Several government-led initiatives are in the works. Currently, the Office of the National Coordinator for Health Information Technology (ONC) is funded with $2 billion to improve adoption of EMRs. There is approximately $30 billion, available over a four-year period beginning in FY2011, in increased Medicare and Medicaid payments to hospitals and physician practices that can certify that they are “meaningful users” of technology. Further, there are penalties mandated for those who do not comply after 2014.
So what does this all mean for emergency department (ED) physicians? First, we will likely see a serious push for EMRs from our hospitals and by our primary care physicians, which will impact our practice. It does not appear that emergency physicians are “eligible providers” at this time, so we won’t be able to qualify for increased payments. We will, however, play a role in defining our hospitals’ objectives, particularly where it comes to computerized physician order entry (CPOE) and quality measurements.
Currently, the “meaningful use” guidelines are organized into objectives and measures for FY2011, FY2013 and FY2015, focusing on health outcomes such as “improving quality, safety, efficiency and reducing health disparities.” In order to become eligible for reimbursement under ARRA, our hospitals will need to prove that they are “meaningful users” – or show that they meet each of the defined objectives and measurements. Recognizing that there are different opinions on whether EMR adoption will impact these outcomes, the measurements that a hospital would have to hit are very specific in order to qualify as a “meaningful user.”
For example, in 2011, 10% of all orders are to be directly entered by an “authorizing provider” (MD, DO, RN, PA or NP). If you have an emergency medicine system that allows order entry, that alone may make up 10% of all hospital orders. That said, the 2013 objectives are to have all orders entered by computerized provider order entry (CPOE). So, if your hospital is attempting to claim increased payments under the stimulus bill, they will very soon ask for your cooperation with CPOE.
Some of the “meaningful use” objectives are much more suited for an outpatient practice then they are for emergency medicine. For example, one 2011 objective is to maintain an up-to-date problem list of current and active diagnoses. Not all current emergency medicine practices update a problem list as a part of care and, by 2013, hospitals will be asked to manage chronic conditions using these lists and decision support. Additionally, if primary care physicians are maintaining this list – particularly in an EMR – and EPs are not updating or helping to manage this list, it will likely impact their practice.
Other outcomes involve maintaining active medications and allergy list, which many hospitals already do. Some of the demographics, advanced directives and even BMI information will have to be added to whatever processes we currently employ. At a patient’s request, hospitals will be asked to provide a copy of discharge instructions electronically, and also provide a copy of health information including lab results, problem list, etc.
There are also specific ARRA objectives for hospitals around quality of care and healthcare information exchange. These objectives explicitly call out the concept of medication reconciliation, as well as the capacity to exchange key pieces of clinical information between providers. In a hospital without a complete integration strategy, these items may be used to pressure EPs into using a module or portion of the EMR that is designed for either inpatient or outpatient physicians.
It is crucially important that emergency physicians are represented in their hospitals when decisions about technology are being made. A very large portion of current hospital admissions come through the ED, and we see a lot of the outpatients in any hospital system. We also place a very large number of the orders that a hospital system processes. There cannot be “meaningful use” of technology without physician use, and the tools must be well designed and enable a good work flow that truly improves the care goals; otherwise, the 2013 and 2015 quality measures will be nearly impossible to achieve.
One last comment about “meaningful use” as it relates to public health, privacy and security. There are measurements for hospitals and providers around submitting electronic data to public health agencies: the year 2011 brings requirements around immunization status; 2013 brings anonymous submission of data for syndromic surveillance. 2010 objectives also include compliance with the Health Insurance Portability and Accountability Act (HIPAA) privacy and security rules, as well as compliance with fair data sharing practices in the Nationwide Privacy and Security Framework.
There may be systems in use now in your hospitals that do not have the type of functionality necessary for a hospital to be compliant with some of these rules. It will be tempting for hospitals to move unilaterally to change out some of the systems that impact those practicing in the ED. I strongly encourage emergency physicians to get involved in the health care informatics decisions that are being made in the hospital – at the very least, in an advisory capacity.