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ONCHIT Releases Preliminary Definition of Meaningful Use

December 30, 2009 News 52 Comments

The federal government announced regulations this evening that define “meaningful use” of EHRs and the CMS incentive program associated with it, barely meeting the December 31 required date for issuing an initial set of standards.

The rules will go into effect 30 days after publication following a public comment period. The meaningful use rule is here (warning: PDF).

The incentive rule (all 556 pages of it) is here (warning: PDF). It contains specifics about percentages of orders, payment schedules, specific numerators and denominators for measures, etc. I gave it a quick skim and got most of the information about use measures, but if someone wants to summarize the payment portion early Thursday, I will post it (since I’ll be at work).

These specifications apply to Stage 1, which take effect in 2011. They fall into four categories of standards: vocabulary, content exchange, transport, and privacy and security.

Stage 2 requirements start in 2013 and Stage 3 requirements in 2015. Those will be defined later by HHS.

This is a summary of the most important information.

CPOE
Practices: Use CPOE for orders involving medications, laboratory, radiology, and referrals.
Hospitals: medications, laboratory, radiology, blood bank, PT, OT, RT, rehab, dialysis, consults, and discharge and transfer.
Orders do not have to be sent electronically to the fulfilling department (lab, pharmacy, etc.)
Practices must enter 80% of their total orders directly by the clinician into the CPOE system. Hospitals must have 10% of all orders entered by CPOE.

Clinical Checking of Orders
Real-time screening (drug-drug interactions and drug-allergy contraindications), formulary check, user ability to maintain screening rules, track user responses to alerts.

Problem List
Longitudinal current and active diagnoses coded in ICD-9-CM or SNOMED CT.
80% of unique patients must have at least one coded problem/diagnosis, with “none” being an allowed entry (hospitals and practices).

E-Prescribing
Practices only.
Must send 75% of non-controlled substance prescriptions electronically.

Active Medication List
80% of unique patients must have at least one coded entry, with “none” being an allowed entry (hospitals and practices).

Medication Allergy List
Longitudinal with allergy history.
80% of unique patients must have at least one coded entry, with “none” being an allowed entry (hospitals and practices).

Demographics
Practices: preferred language, insurance type, gender, race, ethnicity, and data of birth.
Hospitals: all of the above plus date and cause of death if applicable.
80% of patients must have demographics recorded as structured data

Vital Signs
Height, weight, BP, BMI, growth charts for patients 2-20 years old, temperature, pulse.
80% of patients aged 2 and over must have blood pressure and BMI entered.
Children 2-20 must have a growth chart.

Smoking Status
Record if current smoker, former smoker, or never smoked.
Must be recorded for 80% of patients.

Structured lab results
Display results, translate LOINC codes, allow maintenance based on new results.
Must record as structured EHR data 50% of all results that are delivered in positive/negative or numeric format.

Patient Lists
Allow user to select, sort, retrieve, and output patient lists based on demographics, medications, and conditions.

Report Quality Measures to CMS and States
Calculate, display, and submit quality measure results

Patient Reminders
Practices only: issue based on patient preferences, demographics, conditions, and medication list.

Five Clinical Decision Support Rules
Beyond drug screening, based on demographics: diagnoses, lab results, or medication list. Real-time alerts and suggestions based on evidence. Track response to alerts.

Eligibility
Allow user to record and display based on eligibility response from insurer.
Must cover 80% of unique patients.

Submit Claims
Must submit 80% of all claims filed electronically.

Electronic Copy of Health Information to Patients
Allow user to create an electronic copy of test results, problem list, medication list, medication allergy list, immunizations, and procedures. Hospitals must also provide a discharge summary but not procedures.
Must provide an electronic copy of health information to requesting patients within 48 hours.

Electronic Copy of Discharge Instructions
Hospitals only.
Must provide electronically to 80% of discharged patients who request them.

Timely Patient Access to Health Information
Practices only: diagnostic results, problem list, medication list, medication allergy list, immunizations, and procedures. Within 96 hours of availability.
Must provide to 10% of unique patients.

Clinical Summary of Each Office Visit
Practices only: diagnostic results, medication list, procedures, problem list, immunizations.
Must provide for 80% of office visits.

Information Exchange
Enable electronic sending and receiving of diagnostic test results, problem list, medication list, medication allergy list, immunizations, and procedures. Hospital requirements also include a discharge summary.
Must conduct at least one test of exchanging information.

Medication Reconciliation
Compare and merge two or more medication lists into a single list that can be displayed in real time.
Must be performed in 80% of encounters and care transitions.

Submit Data to Immunization Registries
Must conduct at least one test of submitting information.

Submit Lab Results to Public Health Agencies
Hospitals only.
Must conduct at least one test of submitting information.

Submit Syndrome Surveillance Data to Public Health Agencies
Must conduct at least one test of submitting information.

Protect Electronic Patient Information
Unique identifier, emergency access for authorized users, session timeout, encryption where preferred, encryption when exchanging information, maintain audit logs, provide integrity check for recipient of electronically transmitted information, verify user identities and access privileges, record PHI disclosures.
Must conduct a security risk analysis and implement security updates.

Transport Standards
SOAP and REST
HL7 CDA R2 Level 2 CCD or ASTM CCR
ICD-9-CM or SNOMED CT for problem lists
ICD-9-CM or CPT-4 for procedures, moving to ICD-10-PCS or CPT-4 for Stage 2
RXNorm for medication lists
UNII for Stage 2 allergy lists (no standard now)
CDA template for Stage 2 vital signs (no standard now)
UCUM for Stage 2 units of measure (no standard now)
LOINC for lab results
NCPDP Formulary & Benefits Standard 1.0 for drug formulary checks
NCPDP SCRIPT 8.1 or 10.6 for prescription information
ASC X12N and NCPDP for transactions
CMS PQRI 2008 Registry XML for quality measures
HL7 2.5.1 for submitting lab results to public health agencies, with UCUM and SNOMED CT encouraged
HL7 2.3.1 or 2.5.1 for submitted surveillance information to public health agencies and for immunization information
Encryption only if organization sets it as a standard

Median Estimated One-Time Costs for CCHIT-Certified EHRS to Be Certified as Complete EHRs
CCHIT Ambulatory 2008: $1 million
CCHIT 2007/2008 Inpatient: $1.38 million

Median Estimated One-Time Costs for Pre-2008 or Uncertified EHRS to Be Certified as Complete EHRs
Practice EHR: $2.4 million
Hospital EHR: $3.3 million

Estimated Median Industry Costs for EHR Preparation
2010: $61.35 million
2011: $54.53 million
2012: $20.45 million

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Currently there are "52 comments" on this Article:

  1. It’s pretty clear a technocracy has emerged and has taken over a large part of the executive branch of government, previously known as HHS. From what is presented by a magical gloved hand from a hidden place is another burden yoked to the shoulders of the American Taxpayer. This time by Blumenthal and his cohorts who collude behind closed doors to create another episode in the history of the legitimization of electronic health records that are not safety tested and which meet “minimal standards” according to the Tommy Thompson edict of minimal standards.

    What does minimal mean? It means nothing. It means no standard, none, nada, zip or zippo. It means Not Ordinal, Not Nominal, Not Interval, and Not Rational. I am asking you to think about this again, what does minimal mean, Gentlemen? This is what CCHIT is certifying, the Tommy Thompson edict of minimal standards which means no regulation and no benchmark for safety of any kind.

    Clinical Decision Support is an advanced application for EHRs. The EHR industry hasn’t even gotten the basics concerning safety right and already there is force feeding of advanced applications piggybacked to products that are unsafe, buggy, not interoperable, expensive, clumsy, disorienting, and dependent upon hardware and technological quicksand.

    Its interesting, the ACC cardiology camp has filed suit against Sebelius for Medicare cuts that will impact patient care, and today 13 Attorney Generals have also filed suit regarding health reform’s imposed insurance requirement. The AG’s, like the original 13 colonies, have said “NO”. The writer agrees with the right to say no and refusals to accept that which is being pushed upon them couched in the words of reform. Noting that there is money for half-baked electronic garbage products complete with licensing agreements that strip away basic constitutional rights to safety and freedom from predator behavior, but there is no or little money for patients. Taking liberties with this scenario may suggest some are waiting for the sick to have heart attacks and then rob them during the episode.

    The AG’s and ACC are right to file suit, let this be a call to others and let this be a beginning to establishing solid ground for safe reform, that is humane, equitable, efficient, patient centered, effective and timely.

  2. Everybody should have been well-prepared for this regulatory announcement. It is consistent with all of the public meetings and recommendations from the HIT Policy Committee. There really is nothing new here. Last summer’s recommendations are simply being written in very specific regulatory language, which, unfortunately, is necessary. There is now an opportunity for public comment before the regulations become final. Overall, this process has been open and transparent.

    The HIT Policy Committee appears to be acting like a Board of Directors for healthcare IT policy, with Blumenthal as Chair of the Board.

    David Blumenthal is doing an excellent job!

  3. Why would health care professionals be willing to deploy complex user unfriendly time consuming devices that disrupt medical care and cause new errors which put patients at risk while being paid less for their work?

    The Blue dog makes good points.

    These $ billions should be deployed for human resources and direct patient care.

    My best advice: do not purchase or accept to be gifted this equipment.

  4. My best advice: do not purchase or accept to be gifted this equipment.

    Suzie, you should put your money where your mouth is and refuse to use the computer system at whatever hospital you work at. That includes whatever computer you’re using to post on this blog.

  5. “The HIT Policy Committee appears to be acting like a Board of Directors for healthcare IT policy, with Blumenthal as Chairman of the Board.”

    That is all we need is another “nonprofit”, with someone like H. Stephen Lieber or Mark Leavitt at the helm! God help us…

    Don’t forget it was HIMSS BOD that allowed Mark Leavitt’s compensation through HIMSS for the past four years as a “loan”, while he was pretending to be a full-time CCHIT employee and running a “legitimate” certification organization in the state of Illinois.

    Let me repeat, PRETENDING to run a “legitimate” certification organization in Crook County, Illinois, which we all know, was defunct at the time they took govt money.

    Before you pat Blumenthal on the back, remember that Blumenthal is a keynote speaker at HIMSS10. “Lead and prosper”.

  6. Where in the NPRM does it say anything about tracking user responses to drug-drug alerts?

    [From Mr. HIStalk] It does not say recording individual user alerts received or responded to, only to report the number of alerts that were responded do (the wording is a bit vague on whether that’s at the user level, but I’m thinking it’s not).

    Where does it talk about tracking allergy history?

    [From Mr. HIStalk] It doesn’t really say allergy history, but refers to longitudinal care on Page 53: “Enable a user to electronically record, modify, and retrieve a patient’s active medication allergy list as well as medication allergy history for longitudinal care (i.e., over multiple office visits).”

    Where does it specify the values for smoking status?

    [From Mr. HIStalk] The values themselves are not specified, only that the status (current smoker, former smoker, never smoked) must be recorded.

  7. Agree with progrmmer. The best strategy is to put these in all hospitals and if there are defects as has been reported. there will be noticeable complications. Just do it and let’s see what happens. Tests of these systems are not necessary. Just minimal CCHIT certification and the Board of ONC will assure safety.

  8. “ONCHIT Releases Preliminary Definition of Meaningful Use”

    Seems that not all are drinking the Kool Aid being served by ONCHITincluding me.

    How does digital health information captured get transmitted seamlessly between different systems ? There is no common transaciton set defined to do this. Isn’t access to a patient’s health record the holy grail of better healthcare decision making?

    What we are being served is a partial building plan (with parts 2 and 3 to be givin later) and not the complete system spec. This is similar to building a structure given only a foundation spec, without specs for the 1st and subsequent floors.

    Without the entire system design spec known up front, these systems are due to fail in operation as well as cost containment.

  9. In February 2008, the FDA announced that the Bush Administration’s FY 2009 budget request for the agency was just under $2.4 billion: $1.77 billion in budget authority (federal funding) and $628 million in user fees. In June 2008, Congress gave the FDA an emergency appropriation of $150 million for FY 2008 and another $150 million for FY 2009.
    http://en.wikipedia.org/wiki/Food_and_Drug_Administration_%28United_States%29

    Under ARRA, HHS has appropriated $19 billion to implement EHRs. This does not make sense: more money is being spent to implement faulty EHRs under HHS than to regulate them under the FDA!

    If the FDA (a govt agency of HHS) does not have the authority or resources to regulate EHRs as medical devices, that means a full 1200 hours of testing per EHR, then the Attorney Generals of the states should have the courts remand the vendors to their respective states for testing and regulation at the states level, before their products are deployed.

    They should be treated and regulated as any medical device, drug or patient care product that has the potential to endanger life.

    We want reform at the state level and we want safe products, with safety that endures.

  10. They should be treated and regulated as any medical device, drug or patient care product that has the potential to endanger life.

    When a hospital changes it’s procedures for processing patient data on paper does the FDA have to approve the new procedures?

  11. No, the FDA does not approve the new procedures at a hospital.

    The HCO (healthcare organization) complies with state’s level requirements and sets up steering committees that draft policy which guides change and drives it right down to the level SOP (standard operating procedure), which means change is standardized.

    I believe HIMSS and CCHIT will receive more grant funding from the ARRA than the FDA has received to regulate medical devices.

    HIStalk should interview Tommy Thompson about the fine mess he created. He has a lot of esplainin’ to do.

  12. No, the FDA does not approve the new procedures at a hospital.

    Then your demands that the FDA approve EHRs are a pretty obvious double standard.

  13. By all the current estimates Medicare will be insolvent in 2017. Does anyone get the creepy feeling that we’ll spend tremendous amounts of time, effort and money trying to meet MU only to have the incentives disappear into the black hole? Especially if “health care reform” passes? It will not be the first time Congress does not fund a mandate.

  14. Programmer, you seem clueless as to what the govt is responsible for regulating. Why don’t you go to the FDA website and read for yourself what the FDA is supposed to regulate: MEDICAL DEVICES, and how they are funded.

    I prefer that the FDA be given the funding and responsibility to actually do their job. However, the FDA is a govt agency within HHS, and HHS is more concenred with pushing through and funding this mandate that began with the Bush administration, than to fund the FDA to regulate medical devices.

    Former HHS Secretary Tommy Thompson made this all possible with “minimal” regulation, then the pop-up CCHIT was created and awarded a $7.5 million to implement this. And who sits on the CCHIT BOD and CCHIT Commissioners? HIMSS staff and HIMSS’ EHRVA Corporate Members, who are also “volunteers” within several work groups at CCHIT.

    If funding is NOT given to the FDA, responsibility should be given to the States to regulate medical devices, because Patient Safety should be a TOP concern, not enriching the pockets of the vendors, who are also benefiting with increased stock prices.

    Giving more money to to CCHIT’s corrupt “nonprofit” to “certify” products without an actual lab, which was funded and founded by HIMSS and their EHRVA organization, is throwing tax payer money down the drain. Enough is enough.

    Hospital procedures fall under state requirements. Medical devices fall under the FDA.

    “Business as usual” is not an option, while patients die from faulty EHR products that doctors cannot report because of gag clauses in the vendor contracts. I am curious, what is your solution regarding regulating medical devices? As a programmer you know there are problems with these medical devices.

    Blumenthal is an MD and should be more responsible and address the issue of gag clauses which affect Patient Safety. Fortunately, Senator Grassley is investigating, and this provides the necessary checks and balances needed in govt.

  15. Programmer, you seem clueless as to what the govt is responsible for regulating. Why don’t you go to the FDA website and read for yourself what the FDA is supposed to regulate: MEDICAL DEVICES, and how they are funded.

    You can rant that EHRs are “MEDICAL DEVICES” until your face turns purple. That does not make it so.

  16. As a programmer you know there are problems with these medical devices.

    There are not nearly the kind of problems that you seem to think there are. Most problems are very minor. Problems that could affect patient safety, even if only remotely, are fixed very quickly. Your claims about patients dying from faulty EHR are complete fabrications.

  17. Is it my imagination, or did CMS and ONCHIT just kick the can down the road on defining who will “certify” EMRs and whether eligible providers and health systems can self-certify home-grown systems (or off the sheld systems which the vendor is not stepping up to certify)?

  18. “Isn’t access to a patient’s health record the holy grail of better healthcare decision making?
    What we are being served is a partial building plan (with parts 2 and 3 to be givin later) and not the complete system spec. This is similar to building a structure given only a foundation spec, without specs for the 1st and subsequent floors.
    Without the entire system design spec known up front, these systems are due to fail in operation as well as cost containment.”

    But in this case the foundation is being built on the regulations of how the 1st and subsequent floors will be built.

    The CCD/CCR regulations are building the foundation so that systems have the ability to import/export standardized information.

    You can’t just start building a skyscraper without digging the hole and use the infrastructure that has been developed. You can’t just immediately make EHRs talk to each other without having standardized information that they can all share in the same way. Plus, this is software we’re talking about, and you have to give people times to program it.

  19. ACC and AGs are suing for ‘patient safety?’ You need to wake up and wise up. ACC is suing primary for ‘$$$’ because the utilization of cardiac imaging and some other ancillary services has gone through the roof the past 3 years with some clear over utilization. The AGs who are suing are largely Republicans and it is largely a political move/stunt to earn bonus points.

  20. Various people here have made arguments for/against regulation of HIT by government directly.

    Your arguments pro/con are probably moot. The writing is on the wall.

    EU: see “The Medical Products Agency’s Working Group on Medical Information Systems: Project summary” at http://www.lakemedelsverket.se/upload/foretag/medicinteknik/en/Medical-Information-Systems-Report_2009-06-18.pdf

    Canada Drug & Health Products Agency: “Notice – Classification of Medical Devices Class I or Class II patient management software” at http://www.hc-sc.gc.ca/dhp-mps/md-im/activit/announce-annonce/md_notice_software_im_avis_logicels-eng.php

    U.S. (John Glaser): “Electronic Health Record Systems Will Require ‘Some Form of Oversight,’ Government Advisor Says” at http://www.genomeweb.com/dxpgx/electronic-health-record-systems-will-require-some-form-oversight-government-adv

    Finally, I think Blumenthal’s got it right in calling for the leaders of health IT to have formal credentials in both medicine and IT as enabling the best chances for national HIT to widely diffuse and succeed in its stated goals of improving healthcare safety, efficiency and quality:

    “Funding Opportunity Announcement: Program of Assistance for University-Based Training – Targeted Information Technology Professionals in Healthcare Roles” at http://healthit.hhs.gov/portal/server.pt?open=512&objID=1428&mode=2 , and http://hcrenewal.blogspot.com/2009/12/onc-defines-taxonomy-of-health-it.html

    The dual introductions of 1) formal testing/regulation for HIT virtual clinical devices (as in pharmaceuticals and physical medical devices), and 2) a better educated and qualified force of HIT leaders may give the US a chance to succeed in this ambitious project.

    Finally, for the new year I leave you with this thought:

    HIT projects are not computer projects that involve clinicians, they are medical projects that involve computers.

  21. “Practices must enter 80% of their total orders directly by the clinician into the CPOE system. Hospitals must have 10% of all orders entered by CPOE.”

    Are hospitals getting a break from being forced to use this technology because its dangers are becoming evident?

    The clinical practices will experience lower efficiency and more errors from these poorly designed devices.

    An order as simple as coumadin 5 mg. alternating with 2.5 mg qod will be distorted by the device, rendering danger to the patient.

    There is not any economic or safety benefit from these devices.

    The rules and definitions of meaningful use and meaningfully inferior.

  22. ludites, get thee your buggy whips, horse collars…paper based lab results, prescription pads, t-sheets, pitch forks and torches, go march on the HHS office in Washington..the sky is falling..the world is ending and EHR’s will be the death of health care as we know it.

    It is not as if this technology hasn’t actually been around for at least a decade or more by now..talk to physicians who use the technology at successful hospitals at Stage 6 HIMSS adoption they will tell you when the right solution is deployed correctly the technology works, improves efficiency, quality, the safety of patients and actually helps them in making clinical decisions.

  23. RE: Noah Praetor

    No, hospitals are not getting a break but that it is just easier to implement and use a CPOE product in an outpatient setting like a physician practice. Less physicians and no inpatient setting make it less complex. What on earth are these dangers people are talking about? Are there EHR vendors out there who have problems with their code that if a physician puts in 5 mg, it sends a message to a pharmacist for 2.5 mg & not the other important data that a pharmacist uses to make sure this is the accurate dosage (i.e. Height, Weight, lab results, etc)?

  24. PezMan does not understand the problem. He should speak with Programmer for insight. Both should learn of the code error for combination medications that affected hundreds of patients whose doctors used electronic prescribing. It took months to discover that the patients were given medications that only contained one component of the combination. The company covered it up. It required months to fix.

  25. PezMan does not understand the problem. He should speak with Programmer for insight. Both should learn of the code error for combination medications that affected hundreds of patients whose doctors used electronic prescribing. It took months to discover that the patients were given medications that only contained one component of the combination. The company covered it up. It required months to fix.

    I have no idea what you are talking about.

  26. Both should learn of the code error for combination medications that affected hundreds of patients whose doctors used electronic prescribing. It took months to discover that the patients were given medications that only contained one component of the combination. The company covered it up. It required months to fix

    By the way, this sounds like a fabrication. A problem that is common enough that it would affect hundreds of patients should so easy to recreate that it would be fixed very quickly.

  27. Re: David Brailford
    It is not as if this technology hasn’t actually been around for at least a decade or more by now..talk to physicians who use the technology at successful hospitals at Stage 6 HIMSS adoption they will tell you when the right solution is deployed correctly the technology works, improves efficiency, quality, the safety of patients and actually helps them in making clinical decisions.

    Of course, the question still remains whether the stimulus money encourages deployment and adoption of “the right solution” which does in fact provide those benefits or if it encourages deployment of the wrong solutions.

  28. Like Vista, don’t jump into any current EHRs or EMRs or eRx systems. Wait!

    Patient safety problems are being found right and left.

    Down the road (next 3 to 5 years) EHR/EMR and eRx vendors will start closing down for the following reasons…

    1. Market consolidation as the strong survive and weak wither;
    2. Public dollars dry up.

    What’s going to happen to the data that’s stored in the old systems that cease to exist?

    Who’s going to pay for the data being moved from an old system that no longer exists, to one that does?

    Who’s going to pay for all of the migration costs associated with deploying new EHRs/EMRs and eRx’ing systems?

  29. Does it make sense to spend $100k or more (and change untold business processes) to recoup $44k in ‘incentive’ dollars? Even doctors (and I’m one of them) can recognize that is a bad business decision.

  30. John Lynn (see above) can you point me to literature that supports your following statement?

    “…improves efficiency, quality, the safety of patients and actually helps them in making clinical decisions…”

  31. @HIT Consultant.
    That quote was actually from David Brailford. I just quoted him. In fact, my commented asserted that many EHR don’t support those results. I believe a few of them do based on first hand experience. My comment questioned whether the EHR stimulus money encouraged implementation of the many EHR that don’t achieve those goals or the few that do.

  32. John Lynn: Thank you for the clarification. Sorry for the confusion.

    David Brailford: can you point me to literature that supports your following statement?

    “…improves efficiency, quality, the safety of patients and actually helps them in making clinical decisions…”

  33. Does anyone know if the Countries with Universal Healthcare have a viable EHR? Why do I ask such a lame question? If an EHR is so great and reduces costs and improves patient safety, then well…they should have one especially if it is a single payer system. But then again, Government waste is universal.

  34. A newly created federal agency is likely on its way for regulating EHRs, perhaps even other HIT products.

    FDA and CMS are likely candidates as the assigned agency but each has its own problems that make them not well suited for regulating this area.

    FDA: problems include the Class I, II, III designation. EHRs can easily slip into a Class I which translates to minimal oversight. Or it could slip into a 510(k) stubstantial equivalence under Class III which also translates to minimal oversight. Plus, the FDA has other problems.

    CMS: EHRs cover more than just Medicare, Medicaid, and State Children’s Health Insurance Program (SCHIP) patients. Congress would need to pass legislation to provide CMS the authority to regulate EHR systems for all patients. Seems like it would water down CMS focus on what they are meant to focus on, i.e. federal health care programs.

  35. I wonder if the new Federal Agency names will be:

    FEHRA or FHITA (Fear-ah or Fight-ah)?

    You can figure out what the obvious acronyms.

    🙂

  36. Where did you get these figures:

    Median Estimated One-Time Costs for CCHIT-Certified EHRS to Be Certified as Complete EHRs
    CCHIT Ambulatory 2008: $1 million
    CCHIT 2007/2008 Inpatient: $1.38 million

    Median Estimated One-Time Costs for Pre-2008 or Uncertified EHRS to Be Certified as Complete EHRs
    Practice EHR: $2.4 million
    Hospital EHR: $3.3 million

    [From Mr. HIStalk] They are on Pages 102 and 104 of the standards document that I linked to.

  37. 75% of all Rxs written in Michigan are from physicians who work in practices of 4 or less physicians.

    What are the cost implications for these small practices (i.e., 4 or fewer doctors) when the median one-time cost for practice/ambulatory EHRs is $2.4M/$1M?

    Do these one-time costs including implementation, changed business processes, etc.? What about ongoing costs? Hardware, tech support, etc?

    A $44k ‘incentive’ sounds insane juxtaposed to these numbers…

    [From Mr. HIStalk] Those costs you mentioned were for vendors to have their EMRs certified to meet the proposed standards. The incentive document (the bigger one) estimated per-provider costs of $54,000 upfront and $10,000 per year.

  38. Mr. HIStalk. Thanks for the clarification of what should have been obvious. I guess the costs we’re incurring just ‘feel’ like $1M (and in some cases for small practices are really costing that much!). My fingers raced ahead of my brain…

    Regardless, my point stands…that is…

    Spend $54k upfront + $10k per year + changes in business and clinical processes + questionable effcacy of HIT implementation + increased patient safety concerns + increased medical legal concerns + what happens when/if your vendor folds and so on = $44k incentive?????

    [Mr. HIStalk] I tend to agree. Doctors aren’t always astute businesspeople, but it doesn’t really take a full-blown NPV calculation to see the potentially poor ROI. Not to mention that it’s trusting Uncle Sam to be an excellent payor and not to move the carrot, which some doctors have historically found to not be the case. But for docs who were tempted to go with an EMR for non-financial reasons, the incentive could sway them to the “buy” side of the fence. Or, to encourage them to buy cheap EMRs to improve the value proposition since the payment is the same.

  39. HIT Consultant Says:
    David Brailford: can you point me to literature that supports your following statement?

    “…improves efficiency, quality, the safety of patients and actually helps them in making clinical decisions…”

    My point was there are good technology solutions out in the marketplace that have been deployed successfully (the right solution) and correctly which enable organizations to achieve those benefits. Per John Lynn’s comment the legislation doesn’t ensure organizations select the right solution however. Ultimately as with any major aquisition organizations need to go through their due diligence prior to making a decision and the buyer should definately beware.

    There are 70+ hospitals across the country which have acheived Stage 6 EMR adoption under the HIMSS Model..For validation of those benefits these Stage 6 hospitals are a great starting point. I have personal experience of a family member being treated at one of those sites. During the course of treatment it was clearly evident the EHR in use enabled more efficiency in the access to clinical information on my relative, better quality of care through medication verification and reconciliation impacting the safety of my family member during their treatemtn and helped the nurses and physicians make clinical decisions.

    As for literature, suggest you visit the HIMSS Davies Award Website and review the very detailed submissions provided by Hospitals who have applied for the award. The winners were vetted out through a very rigorous process. Also suggest reviewing a little book titled To Err Is Human Building A Safer Health System published by the Institute of Medicine in 1999, Patient Safety: Achieving a New Standard for Care
    Released: November 20, 2003 by the Institute of Medicine and also
    Key Capabilities of an Electronic Health Record System
    Released: July 31, 2003 by the Institute, Crossing the Quality Chasm released in 2001….there is a significant amount of literature..just have to look for it.

  40. I agree with you that are some ‘case studies’ of success, and that deployment is critical. In fact, we need to better define the ‘efficacious elements’ of HIT success. A sufficiently good product is necessary, but not sufficient, for success. Deployment/implmentation is, as you say, “’critical.”

    My point is that there is no literature supporting our current policy of broad deployment of HIT. Your reply supports that assertion. In fact, the available literature (e.g., recent Amer J of Medicine article) in the peer-reviewed literature does not support a national policy of aggressive, broad HIT deployment.

    As hard as it for many to accept (especially when the vendors are being showered with money), we simply do not have the knowledge to broadly and successfully deploy safe, efficacious and cost-effective HIT. And we don’t have the IT infrastructure (e.g., skilled workers) to support it.

    So when people sound like they’re making blanket statements about how the use of HIT leads to cost-efficiency and improved outcomes, I cringe. There are simply no facts to support that kind of claim. But I agree that there are case studies, and that implementation is key.

    As you have done, I can also share examples of personal HIT experiences. In my case, it is with our organization’s poor choice of a SureScripts ‘approved’ eRx product that creates ambiguous Rxs so bad that 2 of 2 pharmacists, and 9 of 12 physicians misinterpreted the dose to the patient.

    Finally, remember that the FDA appropriately does not approve drugs for market because there are case studies of success. Case studies should not drive a broad national policy. We’ve put the cart before the horse.

  41. Addendum…

    The current data indicate that broad implementation of HIT does NOT support cost effiency or improved outcomes. There will be some successes but, in general, successes are the exceptions, not the rule. The rule is that money is wasted, processes are bogged down, patients are subjected to growing and unknown risks.

  42. HIT Consultant,
    I’m sure they didn’t have studies and proof that the highway system would be as beneficial as it was to the US before they built it. It was far from perfect when it was built too. However, can you imagine this country without that type of project?

    I actually agree with you that I think these incentives probably aren’t encouraging the right types of EMR and the right type of EMR use. Plus, it does so little to help the small doctors offices which make up a huge part of the healthcare in America today. However, I think there’s little doubt (study or not) that there’s enormous potential benefit from having doctors using an EMR. I think many of the benefits can’t even be seen until we have them implemented.

    Currently though that’s best done by doctors doing their own due diligence and implementing them effectively instead of government stimulus.

  43. John,

    Thank you for your thoughtful reply.

    A few comments…

    The highway system is based on a lot of science. Do you know how much engineering expertise goes into road building? For example, is engineering not based in a lot of physics (i.e., science)?

    Besides, we need to separate the vision and goal from the reality and implementation. We’d agree that world peace is a great idea, but we’re not throwing huge amounts of money at it to immediately get it. The problem is implementation, not the vision or goal. We need to keep these concepts separate. With world peace we know that the goal, if attainable at all (see Obama’s Nobel acceptance speech), will be done incrementally, on many fronts over time.

    The highway system is not nearly as complex as HIT. This is comparing apples and celery.

    HIT is a medical device and should be treated like any other medical device or drug. In medicine, we have a tradition of demanding proof of efficacy and safety before widespread use. People’s lives are in the balance. Remember snake oil?

    Using your analogy with the highway system is like saying we should allow new fangled financial tools like collateralized debt obligations (CDOs) because they ‘obviously’ work so well. Oops. That didn’t work out too well.

    You said, “However, I think there’s little doubt (study or not) that there’s enormous potential benefit from having doctors using an EMR.”

    Huh? What planet are on you on? What you describe is not the reality of most people struggling to implement HIT. We are suffering from cost overruns, patient safety problems, medical-legal problems, vendors ‘overselling,’ disrupted care processes, etc.

    Our ‘guts’ were wrong about CDO’s. Our ‘gut’s’ are wrong about HIT. It’s not ready for prime time. We need a lot more research and more mature infrastructure before proceed with aggressive national implementation.

    That said, as a physician, I aggressive deploy HIT. For example, I’ve done all Rxs on the computer since 1999. But it’s been done over 20 years, incrementally…and I have a long way to go.

    I used to think that Blumenthal was simply drinking the Kool-Aid. But now I’m beginning to think that he’s the one serving it.

  44. “Huh? What planet are on you on? What you describe is not the reality of most people struggling to implement HIT. We are suffering from cost overruns, patient safety problems, medical-legal problems, vendors ‘overselling,’ disrupted care processes, etc.”

    I’ve certainly heard the stories you’re talking about. The challenge for me is to compare those certainly legitimate and often quoted stories of failure with my first hand experiences where the doctors offices can’t live without their EMR. They’re charting faster. They’re more accurate. They data’s highly available. They’re seeing more patients (after the initial slow down). They’re all VERY happy with their investment in EMR. Now they’re starting to look at the possibilities of what they can do with an EMR that they couldn’t have dreamed of before.

    I should also clarify that I’m talking mostly about ambulatory EMR. Hospital EMRs are a different world.

    While I don’t drink the Kool-Aid that Blumenthal hands out, I also think it’s a shame when EMR is thrown out just because other people failed. When done right an EMR can have tremendous benefits. When done wrong, it can have tremendous consequences.

  45. [Mr. HIStalk] said… I tend to agree. Doctors aren’t always astute businesspeople, but it doesn’t really take a full-blown NPV calculation to see the potentially poor ROI. Not to mention that it’s trusting Uncle Sam to be an excellent payor and not to move the carrot, which some doctors have historically found to not be the case. But for docs who were tempted to go with an EMR for non-financial reasons, the incentive could sway them to the “buy” side of the fence. Or, to encourage them to buy cheap EMRs to improve the value proposition since the payment is the same.

    Reply: My concern is that the HIT has shot itself in the foot by overselling. We’re losing an opportunity. People won’t trust HIT vendors or the gov’t. We building cost overruns, silos, and system that in few years will have unforeseen costs when the weak vendors fail, the strong vendors survive, and someone will have to pay new initial start up costs, migration costs, retraining costs, cost of establishing new business processes with a new EHR, etc.

  46. John Lynn, Agreed. HIT is not all bad, and sometimes it’s even good. But it’s way oversold, and often very bad. We need to be more realistic. More honest about the risks/benefits. We also need to better understand issues of efficacy and safety, especially when we’re using public dollars.

  47. Did you just say “honesty” and “realistic”? Now we’ve found the real problem. There are still both of those things out there. Too bad it’s just in such short supply.

  48. Bankruptcy, mergers, acquisitions, etc are all going to be very common in the near future. They’ve already happened many times (see Misys and Allscripts). 300+ EMR vendors is far too many so it needs to consolidate. I wrote about this back in February: http://www.emrandhipaa.com/emr-and-hipaa/2009/02/06/emr-and-ehr-industry-ready-to-contract/

    I definitely think it’s important that as part of a doctor’s evaluation process that they understand the financial viability of their EMR vendor. This is even more true if you’re talking about a SaaS EHR vendor as I wrote about in this post about SaaS EHR vendors going belly up: http://www.emrandhipaa.com/emr-and-hipaa/2009/02/13/when-a-saas-ehr-software-goes-belly-up/ (no more links so Mr. HIStalk doesn’t ban me)

    I don’t think waiting to implement an EMR is the right answer since there will always be consolidations in the software industry. However, I think understanding the stability, strategic direction, etc of your software vendor is important when selecting an EMR company.







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