Clinical informatics specialists: We need to bring reality into Meaningful Use

Many providers simply aren't on the same playing field when it comes to Meaningful Use, which has played a big part in attestation, according to Dawn Ross, clinical informatics director for Indianapolis-based Indiana University Health.

"There are different levels of interoperability and we're not on the same set of measures," Ross said. "An example is [transmitting] transition of care summaries. What if there's not another Stage 2 provider around? In Indiana we have an amazing health information exchange [that enables us to meet that measure], but others don't have that benefit."

In an exclusive interview with FierceEMR, Ross and Raymon Nance, director of information services at Washington Regional Medical System in Fayetteville, Arkansas, discuss EHR implementation and government mandates from their vantage points as clinical informatics specialists. They talk about their successes and frustrations, as well as their wish lists for future federal efforts. 

FierceEMR: There's been a lot of talk about the Meaningful Use attestation numbers for the 2014 reporting period, especially for Stage 2. Have you attested this year and if so, describe the process.

Dawn Ross: We have met the measures and are attesting [this] week.

Raymon Nance: We have attested to Stage 2, and used the 2014 certification codes. It was similar to attesting to Stage 1, except that in Stage 1, CMS asked for quality measures using common terminology, like "Stroke 1." In Stage 2, there was a different numbering scheme with IRQs, and I didn't have the cross references. I had to run back to my office in the middle of attesting [and get that]. 

FierceEMR: Why do you think so many providers are struggling with Meaningful Use attestation?

Ross: They're not on the same playing field. We have the minor and major leaguers.

Nance: Dawn is exactly right. No one around [my health system] is at the same stage. There are zero providers in Northwest Arkansas I can submit to. People are two to three cycles behind. And from the patient view, I understand why [patient engagement] is being done, but the onus is on the provider to get patients to log into a portal no one is interested in. My parents are just getting Internet on their street and have no interest in the computer.

Also, for those using the flexibility rule, attesting will be a bit more challenging because it combines different levels of codes. You need to have the certification number in hand for each code before you click on any button to attest.

FierceEMR: What are some of the challenges or inadequacies you're finding with the Meaningful Use program?

Nance: There is no such thing as an HL-7 Standard. Vendor 1 may take Segment 1 [of the Standard] and put something in it, and Vendor 2 adds something different. There's also no standardization of the information. We're running so fast that everyone is building nonstandard information just to click on a box and meet Meaningful Use.

It creates extra work and expense. Look at transition of care. We used to hand it to the patient. Because of Meaningful Use, we need to add other elements. Now a copy is handed to the patient, we fax it, we send it electronically, take a picture of it to measure it, and upload it to the patient portal. Maybe it would be better to just load it to the portal and let patients know it's there.

Ross: We really need personal health records, not patient portals. I have five providers [personally] and three portals. You really only need one personal health record, and the health information exchanges could take care of that.

Also, in some instances, the Meaningful Use criteria are further behind that where some [providers] are. We had a great discharge process. But now we're sending a transition of care summary that's not as good as what we had before and not as useful.

FierceEMR: What suggestions do you have for Stage 3?

Nance: It's hard to figure out where to be in Stage 3. Take interoperability. I might be able to share [data] but it may not be in a format that Dawn can read.

One of the challenges in the development process is to come up with a great idea and sit with stakeholders, like nurses, to design it, looking at workflow needs, then go to the programmers, test it, validate it in your workflow and push it out. Here we have a great idea: Meaningful Use and interoperability. But with the government process, the great idea goes straight to the developers. They have to run so hard to program and can't operationalize it until it's in the systems. We're missing the step to operationalize it before developing it. That would not only help the vendors build the systems better but EHRs could be rolled out better.

Ross: It's like designing a house but missing out on the blueprint and designing. And vendors need more time to code for [the changes in the Stages in Meaningful Use]. There needs to be more time from the governmental mandate to when it's implemented.

Nance: You also have to look at the value [of a requirement] against its cost. The advance directives objective in Stage 1 adds value because you now know if a patient has one. But in Stage 3, we'd have to store it or track it to prove that the patient gave us an advance directive. That increases costs because it takes longer for our registration clerks, additional screens in the EHR and storage or scanning. It brings value, but at what cost?

Or look at demographics. I understand collecting that information [is important] for analytics. But without demographics, we couldn't bill. We've had to do it right for 20 years. [Adding that to Meaningful Use] doesn't bring that much value to quality of care.

Nance: If I could dream and afford it, I'd go to Washington D.C. for a month [and confer with those creating the Meaningful Use program]. There are tremendously smart people in D.C. and they give us a high road vision. But we need to bring reality in. Bring in a group of people at the grassroots level and go through, measure-by-measure, before [the government] writes the final regulations. Take practical people and ask if adding gender preference [to the Meaningful Use program] would add value, and then add or not add or modify. Then we would have an excellent product.

Ross: Asking about sexual preferences won't drive patient satisfaction in my facilities.

FierceEMR: What advice do you have for other providers in the program?

Ross: It's important to get out there to comment on proposed Meaningful Use regulations. The government wants our feedback. But don't just complain in them. Be very specific about what the proposals mean [to your organization] technically, operationally and clinically.

You also need a team or person responsible for knowing what the regulations mean and the measures. I'm not an expert on every measure. If you [understand Meaningful Use] you can show how beneficial it is to the patient and show that value to the doctors.

Nance: We're heading in the right direction. Meaningful Use is the right thing to do. EHRs are much more meaningful today than they were five years ago. I see patients in the future asking their providers if they're meaningful users. We just need to know how to get there without the challenges and more benefit.  

Editor's Note: This interview has been condensed for clarity and content.