Unfiltered: Comments on the June 16th Draft of "Meaningful Use"
By Todd J. Fisher

ED NOTE:
Changes to the criteria for CPOE adoption and an accelerated schedule for allowing real-time access to patient information via PHRs were among the updated recommendations for meaningful use when the HIT Policy Committee of the Office of the National Coordinator for Health Information Technology met last Thursday, July 16. Prescient as always, Todd Fisher shares his observations of the initial draft. A link to the Meaningful Matrix from last week’s committee meeting is at the conclusion of this article.

On June 16th, the administration released the first draft outlining their healthcare policy priorities, goals, and objectives with respect to “meaningful use”. I’d like to provide my initial impressions of the administration’s first draft of what is unquestionably the most important set of definitions being reviewed, analyzed and interpreted by the healthcare provider and technology communities today.

First, let me begin by stating that I recognize what was provided on June 16th was an initial draft. Rumors have suggested, in fact, that Dr. Blumenthal indicated he was displeased with the first draft and is asking to have a new draft prepared in the short term. While I was not able to confirm this directly, after reviewing the complete draft thoroughly, I can see how Dr. Blumenthal might consider the initial draft inadequate and in need of much work.

Overall, I'd say the document was assembled very quickly, with little thought provided by people who have actually implemented systems in support of the delivery of care. I know that sounds harsh, but that is my candid opinion. While my comments could probably go on for pages, in the spirit of brevity, I’d like to provide comment on just a few aspects of the proposed "meaningful use" document:

1. The stated “Health Outcomes Policy Priorities” are massively broad and do not lend themselves well to the development of a meaningful strategic plan regarding healthcare IT. By “meaningful strategic plan”, I mean a strategy that can be readily broken down into tactical components.
   
   
2. The “Care Goals and Objectives” are not well articulated or linked. Their current form gives the impression of arbitrariness. Alternatively, I could argue that their current “Care Goal – Objectives” were created to align with specific solutions in mind. It is a gross failure of common sense to assume today’s solutions is the best we can do technologically. The “Care Goal – Objectives” should assume technological innovation and advancement – should encourage it, in fact. The way the “Care Goal – Objectives” are written seems to stifle innovation by assuming existing technologies.
   
   
3. There does not appear to be a standard dictionary of terms. I saw at least three different terms that I believe were intended to refer to what many in the healthcare community would refer to as a Continuity of Care Document (“CCD”). If something like that, something recently touted as so important by so many thought leaders in the healthcare community, can’t be proof-read and distributed with common reference, little room is left for confidence in the components comprising the balance of the draft document.
   
   
4. Many of the measurement objectives are impractical. Often, if one were to truly think through what is being asked of in the measurement objective, one would quickly realize there is no way for an organization to know the type of information required without conducting a complete census. I’m specifically speaking of the objectives that call for a measure of the percent (%) of patients who use this or that. You’d have to know the entire universe of patients to begin the calculation.
   
   

In the spirit of offering a solution and not just a complaint, a much better approach would be to measure adoption of the technologies over time against the outcomes of those patients benefiting from the technology and the cost to deliver care. We know what patients are benefiting from the technology – we capture that information (by "we", I mean the provider community).

Lastly, I don’t believe there is one objective that discusses or encourages the measurement of the cost of care. I thought the four pillars of “meaningful use” were improved patient outcomes, improved physician/patient relationships, measurability of progress, and cost containment.

Now that I've discussed some of what’s wrong or lacking in the administration’s initial "meaningful use" draft, allow me to entertain what I believe to be good aspects of the draft:

1. The idea of providing analytical capabilities to derive new approaches / medical protocols makes great sense and certainly should be part of any meaningful use definition.
   
   
2. The implicit simplification of Ambulatory EMR (“AEMR”) products is a good thing. It is my opinion that most AEMRs are over-engineered and contain a myriad of unused features. These features add complexity and cost to the acquisition, implementation, and support of AEMRs. That may explain the relatively low AEMR adoption rate to date. When in doubt, simplify.
   
   
3. Generally, establishing a framework within which HIT vendors can ensure they are providing useful technology based on meaningful priorities and objectives is a good thing. As you are aware, there are numerous HIT vendors that make software specifically tailored to wrestle providers’ burdensome, inefficient back office operations to the ground. While the American healthcare system has pushed HIT vendors and providers in this direction, such technology ultimately does little to keep costs down and improve patient care. In fact, the need for such technology often drives costs up and definitely creates unnecessary barriers between the physician and patient during visits, as non-patient care data is collected over and over again, turning 10 minutes with your physician into 4 minutes. The care experience is thus damaged.
   
   

Those creating guidelines for “meaningful use” must rely upon our experiences, as care providers and technologists whose focus has been and continues to be on enhancing patient care and containing costs.

Meaningful Use Matrix, July 16, 2009

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