Meaningful Use Stage 3: Looking Ahead

The June Federal Advisory Committee (FACA) meeting on Healthcare IT published the minutes of their meeting this week along with its recommendations for revising Meaningful Use (MU) Stage 3.  While Stage 2 has yet to be finalized, the scope and content of these recommendations clearly points to a subtle, yet important change in the long-term direction of MU. We would like to focus on two areas we feel will have significant impact on having Meaningful Use continue to improve healthcare.

These recommendations are focusing on patient safety and care efficiency at a global level, and they should be viewed as a positive step in improving our healthcare system.  Included in the revisions of Stage 3 would be recognition that healthcare delivery is a continuum, and coordination across all providers at all levels is a cornerstone of effective healthcare.  If these Stage 3 recommendations were to be implemented, then coordination of care would begin in the acute care setting, but electronic integration to sub-acute and/or long term care providers would be a necessary component.  This also recognizes that long term care (LTC) is now providing services previously available only in the acute care setting with the proof being the steady decline in acute care beds while LTC bed capacity continues to grow.

The problem is that LTC is far from ready to integrate with hospital EMRs.  We also have to recognize that unlike an acute care hospital, the phrase “LTC” reflects a variety of facilities that includes Long Term Acute Care (LTAC), Skilled Nursing (SNF), Home Care (HC) and Assisted Living (AL).  Presently, no significant federal funding programs exist to help these facilities implement EMR systems, and even if there were, vendors have been slow to develop LTC EMR systems that reflect the nomenclature, billing, and the scope of care delivery systems found in LTC.

The LTC EMR problem is made even more difficult in that physicians frequently coordinate care but not necessarily while at the facility. This would then require there be some sort of information exchange backbone that brings all the components together independent of where they are.  Health Information Exchanges (HIEs) are becoming more prevalent and the market does have a number of excellent mobile solutions for gathering data, but the technology needed to shunt bidirectional information to and from the provider and to the appropriate EMR (hospital, LTC, office) is still in its infancy.  If we include other providers such as physical therapy, home infusion and other services that are now solidly integrated into LTC, then the amount of work needed to be done and the money to do it with may very well dwarf what has been needed to implement hospital EMRs.

Quality was also foremost on the FACA agenda.  Quality is intimately tied to clinical decision support (CDS) and there is a high level of consensus that this must be driven through standardized data gathered from the EMR.  In order for this to work, however, a number of elements must be in place for this to work.

Hospitals and providers need to have a standardized clinical content reference tool that is seamlessly integrated into the EMR.  This content needs to be coupled with the use of standardized order sets that are structured on evidence-based medicine recommendations but also allows the incorporation of proven best practices for the organization.  The recommendations look to the EMRs to provide this, but    while EMR vendors have suggested that they either have the tools already in their products or that it will be available soon, the market has not been satisfied with what they have seen.  These organizations then look to purchase proven CDS workflow and surveillance tools from third party vendors.  We should not expect this trend to vary. Rather, EMRs should look to facilitate integration with these tools, or the Stage 3 recommendations for quality measurement cannot be achieved.

It was announced that the Committee would begin public comments in November; however with the elections at the same time, it is doubtful that no matter which party gets the keys to the White House in January, any final revisions to Stage 3 would not be presented until well into 2013.  Nevertheless, the ensemble of the proposed revisions do make sense for improving quality, increasing the efficiency of care, and keeping healthcare costs from bankrupting the country.  The problem is that the planners have to look at the totality of their recommendations, and now is the time to identify all the components and interactions these recommendations have and to determine the cost, time, and systems needed properly implement them

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