“I’m from the government, and I’m here to help.” These may be words that strike fear in the hearts and minds of many, but in the case of the Meaningful Use final rule … they may ring true.
After spending my last 24 hours with the new NPRM (Notice of Proposed Rule Making), it’s clear that ONC and their teams did a great job in striking a balance between doing too much and too little – a difficult task to say the least.
If you have been following the effort since the interim rule was published last December, you know that a great deal of concern was expressed by industry stakeholders in the form of comments and suggestions. At one end of the spectrum, there was pressure to add criteria that would make the implementation more difficult and potentially create a barrier to new innovation. For example, there was interest in including more CCHIT functionality such as clinical documentation. Most complete EHRs support this way of capturing information and, since it was a key part of CCHIT certification, it would seem a natural fit for meaningful use if all patient information is to be in an electronic format. But this would have had a significant impact on adoption if 80% of the practices (e.g., those without EHRs today) had to adopt a new process of documenting patient encounters over the next two years. It would have also likely stifled innovation for lighter-weight, modular EHR solutions that might be more easily incorporated without forcing providers to significantly change their current workflows.
The clarification of CPOE in the final rule enables nurses and other licensed professionals to perform these functions without requiring the ordering physician to do the work. Because this is very close to how ordering is performed today, it is likely a more incremental change to practices – achievable without significantly disrupting workflow.
At the other end of the spectrum, there was interest in reducing the criteria that would have made the bar easier to clear but far less effective in achieving any of the real goals set out by HHS. The concern was that achieving all 25 criteria would be almost impossible in the timeframe allocated for Stage 1. Taking this into consideration, ONC included the idea of a core set of 15 criteria that must be met, with the remaining 10 relegated to menu items from which five are to be chosen for Stage 1 (the remaining five then slated to be achieved in Stage 2). This effectively lowered the bar in Stage 1 without significantly altering the outcome by Stage 4 in 2015.
The real impact of the menu sets will be to focus on initial EHR implementation, instead of dealing with exchange criteria like receiving lab results, performing referrals, and instituting electronic patient engagement in Stage 1. This will be particularly important since many of the menu item functions require HIE-like capabilities that are more in line with Stage 2 efforts.
There were also significant reductions in the achievement goals with respect to the percentage of elements covered. For example, the need to perform CPOE was reduced from 80% to 30% of orders placed, ePrescribing was reduced from 75% to 40% of prescriptions written, and medication reconciliation was reduced from 80% to 50%.
So, unlike many efforts that get through Congress, ONC stuck to its guns and created a rule that takes all comments and concerns into consideration in such a way that I think will enable better EHR adoption and innovation. And while we’ll have to wait to see the outcome of the overall effort, it is clear that we’re now set on a path that will lead to new innovations and a shot at a better health care system. My hat’s off to ONC and team on this one.
