January 2014 was a notable milestone for the federal health IT incentive program, known as “meaningful use.” On January 1, “eligible professionals” who had completed at least two years in the program became eligible to move into Stage 2 of the program. In addition, all participants, regardless of stage, must use “2014 edition” certified EHR technology. January also ushered in a new National Coordinator for Health IT, Karen DeSalvo, MD, replacing Farzad Mostashari, MD, who completed his distinguished work at the Office of the National Coordinator (ONC).
On one hand, the program has had very significant positive outcomes, with EHR adoption continuing to climb, along with Stage 1 meaningful use achievement and associated incentive payments, which had reached over 19$B by December 2013. The 2014/Stage 2 capabilities and requirements will enable much more robust standards-based interoperability plus greatly enhanced patient access to their clinical information, among other benefits,
On the other hand, we are starting to see “meaningful use fatigue,” with concerns among providers and vendors about challenging Stage 2 timelines, the many complex Stage 2 requirements, a “perfect storm” of overlapping regulatory requirements (e.g., meaningful use, value-based payment, quality measures, ACOs, ICD-10, etc.) amplified by accelerating private sector changes.
A recent RAND Corporation study sponsored by the American Medical Association suggests that many physicians have concerns about their EHRs and meaningful use. This study, and industry conversations, suggest that EHRs risk being increasingly seen as a compliance mandate, especially by newer adopters, and not an opportunity to apply the benefits (and fun) of technology to enhance care delivery. Indeed, many concerns with usability seem driven by the need for EHRs to support extensive regulatory requirements, including multiple meaningful use measures compounded by workflows needed just to enable these systems to automatically measure meaningful use.
Finally, despite repeated warnings from vendors, the timeline for Stage 2 implementation, relative to availability of certification and meaningful use regulations and critically, all associated requirements and specifications, was very tight, resulting in fewer and later product certifications than in Stage 1. This situation has raised provider and vendor concerns with the need to complete large numbers of implementations in a compressed time period to allow for 2014 meaningful use attestations.
As policymakers look to design Stage 3 and beyond, with a proposed rule expected later this year, it is timely and essential to learn from Stages 1 and 2, including provider (and vendor) desires for increased focus on usability. John Halamka, MD recently blogged that we should shift fundamentally our approach to certification, focusing Stage 3+ on building on the substantial base of progress in Stages 1 and 2 rather than adding major new requirements for providers and vendors to be implemented close on the heels of major certification-driven upgrades. Dr. Halamka argues that we should “declare victory” for meaningful use. I agree with his overall conclusions and approach.
With accelerated implementation of new payment and delivery models, it is essential to recognize that, although EHRs are necessary infrastructure to support these new models, they are not the only major health IT needed, even for care management given the importance of solutions focused on specialty workflows. Accountable, value-based, and integrated care will require new and emerging health IT in such areas as financial management, population health management, analytics, and patient engagement; it is simply not clear, in many situations, which tools are needed for specific use cases, what functionality is most important, and when to deploy people and when to apply technology. The way that we will learn about what works and what will be used is the familiar but powerful combination of vendors designing to meet problems their customers articulate, the market determining which solutions should move forward and be further refined, and government and academic research and thought leadership providing support for this work.
What we do not need, in an area so dependent on innovation and market tests, is to prematurely standardize and define functionality through detailed certification. We also must avoid having centrally mandated requirements further crowd out vendor and provider resources and bandwidth devoted to meeting the needs that our customers and their patients actually identify.
See Part 2 for a suggested way forward.
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