The federal government has, in many ways, lowered the bar for physicians and hospitals to receive reimbursement for implementing electronic medical records (EMRs), while also retaining the fundamental measures to maintain quality and safety, experts say.
The U.S. Centers for Medicare and Medicaid Services (CMS) released its final version of so-called meaningful use rules on Monday, which will be used by the government to qualify EMR implementations for billions of dollars in incentives.
Bill Connelly, an attorney with the Healthcare Division of the New York-based law firm of Manatt, Phelps & Phillips LLP, said the changes made by the CMS in quality measures were significant. The CMS dropped the measures from 90 to 44, and physicians only need report electronically on three.
For example, if a patient has diabetes, a physician or hospital is required to report that they are in fact taking blood pressure readings on that patient, or if a patient has had a heart attack, they must report that they have prescribed an aspirin regimen. Part of the reason for the dropping so many of the requirements in the first phase of meaningful use rules is that CMS itself has no way to receive reports electronically much of the time, Connelly said.
The new rules were finalized after a three-month public comment period during which more than 2,000 recommendations were received by the U.S. Department of Health and Human Services on its preliminary "notice of proposed rule making" effort. The final document is 864 pages long.
In the final rules, CMS does little to promote the electronic exchange of EMRs between hospitals and among states. "There wasn't much to promote health information exchange in the proposed rule, but they scaled it back even further in the final rule," Connelly said.
He added that state health information exchanges will likely be addressed in phase two and three of the rules. Phase two is expected as early as this fall. There has yet to be a date set for phase three of the rules.
Mark Segal, vice president of Government and Industry Affairs for GE Healthcare IT, said CMS basically took what were a set of "all or nothing" rules and accounted for the realities of implementing EMRs in a short time frame. For one, they lowered the percentage of EMRs that had to include patient demographic and vital sign information from 80% to 50%. "It's more attainable. It gives them more leeway," he said.
One thing the CMS had no flexibility with in its rules was the 2015 deadline for implementing EMRs. The timetable for meeting the standards was set in stone by the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. In HITECH, healthcare entities must implement EMRs by 2015 or face monetary penalties in the form of Medicare reimbursement funds.
"I think there's a lot of folks that are all of a sudden realizing that they're in a real predicament. What I sense from talking to other organizations is that they didn't take this quite as serious as they should have," said Bill Fawns, director of IT services for County of Kern Medical Center in Bakersfield, Calif.
In November, Kern Medical Center plans to deploy an OpenVista EMR from Medsphere Systems Corp. The center is a 222-bed acute-care teaching hospital that serves a community of approximately 650,000 and cares for 16,000 inpatients annually.
"Our approach to meaningful use has been to throw it back to our vendor. So contractually we obligated our vendor to deliver meaningful use however the requirements turn out," Fawns said.
He said one of the greatest challenges with deploying an EMR has been setting up a wireless infrastructure in a hospital campus that has a mixture of new and old buildings, and pushback from the hospital staff.
"We're a teaching hospital, so on one end of the spectrum we have residents born with a computer in their hand and so they look at this as an opportunity to move forward; on the other side of the spectrum are the physicians [who] are in their 60s and the very idea of signing onto a computer is a big question mark to them," Fawns said.
While he sympathizes with organizations struggling with implementing EMRs, Fawns said he has mixed feelings about organizations that would complain about the 2015 deadline the government has set.
"We're aggressively going after this. Part of me thinks other organizations could have done that too," he said. "My guess is there will be enough cries that deadline will be extended. But even it it's left as it is now, it is enough time if they want to get serious about an EMR."
Segal said the 2015 deadline is not as dire as it appears. While HHS wanted all entities to achieve stage three meaningful use by 2015, that spurred concerns among healthcare providers who voice their concerns, and were heard.
"In some cases, if you started EMRs later, you were needing to move through each stage in one year. That didn't logically take into account the time needed to progress from one stage to another," Segal said.
The final rules state that reimbursement payments for Medicare providers may begin no sooner than October for eligible hospitals, and no sooner than January 2011 for eligible health care professionals. The rules allow providers to begin EMR implementation in 2012, 2013 or 2014, and still have two full years to implement stage one standards, Segal said.
Health care providers only need to record 90 days of EMR information to report to CMS to qualify for reimbursement payment, instead of a full year as the preliminary rules required.
"The good news is ... if you're able to start demonstrating meaningful use Jan. 1, 2011, then around April 1 they would be able to ... in effect get the money early, which is very useful for covering the cost of doing an upgrade or acquisition," Segal said. "The flipside is you can start later in the year and still get the money."
Not finding self in scenario where had decided not ready to start until 2012 and not then defining in advance you move through move through very quickly.
CMS also changed from its proposed rule the percentage of patients that had to be sent electronic reminders for care management, from 50% all patients 50 years old or over to 20% of all patients 65 and over, Segal said.
CMS also added two new items to the final rules: Healthcare providers will have to provide patient-specific educational resources in EMRs; and they will have to electronically record advance directives, which include living wills and durable powers of attorney for healthcare, Segal said.
Another area that was heavily criticized in the proposed rules that was removed in the final meaningful use standards was revenue cycles and practice management, which involve submitting bills or checking patient eligibility electronically.
"Those could have caused complications. In many cases people don't have a stand-alone EMRs that doesn't include revenue cycle functionality," Segal said.
"One of the good things that happens as you move from a proposed rule to a final rule is people identify all sorts of ambiguities, but also based on comments CMS sought to get a better balance between the ambition of moving the healthcare world forward and the practicalities of what could be achieved," he said.
Lucas Mearian covers storage, disaster recovery and business continuity, financial services infrastructure and health care IT for Computerworld. Follow Lucas on Twitter at @lucasmearian or subscribe to Lucas's RSS feed . His e-mail address is lmearian@computerworld.com .
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