Meaningful Use Stage II

Meaningful Use Stage II

My February, 2010 discussion of Meaningful Use (MU)  (found here) addressed the then proposed 25 elements by which an EMR/EHR (hereafter EMR) would be judged in order to determine if it met the funding standard for MU under the U.S. federal incentive program regulations. Note that in this regard an EMR must be capable of MU, and then MU must be actually achieved by the end user. Capability is established by vendor certification.

As is perhaps common in the sequence of proposed and revised federal regulations, that the scope of the 25 elements received a degree of adverse response that centered on the assertion that they were overly demanding, i.e. we want the money, we just don’t want to work that hard to get it. As a result the 25 required elements were reduced to two sets of requirements in what is now called Stage 1. The first set is 15 required elements while the second is a “menu” of  10 additional elements of which 5 must be chosen.

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Progress (?) on Clinical Decision Support

The AHRQ has released a report (available here) on the implementation of clinical decision support (CDS) software within the context of an EMR. This report reviews the work to date of two AHRQ demonstration grant recipients, Brigham and Women’s Hospital and Yale University School of Medicine. In each of these projects the intent was, at least in part, to implement two or more existing practice guidelines as on line and integrated component of the EMR.

In the context of these projects CDS means the provision of clinical knowledge and patient-specific information to help make decisions that enhance patient care. While this type of general statement remains somewhat vague as to what constitutes such help, the report comments further that in a CDS “the patient’s information is matched to a clinical knowledge base, and patient-specific assessments or recommendations are then communicated effectively at appropriate times during patient care”.  Therefore, as used here, CDS is more than just the effective presentation of integrated patient information, as might be done by a Medical Device Data System (as discussed here) for example. Instead it is knowledge based and the relevant knowledge is used to compare a patient to a predefined pattern in order to “suggest” or “advise” (or “tell”) the clinician what course of treatment is to be followed.

In this regard a CDS is, in older and somewhat forgotten terminology, an expert system. Introduced in the late 1990′s,the idea of an expert system was that the knowledge and expertise of one or more human experts could be captured and implemented as a computer code. Once this code was written (and perhaps verified), it would be possible to enter a new situation within the domain of the expert system, and the expert system would then provide the same result as the original expert or experts. It was further believed that some expert systems could be written that could “learn” such that it actually became more expert than the original experts whose knowledge was tapped (by a knowledge engineer) in its original creation. Of course such learning could only occur if the expert system was given controlled feedback along with having a coding scheme that was self adjusting. Neural nets was one of the popular approaches to such learning.

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The 25 Elements of “Meaningful Use”

The Recovery Act that initiated the process of providing incentive payments for the adoption and use of Electronic Health Records (EHR) included the provision that such systems support “meaningful use” if they are to be certified and funded. Of course if you have to have meaningful use, then meaningful use has to be defined, and them measured. After a round or two of proposals and comments, CMS issued an Interim Final Rule on December 30, 2009. (The idea that a Final Rule can be Interim is itself a masterwork of government speak.) The governments discussion of this process is available here. The Interim Final Rule itself (which runs over 30 pages) is entitled “Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology; Interim Final Rule” and it is available here.  A companion rule posted in the Federal Register (FR) on January 13, 2010, “Medicare and Medicaid Programs; Electronic Health Record Incentive Program; Proposed Rule” is available here.  All of this is part of the Health Information Technology project in the Department of Health and Human Services which is lead by Dr. David Blumenthal who is the National Coordinator for Health IT.

These rules defines 25 functions that together constitute meaningful use. Each of these also has a level of performance that is required for ultimate certification (as listed in the January 13th FR). For example, the first use (see below) of “Use Computer Provider Order Entry (CPOE)” has the criteria that it is used for at least 80% of all orders; but only 10% for hospitals. How an EHR is actually used by the provider is an interesting and important distinction from what the system is capable of, i.e. if the system provides for CPOE but if the users don’t use that capability to an adequate degree, then by these definitions meaningful use is not achieved. Thus what the EHR can do is a necessary but sufficient condition to establish its certifiablity.

The 25 elements and an abbreviated statement of the associated measures are:

1. Use Computer Provider Order Entry (CPOE) (80%/10% hospitals)

2. Implement drug/allergy checks (Enabled)

3. Maintain an up-to-date problem list of current and active diagnoses (80%)

4. E-prescribing (Eligible Professional (EP) only) (75%)

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