The Users' Guide to the Health Reform Galaxy

Health Reformer’s Lexicon: Meaningful Use

The Health Reformer’s Lexicon is a regular feature that will examine key words, terms and phrases in health reform and explore their meaning and orbit. 

The term: Meaningful use – assuring that health information technology (HIT) is used in a meaningful way to provide better patient care.

Congress earmarked billions of dollars to spur investment in “health information technology” (HIT) and electronic health records technology by health care providers, but money came with a string attached known as “meaningful use.” To qualify for these subsidies, doctors and hospitals must put the HIT they purchase to “meaningful use,” to improve the quality, efficiency, safety and coordination of care, and reduce disparities and engage patients and families in their care.

Why it matters: There is a lot of money at stake. Estimates are that between $14.1 billion and $27.3 billion in subsidies could flow to qualifying providers. These funds will help providers invest in HIT infrastructure. As results from the 21st  annual Healthcare Information and Management Systems Society leadership survey indicate,

Asked to identify their single IT priority during the next two years, 42 percent of respondents identified meeting meaningful use criteria.

But as we’ve noted previously on this blog, HIT in and of itself will not improve health care, it is how we implement and use it to engage with providers and patients that truly matters.

Roots: The Health-e Information Technology Act of 2008 was introduced as a bill “to promote the adoption and meaningful use of health information technology.” But the term “meaningful use” was put on the map by the American Recovery and Reinvestment Act of 2009, aka the “stimulus bill” under the bill’s Health Information Technology for Economic and Clinical Health Act provisions.

Where the term appears:  The usage that has mattered most of late came just two days before the end of 2009 when the Centers for Medicare & Medicare Services and the Office of the National Coordinator for Health Information Technology issued proposed rules that can be read here and here to define “meaningful use.” At 700 pages, at least one wag at Modern Healthcare deemed them "meaningful obtuse.“

CMS expects to finalize its meaningful use rule later this year.

What H1N1 taught us about public health preparedness

Richard Hamburg, deputy director of Trust for America's Health, writes about the H1N1 flu outbreak as a test of the nation's public health system with important lessons for emergency preparedness and health reform.

The H1N1 flu outbreak has been a real-world test of the nation’s public health system, and the results are mixed at best.  The good news is that earlier investments in emergency preparedness created a larger stockpile of antiviral medications. But the outbreak also revealed serious, underlying gaps, including a lack of real-time disease surveillance and laboratory testing, outdated vaccine production capabilities, limited hospital surge capacity and a shrinking public health workforce.

The seventh annual edition of  Ready or Not? Protecting the Public’s Health from Diseases, Disasters and Bioterrorism  shows that a band-aid approach to public health is inadequate.  The report found that 20 states scored six or less out of 10 key indicators of public health preparedness. Montana had the lowest score of all with three out of 10.

Variation in preparedness means that where people live can determine how well they are protected from health threats.  In the case of a pandemic or infectious disease outbreak, one weak link in the public health chain – including providers’  reluctance to treat those who are uninsured or underinsured - could result in disaster for everyone.

Where's the magic with electronic medical records?

Mike Painter writes about health information technology and when might be the right time to assess its impact on health care quality and cost.

Last week a new article from The American Journal of Medicine entitled, “Hospital Computing and the Costs and Quality of Care:  A National Study” by Himmelstein, et al. appeared in my Twitter stream.  In fact, Brian Ahier (@ahier), whom I and about 3300 other tweeps like me follow, sent me a DM asking for thoughts.  In that article the authors sort of breathlessly conclude that current hospital computing has minimal impact on quality and no impact on cost.  Shocking.   Actually, it’s the kind of gotcha article that really grates—the kind that isn’t particularly helpful to anyone as the authors seem intent on drawing sweeping conclusions from pretty limited data. 

For starters, how can we draw any conclusions about the impact of widely adopted, meaningfully used electronic records until they’re, well, widely adopted?   As research by  Ashish Jha et al. highlighted in Chapter One of the recently released 2009 RWJF HIT Adoption report (results from that research also published in April NEJM) show that only 1.5% of hospitals have a comprehensive EHR system—and only another 8% have a so-called basic system.  I’m not sure how one can draw important conclusions about national hospital computing given such an unbelievably low national rate of adoption. 

More importantly, though, most do not think that simply adopting, even widely, a technology would ever magically on its own improve quality or lower costs.  I’m not sure why these authors seemed to say otherwise.  The point as many have noted over and over again is for health professionals to adopt and then USE (remember our year long discussion regarding meaningful use?) the technology FOR improved quality, including improved efficiency.  As I discuss extensively in Chapter Five of the 2009 HIT Adoption Report, one important use of the technology will be, for instance, automation of performance measurement and public reporting.   The automation enabled by widely adopted, meaningfully used EHRs will hopefully accelerate the creation of results oriented information—information that will facilitate payment reforms as well as improvement.  We absolutely cannot do the kind of payment reforms that the nation needs without creating measures from the automated collection and aggregation of clinical data.  Bundled payment reforms, like the Prometheus model for example, will not work without this kind of automation—and to get to that automation we need widespread adoption and meaningful use of the technology.  But the adopted technology is only an important step.

We are still nowhere near that kind of use in an environment of ubiquitous electronic records.  Given that small fact, to conclude that there is “evidence” that hospital EHRs “don’t” improve quality or lower costs seems pretty silly.  That’s like saying a stethoscope should, but shockingly doesn’t, improve the quality and cost of care just because an intern buys one and hangs it around her neck. 

The authors end their article asserting that predictions about cost and efficiency improvements from widely adopted EHRs “are premature, at best”.  To me that statement is pretty disingenuous, at best.  What’s premature is expecting magic transformation when folks are just getting the tools out of the box—and trumpeting the lack of that magic transformation as if it’s evidence.

 

Where were you?

Mike Painter, senior program officer at RWJF, writes about the latest report released by RWJF on the adoption of electronic medical records.  He contributed a chapter in the report on quality measurement and how it relates to health information technology.

I distinctly remember the first time I heard the title, “National Coordinator for Health Information Technology”.  It was 2004.  That’s, of course, the year that RAND released its important national report card highlighting the overall mediocre state of health care quality.  You know the one that told us “it’s a flip of a coin.”  I was an RWJF Health Policy Fellow working on the Hill with then Majority Leader Bill Frist’s health policy staff.  There was a flurry of staff activity regarding the president’s pending executive order pushing adoption of the electronic health record and creating a new federal health information technology, dare I say, czar. . . . But what to call this new position?  To be honest, when I initially heard folks say the words, “national coordinator for health information technology,” my first thought was, “Well, that’s a mouthful.”  My second was “It sort of sounds like a character from that TV show, ‘The Love Boat’”.  But I kept those smart remarks to myself and quite quickly got on board—and, to be honest, never looked back. 

At RWJF in 2005, several of us worked with then National Coordinator, Dr. David Brailer, on a partnership effort between the Office of the National Coordinator and RWJF.  With this project we extended a grant to Dr. David Blumenthal, then in Boston, to create a series of national reports that would track the national adoption of the electronic health record over several years as the nation progressed toward wider and wider adoption.  This week we’re issuing our third report in that series. 

Of course, the news is sobering.  This third report highlights yet again that overall adoption of the electronic record is stubbornly, almost shockingly, low in virtually all clinical settings.  This current report also highlights that without focused attention, adoption of electronic health records might make disparities even worse.  Terrific. 

Last but not least, "meaningful use" for patients and consumers

This is the third and final post in a three-part series on the implementation of the health information technology (HIT) provisions in the stimulus package, which called for "meaningful use" of HIT for those who give and get care.  This series was written by David K. Ahern, Judith M. Phalen, and D. Matthew Brothers.

In Part I of this series, we argued that the definition of ‘meaningful use’ should go beyond the matrix of outcomes, goals, and objectives developed by the federal government’s HIT Policy Committee to address the specific behaviors needed by healthcare’s agents (e.g., providers, consumers/patients, payers) to achieve the stated goals.  In Part II, we discussed the ABCs of behavior change –antecedents, behaviors, consequences – that must be in place in order to move providers toward a 21st century healthcare system.  Here, we will examine the role of the ABCs for patients and consumers (words we will use interchangeably here) in making the meaningful use of HIT a reality.

Part II: Putting meaningful use into action for providers

This is the second in a three-part series of posts on the implementation of the health information technology (HIT) provisions in the stimulus package, which called for "meaningful use" of HIT for those who give and get care.  This series was written for us by a team of people at the Health Information Technology Resource Center (HITRC) at Brigham and Women's Hospital in Boston, which provides technical assistance to RWJF’s Aligning Forces for Quality program.  David K. Ahern, PhD is the Director, Judith M. Phalen, MPH is the Associate Director, and D. Matthew Brothers, BA is the Program Associate.

In Part I of this series, we argued that the definition of ‘meaningful use’ should go beyond the matrix of outcomes, goals, and objectives developed by the federal government’s HIT Policy Committee.  We believe it should also determine what those who get, give, and pay for care – healthcare’s agents – need to do in order successfully achieve better health outcomes for all.  In this post we examine these questions:  What behaviors must be adopted by healthcare providers (and how can we reinforce them?) so that they will move lock-step towards an evidence-based, effective, and efficient healthcare system? And, what interferes with the good intentions of those who are trying to do the right thing?

If you're going to pay for performance, measure what matters

(Today's post comes from Francois DeBrantes, CEO of Bridges to Excellence, who also heads up the PROMETHEUS payment demonstration currently being supported by RWJF.)

The “pay-for-performance” movement has become a powerful force in healthcare reform. In P4P compensation models, providers are rewarded for meeting specific quality and efficiency measures. But how do you know those measures are the right ones?

At Bridges to Excellence, we support P4P as a necessary shift away from traditional fee-for-service payment. We believe, if done right, it’s an effective way to drive quality up and costs down. However, a recent study we conducted suggests that P4P programs don’t always measure the processes that matter most.

We analyzed the clinical and financial value of 62 commonly used, generally approved quality measures for ambulatory care. They covered conditions like coronary artery disease, heart failure, diabetes mellitus, osteoarthritis, asthma, and more. The measures were selected by an expert panel, and most were endorsed by organizations like the National Quality Forum, the Ambulatory Care Quality Alliance, or the National Committee for Quality Assurance.

Yet, for all that expert backing, we found that fewer than one-third of these measures had a truly significant clinical and financial impact. Many had some clinical value, but only a handful combined a real financial benefit as well. True, these results may simply reflect the growing pains of a relatively young movement. But if P4P programs don’t get the measures right, we may only be replacing one highly inefficient compensation system with another.

The State of Meaningful Use

By Mike Painter

Is it possible that the State Department is technologically bolder than the HIT Policy Committee?  On Tuesday, that committee convened by the Office of the National Coordinator as required by the American Recovery and Reinvestment Act released some initial recommendations on the definition of "meaningful use" of health information technology.  Then yesterday, the New York Times in an above-the-front-page-fold article reported that the State Department recognized an internet blogging service could change history—right now.  Compare that report about the State Department to the HIT Policy Committee’s recommended vision for the role of patients and families.  The committee envisions that someone would eventually “provide access for all patients” to populated personal health records and some self-management tools by 2015—about six years from now.  It’s not that this vision is bad; it’s just so underwhelming.  Let’s see—the State Department thinks that the Iranian people might be using Twitter today to regain control of their nation—and in our multi-billion dollar ultimate vision for the patient’s role with health information technology we’re still talking about “providing” a couple of interesting tools to patients by 2015.  Is it me, or are we possibly missing a powerful health reform player here—the consumer?

So, as you can see, I listened to this meeting on “meaningful use” and came away with some distinctly mixed impressions.