When the meaningful use rule was first proposed, Daniel Barchi thought that only about 20 percent of hospitals and physicians would meet the requirements in the first two years of the program.
But now the senior vice president and CIO of eight-hospital Carilion Clinic health system in Roanoke, Va., believes that number may be closer to 40 percent. The flexibility of the final rule “has really opened the window for a lot of people,” Barchi says. “CMS is giving providers the benefit of the doubt. If they have invested in infrastructure, this will give them time to continue working on clinical pathways and processes so that what might have seemed unachievable is now achievable.”
Barchi’s response is echoed by most people in the healthcare information technology field, who believe that Dr. David Blumenthal’s team at the Office of the National Coordinator has threaded the needle in terms of maintaining its aggressive stance on pushing electronic health record (EHR) adoption but helping more people sense that the standard is attainable.
Writing on his blog, John Halamka, M.D., CIO of Beth Israel Deaconess Medical Center and of Harvard Medical School, says he was impressed because the final rule means that meaningful use will be achievable by many organizations, and also because the standards and the process to certify their use are sufficiently specific. “Overall, a very good day for ONC, HHS and stakeholders,” he wrote.
Erica Drazen, managing director of CSC's Emerging Practices group, thinks the final rule is good news all around. “It offers more flexibility, and the message is that they are clearly listening.”
She notes that one key change involves computerized physician order entry (CPOE). “They changed it from all orders to just medication orders, but are requiring one CPOE order for every patient.” And, of course, they changed the rule from 10 percent of all orders for hospitals and 80 percent for eligible providers to 30 percent in both settings. In the final rule statement, CMS said: “We believe this relatively low threshold, in combination with the limitation to only medication orders, will allow hospitals and EPs to gain experience with CPOE. However, as providers gain greater experience with CPOE, we believe it is reasonable to expect greater use of the function.”
“In one sense, I am surprised they backed off as far as they did,” Drazen says, “but it is reasonable to back off on CPOE in the physician space. They had set the bar too high.” Drazen describes a few other key shifts by CMS: “They made incorporating lab test results into an EHR as structured data optional, which isn’t a big deal for hospitals, but for physician practices that deal with multiple labs, it would be very difficult.”
CMS also moved providing a summary record at transitions in care and referrals to the menu of optional requirements. “That is one that is going to be tough for hospitals and will probably be deferred,” Drazen says. “Sending reminders for preventive follow-up care to patients will be another one that will be a challenge.”
Besides the core provisions, providers now get to choose five of 10 optional menu items, with two new menu options having to do with providing condition-specific patient education resources and recording advance directives. “Although those are optional for providers, EHR vendors have to be able to do all of these,” Drazen says, “so for the vendors the bar was raised a little bit, even if their customers get to pick and choose.”
Chuck Podesta of Fletcher Allen Health Care, a 562-bed hospital in Burlington, Vt., was probably in a very small minority of CIOs hoping that the final rule would look very much like the proposed one. “I was happy with the stricter guidelines in the proposed rule,” he says. “When we have a chance to impact patient safety and outcomes in a positive way, why would you water that down?”
He thinks it is good CMS didn’t push back the penalty dates. “They have to keep our feet to the fire,” Podesta says, “so it makes sense to make these changes sooner rather than later.”
He understands when people say smaller hospitals might not have the funding or could rush their implementations and fail. “I think the answer to that is to push the carrot forward and help them pay for certified EHR systems upfront,” he adds, “and CIOs, through organizations like HIMSS and CHIME, need to band together and help each other out.” Podesta, whose hospital is at 96 percent CPOE adoption, notes that the 30 percent CPOE threshold will be a challenge for some in-patient settings that haven’t yet made progress on it. “Getting from zero to 30 percent is a lot harder than getting from 30 percent to 50 percent.”
Like Podesta at Fletcher Allen, Barchi says Carilion is in good shape to garner incentives because it is wrapping up a three-year EHR implementation process that started long before anyone envisioned federal guidelines like these.
“We weren’t that concerned about the guidelines in the original rule because we felt confident we could achieve them.”