Meaningful Use: Obstacles in Geriatrics
By Elizabeth S. Roop
Costs and the absence of compelling incentives to invest in health information technology contribute to the sluggish adoption of its meaningful use in geriatrics areas.
As in most healthcare sectors, the adoption of health information technology (HIT) among geriatric care providers is low. It’s a reality that public and private agencies—and providers themselves—hope to change with the promise of incentive funds under the Health Information Technology for Economic and Clinical Health (HITECH) Act.
“Health IT is not at all prevalent in geriatric care settings. In fact, an AHRQ [Agency for Healthcare Research and Quality] report from 2009 notes that HIT usage in the world of long-term care is far behind that in physicians’ offices,” says Patrick Thompson, executive vice president of administration and chief information officer at Amedisys, a Baton Rouge, La.-based provider of home health care and hospice services. “However, there is increasing usage of HIT by home care providers. Several electronic medical record [EMR] companies have programs designed for use by these providers, and data from a recent National Home and Hospice Care Survey found about 41% of home health or hospice providers had EMRs in 2007. That said, in the world of home health nursing, the usage of EMRs is inconsistent.”
Sluggish adoption among geriatric care providers can be traced to many of the same obstacles faced by other provider types. Among the most common are costs and, until now, a lack of any real incentives to invest limited resources into HIT.
However, geriatric care providers also faced several unique challenges. One of the most significant is the lack of commercial options that meet the needs of geriatric care, which is typically provided in multiple settings and by multiple provider types—all of whom would benefit from real-time access to comprehensive patient information.
“EMRs and EHRs [electronic health records] really should start to be the bridge between care planning, healthcare professionals, and maybe even direct care providers, across the continuum, working together on a common template,” says Cheryl Phillips, MD, chief medical officer of On Lok, Inc and immediate past president of the American Geriatrics Society. “Right now, our traditional EMR is a box, a really fancy word processing and billing device. We need so much more for thoughtful geriatric care coordination.”
Phillips, whose organization’s On Lok Lifeways program provides all-inclusive primary, preventive, and long-term care and social services to enable frail elders to live at home, also notes that most commercial EMR offerings simply do not provide the features necessary to drive optimal care.
For example, while tools designed to assess and manage chronic conditions are useful, they don’t distinguish between the needs of younger patients vs. their older counterparts.
“I’m in no way disparaging the EMR as not valuable, but we’re at generation one when we need to be at generation 20,” says Phillips. “We could really be driving optimal geriatric care with more thoughtful geriatric templates and assessment tools and alerts.”
Enter HITECH, Meaningful Use
Because geriatric care is provided in so many settings, many are optimistic that the incentive funds available under HITECH will accelerate adoption within the sector. In a nutshell, there are two programs under which eligible providers can secure incentive payments for the meaningful use of HIT, one for Medicare and one for Medicaid providers. Every eligible provider who is a “meaningful user” of an EMR, as defined by the stage 1 criteria issued by the Centers for Medicare & Medicaid Services (CMS) (see sidebar), can receive up to $44,000 from Medicare or $65,000 from Medicaid.
One criticism expressed by many in the geriatric field is the lack of inclusion of their sector in the discussions about eligibility and structure. As a result, key sectors have been excluded.
For example, “there was no inclusion of the home health and hospice industry at all,” says Michael Fleming, MD, chief medical officer for Amedisys. “However, there are opportunities for us to work in collaboration with others who were included in HITECH. … Data suggests that patient outcomes are better when information sharing takes place among care sites and providers. The implementation and adoption of HIT has also been shown to reduce medical errors and increase resident and patient safety. This information gathering and sharing is the most important solution that HIT provides.”
Phillips points to long-term care as another underrepresented sector. She does not, however, consider it a snub. “I don’t think it was malicious toward long-term care. Rather, the thinking was that long-term care is so far behind that it is a separate strategy,” she says. “Just getting the rural practices and the onesy-twosy practices across the country [to adopt] is difficult enough, so if we have a finite resource, let’s start with that environment. Having said that, it’s not going to happen by wishing.”
Indeed, many in the geriatric care community are confident that HITECH will be the catalyst that drives HIT past the “wish” stage by encouraging broader adoption and use. This, in turn, will deliver the outcomes necessary to convince fence-sitters that HIT can facilitate the information collection and sharing necessary to positively impact care and improve efficiency and productivity.
For example, in the hospital setting, achieving meaningful HIT use will be particularly beneficial to the elder population. This is especially true of criteria mandating the use of e-prescribing, quality measures, and electronic information exchange.
Achieving these capabilities means that “when a patient comes to the hospital, their information will already be populated. It will decrease the patient from having to remember the medications they are on, dosages, etc. It can also [send] reminders to patients when they need preventive care tests,” says Emma Brandon, director of clinical information systems for Camden, N.J.-based Cooper University Hospital.
Brandon suggests older patients will benefit more than others from HIT, as they tend to use medical services more often. “It will decrease repeating the same information at every visit. It will trend tests over a period of time. It will also decrease the amount of redundant, unnecessary tests,” she says.
Indeed, that ability to share patient information was cited most often as the primary overarching benefit meaningful use will have on geriatric care. By enabling providers and caregivers across the spectrum to access the most recent and comprehensive information, HIT will drive improved care coordination and subsequently, improved care outcomes.
“The two [criteria] that really popped out for me were interoperability, which will then allow all different venues of care to communicate, and also e-prescribing with medication reconciliation,” says John Tempesco, FACHE, chief marketing officer for the Informatics Corporation of America (ICA), which takes technology developed by Vanderbilt Medical Center to the broader healthcare market, including a comprehensive health information exchange solution.
He notes that the most common form of medication reconciliation today occurs when a patient or caregiver brings in a bag of medications for evaluation. More often than not, providers will find old prescriptions that were never halted when new ones were written or prescriptions with serious contraindications that were never identified because they were written by multiple prescribers who had no way of knowing what other medications an individual was taking and why.
Widespread information exchange will also benefit older adults who relocate, leaving behind the network of providers who cared for them during the majority of their adult lives. When these individuals become medically dependent, collecting an accurate health history and establishing a comprehensive current view of the patient is nearly impossible.
“All that healthcare knowledge is generally left behind. They must start all over again,” says Tempesco. “So the ability to exchange information not just within but also between communities is going to become more and more relevant as we move forward into this HIT rollout.”
Thompson points to the regional extension centers as a particularly valuable component of the HITECH Act for their ability to accelerate development of the broadband infrastructure necessary to ensure patient data can be exchanged across and between all providers regardless of geographic location.
“The most important development [from HITECH] will be the ability to share appropriate patient data across care settings. Home care nurses could share data directly with physicians and then, on physicians’ orders, share this directly with other physicians or hospitals and emergency departments,” he says.
For Phillips, the most exciting aspect of broader information sharing is the ability to move toward a more holistic approach to caring for the frailest patients. These individuals require a multifaceted care team that can best meet their needs when they have immediate access to any health status changes.
“The design concept that On Lok Lifeways is building its EMR around is that a person’s needs should drive care plans, and care plans should drive documentation of the changes in a person’s life so we can use that in an interdisciplinary function, not just a multidisciplinary function,” she says. “In a community setting, an EMR can become a tool that transcends disciplines and settings of care. What we do with EMRs now is document encounters. When you think about a person-centered care plan, [the EMR] could drive encounters.”
Equally High Skepticism
Expectations may be high in terms of the impact HITECH incentives may have on the adoption and meaningful use of HIT in geriatric care, but so is skepticism. Even those who recognize its value are skeptical that the incentive program, as currently structured, is capable of achieving its goals in the geriatric care sector.
For starters, existing HIT use in the sector is fragmented. Functionality, capabilities, and overall usage vary widely from one provider type to another—something the framers of HITECH failed to take into consideration.
“It always amazes me about Washington that if they come up with a policy or standard, they automatically assume that everyone in the country is up to that level,” says Tempesco. “Our technology is really an interoperability engine that enables people to share information. What we find is that 80% or more can produce information ... but very few have source systems that can consume [that information], that can take an order and produce a result. That has to be the next evolution of HIT to make it truly valuable.”
Rod Baird, president of Geriatric Practice Management, Inc, an Asheville, N.C.-based firm that provides comprehensive physician management services to long-term care practices, is far more blunt. He believes providers who seek out HIT solely to achieve meaningful use under the current rules will wind up with systems that are ill-equipped to meet their needs.
“We have the HITECH Act because … a lot of people for very good reasons were saying we need to have a way of seamlessly exchanging patient information across providers. Lack of ability to do that causes a great deal of delay in decision making and a lot of money. That’s a great idea. But they just took that idea and said it will work everywhere. They then imposed this standard on a world where it works in half, but in the other half it doesn’t,” says Baird.
He adds that the problem stems from the exclusion of the geriatric sector from much of the dialogue that led to development of the meaningful use criteria. As a result, policy makers failed to take into consideration the reality that geriatric providers are rarely able to document patient histories in black-and-white, standardized detail.
Attempting to do so results in “a medical record that is unintelligible,” he says. “When you start dealing with chronically ill older adults as opposed to ambulatory people with emergent problems that lend themselves to quantification, you need to know how someone feels about five and six things, things you’re not going to be able to fix. You’re not going to be able to make them well, but they will hopefully be less impaired by the ailments they have. It’s a judgment and that is something you really don’t get the way EMRs are envisioned and structured, with drop-down menus around objective data mostly related to diagnosis.”
Another danger of attempting to force a structured approach on the geriatric care community is that it may result in physicians making decisions that, while in line with general best practices, run counter to best practices for geriatric patients.
Baird points to the Beers Criteria, a national guideline and reference guide designed to improve the use of medications for elders that is incorporated into most e-prescribing software. These criteria prompt systems to generate an alert or warning if a physician attempts to prescribe a drug that is contraindicated.
For example, Beers flags benzodiazepines as drugs that should not be prescribed because of their dangerous side effects. However, many physicians prefer the use of these drugs to manual restraints for elder nursing home patients suffering from dementia whose behavior becomes unsafe.
“If you’re in a niche world where best practices are contradictory to what the ‘techno-weenie’ programmers say, you’re going to get called to the carpet. That is the real outcome,” says Baird. “We’ll make all kinds of things go wrong clinically; more people will be going to the hospital because physicians won’t take the liability for being the bad actor.
“The government has subdivided its purview into logic-tight boxes and when you span multiple boxes, you can get skewered,” he adds. “We’re dealing with conflicting government mandates. Each on its own may be logical, but when you put them together, they’re not.”
Waiting It Out
Despite his skepticism, Baird remains confident that the CMS will tweak and clarify the existing meaningful use rules to eliminate the contradictions and make it possible for niche providers to benefit from HIT and HITECH.
Until then, he recommends that those who can wait to implement new systems do so. For example, those who are eligible for both the Medicaid and Medicare programs can wait until 2015. Medicaid-only providers can wait until 2016, while Medicare-only providers can wait until 2015.
“If you can avoid being subject to that standard, it’s best to wait until they find out they’ve made a mistake and change it,” Baird says, noting that while Medicare payments are greater for early adopters, the cost of implementing an ill-fitting EHR system may be greater than the incremental revenue. “There is no point in being an early adopter because you can’t do it without Herculean effort and you get no credit.”
Meanwhile, Baird’s company will continue developing interfaces and other modifications for existing systems that will enable member physicians to reap the benefits of HIT. In doing so, they will also be better positioned to achieve meaningful use once standards have been adjusted appropriately.
“Instead of making them lose productivity, I can make doctors happier and more successful by giving them an interface to make them analog providers while I figure out how to digitize the parts that need to be digitized to meet meaningful use criteria,” he says. “It’s all about merging technology with care.”
— Elizabeth S. Roop is a Tampa, Fla.-based freelance writer specializing in healthcare and health information technology.
Breaking Down the HITECH Act and Meaningful Use
The definition of an eligible provider (EP) differs based on the specific incentive program, though in the case of both Medicare and Medicaid, it is based on individual providers. Therefore, each EP within a multiprovider practice may qualify for one incentive payment per year as long as he or she demonstrates meaningful use.
Under the Medicare program, an EP is defined as a doctor of medicine or osteopathy, doctor of dental surgery or dental medicine, doctor of podiatry, doctor of optometry, or chiropractor who is not hospital-based.
A Medicaid EP is defined as a physician, nurse practitioner, certified nurse midwife, dentist, or physician assistant; is not hospital-based; and has a minimum 30% Medicaid patient volume (20% for pediatricians) or practices predominantly in a federally qualified health center or rural health center and has a minimum 30% patient volume attributable to needy individuals.
Hospitals eligible for Medicare payments are paid under the hospital inpatient prospective payment system and must be located in one of the 50 states or the District of Columbia. For Medicaid, eligible hospitals are acute care facilities with at least 10% Medicaid patient volume or children’s hospitals.
In terms of demonstrating meaningful use, the following is a partial list of stage 1 meaningful use criteria issued by the Centers for Medicare & Medicaid Services (CMS). As follows, each criterion applies to EPs and eligible hospitals unless otherwise stated:
A comprehensive criteria list and other program information can be found at the EHR Incentive Program section of the CMS website at www.cms.gov/EHRIncentivePrograms.