'Meaningful Use' by Micky Tripathi

Today, the federal Health Information Technology Policy Committee will meet in Washington. For those of us living in the world of health IT, these are incredibly exciting times. There is now broad recognition that greater use of health information technology will have to be part of any solution to reforming the system going forward, and health reform itself is finally getting the attention it deserves. Perhaps most important, the federal government is poised to spend roughly $47 billion (yes, that’s billion with a “b”) on health information technology over the next decade.

The challenge now is figuring out how to spend this $47 billion wisely. The vast majority of the money – about $45 billion – will come in the form of direct payments to physicians and hospitals starting in 2011. Physicians who see a lot of Medicare or Medicaid patients can qualify for up to $44-$65 thousand each for converting to electronic health records. A hospital that crosses the digital chasm will receive federal incentives in the millions of dollars.

Of the remaining $2b in federal funds, a portion will be awarded to states to create secure data networks so that patient records can be more easily shared among care providers. The rest of the money will be used to fund “regional health information technology extension centers,” which will provide implementation assistance to hospitals and physicians going through the challenging process of converting from paper to electronic records.

The watchword for this new federal funding is a new term that’s entered the health IT lexicon: meaningful use.

In order to receive the federal funds described earlier, physicians and hospitals have to demonstrate that they are using the systems “meaningfully”, that is, according to federal and state guidelines designed to ensure that our taxpayer dollars aren’t going just to computers but ultimately to improved quality and affordability of care. In other words, physicians and hospitals have to not only buy the new systems, they have to prove that they’re using them to improve care before they’ll qualify to get any money back from the government.

While the exact definition of meaningful use is still being finalized, we have a pretty good idea of what it’s going to require. And it’s all good stuff. But nothing worth achieving comes easily, and for most physicians, meaningful use will be no exception. The requirements start off slowly, but they ramp up pretty quickly. For example, in the first phase, by 2011, physicians have to be prescribing medications and getting laboratory results electronically. This may not seem that hard, but the reality is that the majority of physicians don’t do this today. Nationally, only 12% of physicians prescribe electronically, accounting for a paltry 4% of prescriptions. Massachusetts is the leading state in the country in terms of electronic prescribing, but we’re still only at 30% of physicians, so even though we’re ahead of the rest of the country, we’ve got a lot of work to do over the next couple of years.

The second phase of meaningful use will be a big step up and, if it’s even remotely successful, will spur substantial changes in the way health care is conducted. By 2013, physicians and hospitals are going to have to be electronically linked to each other, and they’re going to have use these links for transmitting medical records such as referrals and hospital discharge summaries. In addition, both hospitals and physicians are going to have to make records electronically accessible to patients through so-called “personal health records”. Finally, hospitals and physicians are going to have to be able to send important public health information electronically to public health agencies, and be able to electronically receive public health alerts in return.

All of this may not seem that difficult in the modern internet era, but believe me, it’s going to be extremely difficult. Why’s that? First off, this isn’t Facebook. Sharing data electronically has to be done securely and reliably with security standards and privacy rules that exceed the standards used for web-based banking, for example. In addition, health care isn’t like the banking industry, which is mostly made up of large, corporate institutions that have in-house technical staffs to manage such projects. Health care is a cottage industry. About 90 percent of non-hospital medical visits occur in small physician practices – the medical equivalent of “mom and pop” stores – who don’t have the technical expertise to manage sophisticated computer systems. I doubt that we’ve seen in the history of technology a greater mismatch between the complexity of the systems we’re putting in place and the readiness of the users who are going to be using them.

So what’s going to prevent this from being a complete disaster? We need to recognize that we’re going to have successes and failures. Much of the heavy lifting is going to fall on state governments, which is both a blessing and a curse. It’s a blessing because health care is local, and state governments are much more attuned to local needs than the federal government could ever be. It’s a curse, however, because some states aren’t nearly prepared to shoulder this responsibility.

It’s unclear what the right model is going to be for getting this done right, and like many federal programs, the states are going to be the “laboratories of democracy” which test a wide variety of models. We are already seeing some divergence in state approaches. With regard to governance, some states, such as New York, Rhode Island, and California, are designating non-profit, public-private partnership organizations to act as strategic partners with the state in the management of these funds. Other states, such as Massachusetts, have decided to place the federal funds in state coffers and manage them through existing state procurement channels. With regard to investment strategies, some states, such as New York, Maryland and Vermont, are investing tens of millions of dollars on infrastructure that will allow physicians and hospitals in their states to more quickly and easily achieve meaningful use requirements. Other states are husbanding their funds in the hopes that they can be leveraged to get more federal funds in the future. Massachusetts, for example, has purchased only studies with the $15 million in health IT budgeted in last year’s Health Care Cost Control Act.

My personal opinion is that each state should be focused on a single measure of success – helping the physicians and hospitals in their state to be able to get as much federal incentive dollars as they can, as soon as they can. I believe that states that are investing now and are also forging strategic partnerships with the private sector are going to be the most successful at achieving this objective. Of course, what we’re about to embark on has little precedent, so no one can claim to know the right answer — only time will tell.

Micky Tripathi
President and CEO, Massachusetts eHealth Collaborative

This program aired on August 14, 2009. The audio for this program is not available.


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