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Jodi Sperber Quality and Performance Measurement in Health Care
March 31, 2010
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Meaningful Use: Will the end result be meaningful?
With the cost of health care in the United States continuously increasing, significant
efforts are being made to make systemic improvements that save on cost without
negatively impacting quality of care. Moreover, the true goal is to contain spending
while at the same time making improvements to quality. This endeavor has
numerous components to be considered, given the complexity of the American
health care system.
Over the past 10 years, health information technology has increasingly been viewed
as a vital factor in health reform efforts. To this end, the American Recovery and
Reinvestment Act (ARRA) of 2009, commonly known as the stimulus bill, included a
provision called the Health Information Technology for Economic and Clinical
Health (HITECH) Act. Provisions of this act involve a number of regulations and
programs aimed to support the improvement of health care systems and, ultimately,
help to increase the health of Americans (Blumenthal, 2010; Centers for Medicare
and Medicaid, 2006; Glaser, 2010; Halamka, 2010b).
Of primary interest within HITECH is the development and utilization of electronic
health records (EHRs) as a normative part of the American health care experience.
As a part of this effort, the federal government is interested in boosting the use of
Jodi Sperber Quality and Performance Measurement in Health Care
March 31, 2010
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EHRs among providers receiving payments from Medicare and Medicaid in ways
that are considered to be “meaningful.” How meaningful use gets defined is of great
significance, as new financial incentives rest upon providers and hospitals meeting
minimum standards set forth. As of this paper’s writing, no final decisions have
been issued – the initial proposed rule of meaningful use was issued in December
2009, and public comments on the proposed rule were accepted until March 15
(Department of Health & Human Services, 2009; HHS Press Office, 2009). These
comments are currently under review.
For the purposes of studying meaningful use in more detail, it is worth taking a
moment to delineate electronic medical records (EMR) and EHRs, two terms that
are often conflated. Though frequently used interchangeably they are, technically,
distinct. As defined by the recently disbanded National Alliance for Health
Information Technology (NAHIT), EMRs refer to the “electronic record of health-‐
related information on an individual that is created, gathered, managed, and
consulted by licensed clinicians and staff from a single organization who are
involved in the individual's health and care.” EHRs refer to the “aggregate electronic
record of health-‐related information on an individual that is created and gathered
cumulatively across more than one health care organization and is managed and
consulted by licensed clinicians and staff involved in the individual's health and
care” (Neal, 2008).
Jodi Sperber Quality and Performance Measurement in Health Care
March 31, 2010
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Therefore, while an EMR may be very useful for capturing and organizing
information within a single practice or for a single patient, an EHR can be utilized to
compare commonalities and difference across populations, making it a more robust
mechanism to spot trends, highlight outliers, and support evidence based treatment.
Using these definitions, an EHR can be viewed as an EMR with the capability of
integrating into multiple systems, making it a much more powerful tool for
measuring quality. Thus, the federal government is interested in incentivizing
practitioners who meet EHR standards aimed at improving quality for patients even
as they move around within the larger health care system.
Despite both private and public actions to date, and consensus that the use of health
information technology will likely lead to more efficient, safer, and higher-‐quality
care, the adoption of EHRs in the US has been slow. Lethargy in EHR adoption has
been a topic of discussion amongst researchers, health providers, consumers, and
policy makers for some time. At present, less than 20% of physicians currently use
an electronic records system. Such systems are generally found in larger care
settings including hospitals and large practices, while smaller practices rarely have
such systems in place (DesRoches, et al., 2008; Jha, et al., 2009; Jha, et al., 2006).
Within the federal government, IT modernization efforts are an integral part of the
Health Information Technology Framework. The US Department of Health and
Human Services listed health information technology as a priority for quality
Jodi Sperber Quality and Performance Measurement in Health Care
March 31, 2010
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measurement and data collection, indicating that interoperable electronic records
should be available “to patients and their doctors anytime, anywhere” (Centers for
Medicare and Medicaid, 2006).
To both ease and encourage the transition to EHRs, the proposed meaningful use
definitions and goals for EHRs are broken into three separate stages, scheduled to
be rolled out in sequence between 2011 and 2015. Each stage builds upon the
previous, with financial incentives available at each new stage. Stage 1, which
begins in 2011, focuses primarily on basic EHR capabilities, naming 25 modules for
eligible professionals (EPs) and 23 modules for eligible hospitals that must be met
to be deemed a meaningful EHR user. Stage 2 expands Stage 1 criteria in the areas
of disease management, clinical decision support, medication management, support
for patient access to their health information, transitions in care, quality
measurement and research, and bi-‐directional communication with public health
agencies. Stage 3 focuses on achieving improvements in quality, safety and
efficiency, focusing on decision support for national high priority conditions, patient
access to self management tools, access to comprehensive patient data, and
improving population health outcomes (US Department of Health and Human
Services, 2010).
Jodi Sperber Quality and Performance Measurement in Health Care
March 31, 2010
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Each module within the meaningful use definition contains a specific objective and
measurable goal that must be met for disbursement of the associated financial
incentive. Sample hospital objectives/measures include:
1. Objective: Use of computerized physician order entry (CPOE) for orders (any
type) directly entered by authorizing provider (for example, MD, DO, RN, PA,
NP)
Measure: CPOE is used for at least 10 percent of all orders
2. Objective: Implement drug-‐drug, drug-‐allergy, drug-‐ formulary checks
Measure: The eligible hospital has enabled this functionality
3. Objective: Maintain active medication list.
Measure: At least 80 percent of all unique patients admitted by the eligible
hospital have at least one entry (or an indication of “none” if the patient is
not currently prescribed any medication) recorded as structured data.
4. Objective: Record demographics.
Measure: At least 80 percent of all unique patients admitted to the eligible
hospital have demographics recorded as structured data
5. Objective: Generate lists of patients by specific conditions to use for quality
improvement, reduction of disparities, research, and outreach
Measure: Generate at least one report listing patients of the eligible hospital
with a specific condition.
Similar measures and objectives have been created for providers who do not work
within a hospital system (Beaudoin, 2009a, 2009b). On its face, each module
appears relatively straightforward. However, as evidenced by the lack of EHR
adoption within the US and the lively discussion that is taking place with the initial
definition released, it is clear that there is room for debate on the viability of the
current federal strategy.
Jodi Sperber Quality and Performance Measurement in Health Care
March 31, 2010
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One would be hard pressed to find a provider who is not interested in providing
quality (however they define the word) care. At the same time, a wide range of
studies have suggested that EHRs are an important factor of quality improvement
strategies (Chen, Garrido, Chock, Okawa, & Liang, 2009; MW Friedberg, et al., 2009;
M Friedberg, et al., 2009; Orszag, 2008). With this in mind, it is reasonable to
inquire why all health care providers have not already embraced meaningful use of
EHRs as an automatic member of the overall care approach.
Research to date, as well as comments from experts in the field, consistently
underscore that it is not the mere presence of an EHR that makes a difference, but
rather the use of the information contained as a decision support device that
improves quality (Dexheimer, Talbot, Sanders, Rosenbloom, & Aronsky, 2008; Ford,
Menachemi, Peterson, & Huerta, 2009; M Friedberg, et al., 2009; Poon, et al., 2010;
Sequist, et al., 2005). This distinction is at the heart of the challenge of universal
EHR adoption; crossing the divide between the presence of an EHR and the proactive
use of an EHR is where strategy, creativity, and technological savvy meet.
This paper does attempt to tackle the myriad facets of EHR creation and adoption; to
do so would require volumes as an entire industry is devoted to this pursuit.
Instead, focus is placed specific elements underlying the possibility of adoption and
widespread use of such tools, with an eye towards the overarching question of
Jodi Sperber Quality and Performance Measurement in Health Care
March 31, 2010
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whether or not EHRs will in fact impact the quality of health care in the United
States. These elements include design, interoperability, and patient access to data.
The three elements named are at the heart of moving from EHRs being viewed as
impediments to EHRs being seen as tools to positively impact quality of care for all
patients, regardless of geographic location or health status. Justification for slow
adoption rates are complex, involving cost, variability in EHR platforms, culture
within each practice, a lack of incentives, and a lack of resources to install, train, and
maintain such systems.
While the current meaningful use standards and incentives are limited to Medicare
and Medicaid patients, it is important to remember that providers for these patients
are situated within the larger context of the American health care system, which at
its core is based in a competitive business model. The business of EHRs is a part of
this, with a number of individual vendors vying to gain market share. This has only
increased with the possibility of financial incentives from the federal government.
For evidence of this, one needs to look no further than the most recent Healthcare
Information and Management Systems Society (HIMSS) conference that took place
in early March of this year. Per feedback from attendees, there was a surge in
attendance from EMR and EHR vendors, and everyone was talking about meaningful
use (Dillon, 2010; Halamka, 2010a).
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March 31, 2010
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At present, there is no industry standard on core elements that should be included
within an EMR, and many EHR providers are striving to set the standard (or have
enough market share that they are by default the standard). This means there is a
long list of EHR providers to choose from – a quick web search resulted in over 200
distinct vendors, each offering variations on the general idea of an EHR ("EMR and
EHR Matrix," 2010; John, 2006). For smaller offices, most of who do not have IT staff
knowledgeable about EHRs, the task can seem overwhelming to the point of being
impossible.
It is here that design and interoperability must be carefully considered, as they play
a critical role in the ability to effectively use an EHR. With each company striving to
stand out from the pack, there is a lack of uniformity within current systems. Each
has a unique user interface, meaning there is a learning curve for providers
switching from one vendor to another. Even within vendors, there is variability of
design, as each individual implementation is generally customized based on the
purchaser’s needs. Thus, if a provider has worked with a particular vendor’s system
at Hospital A, there is no guarantee that the same vendor’s EHR will look similar if
the provider takes on a new job at Hospital B. This can be frustrating, and a
deterrent for adoption of the technology.
A frequent concern voiced by physicians is that EHRs are designed to suit the needs
of administrators, rather than reflecting the flow of clinical interactions (Loomis,
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March 31, 2010
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Ries, Saywell, & Thakker, 2002; McDonald, 1997; Smith & Zastrow, 1994). As a
result, the user interface is not well suited for efficient entry from a clinical
perspective. Similar to the learning curve encountered when learning a new system,
the inability to enter data in an intuitive fashion is seen largely as a deterrent and
inefficient use of time, as opposed to being helpful for patient care.
Customization, while reasonable from an individual practice perspective, also leads
to interoperability challenges, as there is generally more focus on tailoring the
interface than forethought on core elements that should be carried through to other
practices. What is often neglected along the way is attention put towards having a
patient’s medical record live anywhere but the place in which it originates. Thus,
using the same Hospital A/Hospital B/same vendor scenario above, it is possible
that a patient can change providers and not have their record travel electronically
with them, even if both systems utilize an EHR from the same company.
Interoperability is not only of concern for providers, but patients as well. Patients
are increasingly interested in the ability to access their own medical information on
an on demand basis. Personal health records (PHRs) are patient-‐facing interfaces
designed to handle this task, and, like EHRs, come in many different forms. Ideally
PHRs are a subset of EHR data, with the capability of being augmented by the
patient and/or multiple data sources to create a more complete health picture.
Large organizations such as Kaiser Permanente have invested heavily in this type of
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tool, most recently partnering with Microsoft to transfer data between internal
systems and Microsoft’s HealthVault, and online data platform (Press Release,
2008a, 2008b). Kaiser is unique, however, in having the resources and willingness
to adopt this type of approach.
The ability of patients to access their information from EHRs as an element of
improving quality of care was a topic covered within the public comments on the
meaningful use proposed definition. Notably, Google, Microsoft, and Dossia (a
consortium of Fortune 500 companies striving to aggregate health information into
a web-‐based platform) submitted joint testimony highlighting the significance of
including PHRs in meaningful use criteria. In their joint comments, they requested
that HHS “clarify that patients have the right to direct EPs and eligible hospitals to
electronically transmit such information to a destination of their choice and…
require that at least 80% of all unique patients seen by the EP are provided timely
electronic access to their health information” (Dossia, Google, & Microsoft, 2010).
Even with the aforementioned concerns in mind, there is a strong case to be made
for the federal government’s efforts to define meaningful use and promote adoption
of EHRs via the use of financial incentives. The staged approach was established
intentionally to allow time for debate and development, and incentives are not tied
to quality improvement until the final stage. Still, without establishing core
Jodi Sperber Quality and Performance Measurement in Health Care
March 31, 2010
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principles early on, it is possible that the efforts will fail to meet the ultimate goal of
quality improvement.
One of the central principles that should be established is the creation of a core set
of data points should be determined for all EHRs, and structured such that these
data elements can be transferred between all EHRs eligible for meaningful use
certification. These data elements could include aspects such as demographics,
allergies, immunizations, and medication lists.
A second, and more controversial, consideration is to allow EHRs utilizing the use of
an open application programming interface (Open API) to qualify for certification
(only EHRs certified by the Certification Commission for Health Information
Technology (CCHIT) are eligible for financial incentives as proposed in the stimulus
package). An Open API entails a set of technologies that enable websites to interact
with one another in a more seamless fashion. This generally presumes web-‐based
applications (in contrast to software installed on a local hard drive), although that is
not required. The benefit of such systems is that it allows for a vast and vibrant
ecosystem of smaller programs to develop and work together to deliver a more
robust overall product. For example, a design specialist could work on a malleable
user interface, while an engineer can implement the back end data elements into
software. It would not be necessary that these two workers be with the same
company. Alternatively, a small company could create a solution to store and track
Jodi Sperber Quality and Performance Measurement in Health Care
March 31, 2010
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data related to a unique set of conditions, which could then be read within the
patient’s EHR.
At present this approach is highly uncommon, and there is some debate over
whether this is due simply to a lack of lobbying power (Blankenhorn, 2009; Douglas,
2009). However, with cloud computing becoming more prevalent, and with an
increasing shift towards democratizing application development (see the success of
Firefox’s add-‐ons as a challenger to Microsoft Internet Explorer for an example of
this approach) it is likely that certification will have to address the possibility of
Open API in the future.
Overall, the development of meaningful use standards is a step in the right direction.
EHRs, when utilized in a systematic and purposeful fashion, can have a tremendous
impact on quality measures. At present the possibilities are tempered by consensus
on how to best define meaningful use, a lack of core standards across all EHRs, and a
general hesitancy within the provider community. By coupling a transparent and
open process with financial incentives, however, large-‐scale change should be seen
over the next five years. Tremendous opportunity for quality improvement exists if
people can remain patient and persistent throughout the process.
Jodi Sperber Quality and Performance Measurement in Health Care
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References cited
Beaudoin, J. (2009a). Eligible Hospital "Meaningful Use" Criteria. Retrieved March 15, 2010, from HIMSS: http://is.gd/b8oQ0
Beaudoin, J. (2009b). Eligible Provider "Meaningful Use" Criteria. Retrieved March 15, 2010, from HIMSS: http://is.gd/b8p0Q
Blankenhorn, D. (2009, March 15). Open source to meet with CCHIT at HIMSS. http://is.gd/b99JZ.
Blumenthal, D. (2010). Launching HITECH. The New England journal of medicine, 362(5), 382.
Centers for Medicare and Medicaid (2006). Strategic Action Plan for 2006 - 2009: Achieving A Transformed And Modernized Health-care System For The 21st Century. Baltimore, MD: US Department of Health and Human Services.
Chen, C., Garrido, T., Chock, D., Okawa, G., & Liang, L. (2009). The Kaiser Permanente Electronic Health Record: transforming and streamlining modalities of care. Health Affairs, 28(2), 323.
Department of Health & Human Services (2009). Health Information Technology. CMS Information Related to the Economic Recovery Act of 2009. Retrieved March 13, 2010, from http://is.gd/aDZbL
DesRoches, C., Campbell, E., Rao, S., Donelan, K., Ferris, T., Jha, A., et al. (2008). Electronic health records in ambulatory care-‐-‐a national survey of physicians. The New England journal of medicine, 359(1), 50.
Dexheimer, J., Talbot, T., Sanders, D., Rosenbloom, S., & Aronsky, D. (2008). Prompting clinicians about preventive care measures: a systematic review of randomized controlled trials. Journal of the American Medical Informatics Association, 15(3), 311-‐320.
Dillon, B. (2010, March 16). HIMSS 2010 Wrap Up. http://is.gd/b920z. Dossia, Google, & Microsoft (2010). Re: CMS-‐0033-‐P; Medicare & Medicaid
Programs; Electronic Health Record Incentive Program Proposed Rule. Unpublished Public Comment. Douglas, M. (2009, March 15). US Market: Open Source EHR and CCHIT certification.
http://is.gd/b99Fh. EMR and EHR Matrix (2010). Retrieved March 20, 2010, from http://is.gd/b8DYS Ford, E., Menachemi, N., Peterson, L., & Huerta, T. (2009). Resistance is futile: but it
is slowing the pace of EHR adoption nonetheless. Journal of the American Medical Informatics Association, 16(3), 274-‐281.
Friedberg, M., Coltin, K., Safran, D., Dresser, M., Zaslavsky, A., & Schneider, E. (2009). Associations Between Structural Capabilities of Primary Care Practices and Performance on Selected Quality Measures. Annals of Internal Medicine, 151(7), 456.
Jodi Sperber Quality and Performance Measurement in Health Care
March 31, 2010
Page 14
Friedberg, M., Coltin, K., Safran, D., Dresser, M., Zaslavsky, A., & Schneider, E. (2009). Electronic Health Records are Associated with Higher Quality in Primary Care Practices.
Glaser, J. (2010). 2009: Reflections on a Transformative Year: The Federal Perspective.
Halamka, J. (2010a, March 2). Dispatch from HIMSS. http://is.gd/b91L6. Halamka, J. (2010b). The ONC Strategy: Acceleration, Standards, and Meaningful Use.
Paper presented at the Massachusetts Health Data Consortium. HHS Press Office (2009). CMS and ONC Issue Regulations Proposing a Definition of
‘Meaningful Use’ and Setting Standards for Electronic Health Record Incentive Program. Retrieved March 13, 2010: http://is.gd/aDYw9
Jha, A., DesRoches, C., Campbell, E., Donelan, K., Rao, S., Ferris, T., et al. (2009). Use of electronic health records in US hospitals. The New England journal of medicine, 360(16), 1628.
Jha, A., Ferris, T., Donelan, K., DesRoches, C., Shields, A., Rosenbaum, S., et al. (2006). How common are electronic health records in the United States? A summary of the evidence. Health Affairs, 25(6), w496.
John. (2006, March 15). Overwhelming List of EMR Companies. http://is.gd/b8FaW. Loomis, G., Ries, J., Saywell, R., & Thakker, N. (2002). If electronic medical records
are so great, why aren't family physicians using them? Journal of Family Practice, 51(7), 636-‐641.
McDonald, C. (1997). The barriers to electronic medical record systems and how to overcome them. Journal of the American Medical Informatics Association, 4(3), 213.
Neal, H. (2008, March 13). EHR vs EMR What’s the Difference? Blog posted to http://is.gd/aqt8q.
Orszag, P. (2008). Evidence on the Costs and Benefits of Health Information Technology: Congressional Budget Office.
Poon, E., Wright, A., Simon, S., Jenter, C., Kaushal, R., Volk, L., et al. (2010). Relationship Between Use of Electronic Health Record Features and Health Care Quality. Medical Care, 48(3), 000-‐000.
Press Release (2008a). Kaiser Permanente and Microsoft Empower Consumers to Take Charge of Their Health. Retrieved March 20, 2010: http://is.gd/b90mu
Press Release (2008b). News Conference Call – Microsoft HealthVault & Kaiser Permanente Pilot Program. Retrieved March 20, 2010: http://is.gd/b907k
Sequist, T., Gandhi, T., Karson, A., Fiskio, J., Bugbee, D., Sperling, M., et al. (2005). A randomized trial of electronic clinical reminders to improve quality of care for diabetes and coronary artery disease. Journal of the American Medical Informatics Association, 12(4), 431-‐437.
Smith, W., & Zastrow, R. (1994). User requirements for the computerized patient record: physician opinions.
US Department of Health and Human Services (2010). Meaningful Use Retrieved March 15, 2010, from http://is.gd/b8pqw