Meaningful Use: “A Kick in the Pants”

EP-turned-CMIO Steven Davidson talks frankly about the challenges of qualifying for Meaningful Use.

EP-turned-CMIO Steven Davidson talks frankly about the challenges of qualifying for Meaningful Use.

In our last installment of the Wired ED, we explained the incentives behind qualifying for meaningful use – how each hospital stood to gain up to $10 million in the coming years by demonstrating that their implementation of electronic health records (EHR) fit the government’s specifications. We looked at the core measures these hospitals would be aiming for, and the big role the emergency department played in those calculations.

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Well finally, after much anticipation and with even more fanfare, the first checks from CMS to hospitals and providers, for qualifying for meaningful use of electronic health records, have been distributed. But the giant lottery-style check props and photo-op smiles aren’t doing much to ease concerns beneath the surface.

In our last installment we only hinted at the struggles taking place behind meaningful use – the meetings, consensus-building, interface testing and personnel training. In fact, I’ve become enmeshed in my own hospital’s efforts on these fronts, both to qualify for MU while simultaneously switching our ED information system. To gain a little perspective, I decided to reach out to Dr. Steven Davidson, the new Chief Medical Information Officer (CMIO) at Maimonides Hospital in Brooklyn.

Davidson’s current job description might seem global – support and improve all of Maimonides’ information needs – but his perspective is rooted in the ED. Davidson was Maimonides’ founding chair of emergency medicine, running one of the largest EDs in the nation. Perhaps for this reason, Davidson has been commended as a CMIO for his focus on clinicians when it comes to adopting EHR. We met up at the recent AMIA conference in Washington DC this past fall, and spoke again recently.

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Every executive in health information technology these days seems to share a sense of urgency. So I asked Dr. Davidson up front if things were on track at his shop.

“We are hell-bent on qualifying for Stage One,” he said. “My concerns are around clinical leaders’ support and staff behavior, rather than implementation nuts and bolts. The real challenge for MU is pulling the data for the reports to CMS. For all these years, the goal of charting was for efficient billing and coding. But now the charts have to feed into reports, into real-time information for the clinical leadership, to adjust operations.”

Davidson is trying to take a long view of the effort. When it comes to creating a workflow for MU reports on various core measures from physician charting, he says, “Doing this safely, to best serve the patients, now must come to the forefront. This isn’t just for MU reporting, to get reward money from the government – it’s for getting the behaviors we wish to elicit from clinicians.”

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“It’s just like any high-stakes football game,” he continued. “The coaches decide strategy, but they need feedback (information from electronic tools) from the players (clinicians) to help advance and develop staff the way they need to be go.”

Davidson cites an example from fellow CMIO and ED doc, John Halamka, who recently served as National Coordinator for Health Information Technology and writes a popular health IT blog. After a chart audit, Halamka found that around 80% of his docs’ charts documented the smoking status, which is well in excess of MU stage one criteria. “But when they tried to pull the smoking data from a structured field, for reporting to CMS on MU,” says Davidson, “they found less than 40% had the content documented in the right manner. That’s a huge problem.”

Demonstrating meaningful use of electronic records isn’t easy – nor was it meant to be. Davidson explains, “The leadership in government, the regulatory agencies, wisely chose a mixture of structural and clinical process measures in this first stage to make those of us at the bedside, those of us clinically engaged, actually use the tool — not just merely install it.”

But MU has a lot of skeptics, from many sides, and with the window on Stage One incentives closing later this year, their criticisms are getting louder. Academics point out that there’s very limited evidence that these MU criteria are safe or effective (see EMR Roundtable on opposing page). Hospitals and providers are worried that the measures are too difficult, and the deadlines too soon. Vendors worry about certification and meeting the reporting demands. Everyone worries that a rushed implementation could be disastrous.

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Sociologist and EHR researcher Ross Koppel has argued that if the software was good, incentives wouldn’t be necessary – and all MU is doing is locking us in to mediocre products for the foreseeable future. Indeed, for all of CMS’ requirements for achieving core measures and vendor certification, MU has no usability requirements. It doesn’t matter if documenting smoking cessation takes two clicks of a mouse, or twenty.

“We’ve got to start somewhere,” says Davidson, though he still acknowledges that usability issues are significant. For instance, he cites medication reconciliation – the process of entering a dozen or more meds into the electronic chart – as an example. “If you get a phone call about a crashing patient, if you’ve got to get up or switch screens, the work you’ve done is for naught. And that’s terrible, and it wastes the efforts of the highest-paid member of the team, and it’s frustrating. Some of this is inevitable with the state of technology today, but it doesn’t mean we should do nothing until the problem’s fixed.”

I asked Davidson if he thought MU would work, nationally, or whether this ambitious effort to spur EHR adoption would be scrapped or scaled back.

“My experience is that the politics weigh far more heavily than the achievable, functional result. My first 25 years in this career were engaged in helping create and gain recognition for EM via clinical and educational means, and sometimes, political activities. I don’t know what’s going to happen nationally, politically. I’m going to do the best I can for my organizations and my community.”

“MU to me is a really good kick in the pants for most of us across the country. But like most things humans do, it’s imperfect. But we don’t have the luxury of waiting anymore for the perfect system. Our government and our citizenry need us to step forward. Let’s fix what we can fix, and get moving.”

Stage One

• Reporting was enabled Jan 3, 2011
• Can report on any 90 day period
• …but hospitals must have attestation to CMS by Nov 30, 2011 to receive FT2011 incentive payments
• Incentives are complex and differ for medicare/medicaid, but up to $2 million is possible for hospitals who achieve MU this year.
• By 2015, hospitals who do not demonstrate MU will see a decline in CMS reimbursements

Stage One of MU has 15 core measures for hospitals, including:

• Reporting on 15 hospital quality measures to CMS (for the first time, including ED LOS and time-to-disposition)
• Computerized physician order entry (CPOE)
• Drug and allergy interaction checking
• Record demographics, smoking status
• Enable electronic copies of discharge instructions
• Implement a “clinical decision support” rule

Stage Two:

• As proposed, stage two ups the ante on most measures (for instance, whereas CPOE was required on 30% of patients for sta
  ge one, it may rise to 80% for stage two. More decision support rules are expected as well)
• Public comment available until late February
• Final Stage Two rules to be announced in Summer 2011