Dr. Farzad Mostashari, the National Coordinator for Health Information Technology, gave opening remarks at ONC’s Health Information Technology Policy Committee meeting. He discussed some of the latest happenings since the last HITPC meeting. This past interim, there were apparently several not so flattering commentaries in the newspapers. He described it as 3 acts in a play.
There were some opinions that ONC is acting as a cheerleader. A review of some cost benefit analysis was done on Meaningful Use incentives and said the data has not demonstrated any cost savings or real health benefit. Further these opinions apparently went on to say that the Meaningful Use effort is misguided and a waste of money. Another large criticism that came Dr. Mostashari’s way was that the government had not yet set any real standards for Health Information Exchange (HIE).
Dr. Mostashari responded by saying there were actually 31 cost studies done on this topic, and 27 out of 31 actually describe some cost benefit – not exactly the “rare exception” described. In addition, Dr. Mostashari asked the question, “if we increase A1C measures for diabetics and save 2 amputations – is it worth it?”
What we’re seeing is that health information technology (HIT) is an infrastructure that once in place, you can do any number of studies and improvements. The question isn’t if we need HIT infrastructure, but really the question is how do we do it and how do we maximize its use?
There are any number of stories of success, like the Minnesota diagnostic imaging scans that went electronic. Before the electronic infrastructure, the decision to approve a scan was convoluted and took 10 min or more. They asked the question, “could we use our electronic health record (EHR) for this approval process by coding the approval logic right into the system?” Once they did, they saw a dramatic decrease in inappropriate and duplicate scans, and it took only 10 seconds for approval.
As for the assertion that “there are no standards”, Dr. Mostashari pointed out that many use cases are now beginning to arrive at consensus standards precisely because of Meaningful Use. It has taken some time, but stage 2 will show some really big changes in the near future. He pointed out that many of the standards are cataloged at the Meaningful Use Stage 2 Standards-Hub.
A series of articles in several news papers around the country came out regarding billing. They found that the decade before meaningful use (2000 – 2009), there was an association between higher severity codes and payments. The implication was that this meaningful use government incentive program to encourage adoption of electronic health records may have had an unintended consequence of increasing both the number of requests and cost of severity codes. Actually, Dr. Mostashari said, it is unclear if many things were simply under coded and now are captured or if there is a great deal of fraud. It is also not clear what the final and total impact is on cost. It is entirely possible that admission levels have improved despite these changes in coding. More substantially, meaningful use was a conscious effort to move systems away from documentation and billing and toward patient centered care coordination and population health. “If we continue to pay for documentation and more visits, that is exactly what we’ll get.”
Farzad mentioned that 76 percent of plans and medical homes expect to be in an Accountable Care Organization (ACO) pay model. You simply can’t do a better job of measuring care without access to good information.
In addition, immutable health logs, a byproduct of meaningful use, help to enforce against fraud. If care is documented that didn’t actually occur, then that is bad care and illegal and we take that very seriously.
We also just heard about results of the open notes project (sponsored by RWJ). Something like 99% of consumers and 100% of providers in the project want this practice of secure and full access to medical records for all appropriate parties to continue to be offered. Again this sort of practice will go a long way to discover out and out fraud.
With all of that said, it is incumbent upon us the HIT policy committee to take another look at documentation for medical purposes and offer guidelines and policies for what is good medical documentation. We need to find out what would be good EHR functionality and what is just “over the line”. Too much documentation just for higher billing codes, bypassing the audit log, or skipping record amendments where we can clarify should be considered in that discussion.
There is real change beginning to occur on the ground. But don’t expect this to be a one shot success. It is and always has been a staged approach. The first stage is collecting structured data. The second stage is thinking about population health and data sharing. The third stage is really getting to the meaningful use of electronic medical records. One commenter said, “let’s be patient here, you can’t ask a two year old to do six year old tricks.”
The largest ever study of diabetes is underway through electronic EHR data and initial findings indicate remarkable improvement in patient care. We owe it to practitioners and vendors to set ambitious goals, provide guidance, and maybe even a little bit of cheerleading.