EHR users, then that doesn’t sound like a good investment used to increase EHR adoption to me.

Currently, doctors must invest time and money to implement EHR systems, but it’s the insurers and payers who ultimately benefit, thanks to a reduction in unnecessary tests and medications.

Source

Couldn’t have said it better myself. Now, how do we change this? Will the current EHR stimulus fix it?