A Neurologist's View of Meaningful Use

to make achieving it less burdensome on the clinical practice of neurology?

The Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) issued a policy on December 30, 2009 setting forth the proposed rules describing how hospitals and physicians could qualify for government money to support the adoption of an EHR. These rules define the so-called “meaningful use” of an EHR as set forth in the HITECH Act, designed to serve as an incentive to promote EHR adoption by reducing the financial burdens these systems impose. The rules were published in the Federal Register on January 13, 2010 (http://bit.ly/dabCMT).

The main provisions of the rules allow for up to $44,000 of incentive monies to be available to an eligible professional (EP). Separate regulations for hospitals were published and will not be discussed here.

It is proposed that the requirements to qualify for this meaningful use of technology occur in three stages. Since first-year use requires only three months of continuous utilization, in order to qualify for the first year of eligibility (2011), an EHR must be implemented and fully functional by October 1, 2011. Instead of discussing all of the individual regulations, (anyone interested can visit http://bit.ly/dabCMT), I will discuss those provisions that are of particular interest to neurologists. (The table on page 22 outlines these provisions).

What changes are needed to the definition of meaningful use of EHR adoption in order

It is important to recognize that this is an ambitious endeavor and the strict mandates reflect the large commitment by CMS to financially support EMR adoption. The technological requirements are particularly progressive. Standardizing data sets and

requiring the true interoperability between disparate systems is certain to go a long way toward the development of a functional national health information network. However, from the clinical perspective, there are provisions in the meaningful use criteria that run counter to current clinical practice and will not further any goals stated by CMS. It is my contention that technology should support the practice of medicine and we should not alter our delivery of care just to justify the adoption of an EHR. As a neurologist, I am most concerned about the quality measures selected for our specialty.

Specifically, PQRI 201 and 203 do not reflect current patient management standards. It is usually a primary care physician (PCP) who treats a patient’s hypertension or hyperlipidemia. In general, neurologists are not trained in the management of these disorders, and our offices are not set up in such a way to optimally treat them. PQRI 202 should also rightly be considered in the realm of the PCP since it would be most efficient for the emergency physician who is deciding about the appropriate lipid management to be responsible for lab investigations. I don’t think that within the definition of “meaningful use,” CMS intended to alter the practice of medicine in such an irrational fashion. The AAN would be glad to supply evidence-based quality data that could be collected regarding conditions within our specialty (eg, Parkinson’s disease, epilepsy, neuromuscular disorders, or Alzheimer’s disease) to show how the EHR can be used to actually improve the quality of patient care. Finally, PQRI 33 applies to hospital-ized stroke patients discharged from an inpatient facility; it is information that would not be captured in an office visit, and so again, should not be used as a demonstra-tion of the meaningful use of an EHR in the outpatient setting.

I do not see how all physicians being required to report the core measures of blood pressure, BMI, and smoking use provides benefit to the patients. As long as the PCP or relevant specialist obtains the informa-tion, the patient receives maximum benefit. Requiring multiple physicians to obtain the same dataset is simply redundant. No improvement in quality of care or demonstration of meaningful use results from this duplication of effort. Finally, in regards to NQF 0022, who decides which medications are excessively dangerous in the elderly and using what criteria? Let’s take a look at the objectives and measures for a couple of the meaningful use criteria and examine several challenges they may pose to a neurology practice. You can find the full set of criteria at http://bit.ly/64CuoH.

Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, and allergies) upon request… within 48 hours.

EP Objective:

Patients must be provided with timely electronic access to their health information (including lab results, problem list, medication lists, allergies) within 96 hours of the information being available to the EP. Timely is defined as within 96 hours of the information being available to the EP, either through the receipt of final lab results or a patient interaction that updates the EP’s knowledge of the patient’s health.

Two of the time-limited criteria need further definition. To make the patient information available “in 48 hours” requires some clarification. What if the request arrives on a Friday afternoon? Is a practice required to have the information available on Sunday? Also, requiring the results of labs and X-rays to be available to the patient within 96 hours of the information being available to the EP could also use clarification. When does the clock actually start ticking? What if a lab says the information was sent via fax or even in a discreet electronic format, yet the clinician never receives the information? I am concerned that these inherent ambiguities may make meaningful use impossible to establish.

Provide clinical summaries to patients for each office visit.

EP Objective:

Clinical summaries must be provided to patients for at least 80% of all office visits. The clinical summary can be provided through a PHR, patient portal on the website, secure e-mail, electronic media such as CD-ROM or USB fob, or printed copy. The after-visit clinical summary contains an updated med-ication list, laboratory and other diagnostic test orders, procedures, and other instructions based on clinical discussionsthat took place during the office visit.

It seems like a logical inconsistency to say on one hand, “We do not propose to include the objective ‘Document a progress note for each encounter’” and yet require the clinician to provide that very information to 80% of patients at all office visits. There clearly needs to be a visit summary available to satisfy this measure; why not make the meaningful use criteria reflect this fact? Finally, I do have some concerns about providing patients unfiltered access to the raw lab and X-ray data. I realize this is the patient-centric, correct thing to do, but an unintended consequence may be the unnecessary patient concern and anxiety this may produce. I can envision numerous phone calls and office requests resulting from these concerns. This may place further demand on physicians and office staff with no provision to compensate offices for these increased patient demands.

Dr. Zuckerman is an MDNG editorial board member and chief of neurology and medical information officer, Baton Rouge General Hospital, Baton Rouge, LA.