Talking “meaningful use” with our CIO.

The American Recovery and Reinvestment Act of 2009 (ARRA) is an $850 billion stimulus package passed by Congress aimed at encouraging economic growth in various industries through government spending. If you’re in healthcare, then you may be able to take advantage of $51 billion that has been allocated to the healthcare industry, $19 billion of which is aimed at the adoption and implementation of Electronic Health Records (EHRs), also known as Electronic Medical Records (EMRs). The only way to get your share of the money is to demonstrate that you are a “meaningful user” of an EHR system. The problem is figuring out what a “meaningful user” is.

My curiosity about being a “meaningful user” led me to the office of our CIO, where I casually asked him if we were going to qualify for any of the funds allocated by the ARRA. He informed me that “meaningful user” had not been completely defined, and is currently a hot topic of discussion.

So, what is a “meaningful user”?
Good question. To qualify as a “meaningful user” you must use a “certified EHR” in a “meaningful manner”. Although no official criteria have been developed, the Healthcare Information and Management Systems Society (HIMSS) has published proposed criteria for “meaningful use” and has gone as far as to recommend that the Certification Commission for Healthcare Information Technology (CCHIT) be the certifying body for EHRs. CCHIT is a private, non-profit organization formed to certify EHRs against a minimum set of requirements for functionality, interoperability and security. Most believe that the CCHIT will have the final say in the certification process, but nothing has been made official.

How will I know if I qualify?
Ah, another good question. HIMMS Analytics, a subsidiary of HIMSS, specializes in collecting and analyzing healthcare IT date. They have developed the EMR Adoption Model (EMRAM) to track EMR progress at hospitals and healhcare systems. The EMRAM utilizes an 8 stage process to represent a hospital’s advancement toward a paperless patient record environment. The 8 stages are listed below (a graphical representation can be viewed here).

Stage 0: Some clinical automation may be present, but all three of the major ancillary department systems for laboratory, pharmacy and radiology are not implemented.

Stage 1: All three of the major ancillary clinical systems are installed:  laboratory, pharmacy and radiology.

Stage 2:  Has all three major ancillary clinical systems that feed a clinical data repository, the database that gathers results from the ancillary systems.  The CDR provides clinician access for retrieving and reviewing results, a controlled medical vocabulary and the foundation for a clinical decision support system.

Stage 3:  This stage must have clinical/nursing documentation that includes vital signs and flow sheets.

Stage 4:  Computerized Practitioner Order Entry is active for use by any clinician.

Stage 5: The hospital has implemented closed loop medication administration, the hallmark of medication safety processes.  The “5 rights” are being followed:  right patient, right medication, right dose, right time, and right route.  Bar coding is in place on the patient, medication and caregiver. The electronic medication administration record (eMAR), the pharmacy system, and CPOE work together to create the closed loop medication administration process.

Stage 6:  Physicians are using online documentation and charting with structured templates.  Clinical decision support and a full complement of radiology picture archiving and communication system modalities are operational.

Stage 7:  The hospital has a paperless EMR environment.  It also has data warehousing and data mining capability to analyze and improve clinical protocols and the capability to send standard summary data to health information exchanges, physician offices and other patient care facilities, and patients’ personal health records.

The difficulty I see will be in defining cutoff points for facilities over the next few years and whether or not the initial inclusion criteria will include CPOE and bedside-barcode scanning (stages 4 and 5). The results of the ASHP national survey on informatics published in the American Journal of Health-System Pharmacy in December of 2008 indicated that only 12% of hospitals were using CPOE and only 24.1% of hospitals were using barcode medication administration at the time of the survey. Based on this information, I suspect that first round funding will begin with hospitals in Stages 2 or 3. Requiring facilities to be as high as stage 4 or 5 would simply deny too many healthcare facilities access to funds that could be used to further their technology. In my opinion funding would ideally be available for hospitals as low as stage 1, as these facilities include those that would benefit the most. Including these facilities would go a long way in advancing patient safety as well. Hopefully the final criteria will be one that will encourage healthcare facilities to pursue technology without excluding those facilities that have not had the opportunity to “catch up”.

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