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Meaningful use

Meaningful use, the $30 billion US investment programme in Electronic Health Records, has reached a crossroads. Where it goes next could have important implication for the whole healthcare IT industry.

With $21 billion spent by the Office of the National co-ordinator so far meaningful use has reached maturity and is coming under intense national scrutiny.

Begun back in 2011 as part of the HITECH health IT investment initiative, itself part of the US economic stimulus act, meaningful use has accelerated adoption of EMRs in hospitals and physician offices, with 80% of hospitals having received incentive funds and 50% of physician offices.

Advocates say that in just three years meaningful use has enabled the US healthcare system to reach a critical mass and achieve a tipping point.

Meaningful use comes in three stages, each more demanding than the last. Stage one set fairly basic requirements that most healthcare providers were able to meet by going out and buying an electronic health record system and beginning to use it.

Stage two, due to come into force in 2014, however goes much further than use of electronic records, focusing on sharing them — with different parts of the hospital, with other hospitals, and with patients

Stage two also creates more clinical quality measures to track; suppliers must demonstrate interoperability (both creating and pushing records as well as consuming and populating them) with at least one other EHR, and systems must let patients view, download and transmit their own electronic records.

Stage three of meaningful use, due in 2016, raises the bar even further with a focus on improving quality, safety, and efficiency, leading to improved health outcomes.

Healthcare providers and suppliers are struggling to meet the demanding stage two requirements in full. A study by the Centers for Disease Control and Prevention found that only 13 percent of physicians have an EHR that meets stage two criteria.

Should policy makers consolidate on progress achieved over the past three years, and ensure benefit is achieved from systems now in use; or should they double up efforts on interoperability, clinical quality, driving workflow improvements, and patient enablement?

A significant number of critics say the surging adoption numbers mask some real problems, including many users unhappy with the usability of EHR systems that have bought and installed to achieve meaningful use incentives.

Some healthcare providers have found that the electronic record systems they implemented to met stage one don’t have the functionality or are not user friendly enough to meet the requirements of later stages.

John Moore, managing director of Chilmark Research, believes the short-term stimulus monies have acted like steroids and have created a boated “false market” that led many providers to implement rigid, inflexible EHR systems, with poor usability and customer service to boot.

In an interview with CIO magazine he added that incentives mean EHR vendors have not been forced to innovate sufficiently and ensure that they deliver a great user experience.

A 2013 report by Black Book Rankings, meanwhile, suggested that as many as 17% of medical practices were so frustrated with their new electronic record systems they were planning to rip and replace them.

Others worry that meaningful use has widened the digital divide in US healthcare. Meaningful use only covers healthcare providers receiving Medicare funding. Behavioral health, most pediatricians and long-term care providers are not covered.

Other concerns focus on rural and critical care providers falling behind on bringing the investment needed for the next stage of meaningful use.

Perhaps the biggest issue is that meaningful use is just one of a wave of initiatives hitting the industry simultaneously. New government requirements, a decline in reimbursement and massive change in the delivery system, including a huge wave of mergers are all occurring at once.

Added to this entire industry also due to implement ICD10 in October, a change that carries huge costs for A recent report suggested that physician practices in particular would struggle to meet the cost. ICD10 implementation has already been delayed once.

Russ Branzell, president of the College of Health Information Management Executives (CHIME), says some CIOs are struggling with the degree of change. “The amount of change hitting us at once means there is a perfect storm for some.”

Braznell says that CHIME still strongly supports meaningful use, but Healthcare CIOs are facing multiple challenges piling up on them at once.

I was away at the HIMSS health IT trade show in New Orleans this week, and was struck by just how similar some of the themes from the Big Easy were for the English NHS.

The main one was how much everyone is talking about interoperability and the need to make data liquid between different healthcare providers and avoiding lock-in within any one system. This was something that ONC co-ordinator Dr Farzad Mostashari described as the tendency to data ‘hoarding’.

Interoperability is the focus of the next stage of meaningful use and looks to be the priority for the next couple of years, after four year in which the dash to EMR has been the focus. The suggestion is that the US is inadvertently creating islands of unconnected digital data.

There was also some interesting research out from Black Book Consulting suggesting that a lot of family doctors are unhappy with the EMR they put in to meet meaningful use requirements and are now looking to change.

With the DH apparently gearing up to have another push on EPRs in England, its interesting to get a perspective on what happens once record systems have gone in. A theme I heard a dozen times over the week is that getting an EMR live is just getting to the starting point, the real job comes in getting the clinical and business benefits from changing processes, redesigning care and reviewing performance.

As well as interoperability there was again a lot of vendors pushing analytics and smart use of data to actually make use of the vast piles of data being generated bu the US healthcare system. Healthcare providers now need to use data effectively to deliver a better patient experience based on understanding how and when they want services, in the way Wallmart or Amazon, was the main message of Thomas Warner, chief executive of Louisiana’s biggest healthcare provider,Ochsner Health System.

The need to provide patients with access to services through the channels they want to use was also the message of Dr Kate Christensen, medical director, internet services at Kaiser Permanente. She told me that they love being able to view test results, book appointments, order prescription refills and email their physician. Interestingly, she says that Kaiser no longer thinks internet services save money, by reducing office visits, but they do lead to better patient retention and more activated patients, more likely to better manage their health. Some 4m Kaiser patients now use My Health Manager, over 63% of the total. Another striking figure quoted by Dr Christensen is that over 22% of patient visits are mobile.

The other big theme that is getting a lot of attention in the US is population health management and accountable care organisations, paying a fixed fee for providing all the healthcare for a given population. A big move from fee for service payment models. It’s all part of the attempted shift to new payment models that can contain runaway healthcare costs.

Just how big that challenge is was set out by former-president Bill Clinton who said the US healthcare system was broken and spending roughly one trillion dollars more a year as a percentage of GDP than leading European healthcare systems. he said the soaring costs of healthcare – about 2.5 trillion dollars a year – were hobbling the US economy and one of the main reasons that median household incomes hadn’t increased in a decade.

Clinton said health IT had a vital role to play both in integrating the system and empowering citizens to take better care of their own health.