The industry is buzzing with anticipation and almost giddy at the prospect of the billions of dollars available in American Recovery and Reinvestment Act of 2009 (ARRA), perhaps better known as stimulus money. Specific to Healthcare Information Technology (HIT), ARRA provides approximately $19 billion for Medicare and Medicaid Health IT incentives over five years (with estimates of $36B over 10 years) as well as $1.1B for Comparative Effectiveness Research (CER) – certainly those dollar figures have the potential to put a smile on many Health IT corporate faces. 

Overarching the ARRA money is the Meaningful Use Matrix.  This matrix will lay out a series of requirements and measurements to assure meaningful use of the HIT and compliance with meaningful use and thus the money.   So what is the big deal about meaningful use, well it is the government’s financial stick to improve healthcare.

Here is a very short overview:

·     Authorizes ONCHIT to provide competitive grants to states for loans to providers.

·    Medicare incentive payments would be based on an amount equal to 75% of the Secretary’s estimate of allowable charges, up to $15,000 for the first payment year.  Incentive payments would be reduced in subsequent years: $12,000, $8,000, $4,000, and $2000, after 2015. 

·    Physicians who report using an EHR that is also capable of e-prescribing would be eligible for EHR incentives only.

·    Early adopters, whose first payment year is 2011 or 2012, would be eligible for an initial incentive payment up to $18,000.  In 2014, the payment limit would equal $12,000

·    For eligible professionals in a rural health professional shortage area, the incentive payment amounts would be increased by 10 percent.

·    Physicians cannot take advantage of the incentive payment programs under both the Medicare and Medicaid programs

·    Physicians who do not use a certified Health IT system would face reduction in their Medicare fee schedule of -1% in 2015, -2% in 2016, and -3% in 2017 and beyond. 

·    Allows HHS to increase penalties beginning in 2019, but penalties cannot exceed 5%. 

If you made it past all these criteria, the real question is much bigger – the point of all this is to improve the quality of care in our healthcare system, improve patient satisfaction and drive down costs.   The Meaningful Use Matrix requires a myriad of reports to support the meaningful use claims.  In any case, the concept is fantastic although is it realistic?

You can say it has to be, but historically incentives like these may not be the drivers especially if the use of EMRs does not save a clinician time or enhance their decision-making capabilities.  Additionally, perhaps the hardest component of the Meaningful Use Matrix is not adoption of HIT, but the reporting requirement associated with HIT.  Let’s focus on one seemingly easy report that is a required measure of meaningful use in 2011 (as specified in the meaningful use matrix).  The measure requires reporting quality measures to CMS such as percent of diabetic patients with A1c under control.   Seems relatively easy.  From a human perspective it is, but meaningful use requires use of HIT – this presents a huge increase in complexity.  Let’s pick it apart:

1.      If the are multiple systems how do we track what a A1c test is, it maybe be denoted as Hemoglobin A1c, HbA1c, diabetes blood glucose test, diabetes blood test, blood test for insulin levles, diabetic blood glucose test just to name a few.  This is a complex and expensive issue to program a computer to recognize all these different semantics.

2.      Reference ranges - these vary by age, sex, race, and even ethnicity, but are required in order to build the report.

3.      What is a diabetic patient, again easy for a human to understand – massively complex for a computer.  Is it a diagnosis code, a DRG from the billing system, a compilation of lab results, how do you tell a computer what the profile for a diabetic patient is?

4.      Under control – this is a potentially ”fuzzy” objective call for even a human, let alone a computer.

So how meaningful is meaningful use?  The example above is just one of many, many reports each with a level of complexity of at least this magnitude.  One component that may help is interoperability.  Interoperability comes in two basic flavors, semantic and syntactic.  Semantic interoperability is the ubiquitous use of standardized vocabularies so data can be exchanged and the meaning kept intact.  In out A1c example, LOINC codes would help significantly.  Syntactic interoperability is the standard formatting for machine-to-machine exchange of data, i.e., HL7.  The challenge for syntactic interoperability is that the power and beauty of HL7 comes in its flexibility.  Flexibility is the archenemy of interoperability.  Flexible, interpretable formats introduce complexity and variability – exactly what is not needed.   The semantic challenge is tha the industry as a whole has wrestled with standard vocabularies for decades with some progress, but no generalized acceptance.   Moving forward interoperability of all kinds will be required, but is it realistic to have implemented by 2011 – most likely not.

In any case, these reporting requirements of Meaningful Use have the true potential to dampen, diminish or even nullify the industry attempts at Meaningful Use.  Does this mean we should just save ourselves the headaches and fold up the tent and go home - absolutely not!  What it means we, as industry professionals,  proceed with the caution and care demanded by the situation.  Meaningful Use is indeed meaningful, perhaps just not in the compressed timeframe.  The reporting requirements of meaningful use are the elephant in the room and we all know how to eat an elephant – one small bite at time.  So get your knife and fork ready and start finding the perfect spot for that first meaningful bite.

Dale Will

Associate Partner

Photo Source: http://chilmarkresearch.com/2009/06/26/our-meaningful-use-comments/