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This diary is part three of a series; you can find the first two here and here.

As anyone reading this probably knows, the most popular way for House republicans to pay for...well...anything these days is to try to use unspent stimulus money. Eventually, this might lead one to ask why, more than two years after the stimulus was passed, there's still a pile of money sitting around unspent? Well, remember that the stimulus was actually called the American Recovery and Reinvestment Act; while the Recovery bit gets most of the attention (and of course, infrastructure spending aka Reinvestment is one of the most effective ways to stimulate the economy), some of the spending was more long-term. What I'm going to talk about in this diary is the HITECH, or Health Information Technology for Economic and Clinical Health, Act - part of the stimulus bill that sets aside money to provide incentives for meaningful use of health care information technology. These incentive programs are expected to cost the federal government approximately $14.6 billion between 4014 and 2019, while providing significant cost savings due to the increased efficiency and better care that EHRs allow doctors to provide.

It may not get a lot of play in the papers, but right now the words "meaningful use" are extremely important to any hospital administrator who deals with Medicare and Medicaid patients. The act provides for financial incentives (in the form of increased Medicare/Medicaid payments) for health care provides who make meaningful use of EHR (electronic health record) technology; in a few years, this will change to penalties (decreased reimbursement) for anyone who doesn't make meaningful use. As you can imagine, interest in EHRs is now at an all-time high (I know my employer hasn't been able to hire enough people for the last few years, and I suspect that's partially responsible for me having a job!), with hospitals and clinics now having federal money to help cover the initial costs of installing an EHR (which can be significant). Incentives for professionals are up to $44k over five years for Medicare and up to $63,750 over six years for Medicaid; incentive payments for hospitals start at $2 million.

The meaningful use requirements phase in gradually (and in fact are still being written). The goal is to have all medical provides use EHR technology to improve the quality of care, both at the individual level and in the population as a whole, while maintaining patient privacy and security (the HITECH Act also updates HIPAA protections). Organizations must show that they are using a certified EHR in a meaningful manner, for electronic exchange of information, and to submit clinical quality measures (these measures are what's still being developed).

The stage one requirements, which became available in 2010, relate to data capture and sharing; at this point the goal is to be using the technology. In the first year, organizations only have to report on a 90 day period (after that, the full year will be reported on); organizations must attest to each measure with either a yes/no or a percentage. In stage 1, professionals must meet 15 core objectives, plus 5 more objectives chosen from a menu of 10, and 6 clinical quality measures (out of 41). Hospitals must complete 14 core objectives, plus 5 more from the menu of 10, and 15 clinical quality measures. The five objectives not chosen for stage one must be completed in stage two; however, there is flexibility built into the rules so that providers aren't penalized for not meeting measures that don't apply to them.

We won't go over all of the core objectives here (although I'll probably cover them all in the book I'm writing) but here's a representative sample. Note that the percentages here are for stage one and will likely increase for stage two.

* Computerized Provider Order Entry (CPOE) - More than 30% of unique patients who have at least one medication and have been admitted to the hospital (or seen by the medical professional) have at least one medication order that was entered using CPOE.

* Maintain Active Medication List - More than 80% of all unique patients seen by the provider or admitted to the hospital must have at least one medication listed, or an indication that the patient is not currently prescribed any medications.

* Smoking Status - More than 50% of all unique patients...... age 13 or older must have their smoking status recorded.

* Electronic Copy of Health Information - More than 50% of all patients.... who request an electronic copy of their health information are provided with it within 3 business days. (There is a similar requirement for discharge instructions).

As you can see, the stage one objectives are largely concerned with making sure the patient's information in the system is accurate and up to date, that providers are placing orders directly in the system rather than writing them out, and that patients have timely access to their health information.

The government has been collecting comments on the proposed rule for stage two (the comment period closed on May 7). In addition, the stage one rule is being revised based on provider feedback. Some of the parts of the proposed stage two rule are controversial; for example, as written the stage two rule would require that at least ten percent of patients have contacted the provider using EHR technology. While some doctors feel it's unfair for them to be penalized for the behavior of their patients, the government feels that absent the rule, providers may not be pushing patients to send electronic messages (however, they have indicated a willingness to lower the percentage, perhaps to 5%). Another controversial requirement is that a certain percentage of patient records being transferred between facilities go between different EHRs; in many parts of the country, this isn't practical because most facilities in an area may be using the same EHR software (so this requirement may be dropped in the final rule).

I wanted to briefly mention the security requirements as well. The problem...well, one of many problems...with paper charts is that there's no way to tell who's been looking at them. Auditing capabilities built in to EMR software mean that if a provider accesses information that he or she has no legitimate reason for viewing, it can be detected immediately. (Generally, we don't want to prohibit access, since any information might be needed in an emergency, but we can notify a compliance officer anytime someone accesses data for a patient that he or she isn't responsible for). Increased penalties for noncompliance give hospitals and clinics a large incentive to carefully monitor access to protected health information.


I haven't decided what my next diary will be about, but I'm open to requests. Due to feedback on my previous diaries (and my desire to not get overly long or technical in these diaries) I'm also working on a short book about the subject, which I hope to publish on the Kindle next month; I'm open to suggestions there as well.

Originally posted to wmspringer on Thu May 17, 2012 at 01:47 PM PDT.

Also republished by Community Spotlight.

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Comment Preferences

  •  Price and quality of care transparency (2+ / 0-)
    Recommended by:
    Chi, LI Mike

    should be the subject of your next diary. Providers hate both.

  •  I'd vote for continuum of care (4+ / 0-)
    Recommended by:
    wmspringer, LI Mike, DBunn, Dallasdoc

    and how EHR improve this greatly, especially for Medicare and Medicaid patients (where this is a huge problem).

    Words can sometimes, in moments of grace, attain the quality of deeds. --Elie Wiesel

    by a gilas girl on Thu May 17, 2012 at 03:21:07 PM PDT

  •  Appreciate your diary (8+ / 0-)

    As a former hosp admin I am familiar with EHR and the issues associated with implementation and use.

    About this:

    I wanted to briefly mention the security requirements as well. The problem...well, one of many problems...with paper charts is that there's no way to tell who's been looking at them.

    My slightly different angle is that many legitimate eyes may need the medical record

    Utilization Management
    Quality Assurance
    Patient Accounts
    Social Services

    Especially in a large hospital, such as where I worked, it is not unusual as any given time for a chart to have simultaneous claims on its info. With a paper chart, a rigorous control system is needed to be able to track down and re-route a chart. With an EHR, those with legitimate needs can access what they want when necessary.

    Example: Some third party payer is doing a billing audit to determine if the medical claim matches to the chart documentation (You billed for Hypertension, the patient actually had diabetes, e.g.), call comes in to the surgery clinic that the patient came in for a follow up visit and the chart is needed. Chart is then re-routed form the auditors to the clinic.

    This is labor intensive stuff. Be nice that with the click of a few buttons the info is available rather than impatiently hoping that the chart shows up after you've called for its retrieval.

  •  Security: (1+ / 0-)
    Recommended by:

    My medical records are on a thumb drive that I carry in my hiking vest or pants pocket. It is password protected. Of course, I could be unconscious when it is needed, so I wrote the password on the outside. This is the one case where I figure privacy definitely takes a back seat to safety.

    That, in its essence, is fascism--ownership of government by an individual, by a group, or by any other controlling private power. -- Franklin D. Roosevelt --

    by enhydra lutris on Thu May 17, 2012 at 09:19:29 PM PDT

  •  one of the problems with meaningful use (3+ / 0-)
    Recommended by:
    emobile, FishOutofWater, cynndara

    is that the things the feds look at pertain way more to adults than peds patients. That's true for this, for PQRI and for a variety of things meant to incentivize docs.

    When your primary population is children, there's little incentive to use this kind of system. I use it, but ugh, only because I have to.

    "Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly and applying the wrong remedies." - Groucho Marx

    by Greg Dworkin on Thu May 17, 2012 at 09:44:00 PM PDT

    •  Proscriptive meaningful use requirements (1+ / 0-)
      Recommended by:

      will get in the way of technological improvements and will cause problems for certain specialties such as yours.

      Electronic records have many advantages over paper records (see hops. admin's comment above) but bureaucratic requirements may turn EHR into a millstone for docs like you.

      I managed the (ObGyn) office net and made sure the EMR and billing systems were functioning properly for over 5 years, so I am pretty familiar with the issues. I am becoming concerned about the direction "meaningful use" requirements are taking.

      look for my eSci diary series Thursday evening.

      by FishOutofWater on Fri May 18, 2012 at 06:00:00 AM PDT

      [ Parent ]

  •  Nice refresher (0+ / 0-)

    I work in my state's HIE and I definitely can appreciate gettign the big picture, as this diary helps do.

    "And once again, the forces of niceness and goodness have triumphed over the forces of evil and rottenness." --Maxwell Smart

    by emobile on Thu May 17, 2012 at 10:45:47 PM PDT

  •  i just discovered this series (5+ / 0-)

    and wish I had seen them earlier.  i am a nurse who, in his former life, was a software engineer, and these EMRs are a huge pain in the ass to me, they are absolutely terrible to use!  i am working on my own medical software, and as some one who has to use these unfortunate products every day, hopefully i can improve upon them.

    application fragmentation is, unfortunately, a big deal for me, when, in my day-to-day business of just documenting patient care I have to access, at a minimum, 4 applications, with their own login information, user interfaces and metaphors, and all expertly designed to be of limited use to clinical staff.  I cannot even access one application to get the full overview of a patient - EMRs don't show you orders, medications, multi-disciplenary progress notes, lab and radiology studies, OR and procedure information, etc.  Many EMRs will have some off this information, but none that I encountered will tell me all that I need to know.

    Add in to the fact that frequently patient's are poor historians, and their medical history is often documented across organizations, and the whole thing is a mess.  Lets not even bring up downtime and having to revert back to paper-based systems.

    Lastly, EMR technology and design techniques are so far behind current software engineering design and techniques that it is perplexing.  The EMR I am using right now runs on Windows XP in IE6 - talk about old.

    Enough ranting though, I do applaud the governments leadership on this issue.  This just goes to show that frequently, corporations are far more inefficient than the government, people just hate to think that!

    •  Integration is huge (0+ / 0-)

      When you have providers who buy different parts of the system from different vendors, or vendors who acquire different parts of their suite from different places (say, build an inpatient EMR, acquire a company that makes radiology software, etc) you end up with exactly the scenario you mentioned - you might have all the information you need, but you can't access it all from one place and you don't have a consistent UI across the organization.

      I believe I talked about this briefly in one of my previous diaries, where a nurse switched from one of our applications to another (inpatient to pediatrics, I believe) without noticing she'd done so, because the entire suite is designed from the ground up so that you don't even need to realize you're moving between different pieces of the software - everything works the same way, and all the information that you might need should be available.

    •  nathanfl, It has been my experience that the (1+ / 0-)
      Recommended by:

      programers that use IE anything to get something done are either inept or lazy or both.

      Kludge together a bunch of APIs and you have an app.
      I am not a programmer but I did have to support a consulting firm of a hundred or so coders, auditors and Clinical Document Improvement people all over the US.

      We had a Windows, Dell only shop and I could never understand why we ported all of our web apps to IE.

      It is so much easier to write apps to the browser standards than try to tweek the software to work with IE.

      Between the coding softwares (plural), the various OSs
      (ME to Vista), IE 5 through 7 various MS Office versions, and educational packages and updates we sent out, day to day was let us say a challenge.

      /rant off


      This just goes to show that frequently, corporations are far more inefficient than the government, people just hate to think that!

      "People who see a contradiction between science and the bible don't really understand either." PvtJarHead

      by Tinfoil Hat on Fri May 18, 2012 at 08:58:24 AM PDT

      [ Parent ]

    •  As a physician having used a (2+ / 0-)
      Recommended by:
      wmspringer, nathanfl

      community-wide EMR for 5 years and would hate to go back to paper, I would really love to see much improved programming going in to the design.  Too many clicks, too many pop up boxes that get in the way, too little ability to see several windows at once.  I wish gamer programmers could get involved.  They understand the slick user experience.  Currently we are not even user friendly.  Actually our product is fairly user annoying.  


      The real beauty is the connectedness.  I  get all the hospital reports (H & P's, op notes, lab, imaging reports and the images, etc) and all the local lab data feeding into our record.  Each physician on the system (many) contributes to the patient's chart and can see what all the other physicians have entered.  Plus we providers can contact each other directly thru "flags" to coordinate care.  

      We never have to look for charts, wait for reports to get faxed over, call to get physician records sent, or even wait for other personnel to get done with their bit before we can start.  

      I was wise enough to never grow up while fooling most people into believing I had. - Margaret Mead

      by fayea on Fri May 18, 2012 at 02:55:44 PM PDT

      [ Parent ]

  •  Significant obstacles (2+ / 0-)
    Recommended by:
    FishOutofWater, Tinfoil Hat

    I would like to you to expand more on the significant obstacles to full utilization across the spectrum of the healthcare delivery system (cost not withstanding)...also the proliferation of standalone departmental systems ("islands of information" issues), the trauma of implementation and training, the importance of the ergonomics of the user interface in accepatibility, ease of use, and compliance.

  •  Where I work (0+ / 0-)

    I'm not saying where but we give checks :)

    When we request all the records on a claimant the doctor either sends them in to be scanned or submits them electronically.

    They appear in the claimants electronic file which I can even refer to doctors in other states that work for our agency to be asessed if our consultants get backed up.

    Back in the day I remember reports getting lost, medical piled up on my desk waiting to be filed in claims.

    It's sad but given the way medical records are, I probably actually get a better picture of the persons problems than the doctor who doesn't have acces to all the sources.

    One time my dad had a test and the doctor sent him to the hospital. When he got there they had to run all the tests over again and keep him overnight because they couldn't get a hold of the doctor who did the test nor a copy of it.

    I thought how wasteful our current system of non centralized records are.

  •  In theory it sounds good (2+ / 0-)
    Recommended by:
    david78209, cynndara

    But having had experience dealing with medical records because of a family member with serious chronic illness, I am appalled at the level of errors charted into paper records. I don't see how electronic records are going to do anything more than make a bad problem worse.


    After every visit, admission, contact, etc., we request the records as frequently they contain factual errors.  We then go through the time-consuming rigamarole of getting the errors corrected. With kludgey paper records the errors are usually pretty well contained at the source.  With EMR the speed in which errors can be propagated scares me.

    I realize that in theory errors could also be corrected at electronic speeds but will that actually happen?

    Most people would be completely shocked at the inaccuracies in existing medical records of their care. I know I was when I first discovered it. Now, nothing surprises me: electronic copies of cardiac imaging tests of other patients (with names attached) sent to us as my husband's; critical errors in describing whether implanted devices are, or are not, able to give off drugs in situ; wrong medications charted; inaccurate counts of the actual number of X-ray exposures need to perform tests (inept tech kept repeating and repeating and repeating); incorrect pt history details (e.g. describing life-long non-smoking, thin person as obese, ex-smoker). And that's just for starters.

    For now, we refuse in writing to allow our records to be entered in the local EMR system.


    •  Quality care initiatives built into ACA (2+ / 0-)
      Recommended by:
      divineorder, cynndara

      Not sure of its status, but there's also supposed to be a very well-funded plan to review EMR systems, patient and provider data to root out errors and improve the quality of care.  

      For instance, a well designed program could find those cases like your dad's and target them for improvement.

      But unless patient advocates (who are actual consumers, not employees of providers) are included at every level of the decision-making process,  these outcomes won't be successful.

      I haven't been staying up with consumer involvement in this process, but suspect its been largely ignored or glossed over.  But if we want to see real improvement, the role of the patient as decision-maker and whistle blower is critical.  

      "We must not confuse dissent with disloyalty." Edward R. Murrow

      by Betty Pinson on Fri May 18, 2012 at 02:34:06 PM PDT

      [ Parent ]

    •  I see it differently (0+ / 0-)

      When I lived in Colorado, my doctor's office used paper records. I never saw what was in mine. On one occasion, the nurse actually pulled the wrong record (my dad went to the same doctor and has the same name).

      Now, everybody I go to is using an EMR (the one my company makes, actually). I can generally see the screen while they're putting in information. When I went to the ER last year, I told the nurse I'd taken an aspirin and she put it in as aspirin being something I took regularly; next time I saw my doctor, that popped up on the screen (different location, same record) so I was able to point it out and have it removed.

      I can also see all of my test results on my computer (or phone).

      So, yeah, I have a lot more confidence in electronic records than paper records.

  •  "maintain active medication list" (3+ / 0-)
    Recommended by:
    FishOutofWater, david78209, cynndara

    Ha! My e-chart has every med. prescribed in the last 3 years. NO ONE updates it even though they print out a list for me to okay about once a month.

    So far, I've had three total FU's with getting prescriptions. They fill the wrong amount, they fax the wrong pharmacy, and they fail to get prior authorizations.

    My hospital has a way to access online records, but it no longer lets me use the prescription part because it is so screwed up.

    This program should have AIRTIGHT evaluations of efficacy. ha, dreaming on . . . .

    •  I've seen that as well (0+ / 0-)

      To me it seems the IT system is working ok, the problem is in quality of the data.

      It's amazing to see the health care field struggle to adapt to systems that most people and institutions have been working with for a decade or more. What took so long?

      My biggest concern continues to be patient privacy.  Even with the best intentions, there's no perfectly secure system.  Without best intentions, there's a lot of money to be made in selling this data.

      The most effective protection for patients is good prevention. That means patient privacy regulations that have steep and stiff penalties including right to private action.    Those who want to abuse private medical information (employers, creditors, insurance companies, etc.) will only be deterred if the penalties greatly exceed the profits from breaking the law.

      We don't have good patient privacy laws at this time.  While onerous for those who have to obey them, they are alarmingly lax in the area of enforcement.

      "We must not confuse dissent with disloyalty." Edward R. Murrow

      by Betty Pinson on Fri May 18, 2012 at 02:42:52 PM PDT

      [ Parent ]

      •  One of the problems (0+ / 0-)

        with privacy regulations is that they can inhibit the corrective process.  People who would know that information is inaccurate or misleading aren't allowed to look at the files.  People who are allowed to look at the files often can't tell their butts from a hole in the ground.  And usually patients are the LAST to be given access to inaccurate information, because medical providers try to cover up for each other's errors -- THEY'RE playing on the same team, don't you know.  The patient is expected to be a compliant child dutifully following the orders of people who didn't have a clue when giving them.

        The medical profession needs to wise up and realize that for the most part it isn't the military, and has no right to order competent adults around like tin soldiers.  Patients must be allowed to make the decisions, and their access to their own information must be recognized as pre-eminent, both in accuracy (the patient knows what he ate for breakfast; YOU are just guessing) and in responsibility (the patient must be fully informed in order to make responsible decisions, not "protected" from whatever facts The Professionals deem too unsettling or complex).

    •  The sad thing is that the humans that (1+ / 0-)
      Recommended by:

      use these computerized systems come to  believe that the computer is doing their work, so they don't feel as actively engaged in making it right.  It is all too easy to assume the med list in the machine is right.  One of the meaningful use requirements is to check the med list and say you did.  My office really does check and fix the med list every visit, but I realize that other offices simply say they did but don't really do it.  

      I was wise enough to never grow up while fooling most people into believing I had. - Margaret Mead

      by fayea on Fri May 18, 2012 at 03:02:56 PM PDT

      [ Parent ]

      •  Right (0+ / 0-)

        That's not a fault of the system, that's an indication that you should find a new doctor's office.

        I should also think there would be some kind of liability if you get the wrong treatment because the medication list was inaccurate after the clinic has certified that they've checked it.

        •  unfortunately I can't change docs (0+ / 0-)

          I'm in a clinical trial for an experimental drug that has kept my cancer at bay for four years!!!

          I could change my internist, except that having my doctor is in one institution, as bad as the record keeping is, is better than having separate offices. My sister's HMO, which is pretty stingy with the medical treatment is great on the computer communication.

        •  I double check and triple check my meds and orders (0+ / 0-)

          mistakes can be life-threatening for me, and I have no intention of dying from something preventable!  Its a worry and a huge challenge when one is ill, but for now I'm doing pretty well.

  •  Again, the dreaded "Q-word" (1+ / 0-)
    Recommended by:
    Organizations must show that they are using a certified EHR in a meaningful manner, for electronic exchange of information, and to submit clinical quality measures (these measures are what's still being developed).
    It rolls off the tongue so easily.
    It's easy to envision.
    It's almost impossible to measure.
    Anybody who claims to measure the quality of medical care should be considered a charlaitan until proven otherwise.
    Anyone who claims to measure it and report the result with one number should be considered a charlaitan.
    And a whore.

    We're all pretty strange one way or another; some of us just hide it better. "Normal" is a dryer setting.

    by david78209 on Fri May 18, 2012 at 12:25:42 PM PDT

  •  Always ask for a copy of your electronic health (0+ / 0-)

    records.  I was surprised at the number of significant inaccuracies in mine, when I saw it.  No apparent interest in making noted corrections, either.

    Democrats give you the Bill of Rights; Republicans sell you a bill of goods!

    by barbwires on Fri May 18, 2012 at 02:36:20 PM PDT

  •  I can interact with my doctor via email (1+ / 0-)
    Recommended by:

    I was encouraged to set up an online account with my doctor.  As I use the computer for a lot of things, I signed up.  It is wonderful.  I get lab results within hours of tests.  I can contact my Dr anytime with a question and get a reply within hours. So much for waiting by the phone for days to ask a question.  I didn't realize this was part of the stimulus program and I am fulfilling their 10% requirement.  It's win win.  Thanks for the explanation.  

    •  Lucky you. (0+ / 0-)

      Most health providers have been told that e-mail is an Insecure form of communication, and therefore its use, even at the direct request of the patient, violates HIPAA.

      •  that's not the issue (0+ / 0-)

        the issue is not wanting email to be used for emergent conditions or feel obligated to check it every day, including weekends holidays and vacations.

        I never want to get an email while I am vacation that says 'my son can't breath, call me."

        And yes, people really do write that

        "Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly and applying the wrong remedies." - Groucho Marx

        by Greg Dworkin on Fri May 18, 2012 at 05:47:09 PM PDT

        [ Parent ]

  •  my son got a nice temp job (0+ / 0-)

    as a lead tech for Dell in a local hospital because of the stimulus funds for changing over all the computers etc. for the physician offices due to these regulations.

  •  That's a good point about privacy (0+ / 0-)

    In that paper records don't tell you who was looking at them, and when they looked at them.

    Makes me feel MUCH better about the electronic records, even though I always thought they had to be better.

    Women create the entire labor force. Think about it.

    by splashy on Tue May 22, 2012 at 12:23:13 AM PDT

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