CMS releases final meaningful use rule
The rule explained and what you can do
They just happened to go public at about the same time the Centers for Medicare & Medicaid Services' (CMS') final rule on "meaningful use" as part of the HITECH Act and The Leapfrog Group's study results on computerized physician order entry (CPOE) systems and its subsequent call for action to monitor the safety of such systems and to develop best practices. CPOE is characterized by many as the largest and most difficult part of electronic health record (EHR) implementation, now a must for hospitals reimbursed by CMS.
First, what is in the final rule on meaningful use? Allison Viola, MBA, RHIA, is director, federal relations for the American Health Information Management Association (AHIMA). She says the HIT standards for Stage 1 originally established 23 measures for reporting. In response to comments, CMS did make some revisions in the final version.
"The final regulation published on July 13 provided some relief to hospitals in that CMS divided the HIT functionality measures into two categories, a 'core set' of objectives and 'menu set' of objectives. Under this new approach, eligible hospitals and critical access hospitals [CAHs] would be required to satisfy 1) the core set of measures, and 2) a selection of five objectives from the menu set of objectives. As a result of this modification from the proposed regulation, the required set of measures to report on has been reduced from 23 to 14 from the core set and five from the menu set, totaling 19 measures in all for the HIT functionality measures. The threshold for the measures has also been tweaked a bit to the benefit of an eligible hospital," she says.
"But make no mistake. After Stage 1, CMS plans to turn up the heat on the reporting requirements," she adds.
She suggests the following for hospitals and quality improvement directors to prepare for the incentive program, which will begin with reporting this fall for the fiscal year 2011:
- "If your hospital plans to participate in this incentive program, implementing CPOE is one of the required objectives and measures. Implementing CPOE is complex and often costly to integrate with a hospital's clinical and administrative workflow. This is an area where quality improvement professionals will play a critical role to ensure the workflow integrates successfully with CPOE and that data integrity is maintained throughout the process," she says.
- "Maintaining up-to-date problem lists have long been a source of challenges for hospitals, as there is not one specified method for capturing and maintaining the information. CMS makes it clear along with the Office of the National Coordinator's [ONC] final regulation that was released the same day... that the problem list must be recorded as structured data, and in this context ONC adopted ICD-9-CM or SNOMED-CT for this measure. CMS will not accept the use of free text in capturing problem lists; therefore, if your hospital has traditionally been using free text and you plan to participate in the incentive program, you may select one of the options. This may require the establishment of an internal multidisciplinary coordinating committee to identify and agree upon the standards of data use for problem lists."
- "Reporting hospital clinical quality measures to CMS or the states is another set of measures identified within the HIT functionality measures that requires the use of an attestation methodology for the first year of reporting as a condition of demonstrating meaningful use. This requirement has not changed from the proposed regulation."
She adds that "CMS significantly reduced the clinical quality measures by approximately 43% to only those measures that can be automatically calculated by a certified EHR technology and are further limited to those for which electronic specifications are currently available.... Stage 1 is a reporting requirement only, so hospitals only need to report values as they are calculated and displayed by certified EHR technology. Eligible hospitals and CAHs will report numerators, denominators, and exclusions, even if one or more values as calculated by their certified EHR technology is zero," she says. CMS has not added any measures not already part of the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program.
Stage 1 is entirely about data capture in the EHR, says Jane Metzger, principal researcher, emerging practices of CSC Corp. She says the rule for Stage 1 defines what it means to implement an EHR system. "[I]t says you have to be keeping an allergy list, you have to be keeping a problem list, which by the way is a physician-maintained problem list electronically."
At this point, she says, Stage 1 is the only part "we know the details of."
"And in the time frame of 2011, 2012, an awful lot of people are going to be hoping to attain Stage 1 or get as far along as they can. Because the longer it takes to reach Stage 1, the shorter a time you're going to have to work on Stages 2 and 3 because there's an end date when you're no longer eligible for incentives and you are eligible for disincentives."
It's going to be a "big stretch" for a lot of hospitals, and quality improvement professionals are going to be playing lead roles, she says. She characterizes the move to EHRs as not being an IT issue, but rather a change management one something QI people know all about.
She says the way meaningful use is defined "includes things that directly fall within the purview of quality improvement. It includes the use of clinical decision support. It includes a big focus on quality measurement and on actively using the system to help manage patients. For instance, one of the requirements is to be able to generate reports that allow you to look at patients by condition."
QI directors must be at the table working with IT and the vendor in how and what data will be captured, she says. During implementation, you must verify that every data element needed for the quality measures "is in fact being captured in a coded way so you can use it in reports," she says.
Studies have reported the low number of hospitals that actually have an EHR system. In an article published in the New England Journal of Medicine in 2009, of 63.1% of the hospitals that responded to a survey, only 1.5% had a "comprehensive" system and 7.6% had a "basic" system. Only 17% had implemented CPOE.1
Referencing the majority of hospitals that do not have an EHR system, Metzger says, "the bulk of the information [needed to meet meaningful use criteria] they do not have electronically." And she cautions that hospitals be prepared for Stages 2 and 3 in which the focus will shift from data capture to measurement and an increase in the numbers of measures.
"To get this successfully implemented in the hospital, they're going to need lots of order sets and all of that is committee process and basically quality improvement. So I think they need to be front and center," she says.
In response to the final rule, the American Hospital Association published a statement in which it expressed concern "that the requirements may be out of reach for many of America's hospitals." The association also expressed concern about CPOE implementation: "We also are concerned that the rule requires hospitals to immediately use CPOE, which can be complicated, costly to implement, and takes time to do right." (To read the entire statement, visit http://www.aha.org/aha/press-release/2010/100713-st-HIT.html.)
Reference
- Jha AK, DesRoches CM, Campbell EG. Use of Electronic Health Records in U.S. Hospitals N Engl J Med. 2009 Apr 16;360(16):1628-38. Epub 2009 Mar 25.
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