Keeping Meaningful Use From Becoming Meaningless Abuse: A Cardiology/Electrophysiology Perspective

The terms Meaningful Use (MU), Office of the National Coordinator (ONC), Electronic Health Record (EHR), Electronic Medical Record (EMR), Health Information Technology (HIT), and Eligible Professional (EP — sadly, an abbreviation that has been hijacked from our profession) have all recently achieved celebrity status in the medical lexicon, having joined the likes of CMS (Centers for Medicare and Medicaid Services) and Health Insurance Portability and Accountability Act (HIPAA). Like most celebrities, these terms elicit reactions of either adulation or contempt. 

It behooves both cardiologists and electrophysiologists to understand them and their consequences on the practice of our profession. Mandates, whether from the government or the private sector, have elements that are good, bad and ugly. The purpose of this article is to provide an overview of the following:

1. What is MU and its goals?
2. What is the financial impact of MU to EPs?
3. What are the benefits and risks of MU as it is currently being executed?
4. Will MU in its current state achieve its goals?

We have created an online questionnaire to better understand how the readers of this article view MU and the push toward EHRs.

What is MU, and how did it come to be?

The Beltway jargon “meaningful use” was crafted to imply that the adoption of health information technology solutions is not enough but that eligible professionals and hospitals must demonstrate that the technology is used in a way to improve the safety, quality and efficiency of the health services delivered.

The goals of MU have been to implement a program that achieves, in a step-wise fashion, the transformation of the health system to a system that is patient centric, high quality, safer, and transparent. The final goal is to improve population health as measured by outcomes. The primary tools for HIT to reach this new system are to use electronic clinical decision support (CDS), record patient data electronically in a standardized structured fashion, report quality measures electronically, promote health information exchange (HIE), and improve patient engagement by creating a national electronic record system that is patient centric and patient accessible. 

The three phases of MU include: Stage I – Data capture and sharing; Stage II – Advanced clinical processes; and Stage III – Improved outcomes (Table 1). The MU program was launched with the HITECH  (Health Information Technology for Economic and Clinical Health) legislation that has provided the funding for incentives as well as establishing HIT Policy and Standards committees to promulgate proposed rules around this program. 

What is the financial impact of MU to EPs? 

The stimulus for EPs and hospitals to adopt this program is a financial “carrot and stick” approach. 

The Carrot:

The total maximum incentive amount that an EP can be paid under the Medicare EHR Incentive Program is $44,000 over five consecutive years of program participation. To receive the maximum incentive, the MU participation must start in 2011 or 2012. If not initiated by 2014, the EP is not eligible to receive any incentive payment under the Medicare EHR Incentive Program.

The total maximum incentive amount that you can be paid under the Medicaid EHR Incentive Program is $63,750 over six years of program participation. Participation in the program does not have to occur during consecutive years. EPs may receive the maximum Medicaid incentive payment as long as participation in the program is begun by 2016. 

The Stick:

The penalties — Medicare EPs who do not meet the requirements for meaningful use by 2015 and in each subsequent year are subject to downward payment adjustments to Medicare reimbursements that start at 1% per year, up to a maximum 5% annual adjustment. 

What are the benefits and risks of MU as it is currently being executed?

The benefits of this ambitious program to the health system would be the widespread adoption of HIT with standardized functionalities that could result in improved quality, transparency and outcomes. 

EPs would certainly welcome and endorse any process that would improve clinical outcomes through:

1. Early identification of patients at risk and implementation of aggressive preventive measures.
2. Improve accuracy of diagnoses and therapeutic interventions with the aid of CDS, as well as have EMRs/EHRs that update new medications and evidence-based guidelines as they become available.
3. HIT that enhances and does not impede clinical workflow by providing a graphical user interface that is intuitive, easily navigated, and can produce accurate documentation of the physician-patient interaction, not only for outpatient primary care, but by specialty-, surgical- and hospital-based clinical work.
4. Interoperability and interfacing of systems from different vendors.
5. Multiple level query functions.
6. Improved patient compliance and accountability.
7. Hold software vendors and patients accountable for their participation in this process and its outcomes.

The details of Table 1 show that while patient involvement in their health status is addressed at various stages of MU, the entire penalty for not achieving this goal is placed on the EP. It is unlikely that such a goal will be achieved without a carrot/stick for the patient. There are also no penalties applied to software vendors for systems that impede the clinical workflow or fail to deliver MU goals due to intrinsic shortcomings in the software. Finally, there is no recourse for EPs and health systems to hold the government responsible for mandating time-constrained goals associated with penalties despite expert testimony regarding the unavailability of adequate IT tools to achieve these mandates (discussed below).¹ 

It should be kept in mind that many of the software systems created for HIT have had scheduling, billing, and coding as the primary directive of the development platform instead of being based on clinical workflow, decision, and support. The consequence is a significant disruption of physician workflow, leading to resistance to adoption.² While some blame lack of physician desire as the main impediment to physician adoption of EMRs, these individuals overlook several other factors such as software platforms that marginalize the physician user, EMR use by physicians leading to patient dissatisfaction,³ EMR inability to prevent human error,⁴ and EMR inability to accurately track quality.⁵

Adding insult to injury, many of the critical aspects of patient management and safety such as drug databases, CDS, and query of clinical management/outcomes often require third-party software separate from the EMR vendor, which further complicates interoperability issues and steeply increases costs.^6,7 

The challenges and importance of interoperability even between two governmental health organizations, the VA and the Defense Department, was recently in the spotlight. The two organizations had originally planned to build a single integrated health system, but have now announced the cancellation of this project. Instead, they are now focusing all resources on trying to create interoperability interfaces between the VA and Defense Department systems.⁸ If two established, homogenous governmental HIT systems are facing this challenge, one can imagine the far greater complexity of HIE in the private sector. 

Despite these concerns, it is encouraging to note that there are limited data that support improvement in outcomes and mortality reduction, particularly in patients with pneumonia and myocardial infarction at hospitals that have more IT with CDS support.⁹ 

The fundamental question is whether the current HIT tools available to EPs, the financial incentives as currently structured, and the time frame of proposed implementation, are truly achievable and cost effective. Alternatively, if our HIT tools are inadequate to achieve these goals, are we wasting taxpayer dollars under the current plan? In the latest CMS data, nearly 200,000 providers have been paid a total of $10.⁷ billion under the federal incentive payment program. A large amount of this money has gone to the larger EHR vendors. As pointed out in a recent New York Times article,¹⁰ it was the optimistic predictions in a report by the RAND Corporation in 2005 which helped to drive explosive growth in the electronic records industry and encouraged the federal government to initiate a program to give billions of dollars in financial incentives to hospitals and doctors that put the systems in place. The report predicted that “widespread use of electronic records could save the United States health care system at least $81 billion a year, a figure RAND now says was overstated. The study was widely praised within the technology industry and helped persuade Congress and the Obama administration to authorize billions of dollars in federal stimulus money in 2009 to help hospitals and doctors pay for the installation of electronic records systems.”¹⁰ This RAND report “was paid for by a group of companies, including General Electric and Cerner Corporation that have profited by developing and selling electronic records systems to hospitals and physician practices. Cerner’s revenue has nearly tripled since the report was released, to a projected $3 billion in 2013, from $1 billion in 2005.”¹⁰

Fast forward to 2013, when the College of Healthcare Information Management Executives (CHIME) received a “request for information” from CMS to assess the readiness of their organizations for electronic submissions of clinical quality measures for the CMS’ Hospital Inpatient Quality Reporting program created under the Medicare Prescription Drug.¹

CHIME praised the CMS for seeking to harmonize the reporting of clinical quality measures, but warned that “workflow and technology implications of complete and accurate electronic quality reporting are not fully understood.”¹

Will MU in its current state achieve its goals?

The question comes down to defining the true goals and their respective priorities: Improving clinical care or reducing health care expenditures in the near future? Is it valid to assume that health care spending in the near future will decrease, if in fact, we are more effective at identifying individuals at risk and with disease? The consequence may very well be that health care expenditures sharply increase in the short term as these newly identified patients receive more aggressive preventive and secondary therapy. The short-term costs would be directly proportional to the prevalence of the “at-risk” cohort in the population. The larger this pool, the more costs would be incurred with enhanced identification of this pool. Given the prevalence of obesity among U.S. adults is nearly 36%¹¹ and is associated with a high risk of diabetes, hypertension, and atherosclerosis, enhanced identification and intervention would be expected to increase health care expenditures in the short term. However, short term may mean several decades given the time course of disease progression and symptomatic manifestation in this population. Interestingly, MU stage 3 mentions patient access to self-management tools; however, no penalties for not utilizing such tools. In a free society, EPs can recommend ways to improve health, but cannot be held accountable for lack of patient compliance and widespread availability of inexpensive, unhealthy food products. Unless individual patients and the companies that profit from production of unhealthy food groups or substances have “skin in the game,” we may be deceiving ourselves that we will improve all but hospital-based inpatient acute care events. In fact, between 1996-2006, there was already a significant reduction in mortality associated with acute MI in the U.S., attributed to multiple factors including process improvements such as care sets with increased use of aspirin as well as newer medications and invasive procedures, all of which added to the cost of therapy.¹² While EMRs may further aid in this process, they are certainly not a prerequisite, since this improvement was seen even before widespread adoption of EMRs and computerized physician order entry (CPOE). HIT, however, also adds a significant cost to the delivery of care.

For those of us who are true EPs (in this case, electrophysiologists), consider the condition of atrial fibrillation. As ablation for atrial fibrillation improves in both efficacy and safety, we may see a short-term paradoxical increase in the cost of treating such patients with increased use of ablation, and the true long-term economic benefits may not be seen unless such patients are followed for a decade or more in properly designed registries that would reflect whether reductions in arrhythmia, hospitalizations, strokes, heart failure, and death translate into lesser economic burden of this disease. This is certainly an area where well-designed EHRs can help in obtaining such long-term data. Unfortunately, even current EHRs that are geared toward primary care physicians will require significant sophisticated enhancements and customization to accurately track more complex disease management in fields like cardiology.

Recent articles examining Medicare expenditures confirm a significant increase in health systems utilizing EHRs.¹³ The reflexive response by those who have a propensity to villify  physicians cry EHR fraud, without considering that more accurate documentation and coding software allow physicians to claim money that had been left on the table for years.¹⁴ Those physicians who are inclined to cut and paste from templates were able to do so even in the era of dictated transcription.

The major limitation of the current HIT environment has been the limited HIT vendor solutions that are usable at the point of care. The ONC certification process has focused on functionality without testing usability; thus, many of the vendor solutions are extremely workflow unfriendly. The current hospital environment is one in which the HIT vendor selection is typically driven by the chief financial officer; therefore, the solutions selected are about charge capture and maximizing coding/billing opportunities with less attention to clinical data capture or workflow.¹⁵ The evidence that widespread HIT adoption including CPOE will improve care and reduce costs is weak at best.^16,17 The lack of randomized clinical trials to test technology solutions substantially weakens the rationale that HIT will be the premier transformative solution for the health care system. 

With this backdrop of technically limited software, despite which, the federal government is mandating EPs and health systems define a short track to MU, we also have the looming conversion from ICD-9 to ICD-10, which is poised to wreak havoc on health systems already facing significant HIT-induced financial and physician workflow stress.¹⁸ The new ICD-10 environment will have a major impact on clinical workflow requiring a more granular documentation effort with little value on enhanced care delivery. Finally, current regulations that raise the barrier to entry to all but the largest EHR companies may stifle smaller and more innovative companies that could provide more effective solutions to the desired clinical goals.

We feel that properly designed EHRs will improve our ability to provide cost-effective, high-quality care; however, cost of care and quality of care do not always track concurrently and may be out of phase for several years, even with an ideal “EHR.” Ultimately, trying to lower the cost of U.S. health care by placing the bulk of the financial burden and responsibility for health care costs on EPs and health systems alone will not succeed. There will need to be economic incentives/penalties for patients, supply/device manufacturers, pharmaceutical companies, HIT companies, insurance companies, attorneys, and politicians, in order to effectively lower costs. Unless several of the significant shortcomings outlined above are addressed in a meaningful manner, which may mean slowing or halting our current HIT train in order to plot a new course, we may be on the fast track toward the precipice overlooking the abyss of meaningless abuse.

Professional Societies

The cardiology community is fortunate to have the ACC and HRS actively engaged in discussions with ONC and CMS regarding the MU program and EHR certification, as well as preparing and educating members about the new challenges of advanced HIT adoption. 

More information may be obtained at “www.cardiosource.org/healthit” and “https://bit.ly/153j2qI”. 

Disclosures: Dr. Mitra reports that outside the submitted work he is a consultant with Medtronic, is employed by Beacon Health System, and has received honoraria (for speaker’s bureau) from Boehringer Ingelheim; Dr. Mitra also reports HIT software/consultancy with Advanced Health Logic. Dr. Mirro reports that outside the submitted work he is a consultant with St. Jude Medical, is employed by Parkview Health System, has received honoraria from Sanofi, and has stock/stock options in iRhythm.  

References

1. Correll, Richard A., and George T. Hickman. “Request for Information on Hospital and Vendor Readiness for Electronic Health Records Hospital Inpatient Quality Data Reporting.” Letter to Marilyn Tavenner. 28 Jan. 2013. Web. 11 Feb. 2013. <https://www.cio-chime.org/advocacy/resources/download/CHIME_Response_to_CMS_IQR_RFI.pdf>.
2. “External Pressures Force Community Hospitals to Reconsider EMR Systems.” KLAS, 17 Dec. 2012. Web. 11 Feb. 2013. <https://www.klasresearch.com/news/pressroom/2012/CommCIS>.
3. Shaffer VA, Probst CA, Merkle EC, Arkes HR, Medow MA. Why do patients derogate physicians who use a computer-based diagnostic support system? Med Decis Making. 2013;33:108-118. 
4. Sparnon E, Marella WM. The role of the electronic health record in patient safety events. Pa Patient Saf Advis. 2012;9:113-121. 
5. Kern LM, Malhotra S, Barrón Y, et al. Accuracy of Electronically Reported “Meaningful Use” Clinical Quality Measures: A Cross-sectional Study. Ann Intern Med. 2013;158:77-83. 
6. “Providers Get Help From Clinical Decision Support Evidence Vendors but Still Face Obstacles.” KLAS, 22 Jan. 2013. Web. 11 Feb. 2013. <https://www.klasresearch.com/news/pressroom/2013/cds>. 
7. “Continuing Connectivity Struggles Lead to Declining Satisfaction Scores for HIE Vendors.” KLAS, 6 Nov. 2012. Web. 11 Feb. 2013. <https://www.klasresearch.com/news/pressroom/2012/HIE2>. 
8. Remarks by Secretary Panetta and Secretary Shinseki from the Department of Veterans Affairs. Available online at https://www.defense.gov/transcripts/transcript.aspx?transcriptid=5187. Accessed February 11, 2013.
9. Amarasingham R, Plantinga L, Diener-West M, Gaskin DJ, Powe NR. Clinical information technologies and inpatient outcomes: a multiple hospital study. Arch Intern Med. 2009;169:108-114.  
10. Abelson, Reed, and Julie Creswell. “In Second Look, Few Savings From Digital Care Records.” The New York Times, 10 Jan. 2013. Web. 11 Feb. 2013. <https://www.nytimes.com/2013/01/11/business/electronic-records-systems-have-not-reduced-health-costs-report-says.html?_r=0>.
11. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity in the United States, 2009-2010. NCHS Data Brief. 2012 Jan;(82):1-8. 
12. Orozco-Beltran D, Cooper RS, Gil-Guillen V, et al. Trends in mortality from myocardial infarction. A comparative study between Spain and the United States: 1990-2006. Rev Esp Cardiol (Engl Ed). 2012;65:1079-1085. 
13. Abeson, Reed, Julie Creswell, and Griff Palmer. “Medicare Bills Rise as Records Turn Electronic.” The New York Times, 21 Sept. 2012. Web. 11 Feb. 2013. <https://www.nytimes.com/2012/09/22/business/medicare-billing-rises-at-hospitals-with-electronic-records.html?pagewanted=all>.
14. Moukheiber, Zina. “Blame Technology For The Rise In Medicare Billing, Not Doctors.” Forbes Magazine, 26 Sept. 2012. Web. 11 Feb. 2013. <https://www.forbes.com/sites/zinamoukheiber/2012/09/26/blame-technology-for-the-rise-in-medicare-billing-but-not-doctors/>. 

15. Howell, Dewey, MD, PhD. “Medication Reconciliation, CPOE and Patient Safety: One Physician’s Viewpoint.” EHM. Web. 11 Feb. 2013. <https://www.executivehm.com/article/Medication-Reconciliation-CPOE-and-Patient-Safety-One-Physicians-Viewpoint/>.
16. Berger RG, Kichak JP. Computerized physician order entry: helpful or harmful? J Am Med Inform Assoc. 2004;11:100-103. 
17. Al-Dorzi HM, Tamim HM, Cherfan A, Hassan MA, Taher S, Arabi YM. Impact of computerized physician order entry (CPOE) system on the outcome of critically ill adult patients: a before-after study. BMC Med Inform Decis Mak. 2011;11:71. 
18. “Few Healthcare Providers Are Prepared for ICD-10 Despite Ticking Clock.” KLAS, 25 Oct. 2011. Web. 11 Feb. 2013. <https://www.klasresearch.com/News/PressRoom/2011/ICD-10>.

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Both authors are members of the American College of Cardiology Informatics Committee, and Dr. Mirro is a member of the Heart Rhythm Society Informatics Work Group. Dr. Mitra is a founding member of Advanced Health Logic™, an HIT software and consulting company. The views expressed in the article are those of the authors only and should not be construed to reflect the views of their affiliated institutions, companies, the American College of Cardiology, or the Heart Rhythm Society.