Meaningful Use Dialogue and What Pediatricians Need to Know

==> Read Newer Articles about Meaningful Use at pedsource/ehrmoney

Back in April, we reviewed some of the preliminary details of EHR incentives built into The American Recovery and Reinvestment Act of 2009 (ARRA), its potential affect on pediatricians, and some of the glaring holes in the provision that had yet to be addressed. Among the questions left unanswered in this provision were the definition of the terms "Meaningful Use" and "certified."

While the U.S. Department of Health and Human Services (HHS) has made strides to tackle and define these terms, the effort to come to an agreement has become very complicated and has raised many questions about the inconsistencies between the nature of using an EHR in a meaningful way and the definition as determined by HHS, as well as the far-reaching impacts the term may have down the road.  There is very little child health focus to the process, though the AAP, via CCHIT and other avenues, is doing its best (see Chip Hart's blog post about the high level of pediatric representation at a recent CCHIT meeting.)

Now that the dialogue is underway, we ask how meaningful use relates to pediatricians, and what do they need to know? We talked to three front-line pediatricians who have been closely involved with the discussion to bring to you their perspectives on this issue:

What should pediatricians know about "Meaningful Use?"

Dr. Mort Wasserman, a Professor of Pediatrics at UVM and Director of Pediatric Research in Office Settings (PROS), said that all pediatricians, but especially those who are owners, or co-owners of a business need to know a lot about the issue, because there are financial implications that will likely impact them. "Pediatricians need to pay particular attention to the dialogue because, Medicare typically drives decisions made by the Center for Medicare and Medicaid Services, and since pediatricians aren’t reimbursed by Medicare, the dialogue could be driven by people who are. Pediatricians need to speak up meaningfully or decisions that affect them will be made without their input."

What does "Meaningful Use" mean to pediatricians?

Dr. Bill Zurhellen, a pediatrician at Putnam Valley Pediatrics and is a member of the Certification Commission for Healthcare Information Technology (CCHIT) Child Health Workgroup, said that for him there are two very different meanings of the term "meaningful use." "The first is about qualifying for stimulus money through the adoption of Health Information Technology.  The second, from my perspective is not looking to get money, but to put technology into use to improve healthcare–that's real meaningful use."

Dr. Andy Spooner, a general pediatrician, and the chief medical information officer at the Cincinnati Children's Hospital who is leading the hospital's EMR implementation, has a similar outlook about the definition of meaningful use and its relationship to pediatrics. "Meaningful use is less about functionality and more about what HHS says you have to do. It's quite distressing and it has little to do with pediatrics."

While pediatric-specific measurements work for adults, adult measures do not work always for children. Despite this, however, there is a current list of measures being reviewed as requirements for meaningful use, few of them relate to the pediatric specialty. Dr. Spooner gave as an example of a quality measure the issue of dosing safety. "From a pediatric perspective, one of the most important safety issues is getting the dose size right for the size of the child." This feature is as necessary to ER doctors as pediatricians who prescribe medication to children on a daily basis, he said. "People shouldn't be buying a system without basic pediatric functionality. There are few 'fancy' pediatric functions."

What do you see the impact of this dialogue being on pediatricians?

Dr. Wasserman said that meaningful use intends to create changes to improve quality of care, though he also stated that implementing an EHR is certainly not the only way to do that. "The big misapprehension is that people in power think it is easier to do quality measurements with an EHR. That may be the case in 2020, but it won't be in 2010. The truth is it's hard to extract data from EHRs, as they are currently built. Maybe the next generation of EHRs will be better, but to my knowledge, the ability to document and readily extract data in a way that will help improve quality of care does not yet exist.

Some day down the road, features built into EHRs will allow them to be put to meaningful use by practitioners desiring to improve quality. My professional interest is in helping pediatricians do better.  EHRs will help accomplish that task in the long term. The perspective in Washington is that there will be short term gains and that making short term investments will pay off.  My feeling is that these investments will pay off, but not right away."

Dr. Spooner said that meaningful use is a good thing to examine as a topic. "What you don't want from an EHR is a very expensive word processor. If we use them as word processors, we're never going to get off the dime. Legibility is not quality."

In our EMR implementation, we're trying to build quality measurements into the implementation. It's extremely hard because EMRs are not designed for data management. You think you will get all this reporting once you've gone paperless, that you will be able to pose any clinical question to the computer. If you want to get discreet, reliable data in the first place, you have to design software to do that in the first place, then enter the information, then incorporate into your workflow.

In a research environment, people are much better at collecting data. This is because of two major differences–they've thought long and hard about what data they need, and they have people to do data input. Neither of these apply in the standard for implementing an EHR. We spend all this time and money designing templates, but we need flexibility to get through the day, and ultimately, collecting data points is a huge interruption of workflow.

So, what's the solution? We are good at collecting billing data, because getting paid depends on being able to do this. For collecting clinical data, we're still at the embryonic stage of being able to do this. Right now, we need to use E&M guidelines. When a pediatrician sees a patient with asthma, if they could spend the same twenty minutes that they now have to spend generating notes, instead filling out five boxes in the screen, that's how we can move quality along."

Dr. Zurhellen said that the real goal is to improve quality of care, and to do that, one needs to be able to analyze data and show better outcomes."This will take years and a lot of money. Just sending something electronically does not mean it's better. We have to go back to looking at outcomes. Is a patient's status improved or not improved?

In the end, meaningful use is not meaningful if you're not improving the quality of care. I'm absolutely pro EHR from a healthcare for children perspective. First, we have to implement HIT that will give us the tools to truly reform health care, then we need to reform payment. Currently, I get paid the same amount as the guy down the street no matter how good or bad a job I do. We're stuck in a de-incentive mode.

One thing to remember is that the opposite of an incentive is a penalty. One of the potential impacts of this discussion down the road, is that once pediatricians move to an EHR and demonstrate meaningful use, payers could then ask them to do the same. In order to demonstrate meaningful use, you have to send information, and then the insurance companies could use this information against you to pay you less money. Insurance companies are always looking for a way to cut payment.

I think in the long run, we're going to win the battle. I want to do better, I want pediatricians to do better, while demonstrating what works best. If it works better, we should do it. That's what we have to look for."

Conclusions

What conclusions can we draw from these perspectives?  PCC agrees with many of the points made by all three of these pediatricians, in the difference between true meaningful use in improving care for patients and the HHS definition of Meaningful Use, which is causing a shift in focus and polarizing the conversation. Unfortunately, the focus is on the money and not truly improving care.

We do, however, believe that if pediatricians strive for true meaningful use in improving care they will succeed, and can do so using existing capabilities of computerized systems (certified EHRs or not). PCC clients are already notifying practices of missing HIB or Flu shots at each visit or tracking, recalling, and educating patients in active obesity management programs, proving that it can be done. Sadly, too many of the existing quality improvement programs have little pediatric focus.

Pediatricians and their practices can also do a lot to right the course of the ship, especially by making their voices heard in ways such as public commentary periods (CCHIT will open one up later this year), Health IT Policy Committee Meetings, or other public forums, like this discussion forum solely focused on meaningful use. PCC will also continue to watch the conversation take shape and keep you informed on PedSource through Chip's Blog, news articles in the library, and in the PedTalk and PartnerTalk discussion forums. Additionally, PCC's Chip Hart continues to participate in the CCHIT Child Health Workgroup, and is focused on voicing the need for a pediatric-specific focus in the discussion.

Finally, each pediatrician should demand pediatric specific functionality from his or her billing service, billing system, or EHR at every possible opportunity. The health care needs of children always take a back seat, especially in the face of Medicare-driven policy decisions; it's time to advocate for yourselves and children!