Blog

 

Meaningful Use Part One

Thursday, November 15, 2012 // Uncategorized

EMRs (electronic medical records) = EHRs (electronic health records)

They are supposed to help improve the quality of medical care in this country.  To this end the federal government is giving financial incentives for their adoption.  This includes incentives to purchase and install the software and to use it.  The last bit entails “Meaningful Use”.  This is the term coined for the use of the software.  It has to be able to perform certain tasks.  All of this sounds laudible, but the road to hell in medicine, as in life, is paved with good intentions.  There is an extraordinary drop in productivity while physicians struggle to check the boxes.  Patients will notice that there doctor or his extenders is spending a lot  clicking on  these boxes so that they can get paid 1% more from Medicare.  Here is one of the original articles in the New England Journal.  Many of the ideas that became law seem to originate in Boston.  It’s a classic disconnect between the Ivory Tower and the real world and between the federal government and those in the frontline of patient care.

Perspective

The “Meaningful Use” Regulation for Electronic Health Records

David Blumenthal, M.D., M.P.P., and Marilyn Tavenner, R.N., M.H.A.

N Engl J Med 2010; 363:501-504August 5, 2010DOI: 10.1056/NEJMp1006114

Share:
 
 
 
 
 
 

Article
Citing Articles (129)

Letters

The widespread use of electronic health records (EHRs) in the United States is inevitable. EHRs will improve caregivers’ decisions and patients’ outcomes. Once patients experience the benefits of this technology, they will demand nothing less from their providers. Hundreds of thousands of physicians have already seen these benefits in their clinical practice.

But inevitability does not mean easy transition. We have years of professional agreement and bipartisan consensus regarding the potential value of EHRs. Yet we have not moved significantly to extend the availability of EHRs from a few large institutions to the smaller clinics and practices where most Americans receive their health care.

Last year, Congress and the Obama administration provided the health care community with a transformational opportunity to break through the barriers to progress. The Health Information Technology for Economic and Clinical Health Act (HITECH) authorized incentive payments through Medicare and Medicaid to clinicians and hospitals when they use EHRs privately and securely to achieve specified improvements in care delivery.

Through HITECH, the federal government will commit unprecedented resources to supporting the adoption and use of EHRs. It will make available incentive payments totaling up to $27 billion over 10 years, or as much as $44,000 (through Medicare) and $63,750 (through Medicaid) per clinician. This funding will provide important support to achieve liftoff for the creation of a nationwide system of EHRs.

Equally important, HITECH’s goal is not adoption alone but “meaningful use” of EHRs — that is, their use by providers to achieve significant improvements in care. The legislation ties payments specifically to the achievement of advances in health care processes and outcomes.

HITECH calls on the secretary of health and human services to develop specific “meaningful use” objectives. With the Centers for Medicare and Medicaid Services (CMS) in the lead, the Department of Health and Human Services (DHHS) has used an inclusive and open process to develop these criteria, providing an extensive opportunity for public and professional input. The department published proposed meaningful use requirements on January 16, 2010. The proposal prompted some 2000 comments. This week, the DHHS is releasing a final regulation for the first 2 years (2011 and 2012) of this multiyear incentive program. Subsequent rules will govern later phases.

Although the intent of our January proposals has been retained and indeed affirmed through the rule-making process, the final regulation also incorporates significant changes — a response to the comments and experience that diverse stakeholders shared with us. In particular, concerns about the pace and scope of implementation of meaningful use led us to adopt a two-track approach regarding the objectives that allow practices and hospitals to qualify for incentive payments in the first 2 years of the program.

The most important part of this regulation is what it says hospitals and clinicians must do with EHRs to be considered meaningful users in 2011 and 2012. In the original proposal, we identified a broad set of objectives, all of which would need to be met. This included 23 objectives for hospitals and 25 for clinicians. The DHHS received many comments that this approach was too demanding and inflexible, an all-or-nothing test that too few providers would be likely to pass.

In the final regulation, we have divided these elements into two groups: a set of core objectives that constitute an essential starting point for meaningful use of EHRs and a separate menu of additional important activities from which providers will choose several to implement in the first 2 years (see tableSummary Overview of Meaningful Use Objectives.).

Core objectives comprise basic functions that enable EHRs to support improved health care. As a start, these include the tasks essential to creating any medical record, including the entry of basic data: patients’ vital signs and demographics, active medications and allergies, up-to-date problem lists of current and active diagnoses, and smoking status.

Other core objectives include using several software applications that begin to realize the true potential of EHRs to improve the safety, quality, and efficiency of care. These features help clinicians to make better clinical decisions — and avoid preventable errors. To qualify for incentive payments, clinicians must start employing such clinical decision support tools. They must also start using the capability that undergirds much of the value of EHRs: using records to enter clinical orders and, in particular, medication prescriptions. Only when providers enter orders electronically can the computer help improve decisions by applying clinical logic to those choices in light of all the recorded patient data. And to begin extending the benefits of EHRs to patients themselves, the meaningful use requirements will include providing patients with electronic versions of their health information.

In addition to the core elements, the rule creates a second group: a menu of 10 additional tasks, from which providers can choose any 5 to implement in 2011–2012. This gives providers latitude to pick their own path toward full EHR implementation and meaningful use.

For example, the menu includes capacities to perform drug-formulary checks, incorporate clinical laboratory results into EHRs, provide reminders to patients for needed care, identify and provide patient-specific health education resources, and employ EHRs to support the patient’s transitions between care settings or personnel.

For most of the core and menu items, the regulation also specifies the rates at which providers will have to use particular functions to be considered meaningful users. Reflecting the views and experiences shared during the comment period, these rates will enable significant progress toward improving care — but are also achievable by average practices and providers in the early years.

The HITECH legislation further requires that meaningful use include electronic reporting of data on the quality of care. In the final regulation, we have simplified the January proposals for quality reporting, while still building toward a robust reporting capability that will inform providers about their own performance and will eventually inform the public as well. Clinicians will have to report data on three core quality measures in 2011 and 2012: blood-pressure level, tobacco status, and adult weight screening and follow-up (or alternates if these do not apply). Clinicians must also choose three other measures from lists of metrics that are ready for incorporation into electronic records.

The meaningful use rule is part of a coordinated set of regulations to help create a private and secure 21st-century electronic health information system. On June 18, 2010, the DHHS issued a rule that laid out a process for the certification of electronic health records, so that providers can be assured they are capable of meaningful use. The department has also issued still another regulation that lays out the standards and certification criteria that EHRs must meet in order to be certified. Finally, realizing that the privacy and security of EHRs are vital, the DHHS has been working hard to safeguard privacy and security by implementing new protections contained in the HITECH legislation.

The meaningful use rule strikes a balance between acknowledging the urgency of adopting EHRs to improve our health care system and recognizing the challenges that adoption will pose to health care providers. The regulation must be both ambitious and achievable. Like an escalator, HITECH attempts to move the health system upward toward improved quality and effectiveness in health care. But the speed of ascent must be calibrated to reflect both the capacities of providers who face a multitude of real-world challenges and the maturity of the technology itself.

As part of this process, the DHHS is establishing a nationwide network of Regional Extension Centers to assist providers in adopting qualified EHRs and making meaningful use of them. The DHHS is committed to the support, collaboration, and ongoing learning that will mark our progress toward electronically connected, information-driven medical care. We hope that providers and consumers will now join us in the effort to assure that we make the best possible use of our most precious health care resource: information about the patients we serve.

 

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

This article (10.1056/NEJMp1006114) was published on July 13, 2010, at NEJM.org.

Source Information

Dr. Blumenthal is the national coordinator for health information technology at the Department of Health and Human Services, and Ms. Tavenner is the principal deputy administrator of the Centers for Medicare and Medicaid Services — both in Washington, DC.

 

Citing Articles

  1. 1Bhushan Kapoor, Martin Kleinbart. (2014) Building an Integrated Patient Information System for a Healthcare Network. Journal of Cases on Information Technology 14:2, 27-41
    CrossRef
  2. 2Alex H. Cho, Lori A. Orlando. Clinical Implementation of Genomic Medicine in Primary Care. In: Genomic and Personalized Medicine. Elsevier, 2013:295-305.
    CrossRef
  3. 3Gregory J. Downing. Knowledge Management to Support Personalized Healthcare. In: Genomic and Personalized Medicine. Elsevier, 2013:332-339.
    CrossRef
  4. 4Deborah A. Greenwood, Carol A. Parise, Tami A. MacAller, Andrea I. Hankins, Kristin R. Harms, Leslie S. Pratt, Joan E. Olveda, Kimberly A. Buss. (2012) Utilizing clinical support staff and electronic health records to increase tobacco use documentation and referrals to a state quitline. Journal of Vascular Nursing 30:4, 107-111
    CrossRef
  5. 5Frank J. Manion, Marcelline R. Harris, Ayse G. Buyuktur, Patricia M. Clark, Lawrence C. An, David A. Hanauer. (2012) Leveraging EHR Data for Outcomes and Comparative Effectiveness Research in Oncology. Current Oncology Reports 14:6, 494-501
    CrossRef
  6. 6Amanda F. Elliott, Arthur Davidson, Flora Lum, Michael F. Chiang, Jinan B. Saaddine, Xinzhi Zhang, John E. Crews, Chiu-Fang Chou. (2012) Use of Electronic Health Records and Administrative Data for Public Health Surveillance of Eye Health and Vision-Related Conditions in the United States. American Journal of Ophthalmology 154:6, S63-S70
    CrossRef
  7. 7Sittig, Dean F., Singh, Hardeep, . (2012) Electronic Health Records and National Patient-Safety Goals. New England Journal of Medicine 367:19, 1854-1860
    Full Text
  8. 8Arash Anoshiravani, Gregory L. Gaskin, Mark R. Groshek, Cynthia Kuelbs, Christopher A. Longhurst. (2012) Special Requirements for Electronic Medical Records in Adolescent Medicine. Journal of Adolescent Health 51:5, 409-414
    CrossRef
  9. 9Amirhossein Takian, Tony Cornford. (2012) NHS information: Revolution or evolution?. Health Policy and Technology
    CrossRef
  10. 10Kathrin Cresswell, Aziz Sheikh. (2012) Organizational issues in the implementation and adoption of health information technology innovations: An interpretative review. International Journal of Medical Informatics
    CrossRef
  11. 11, Lisa M. Kern, Yolanda Barrón, Rina V. Dhopeshwarkar, Alison Edwards, Rainu Kaushal. (2012) Electronic Health Records and Ambulatory Quality of Care. Journal of General Internal Medicine
    CrossRef
  12. 12Peter Gordon, Eli Camhi, Ron Hesse, Michelle Odlum, Rebecca Schnall, Martha Rodriguez, Esmerlin Valdez, Suzanne Bakken. (2012) Processes and outcomes of developing a continuity of care document for use as a personal health record by people living with HIV/AIDS in New York City. International Journal of Medical Informatics 81:10, e63-e73
    CrossRef
  13. 13Yajiong Xue, Huigang Liang, Xiaocheng Wu, Hai Gong, Bin Li, Yuxia Zhang. (2012) Effects of electronic medical record in a Chinese hospital: A time series study. International Journal of Medical Informatics 81:10, 683-689
    CrossRef
  14. 14Emily J. Campbell, Arun Krishnaraj, Mitchell Harris, Sanjay Saini, James M. Richter. (2012) Automated before-procedure electronic health record screening to assess appropriateness for GI endoscopy and sedation. Gastrointestinal Endoscopy 76:4, 786-792
    CrossRef
  15. 15Lina Lander, Donald G. Klepser, Gary L. Cochran, Daniel E. Lomelin, Marsha Morien. (2012) Barriers to Electronic Prescribing: Nebraska Pharmacists’ Perspective. The Journal of Rural Healthno-no
    CrossRef
  16. 16Gail M. Keenan, Elizabeth Yakel, Yingwei Yao, Dianhui Xu, Laura Szalacha, Dana Tschannen, Yvonne Ford, Yu-Chung Chen, Andrew Johnson, Karen Dunn Lopez, Diana J. Wilkie. (2012) Maintaining a Consistent Big Picture: Meaningful Use of a Web-based POC EHR System. International Journal of Nursing Knowledge 23:3, 119-133
    CrossRef
  17. 17Mark D. Kaufmann, Shraddha Desai. (2012) Special Requirements for Electronic Health Records in Dermatology. Seminars in Cutaneous Medicine and Surgery 31:3, 160-162
    CrossRef
  18. 18Balwinder Singh, Amandeep Singh, Adil Ahmed, Gregory A. Wilson, Brian W. Pickering, Vitaly Herasevich, Ognjen Gajic, Guangxi Li. (2012) Derivation and Validation of Automated Electronic Search Strategies to Extract Charlson Comorbidities From Electronic Medical Records. Mayo Clinic Proceedings 87:9, 817-824
    CrossRef
  19. 19Ronald J. Teufel, Abby Swanson Kazley, Myla D. Ebeling, William T. Basco. (2012) Hospital Electronic Medical Record Use and Cost of Inpatient Pediatric Care. Academic Pediatrics 12:5, 429-435
    CrossRef
  20. 20Jason S. Lane, Warren S. Sandberg, Brian Rothman. (2012) Development and implementation of an integrated mobile situational awareness iPhone application VigiVUTM at an academic medical center. International Journal of Computer Assisted Radiology and Surgery 7:5, 721-735
    CrossRef
  21. 21Maura J. McGuire, Gary Noronha, Lipika Samal, Hsin-Chieh Yeh, Susan Crocetti, Steven Kravet. (2012) Patient Safety Perceptions of Primary Care Providers after Implementation of an Electronic Medical Record System. Journal of General Internal Medicine
    CrossRef
  22. 22Gina R. Kruse, Jennifer H. K. Kelley, Jeffrey A. Linder, Elyse R. Park, Nancy A. Rigotti. (2012) Implementation of an Electronic Health Record-Based Care Management System to Improve Tobacco Treatment. Journal of General Internal Medicine
    CrossRef
  23. 23Cara B. Litvin, Steven M. Ornstein, Andrea M. Wessell, Lynne S. Nemeth, Paul J. Nietert. (2012) Adoption of a clinical decision support system to promote judicious use of antibiotics for acute respiratory infections in primary care. International Journal of Medical Informatics 81:8, 521-526
    CrossRef
  24. 24Deborah W. Garnick, Margaret T. Lee, Peggy L. O’Brien, Lee Panas, Grant A. Ritter, Andrea Acevedo, Bryan R. Garner, Rodney R. Funk, Mark D. Godley. (2012) The Washington circle engagement performance measures’ association with adolescent treatment outcomes. Drug and Alcohol Dependence 124:3, 250-258
    CrossRef
  25. 25Joseph J. Vicari. (2012) The future value of ambulatory endoscopy centers in the United States: challenges and opportunities. Gastrointestinal Endoscopy 76:2, 400-405
    CrossRef
  26. 26Jeffrey S. Harman, Kathryn M. Rost, Christopher A. Harle, Robert L. Cook. (2012) Electronic Medical Record Availability and Primary Care Depression Treatment. Journal of General Internal Medicine 27:8, 962-967
    CrossRef
  27. 27Elizabeth S. Chen, Genevieve B. Melton, Indra Neil Sarkar. (2012) Translating standards into practice: Experiences and lessons learned in biomedicine and health care. Journal of Biomedical Informatics 45:4, 609-612
    CrossRef
  28. 28Kimberlee Snyder, Lynne L. Ornes, Pat Paulson. (2012) Engaging Patients Through Your Website. Journal for Healthcare Qualityn/a-n/a
    CrossRef
  29. 29Christine A. Caligtan, Diane L. Carroll, Ann C. Hurley, Ronna Gersh-Zaremski, Patricia C. Dykes. (2012) Bedside information technology to support patient-centered care. International Journal of Medical Informatics 81:7, 442-451
    CrossRef
  30. 30Jessica S. Ancker, Alison M. Edwards, Melissa C. Miller, Rainu Kaushal. (2012) Consumer Perceptions of Electronic Health Information Exchange. American Journal of Preventive Medicine 43:1, 76-80
    CrossRef
  31. 31Ajit Appari, M. Eric Johnson, Denise L. Anthony. (2012) Meaningful Use of Electronic Health Record Systems and Process Quality of Care: Evidence from a Panel Data Analysis of U.S. Acute-Care Hospitals. Health Services Researchn/a-n/a
    CrossRef
  32. 32ROBERTA L. HARRISON, FRANK LYERLA. (2012) Using Nursing Clinical Decision Support Systems to Achieve Meaningful Use. CIN: Computers, Informatics, Nursing 30:7, 380-385
    CrossRef
  33. 33D.J. Albers, George Hripcsak. (2012) Estimation of time-delayed mutual information and bias for irregularly and sparsely sampled time-series. Chaos, Solitons & Fractals 45:6, 853-860
    CrossRef
  34. 34J. P. Weiner, J. B. Fowles, K. S. Chan. (2012) New paradigms for measuring clinical performance using electronic health records. International Journal for Quality in Health Care 24:3, 200-205
    CrossRef
  35. 35Shaline Rao, Craig Brammer, Aaron McKethan, Melinda B. Buntin. (2012) Health Information Technology. Primary Care: Clinics in Office Practice 39:2, 327-344
    CrossRef
  36. 36Michael Klompas, Jason McVetta, Ross Lazarus, Emma Eggleston, Gillian Haney, Benjamin A. Kruskal, W. Katherine Yih, Patricia Daly, Paul Oppedisano, Brianne Beagan, Michael Lee, Chaim Kirby, Dawn Heisey-Grove, Alfred DeMaria, Richard Platt. (2012) Integrating Clinical Practice and Public Health Surveillance Using Electronic Medical Record Systems. American Journal of Public Health 102:S3, S325-S332
    CrossRef
  37. 37Michael Klompas, Jason McVetta, Ross Lazarus, Emma Eggleston, Gillian Haney, Benjamin A. Kruskal, W. Katherine Yih, Patricia Daly, Paul Oppedisano, Brianne Beagan, Michael Lee, Chaim Kirby, Dawn Heisey-Grove, Alfred DeMaria, Richard Platt. (2012) Integrating Clinical Practice and Public Health Surveillance Using Electronic Medical Record Systems. American Journal of Preventive Medicine 42:6, S154-S162
    CrossRef
  38. 38Charles Friedman, Michael Rigby. (2012) Conceptualising and creating a global learning health system. International Journal of Medical Informatics
    CrossRef
  39. 39Courtney R. Lyles, Lynne T. Harris, Luesa Jordan, Lou Grothaus, Linda Wehnes, Robert J. Reid, James D. Ralston. (2012) Patient Race/Ethnicity and Shared Medical Record Use Among Diabetes Patients. Medical Care 50:5, 434-440
    CrossRef
  40. 40Cara B. Litvin, Kimberly S. Davis, William P. Moran, Patty J. Iverson, Yumin Zhao, Jane Zapka. (2012) The Use of Clinical Decision-Support Tools to Facilitate Geriatric Education. Journal of the American Geriatrics Societyn/a-n/a
    CrossRef
  41. 41Rupananda Misra, Barbara C. Wallace. Designing the E-Health Message. In: Telemedicine and E-Health Services, Policies, and Applications. IGI Global, 2012:216-245.
    CrossRef
  42. 42John D. D’Amore, Dean F. Sittig, Roberta B. Ness. (2012) How the Continuity of Care Document Can Advance Medical Research and Public Health. American Journal of Public Healthe1-e4
    CrossRef
  43. 43Nan Xiao, Raj Sharman, Ranjit Singh, Gurdev Singh, Andrew Danzo, H.R. Rao. (2012) “Meaningful Use” of ambulatory EMR: Does it improve the quality and efficiency of health care?. Health Policy and Technology 1:1, 28-34
    CrossRef
  44. 44Teri Leventhal, J. Peyton Taliaferro, Kenneth Wong, Cortney Hughes, Seong Mun. (2012) The Patient-Centered Medical Home and Health Information Technology. Telemedicine and e-Health120203072852003
    CrossRef
  45. 45Mercedes Alfaro, Julio Bonis, Rafael Bravo, Enrique Fluiters, Sergio Minué. (2012) Nuevas tecnologías en atención primaria: personas, máquinas, historias y redes. Informe SESPAS 2012. Gaceta Sanitaria
    CrossRef
  46. 46Ivan K. Ip, Louise I. Schneider, Richard Hanson, Dana Marchello, Patricia Hultman, Michael Viera, Brian Chiango, Katherine P. Andriole, Andrew Menard, Susan Schade, Steven E. Seltzer, Ramin Khorasani. (2012) Adoption and Meaningful Use of Computerized Physician Order Entry With an Integrated Clinical Decision Support System for Radiology: Ten-Year Analysis in an Urban Teaching Hospital. Journal of the American College of Radiology 9:2, 129-136
    CrossRef
  47. 47Adeel Siddiqui, Keith Jay Dreyer, Supriya Gupta. (2012) Meaningful Use. Academic Radiology 19:2, 221-228
    CrossRef
  48. 48Christine Rini, David A. Williams, Joan E. Broderick, Francis J. Keefe. (2012) Meeting them where they are: Using the Internet to deliver behavioral medicine interventions for pain. Translational Behavioral Medicine
    CrossRef
  49. 49Walker, James, McKethan, Aaron, . (2012) Achieving Accountable Care — “It’s Not About the Bike”. New England Journal of Medicine 366:2,
    Full Text
  50. 50D Yoon, M Y Park, N K Choi, B J Park, J H Kim, R W Park. (2012) Detection of Adverse Drug Reaction Signals Using an Electronic Health Records Database: Comparison of the Laboratory Extreme Abnormality Ratio (CLEAR) Algorithm. Clinical Pharmacology & Therapeutics
    CrossRef
  51. 51Klaus Mergener. (2012) Impact of Health Care Reform on the Independent GI Practice. Gastrointestinal Endoscopy Clinics of North America 22:1, 15-27
    CrossRef
  52. 52Don Downing. (2012) Inviting the pharmacist: a model for improved reproductive care access. Contraception 85:1, 2-4
    CrossRef
  53. 53Veronica Y. Cochran, Brenda Blair, Laurie Wissinger, Terri D. Nuss. (2012) Lessons Learned From Implementation of Postdischarge Telephone Calls at Baylor Health Care System. JONA: The Journal of Nursing Administration 42:1, 40-46
    CrossRef
  54. 54Spencer D. Dorn. (2012) Health Care Reform: 2012 Update. Gastrointestinal Endoscopy Clinics of North America 22:1, 1-14
    CrossRef
  55. 55Kathrin M Cresswell, Allison Worth, Aziz Sheikh. (2012) Integration of a nationally procured electronic health record system into user work practices. BMC Medical Informatics and Decision Making 12:1, 15
    CrossRef
  56. 56Olena Mazurenko, Gouri Gupte, Valerie A. Yeager. International Medical Graduates and Health Information Technology Use in the United States. Emerald Group Publishing, 2012:121-140.
    CrossRef
  57. 57Abby Swanson Kazley, Mark L. Diana, Eric W. Ford, Nir Menachemi. (2012) Is electronic health record use associated with patient satisfaction in hospitals?. Health Care Management Review 37:1, 23-30
    CrossRef
  58. 58A. Gettinger, A. Csatari. (2012) Transitioning from a Legacy EHR to a Commercial, Vendor-supplied, EHR. Applied Clinical Informatics 3:4, 367-376
    CrossRef
  59. 59Srinivas Emani, Cyrus K Yamin, Ellen Peters, Andrew S Karson, Stuart R Lipsitz, Jonathan S Wald, Deborah H Williams, David W Bates. (2012) Patient Perceptions of a Personal Health Record: A Test of the Diffusion of Innovation Model. Journal of Medical Internet Research 14:6, e150
    CrossRef
  60. 60Leonie Heyworth, Fang Zhang, Chelsea A Jenter, Rachel Kell, Lynn A Volk, Micky Tripathi, David W Bates, Steven R Simon. (2012) Physician Satisfaction Following Electronic Health Record Adoption in Three Massachusetts Communities. Interactive Journal of Medical Research 1:2, e12
    CrossRef
  61. 61Kelly K. Adams, Ashley Beem, Elizabeth Diener, T. Allen Merritt. (2011) Protecting the Vulnerable: The Importance of Effective Parental Tobacco-Dependence Treatment During Prenatal and Newborn Care. Pediatric Allergy, Immunology, and Pulmonology111222122704000
    CrossRef
  62. 62Lisa E. Hines, Kim R. Saverno, Terri L. Warholak, Ann Taylor, Amy J. Grizzle, John E. Murphy, Daniel C. Malone. (2011) Pharmacists’ awareness of clinical decision support in pharmacy information systems: An exploratory evaluation. Research in Social and Administrative Pharmacy 7:4, 359-368
    CrossRef
  63. 63Sana M. Al-Khatib. (2011) New directions in clinical outcomes assessment. Journal of Interventional Cardiac Electrophysiology 32:3, 221-226
    CrossRef
  64. 64TRISHA GREENHALGH, JILL RUSSELL, RICHARD E. ASHCROFT, WAYNE PARSONS. (2011) Why National eHealth Programs Need Dead Philosophers: Wittgensteinian Reflections on Policymakers’ Reluctance to Learn from History. Milbank Quarterly 89:4, 533-563
    CrossRef
  65. 65Hardeep Singh, David C. Classen, Dean F. Sittig. (2011) Creating an Oversight Infrastructure for Electronic Health Record–Related Patient Safety Hazards. Journal of Patient Safety 7:4, 169-174
    CrossRef
  66. 66Scott J. Ellner, Paul W. Joyner. (2011) Information Technologies and Patient Safety. Surgical Clinics of North America
    CrossRef
  67. 67Richard J. Holden. (2011) What Stands in the Way of Technology-Mediated Patient Safety Improvements? A Study of Facilitators and Barriers to Physicians’ Use of Electronic Health Records. Journal of Patient Safety 7:4, 193-203
    CrossRef
  68. 68Hassan Tetteh. (2011) Projected Lifetime Risks and Hospital Care Expenditure for Traumatic Injury. Journal of Surgical Research
    CrossRef
  69. 69Dukyong Yoon, Byung-Chul Chang, Seong Weon Kang, Hasuk Bae, Rae Woong Park. (2011) Adoption of electronic health records in Korean tertiary teaching and general hospitals. International Journal of Medical Informatics
    CrossRef
  70. 70Alex R. Kemper, Nita Patel. (2011) An integrated data systems approach to amblyopia prevention. Journal of American Association for Pediatric Ophthalmology and Strabismus 15:6, 519-520
    CrossRef
  71. 71Ben-Tzion Karsh, Richard Holden, Calvin Or. Human Factors and Ergonomics of Health Information Technology Implementation. CRC Press, 2011:249-264.
    CrossRef
  72. 72George L. Jackson, Sarah L. Krein, Dale C. Alverson, Adam W. Darkins, William Gunnar, Nancy D. Harada, Christian D. Helfrich, Thomas K. Houston, Thomas F. Klobucar, Kim M. Nazi, Ronald K. Poropatich, James D. Ralston, Hayden B. Bosworth. (2011) Defining Core Issues in Utilizing Information Technology to Improve Access: Evaluation and Research Agenda. Journal of General Internal Medicine 26:S2, 623-627
    CrossRef
  73. 73Zeke Zamora, Brenda McCall, Laura Patel, Kevin Biese, Michael LaMantia, Tim Platts-Mills, Nelson Naus, Hans P. Jerkewitz, Charles B. Cairns, Jan Busby-Whitehead, John S. Kizer. (2011) Implementation of a Web-Based System to Improve the Transitional Care of Older Adults. Journal of Nursing Care Quality1
    CrossRef
  74. 74Abby Swanson Kazley, Mark L. Diana, Nir Menachemi. (2011) The agreement and internal consistency of national hospital EMR measures. Health Care Management Science 14:4, 307-313
    CrossRef
  75. 75Ann Kutney-Lee, Deena Kelly. (2011) The Effect of Hospital Electronic Health Record Adoption on Nurse-Assessed Quality of Care and Patient Safety. JONA: The Journal of Nursing Administration 41:11, 466-472
    CrossRef
  76. 76RONALD J. PISCOTTY, HUEY-MING TZENG. (2011) Exploring the Clinical Information System Implementation Readiness Activities to Support Nursing in Hospital Settings. CIN: Computers, Informatics, Nursing 20:11, 648-656
    CrossRef
  77. 77Thomas D. Sequist, Shane M. Morong, Amy Marston, Carol A. Keohane, E. Francis Cook, E. John Orav, Thomas H. Lee. (2011) Electronic Risk Alerts to Improve Primary Care Management of Chest Pain: A Randomized, Controlled Trial. Journal of General Internal Medicine
    CrossRef
  78. 78Stephen James Canon, Jody Ann Purifoy, Gerald M. Heulitt, William Hogan, Christopher Swearingen, Mark Williams, Seth Alpert, Diane Young. (2011) Results: Survey of Pediatric Urology Electronic Medical Records—Use and Perspectives. The Journal of Urology 186:4, 1740-1745
    CrossRef
  79. 79Thomas S. Seufert, Patricia M. Mitchell, Allison R. Wilcox, Julia E. Rubin-Smith, Laura F. White, Kerry K. McCabe, Jeffrey I. Schneider. (2011) An Automated Procedure Logging System Improves Resident Documentation Compliance. Academic Emergency Medicine 18, S54-S58
    CrossRef
  80. 80Thomas D. Sequist. (2011) Health Information Technology and Disparities in Quality of Care. Journal of General Internal Medicine 26:10, 1084-1085
    CrossRef
  81. 81Classen, David C., Bates, David W., . (2011) Finding the Meaning in Meaningful Use. New England Journal of Medicine 365:9, 855-858
    Full Text
  82. 82Jeffrey J. Sands, Jose A. Diaz-Buxo. (2011) Improving the Delivery of Coordinated and Individualized Care. Seminars in Dialysis 24:5, 593-596
    CrossRef
  83. 83Ted Louie. (2011) Practical Advice on EMRs, Part 2. Infectious Diseases in Clinical Practice 19:5, 350-351
    CrossRef
  84. 84Carlene J. Campbell, Dorothea E. McDowell. (2011) Computer Literacy of Nurses in a Community Hospital: Where Are We Today?. The Journal of Continuing Education in Nursing 42:8, 365-370
    CrossRef
  85. 85Michael A. Steinman, Steven M. Handler, Jerry H. Gurwitz, Gordon D. Schiff, Kenneth E. Covinsky. (2011) Beyond the Prescription: Medication Monitoring and Adverse Drug Events in Older Adults. Journal of the American Geriatrics Society 59:8, 1513-1520
    CrossRef
  86. 86Christine A. Caligtan, Patricia C. Dykes. (2011) Electronic Health Records and Personal Health Records. Seminars in Oncology Nursing 27:3, 218-228
    CrossRef
  87. 87Zubin J. Eapen, Eric D. Peterson, Gregg C. Fonarow, Gillian D. Sanders, Clyde W. Yancy, Samuel F. Sears, Mark D. Carlson, Anne B. Curtis, Laura Lee Hall, David L. Hayes, Adrian F. Hernandez, Michael Mirro, Eric Prystowsky, Andrea M. Russo, Kevin L. Thomas, Sana M. Al-Khatib. (2011) Quality of care for sudden cardiac arrest: Proposed steps to improve the translation of evidence into practice. American Heart Journal 162:2, 222-231
    CrossRef
  88. 88Edie E Zusman. (2011) Meeting Meaningful Use Objectives for Electronic Health Record Implementation. Neurosurgery 69:2, N24-N26
    CrossRef
  89. 89George Demiris, Debra Parker Oliver, Elaine Wittenberg-Lyles. (2011) Technologies to Support End-of-Life Care. Seminars in Oncology Nursing 27:3, 211-217
    CrossRef
  90. 90Lisa M. Korst, Carolyn E. Aydin, Jordana M.K. Signer, Arlene Fink. (2011) Hospital readiness for health information exchange: Development of metrics associated with successful collaboration for quality improvement. International Journal of Medical Informatics 80:8, e178-e188
    CrossRef
  91. 91Michael F. Chiang, Michael V. Boland, Allen Brewer, K. David Epley, Mark B. Horton, Michele C. Lim, Colin A. McCannel, Sayjal J. Patel, David E. Silverstone, Linda Wedemeyer, Flora Lum. (2011) Special Requirements for Electronic Health Record Systems in Ophthalmology. Ophthalmology 118:8, 1681-1687
    CrossRef
  92. 92Ana M. Palacio, Leonardo J. Tamariz, Claudia Uribe, Hua Li, Ellen J. Salkeld, Leslie Hazel-Fernandez, Olveen Carrasquillo. (2011) Can Claims-Based Data Be Used to Recruit Black and Hispanic Subjects into Clinical Trials?. Health Services Researchn/a-n/a
    CrossRef
  93. 93Joel Handler, Daniel T. Lackland. (2011) Translation of hypertension treatment guidelines into practice: a review of implementation. Journal of the American Society of Hypertension 5:4, 197-207
    CrossRef
  94. 94J. P. Palma, P. J. Sharek, D. C. Classen, C. A. Longhurst. (2011) Topics in Neonatal Informatics: Computerized Physician Order Entry. NeoReviews 12:7, e393-e396
    CrossRef
  95. 95Garrett Eggers, Matt Jenkins, Scott Mark, Kelley Wasicek. (2011) Director’s Forum – Meaningful Use: Why Is It Meaningful to Pharmacists?. Hospital Pharmacy 46:7, 540-543
    CrossRef
  96. 96Lixia Yao, Yiye Zhang, Yong Li, Philippe Sanseau, Pankaj Agarwal. (2011) Electronic health records: Implications for drug discovery. Drug Discovery Today 16:13-14, 594-599
    CrossRef
  97. 97G. Kim. (2011) The Impact of Medication Reconciliation in a Children’s Hospital. AAP Grand Rounds 25:6, 70-70
    CrossRef
  98. 98Mark McClellan. (2011) Reforming Payments to Healthcare Providers: The Key to Slowing Healthcare Cost Growth While Improving Quality?. Journal of Economic Perspectives 25:2, 69-92
    CrossRef
  99. 99Jakka Sairamesh, Martin L. Griss, Patricia A. Weber, Stanley Hum, Steven L. Garverick, Ravi Nemana, Wil Yu, Fred W. Hosea, Amar K. Das, Harold Garner. (2011) Innovation in Healthcare Intelligence. American Journal of Preventive Medicine 40:5, S234-S237
    CrossRef
  100. 100J.B. Jones, Nirav R. Shah, Christa A. Bruce, Walter F. Stewart. (2011) Meaningful Use in Practice. American Journal of Preventive Medicine 40:5, S179-S186
    CrossRef
  101. 101Subha Madhavan, Amy E. Sanders, Wen-Ying Sylvia Chou, Alex Shuster, Keith W. Boone, Mark A. Dente, Aziza T. Shad, Bradford W. Hesse. (2011) Pediatric Palliative Care and eHealth. American Journal of Preventive Medicine 40:5, S208-S216
    CrossRef
  102. 102Joseph Finkelstein, Michael S. Barr, Pranav P. Kothari, David K. Nace, Matthew Quinn. (2011) Patient-Centered Medical Home Cyberinfrastructure. American Journal of Preventive Medicine 40:5, S225-S233
    CrossRef
  103. 103Richard P. Moser, Bradford W. Hesse, Abdul R. Shaikh, Paul Courtney, Glen Morgan, Erik Augustson, Sarah Kobrin, Kerry Y. Levin, Cynthia Helba, David Garner, Marsha Dunn, Kisha Coa. (2011) Grid-Enabled Measures. American Journal of Preventive Medicine 40:5, S134-S143
    CrossRef
  104. 104Mollie H. Ullman-Cullere, Jomol P. Mathew. (2011) Emerging landscape of genomics in the electronic health record for personalized medicine. Human Mutation 32:5, 512-516
    CrossRef
  105. 105Bradford W. Hesse, Robert T. Croyle, Kenneth H. Buetow. (2011) Cyberinfrastructure and the Biomedical Sciences. American Journal of Preventive Medicine 40:5, S97-S102
    CrossRef
  106. 106A. N. Kho, J. A. Pacheco, P. L. Peissig, L. Rasmussen, K. M. Newton, N. Weston, P. K. Crane, J. Pathak, C. G. Chute, S. J. Bielinski, I. J. Kullo, R. Li, T. A. Manolio, R. L. Chisholm, J. C. Denny. (2011) Electronic Medical Records for Genetic Research: Results of the eMERGE Consortium. Science Translational Medicine 3:79, 79re1-79re1
    CrossRef
  107. 107William J. Oetgen, J. Brendan Mullen, Michael J. Mirro. (2011) Cardiologists, the PINNACLE Registry, and the “Meaningful Use” of Electronic Health Records. Journal of the American College of Cardiology 57:14, 1560-1563
    CrossRef
  108. 108O’Malley, Ann S., . (2011) Tapping the Unmet Potential of Health Information Technology. New England Journal of Medicine 364:12, 1090-1091
    Full Text
  109. 109Sharona Hoffman, Andy Podgurski. (2011) Meaningful Use and Certification of Health Information Technology: What about Safety?. The Journal of Law, Medicine & Ethics 39, 77-80
    CrossRef
  110. 110Devin M. Mann. (2011) Making Clinical Decision Support More Supportive. Medical Care 49:2, 115-116
    CrossRef
  111. 111Clyde H. Evans, Suzanne B. Cashman, Donna A. Page, David R. Garr. (2011) Model Approaches for Advancing Interprofessional Prevention Education. American Journal of Preventive Medicine 40:2, 245-260
    CrossRef
  112. 112L. Grabenbauer, A. Skinner, J. Windle. (2011) Electronic Health Record Adoption – Maybe It’s not about the Money. Applied Clinical Informatics 2:4, 460-471
    CrossRef
  113. 113Vikrant G Deshmukh, N Brett Sower, Cheri Y Hunter, Joyce A Mitchell. (2011) Integrating historical clinical and financial data for pharmacological research. BMC Medical Research Methodology 11:1, 151
    CrossRef
  114. 114G. L. Gaskin, C. A. Longhurst, R. Slayton, A. K. Das. (2011) Sociotechnical Challenges of Developing an Interoperable Personal Health Record. Applied Clinical Informatics 2:4, 406-419
    CrossRef
  115. 115Hilary Placzek, Lawrence C. Madoff. (2011) The use of immunization registry-based data in vaccine effectiveness studies. Vaccine 29:3, 399-411
    CrossRef
  116. 116Dean F Sittig, Adam Wright, Seth Meltzer, Linas Simonaitis, R Scott Evans, W Paul Nichol, Joan S Ash, Blackford Middleton. (2011) Comparison of clinical knowledge management capabilities of commercially-available and leading internally-developed electronic health records. BMC Medical Informatics and Decision Making 11:1, 13
    CrossRef
  117. 117AMY J. BARTON. (2011) The Electronic Health Record and “Meaningful Use”. Clinical Nurse Specialist 25:1, 8-10
    CrossRef
  118. 118Teresa Longobardi, John R Walker, Lesley A Graff, Charles N Bernstein. (2011) Health service utilization in IBD: comparison of self-report and administrative data. BMC Health Services Research 11:1, 137
    CrossRef
  119. 119Alex H Krist, Eric Peele, Steven H Woolf, Stephen F Rothemich, John F Loomis, Daniel R Longo, Anton J Kuzel. (2011) Designing a patient-centered personal health record to promote preventive care. BMC Medical Informatics and Decision Making 11:1, 73
    CrossRef
  120. 120Fina Kurreeman, Katherine Liao, Lori Chibnik, Brendan Hickey, Eli Stahl, Vivian Gainer, Gang Li, Lynn Bry, Scott Mahan, Kristin Ardlie, Brian Thomson, Peter Szolovits, Susanne Churchill, Shawn N. Murphy, Tianxi Cai, Soumya Raychaudhuri, Isaac Kohane, Elizabeth Karlson, Robert M. Plenge. (2011) Genetic Basis of Autoantibody Positive and Negative Rheumatoid Arthritis Risk in a Multi-ethnic Cohort Derived from Electronic Health Records. The American Journal of Human Genetics 88:1, 57-69
    CrossRef
  121. 121M. Kantor, A. Wright, M. Burton, G. Fraser, M. Krall, S. Maviglia, N. Mohammed-Rajput, L. Simonaitis, F. Sonnenberg, B. Middleton. (2011) Comparison of Computer-based Clinical Decision Support Systems and Content for Diabetes Mellitus. Applied Clinical Informatics 2:3, 284-303
    CrossRef
  122. 122Isaac S Kohane. (2011) No small matter: qualitatively distinct challenges of pediatric genomic studies. Genome Medicine 3:9, 62
    CrossRef
  123. 123Monica Horvath, Janet Levy, Pete L’Engle, Boyd Carlson, Asif Ahmad, Jeffrey Ferranti. (2011) Impact of Health Portal Enrollment With Email Reminders on Adherence to Clinic Appointments: A Pilot Study. Journal of Medical Internet Research 13:2,
    CrossRef
  124. 124(2010) Electronic Health Records. New England Journal of Medicine 363:24, 2372-2374
    Full Text
  125. 125Michael V. Boland. (2010) Meaningful Use of Electronic Health Records in Ophthalmology. Ophthalmology 117:12, 2239-2240
    CrossRef
  126. 126C. P. Friedman, A. K. Wong, D. Blumenthal. (2010) Achieving a Nationwide Learning Health System. Science Translational Medicine 2:57, 57cm29-57cm29
    CrossRef
  127. 127G. Kim. (2010) Clinical Decision Support (“Smart Forms”) in Ambulatory Care. AAP Grand Rounds 24:5, 59-59
    CrossRef
  128. 128William B. Millard. (2010) Electronic Health Records: Promises and Realities. Annals of Emergency Medicine 56:4, A19-A25
    CrossRef
  129. 129Kuang-Yi Wen, Gary Kreps, Fang Zhu, Suzanne Miller. (2010) Consumers’ Perceptions About and Use of the Internet for Personal Health Records and Health Information Exchange: Analysis of the 2007 Health Information National Trends Survey. Journal of Medical Internet Research 12:4,
    CrossRef

 

Electronic Health Records

N Engl J Med 2010; 363:2372-2374December 9, 2010DOI: 10.1056/NEJMc1010028

Article

To the Editor:

Health care entities compliant with the recent rules for “meaningful use” of electronic health records (EHRs) (Aug. 5 issue)1 will receive a share of billions in federal payments. EHRs can improve the quality of care, but the benefits provided will depend on the details of design and implementation. EHR-induced risks include use errors (an interaction between the user and the technology that is neither what the user expected nor what the designer intended), inefficiencies, miscommunication, and workarounds.2-5 Until there is a better understanding of the safety and usability of EHRs, their widespread promulgation is premature. The adverse consequences of the rush to EHR adoption — spurred by incentives — are many. Most health care entities, which do not have the knowledge or resources to properly evaluate EHRs, will make uninformed purchase decisions favoring products promoting the capture of “meaningful use” rather than usability or safety. Many will short change the local customization required to make EHRs efficient, usable, and safe. Pressure on clinicians to maximize “use” will lead to workarounds and faulty use reporting. Postmarket surveillance of adverse events related to health information technology will fail, since neither vendors nor health care entities have reporting incentives.

Current federal initiatives to address these issues amount to less than 1% of the planned incentives. The horse is out of the barn without a bridle or reins.

No potential conflict of interest relevant to this letter was reported.

 

5 References

    1. 1Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med 2010;363:501-504

    1. 2Weiner JP, Kfuri T, Chan K, Fowles JB. “e-Iatrogenesis”: the most critical unintended consequence of CPOE and other HIT. J Am Med Inform Assoc 2007;14:387-388

    1. 3Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc 2006;13:547-556

    1. 4Halbesleben JR, Wakefield DS, Wakefield BJ. Work-arounds in healthcare settings: literature review and research agenda. Health Care Manage Rev 2008;33:2-12

  1. 5Walker JM, Carayon P, Leveson N, et al. EHR safety: the way forward to safe and effective systems. J Am Med Inform Assoc 2008;15:272-277

To the Editor:

The article by Blumenthal and Tavenner highlights the large gulf separating decision makers in Washington from those of us on the front lines of health care reform. The authors rightly point out the still-unproved benefits of EHRs and their “meaningful use,” but they ignore the most important aspect of meaningful use as it relates to patient care: the sophistication of the software. Because of the enormous and immediate financial incentives available to implement this plan, hospitals are rushing to initiate programs that are far from user-friendly or safe, often requiring physicians to beta-test EHRs being written even as they are being installed (imagine running an iPhone on DOS). This might be forgivable if not for the serious risks EHRs pose to patients’ health and privacy, the very goals the authors laud. In the Wild West of commercial EHRs, there is virtually no regulation of program content or sophistication. The Centers for Medicare and Medicaid Services (CMS) need to commit resources to the development of high-quality software and to the certification of its safety for patients.

Robert F. Taylor, M.D.
Oncology Alliance, Milwaukee, WI

No potential conflict of interest relevant to this letter was reported.

 

To the Editor:

Blumenthal and Tavenner recognize the complexities of implementing EHRs. Among these complexities are massive costs and questions about the reliability and security of the information. Defined communication limits are inherent to competitive EHR systems, hindering information exchange in a large and mobile society. In addition, physicians are naive about commercial and technical aspects of EHR. These issues were recently reviewed in the Wall Street Journal.1

Fortunately, American taxpayers have already developed, paid for, tested, and used the world’s best EHR system: the Veterans Health Information Systems and Technology Architecture (VistA). Nearly 18.5 million veterans were enrolled by the spring of 2010, an accomplishment that is receiving belated recognition.2 To promote the public welfare, medical organizations should create a not-for-profit Joint Commission on Electronic Health Records that would provide VistA with the business and technical administration it needs to make this technology available to the entire U.S. population.

No potential conflict of interest relevant to this letter was reported.

 

2 References

    1. 1Johnson A. Doctors get dose of technology from insurers. Wall Street Journal. August 9, 2010.

  1. 2Longman P. Best care anywhere. 2nd ed. Sausalito, CA: PoliPoint Press, 2010.

Author/Editor Response

The “meaningful use” regulation developed by the Office of the National Coordinator for Health Information Technology (ONC) and the CMS offers the nation a blueprint for the development of an infrastructure for its health information technology. When effectively implemented, health information technology offers tremendous potential to improve the quality and efficiency of care.

Both Weinger and Taylor share concerns about the maturity of current EHR products. We believe that current records are fully capable of improving the quality and safety of health care. Furthermore, we believe that considerable innovation in the market for EHRs will result from the availability of stimulus funds. Existing systems are rapidly improving, and substantial new product offerings are being made available. Absent the “meaningful use” incentive program, we are certain that the innovation Weinger and Taylor deem necessary would be much slower in coming.

Weinger notes concerns about the safety of EHR products. The widespread implementation of EHRs will, in our opinion, improve the overall safety of care. However, the federal government and private actors have the responsibility to do everything possible to ensure that the implementation and use of EHRs are as safe as they can possibly be. The ONC is working on initiatives to promote this goal.

Rodkey offers the important perspective that there is much to learn from the experience of the Department of Veterans Affairs in its successful implementation of the VistA program and that physicians would benefit from technical assistance to successfully implement EHR systems. The federally supported Regional Extension Center program aims to distill the learning from effective implementations of this kind and provide critical support to those physicians who need it most.

The process of the nationwide implementation of health information technology will be challenging. Nonetheless, we believe that the evidence base and experience of most front line providers who have made the transition support the broad, safe adoption and meaningful use of EHRs, and we are working diligently toward this end.

David Blumenthal, M.D., M.P.P.
Marilyn Tavenner, R.N., M.H.A.
Department of Health and Human Services, Washington, DC

Since publication of their article, the authors report no further potential conflict of interest.

 

0 Comments
 

Leave a Reply

Your email address will not be published. Required fields are marked *