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.