View source for Meaningful use

'''Meaningful use''' is prominently used in [[HITECH|Health Information Technology Economy and Clinical Health Act (HITECH)]] provisions of the [[ARRA|American Recovery and Reinvestment Act (ARRA)]]. <ref name="arra law">ARRA law http://www.gpo.gov/fdsys/pkg/PLAW-111publ5/html/PLAW-111publ5.htm</ref> It was further defined by the [[CMS|Center for Medicare and Medicaid Services (CMS)]] in a way that describes the use of health information technology for use among professionals.

The [[ARRA|American Recovery and Reinvestment Act]] of 2009 authorized the [[CMS|CMS]] to provide financial incentives to providers and hospitals for adopting [[Meaningful use|meaningful use]] of certified [[EMR|electronic health record (EHR)]] technology.

Under this authority the [[Office of the National Coordinator for Health Information Technology (ONC)]] has begun to setup standards, implementation specifications, and certification criteria for [[EMR|electronic medical record]] technology.  The final rules should be completed by the end of 2010.

= Guidelines =

The Office of the National Coordinator for Health Information Technology (ONC) has listed the following goals as a guide: <ref name="lyman 2010">Jason A Lyman, Wendy F Cohn, Meryl Bloomrosen, and Don E Detmer. Clinical decision support: progress and opportunities. Clinical decision support: progress and opportunitie. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2995690/</ref>

# Promote interoperability and where necessary be specific about certain content exchange and vocabulary standards to establish a path forward toward semantic interoperability.
# Support the evolution and timely maintenance of adopted standards
# Promote technical innovation using adopted standards
# Encourage participation and adoption by all vendors, including small businesses
# Keep implementation costs as low as reasonably possible
# Consider best practices, experiences, policies, frameworks, and the input of the HIT Policy Committee and HIT Standards Committee in current and future standards
# Enable mechanisms such as the Nationwide Health Information Network (NHIN) to serve as a test-bed for innovation and as an open-source reference implementation of best practices
# To the extent possible, adopt standard that are modular and not interdependent.
    
The standards to be adopted are based on current industry practices and rely on the following:  [[HL7|Health Level 7]], Inc (HL-7); National Institute of Standards and Technology (NIST) and Integrating the Health care Enterprise (IHE); [[SNOMED|SNOMED CT]]; [[ICD|International Statistical Classification of Diseases (ICD)]], [[LOINC]], NCPDP and [[RxNorm]]. <ref name="ehr incentive program pdf">Department of Health and Human Services. Electronic Health Record Incentive Program. http://www.gpo.gov/fdsys/pkg/FR-2010-01-13/pdf/E9-31217.pdf</ref> <ref name="ehr incentive program html">Department of Health and Human Services. Electronic Health Record Incentive Program; Proposed Rule. Federal Register Volume 75, Number 8 (Wednesday, January 13, 2010). http://edocket.access.gpo.gov/2010/E9-31217.htm</ref>

= Introduction =

In order for eligible providers and hospitals to qualify for federal stimulus dollars, they must use  certified [[EMR|electronic health technology]] in order to measure clinical quality. The United States federal government outlined the proposed criteria to achieve meaningful use in the Medicare and Medicaid Programs; Electronic Health Record Incentive Program; Proposed Rule of January 13, 2010. [http://edocket.access.gpo.gov/2010/E9-31217.htm] Most health care organizations are trying to  achieve meaningful use although there are struggles.  [http://www.ihealthbeat.org/special-reports/2010/small-midsize-physician-practices-could-face-barriers-in-meeting-meaningful-use-criteria.aspx] [[http://journal.ahima.org/2010/02/17/clinical-quality-measures-for-providers/]

= Measures of clinical quality =

The 25 measures involved in using health information technology  for physicians, are separated into 5 initiatives. In order to qualify for stimulus dollars, the eligible provider must meet all the targets specified in the rule during a 90 day reporting period.

= Program Structure =

The [[Centers for Medicare and Medicaid Services (CMS)]] has stated meaningful use can reform the health care system and improve health care quality, efficiency, and patient safety in three stages. [http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html] Within the 3 stages, the program has gradually increasing requirements for participation. All Eligible Professional and Eligible Hospitals begin participating their first year by meeting the Stage 1 requirements for a 90-day period. They continue to complete Stage 1 certification by participating for a full year. After meeting Stage 1 requirements for a minimum of 1 full year plus the 90-day initial measurement, providers can then quality for Stage 2. Stage 2 also requires a 90-day measurement period followed by a full year of participation at which point the Eligible Providers and Eligible Hospitals will have qualified for Stage 2 certification. Note that measuring length of participation, Eligible Providers will use the calendar year, while Eligible Hospitals use their fiscal year. Note the details regarding the incentive payments, as well as payment reductions are not included here, but can be found on the CMS.gov EHR Incentive Program webpage. [http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html] 

The program structure includes both a core and a menu set of objectives with specific requirements for achieving Meaningful Use for both Eligible Professionals (EP)and Eligible Hospitals (EH). Additionally, Eligible Professionals and Eligible Hospitals are also required to report Clinical Quality Measures.

* Core Objectives are a list of measures that must all be achieved. 

* Menu Objectives  are a list of measures where a portion of the measure must be achieved. 

* [[Clinical Quality Measures]] (CQMs) consist of a combination of required core measures and alternative measures. 

''Note the list of Core/Menu Set Objectives and Clinical Quality Measures can change based on EP or EH status, Stage of the program and year of participation.'' 

== Stage 1 ==

=== Core and Menu Set Objectives ===

Eligible Professionals: There are a total of 25 meaningful use objectives. To qualify for an incentive payment, all 15 core objectives must be achieved along with 5 of the 10 menu set objectives. 

Eligible Hospitals: There are a total of 24 meaningful use objectives. To qualify for an incentive payment, all 14 core objectives must be achieved along with 5 of the 10 menu set objectives. 

In their paper [[A Journey through Meaningful Use at a Large Academic Medical Center: Lessons of Leadership, Administration, and Technical Implementation]], the authors (Unger, M., Aldrich, A., Hefner, J., & Rizer, M. 2014, August 1)point out how they methodically set out to accomplish the stage-1 compliance in a large Academic Hospital setting and what others can learn from their experience.<ref>Unger, M., Aldrich, A., Hefner, J., & Rizer, M. (2014, August 1). A Journey through Meaningful Use at a Large Academic Medical Center: Lessons of Leadership, Administration, and Technical Implementation. Retrieved February 7, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4272440</ref>

Additional details regarding Stage 1 Core and Menu Objectives is available on the Stage 1 CMS webpage. [http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html]

=== Clinical Quality Measures ===

Eligible Professionals: EPs must report on 6 total clinical quality measures comprised of 3 required core measures (or 3 alternate core measures) and 3 additional measures (selected from a set of 38 clinical quality measures).

Eligible Hospitals: EHs must report on all 15 core clinical quality measures.

Additional details on the 2011-2013 CQM core and alternative Clinical Quality Measures can be found on the CMS CQM webpage.
[http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/ClinicalQualityMeasures.html]


''Note for Stage 1 attestation in 2013, no changes have been made to the Clinical Quality Measure as originally published to meet Stage 1 in 2011 or 2012. However, starting in 2014, Stage 1 attestation will require reporting based on the 2014 CQMs finalized as part of Stage 2. (see below Stage 2 CQMs)''

== Stage 2 ==

In order to participate in Stage 2, the Eligible Professional or Eligible Hospital must have met the achieved Stage 1 certification.

=== Core and Menu Set Objectives ===

Eligible Professionals: There are a total of 23 meaningful use objectives. To qualify for an incentive payment, all 17 core objectives must be achieved along with 3 of the 6 menu set objectives. 

Eligible Hospitals: There are a total of 22 meaningful use objectives. To qualify for an incentive payment, all 16 core objectives must be achieved along with 3 of the 6 menu set objectives. 

For both EP and EH, you will notice some changes to the Core and Menu Set Objectives including:
*Some objectives have been “retired” from the program altogether, affecting both Stage 1 in 2013 forward as well as Stage 2
*Some objectives have moved from the Menu Set to the Core Set and in some cases combined with pre-existing objectives
*New objectives have been added to both the Core and Menu Set, while some of the original objectives remain in both categories with higher thresholds to meet the objective

For additional details regarding the Stage1 & 2 changes to the EP Objectives, please see the CMS EP Objective Comparison Table. [http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage1vsStage2CompTablesforEP.pdf]
 
For additional details regarding the Stage1 & 2 changes to the EH Objectives, please see the CMS EH Ojbective Comparison Table. [http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage1vsStage2CompTablesforHospitals.pdf]

=== Clinical Quality Measures ===

In Stage 2, CQMs are no longer part of the core measure objective set, however EPs and EHs are required to continue to set them based on the Stage 2 rules.  In addition to these new CQMs, all EPs and EHs beyond their first year of meaningful use will be required to submit this data electronically.

Eligible Professionals: EPs must report on 9 our of the 64 approved clinical quality measures. A minimum of 3 of the selected CQMs must also cover the National Quality Strategy domains. There is also a set of core CQMs that are recommended, although not required. <ref name="final rule 2014 cqms ep measures">EP Stage 1 & 2 changes to the CQMs, starting 2014, CMS 2014 EP Final Rule. http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/EP_MeasuresTable_Posting_CQMs.pdf</ref>

Eligible Hospitals: EHs must report on 16 out of 29 approved core clinical quality measures. As with the EP requirement, a minimum of 3 of the selected CQMs must also cover the National Quality Strategy domains. <ref name="final rule 2014 cqms eh">EH Stage1 & 2 changes to the CQMs, starting in 2014, CMS 2014 EH Final Rule. http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/2014_CQM_EH_FinalRule.pdf</ref>

== Stage 3 ==

As of March 2013, there are no formal published timelines for Stage 3 nor are there any proposed Core/Menu Set Objectives or Clinical Quality Measures. The focus of the program and of CMS is currently on encouraging participation in the two published stages and also the industry [[Transitioning from ICD-9 to ICD-10]]. 

=== First Initiative: Improve quality, safety, efficiency, and reduce health disparities ===

# Use CPOE for all orders for 80% of orders
# Enable drug based alerts
# Maintain an up-to-date problem list of current and active diagnoses for 80% of patients
# E-prescribe for 75% of prescriptions
# Maintain an active medication list for 80% of patients
# Maintain an active allergy list for 80% of patients
# Record structured demographic data for  80% of patient
# record vital signs in the EMR for 80% of patients
# Record smoking status of 80% of patients 
# Incorporate laboratory testing as structured data 50% of the time
# Generate a list of patients  for quality improvement or outreach
# Report ambulatory quality data to the Center for Medicaid and Medicare services
# Send  reminders to patients per their preference for 50% of patients
# Implement 5 clinical decision support rules
# check insurance eligibility  electronically for 80% of patients
# Submit claims electronically for 80% of patients

=== Second initiative: Engage patients and their families ===

# Provide 80% of patients  who request it, a copy of their health information within 48 hours
# Provide 10% of all patients  with electronic access to to their health data within 96 hours of its availability. 
# Provide 80% of patients a clinical summary of their visit

=== Third initiative :Improve care coordination ===

# Demonstrate the ability to electronically share  clinical information between organizations
# Perform medication reconciliation  for 80% of encounters
# Provide a summary of care record  for 80%  of  referrals and transitions in  care

=== Fourth initiative: Improve Population and Public Health ===

# Demonstrate electronic submission of  immunization to state immunization registries
# Demonstrate the ability to exchange information with public health agencies

=== Fifth Initiative: Ensure Adequate Privacy and Security Protections for Personal Health Information ===
# Protect electronic health information  by implementing appropriate technologies.

The interim rule goes on to state that physicians will be required to report on  a subset of  90 clinical quality measures  related to specialty.(5)  The exact quality measures to be selected, and modifications to the use metrics will be available late in the spring of 2010  when the final rule is published. 

= The Impact of Meaningful Use =
Many eligible healthcare professionals are scrambling to meet the meaningful use criteria and deadlines for many reasons; primarily to maximize Medicare and Medicaid reimbursements, leverage technology to provide better patient care and create efficiencies in prescribing, registry reporting, transition of care and medical records management.4 

Knowing full well that implementing an electronic health record system and consequently proving meaningful use will require resources to accomplish, with the focus on the implementation factor, the impact to healthcare support services such as the medical records department, has been overlooked or,  if known, ignored.

In their paper [[Bridging the gap: Leveraging business intelligence tools in support of patient safety and financial effectiveness]], the authors (Ferranti, J., Langman, M., Tanaka, D., McCall, J., & Ahmad, A. 2010, March 1) point out that, While meaningful use is a commonly recognized term within the industry, the underlying key objective of meaningful use – “transformation of our care delivery system through care and cost optimization and patient engagement and their impact on technological and cultural shifts” is less well understood and that, through years of use of less flexible and hard to maintain legacy and proprietary systems, financial , clinical and administrative data have been separated into their own silos and bringing them in a meaningful way to accomplish the objective of care and cost optimization is a serious undertaking, unless a thoughtful and systematic HIT services research is employed.<ref>Ferranti, J., Langman, M., Tanaka, D., McCall, J., & Ahmad, A. (2010, March 1). Bridging the gap: Leveraging business intelligence tools in support of patient safety and financial effectiveness. Retrieved February 15, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3000785/</ref>

= Meaningful use definition =

“Meaningful use is ultimately linked to achieving measurable outcomes in patient engagement, care coordination, and population health.”1 Meaningful use is being defined by the Centers for Medicare and Medicaid Services as “how to best frame (these) measures including measurement of key public health conditions, measuring health care efficiency, and measuring the avoidance of certain adverse events.” 1

Meaningful use measures with impact on support services.
* Measure:  Record Advance Health Care Directive (AHCD)
* Stage 1:  50% (hospital requirement only).  
* Make core requirement.  
* For EP and EH: 50% of patients >=65 years old have recorded in the electronic health record (EHR) the result of an advance directive discussion and the directive itself if it exists.

= Impact =

Advance health care directives are legal documents, which allow the patient to chose his or her end-of-life decisions ahead of time.3  50% of all admitted patients 65+ should have documented in their health record that there was a discussion about, or documentation of, an advance directive.  Hospitals have been actively pursuing this meaningful use criteria as it is seems to be an easy goal to accomplish because the time and effort to implement this procedure electronically appears minimal with low impact to the workflow.  However, the unexpected consequence of implementing this criterion without full workflow process analysis proved to negatively impact clinical support services at healthcare facilities.  Colleena Kirby, the legal documents processor in the medical records administration department at a large health maintenance organization in Hawaii reports that there was an average of 10 AHCD per day pre-meaningful use.  Post-meaningful use implementation about 60 AHCD per day arrives for processing.5   The AHCD workflow consists of filtering for errors, rejecting erroneous AHCD, sending out rejection letters, scanning, indexing and documenting the AHCD.  This process took approximately two hours a day for 10 AHCD.  With the number increasing to 60 per day, the processing of AHCD was creating a backlog of all other documentation processing and was requiring resources which were not available to the medical records administration department.  Consequently all legal documents processing started backlogging, which impacted patient care, revenue cycle and legal departments.5

How clinical information systems can help:  The use of the EHR can be used by healthcare providers to document that a conversation regarding AHCD was discussed with the patient, which also qualifies as part of the 50% of AHCD for meaningful use.  However, many providers and facilities will accept the paper document and send to the medical records administration, or scanning department, to process and scan in the document itself as proof of discussion of the AHCD.   Document management systems which utilize a scan-on-demand function, which can feed scans into the EHR via fax or PDF, can help integrate the paper and electronic records, alleviating the impact to support services departments while not requiring more full-time resources to complete the work and also fulfilling meaningful use criteria.

= Reviews =
* [[Meaningful Use Stage 2 for Eligible Professionals (EP) for the Medicare EHR Incentive Program]]
* [["Meaningful use" of electronic health records and its relevance to laboratories and pathologists]]
* [[Sustaining "Meaningful Use" of Health Information Technology in Low-Resource Practices]]
* [[Overcoming challenges to achieving meaningful use: insights from hospitals that successfully received Centers for Medicare and Medicaid Services payments in 2011]]

= References =
<references/>

= Bibliography =
# U.S. Department of Health and Human Services The Office of the National Coordinator for Health Information Technology.   Meaningful use:  a definition.  2009.  Available from URL: http://healthit.hhs.gov/portal/server.pt?open=512&objID=1325&mode=2.  Accessed 2011 May 21.
# U.S. Department of Health and Human Services The Office of the National Coordinator for Health Information Technology.   Meaningful use matrix.  2009.  Available from URL:   http://healthit.hhs.gov/portal/server.pt/document/872719/meaningful_use_matrix_pdf.  Accessed 2011 May 21.  
# Medline Plus.  Advance directives.  Available from URL:  http://www.nlm.nih.gov/medlineplus/advancedirectives.html.  Accessed 2011 May 21.
# Healthcare Information and Management Systems Society.  The consequences of not pursuing meaningful use.  2010.  Available from URL:   http://www.himss.org/ASP/topics_News_item.asp?cid=74732&tid=9.  Accessed 2011 May 21.
# Kirby C.  [Personal interview, 15 May] Honolulu; 2011 (unpublished).
# Stimulus : American Recovery and Reinvestment Act of 2009 Public Law 111-5 Official Text. Lanham, MD: Government Institutes / Bernan Press; 2009.
# CMS. Medicare and Medicaid Programs; Electronic Health Record Incentive Program.  Proposed Rule.  Fed Regist; 2010. p. 1844-2011
# Lewis P. [http://www.e-healthcaresolutions.com/AMA/aciphex-amednews-0310-inter.php?url=http://www.ama-assn.org/amednews/2010/04/19/bisa0419.htm "Meaningful Use"  takes time (HIMSS 2010 conference).] In: amednews: American Medical News; 2010.
# Kennedy D. [http://www.ihealthbeat.org/special-reports/2010/small-midsize-physician-practices-could-face-barriers-in-meeting-meaningful-use-criteria.aspx] Small, Mid-Sized, Physician practices Could Face Barriers in Meeting 'Meaningful Use' Criteria. iHealthBeat 2010:1.
# Heubusch. [http://journal.ahima.org/2010/02/17/clinical-quality-measures-for-providers/] Clinical Quality Measures for Providers. J AHIMA 2010.

[[Category:Definition]]
[[Category:Interoperability]]