CMIO musings: Is meaningful use still meaningful?

As we begin a new year, reflecting on the past will be important to move forward in a truly meaningful way — not just in name.

Meaningful use, as it is called, is one of those programs we should reflect on.

The program began in 2009 with the enactment of the American Reinvestment and Recovery Act and its accompanying Health Information Technology for Economic and Clinical Health Act — laws that drastically changed the way hospitals use IT. Specifically, the HITECH Act authorized nearly $36 billion in incentive payments for the use of health IT, leading providers to scramble to implement new technologies and opening the floodgates for EHR and IT vendors to develop them.

Healthcare providers could see monetary gains by demonstrating "meaningful" use of their IT by submitting select data to CMS. Those who didn't or couldn't demonstrate meaningful use faced penalties. CMS split the meaningful use program into three stages.

Although reporting requirements vary slightly for providers in outpatient and inpatient settings, Stage 1 emphasized adoption, as well as data capture and sharing, and covered a period from 2011 to 2013. Stage 2 targeted advanced clinical processes such as interoperability and health information exchange, and ran from 2014 to 2016. In Stage 3, the program focuses on optimizing outcomes with the EHR, and requires meeting eight criteria with a certified EHR technology (CEHRT), including:

  • security assessments of vulnerabilities to protected health information;
  • electronic prescriptions;
  • clinical decision support;
  • certain requirements of Computerized Physician Order Entry;
  • patients' electronic access to their data;
  • care coordination via patient engagement;
  • interoperability through HIE; and
  • submission of public health and clinical data to select registries.

Stage 3 is optional for 2017 but mandatory for 2018.

The program later changed its name so that by now, it's called "advancing care information" and is part of the Medicare Merit-based Incentive Payment System. It's important to note that MIPS only applies to office-based physicians or other clinicians reimbursed by Medicare, so ACI attestation is only required for those physicians participating in MIPS. Since its implementation, a number of rules have been modified. For example, physicians used to earn payments under meaningful use, but that portion was phased out. Now physicians who submit meaningful use data incorporate it to comprise 15 to 25 percent of their MIPS score.

In its early days, healthcare providers rushed to sign up for the incentives.  By January 2011, the year incentive payments began, 118,819 eligible providers and 2,320 eligible hospitals received approximately $5.4 billion in payments — or $18,600 and $1.37 million per participating provider and hospital, respectively.

As the years went on, incentive payments and participating providers increased. In fact, in just that first year the total number of EPs receiving payments climbed from 79,642 to 268,461 between 2011 and 2012 — an increase of just over 337 percent. However, in 2013 — the final year providers could attest for Stage 1 — participation slowed, as did the payments.

In 2015, when stage 2 started, EHR vendors struggled to grapple with the changes, in part fueled by a delayed release of ICD-10. CMS adjusted its attestation period from 365 days down to 90 (as an alternative option), but despite the restructuring, participation and payments continued to diminish. The number of EPs receiving payments in 2014 dropped roughly 70 percent, compared to the hospitals receiving payments, which saw a 15 percent dip.

In October 2015, CMS modified Stage 2 to ease reporting requirements and align them with other quality reporting programs. The final rule also set Stage 3 in 2017 and honed in on using advanced use of CEHRT to support clinical effectiveness, health information exchange and quality improvement. Stage 3 is intended to align the timelines and requirements for clinical quality measure reporting in the Medicare and Medicaid EHR Incentive Programs with other CMS quality reporting programs that use CEHRT in an effort to reduce provider burden associated with reporting on multiple CMS programs and enhance CMS operational efficiency.

Meaningful use was initially viewed as a potential positive step forward.  However, meaningful use requirements have become checkboxes and hospitals expend significant resources into meeting the requirements that may or may not improve patient outcomes.

While policymakers' original intent for meaningful use was for the program to accelerate EHR adoption and optimization — goals that have, for the most part, been met by nearly 99 percent of U.S. hospitals using EHRs — meaningful use has been disjointed since Stage 1. It may have fostered fewer errors and advanced prescription drug monitoring, but meaningful use requirements have increased the time and effort physicians and nurses put into their medical charting — hence the term "EMR care" instead of patient care.. Healthcare providers are left asking, "Is there a connection between meaningful use and the delivery of high-quality care, or is this just another checklist?"

Now, nearly nine years after its implementation, hospitals are looking for what's next. Here are my recommendations for the direction meaningful use should take.

Reward patients for their engagement. Getting patients interested and engaged with their care can be a challenge. What if the meaningful use program encouraged insurance companies to incentivize patients to log onto their portals? That way, patients would potentially stay educated about their care. In a portable society like ours, patients should be taking their data with them anyway. At the end of the day, not only could incentivizing patient signup foster higher engagement, it could relieve physicians of some stress.

Incentivize the vendors as well as the hospitals. Hospitals have to take on the burden of developing their own application programming interfaces so patient portals can communicate with their customized EHR.  However, if vendors would prioritize interoperability of their products for the society at large, more acceptable products — including portals — could be created. When individual hospitals are incentivized, a mix of challenges ensues relating to ease of use and data sharing — and customized solutions with the least dollars spent as everyone will try to meet the minimum requirements possible. This pathway is setting us up for more IT headaches.

Instead, the government could incentivize cooperation among vendors in addition to hospitals in order to make these collaborations feasible from a business standpoint as well as increasing convenience for all consumers — primarily patients.

Take, for example, Apple's latest announcement. The technology company is rolling out a health records feature tucked in its Health app as part of the latest iOS update. Apple is collaborating with EHR vendors like Epic and Cerner, but also major hospitals, including Geisinger, Penn Medicine and Cedars-Sinai. The feature will allow patients to input their EHR data and share it with physicians wherever they go.

Although the meaningful use program set out to improve patient care and health through technology, it has become somewhat of a burden on providers and doesn't necessarily coordinate with clinical care. The program has become just another checklist providers must fill out in order to avoid financial penalties. Meaningful use needs to truly incentivize meaningful use — not just in name.

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