In the face of rising costs, inconsistent quality, and the recent economic decline, strategies aimed at creating a more efficient health care system now rank among the most contested political issues in the U.S. As evidenced by the attention given to health information technology (HIT) in the Health Information Technology for Economic and Clinical Health (HITECH) Act, which was incorporated into the American Recovery and Reinvestment Act of 2009 and the Affordable Care Act of 2010, HIT has become an important component of the federal government’s attempts to reduce health care costs while increasing quality of care.
Creation of an oversight committee, the release of stimulus funding, and the offer of financial inducements to move to computer-based reporting (with financial penalties for noncompliance to follow) have provided an incentive for more physicians to adopt and use HIT. The government has set a goal of universal electronic health record (EHR) adoption before 2015.1-4 These incentive programs, which will affect all U.S. physicians, have raised great concern among surgeons due to their complexity and perceived preferential treatment of primary care physicians.5,6 Government recognition of these issues has allowed specialty groups to voice their concerns with the goal of ultimately editing incentive program criteria to be more inclusive of other specialties.
The Stage 1 final rule was implemented in 2011 and calls for adherence to 15 core set objectives, five out of 10 menu set objectives, and six clinical quality measures. The proposed Stage 2 rule was released for comment in February 2012 with the intent of increasing the core objectives to 17, three out of five menu set objectives, and 12 clinical quality measures. Numerous organizations representing the entire spectrum of health care responded with comments for the May 7 deadline.
Stage 3, the final stage, will clearly be the first major opportunity for surgeons to see how HIT can be applied to surgical care, given that Stages 1 and 2 have largely focused on getting the infrastructure in place. Because the criteria are still evolving based on physician feedback, it is important at this time for surgeons to learn how HIT and HIT-related legislation affects surgical practice and the current issues that need be addressed in the most recent round of proposed regulations.
Furthermore, with the American Board of Medical Specialties adopting a new sub-certificate in clinical informatics, the surgical profession will need to develop a cadre of well-trained surgical “informaticians” to help ensure that the continued development of HIT meets the unique needs of surgical practice.
HIT is a broad term encompassing any fusion of electronic information processing with medicine. In the U.S., communication technology is subsumed within HIT, whereas internationally the acronym HICT is used to signify the importance of communication as well as information. Another key term is “biomedical and health informatics,” which is used to describe the science of information use in health care delivery, research, and public health. Some consider HIT to be focused on the technology whereas informatics is focused on technology’s proper use in order to achieve desired goals. Both are essential concepts.
Additional features of HIT and robust EHRs include decision support for clinicians and patients, electronic reminders, telemedicine, secure electronic health communication, knowledge retrieval systems, and data exchange networks. (See Table 1)7-9, 10
Data exchange networks are secure data warehouses of predetermined clinical information from numerous hospitals and clinical settings. These systems allow clinicians to retrieve patient data across the continuum of care, even when it is from outside of the clinician’s hospital network.
The Indiana Network for Patient Care (INPC) is one such data exchange. Created in 1994 with funding from the National Institutes of Health and the National Library of Medicine, it merges data from five major Indianapolis, IN, hospital systems, including 11 hospitals and 100 geographically distinct clinics and ambulatory surgery centers. All INPC participants submit a range of medical information to a separate EHR vault in a central INPC server. Now, for example, when a patient is seen in any of the INPC emergency departments, information from all five networks may be viewed in one consolidated virtual medical record.11
HIT’s effect on surgical practice
In 2011, the U.S. Centers for Disease Control and Prevention (CDC) reported that only 57 percent of physicians were using an EHR, with physicians at small and rural hospitals less likely to use any type of HIT.8,9 In the face of the slow rate of adoption, it is important that physicians understand how their practice may benefit from HIT implementation (see Table 2). Although most evidence concerning HIT has focused on large hospitals or primary care groups, the same benefits likely apply to surgical practice as well.
Nonetheless, implementation may be a stressful process initially, depending on the product implemented as well as how much training is provided beforehand. Evaluation data from AmericanEHR Partners show that if fewer than three days are spent in training before EHR implementation, successful use and/or subsequent satisfaction is negatively affected.12 It is safe to say that EHRs and their use are not fixed but dynamic, and improvements in both safety and functionality can be expected. Challenges remain; in particular, insufficient interoperability between systems remains a persistent problem, among others.
The evidence shows that proper HIT use may increase consistency and quality of care, while reducing health care costs and medical staff workload.7,13,16 As a result, Congress has passed multiple bills to incentivize physicians to adopt HIT, including the following:
Medicare Improvements for Patients and Providers Act of 2008. This act included the Electronic Prescribing (eRx) Incentive Program that created an annual financial incentive to encourage physicians to e-prescribe with any system that allowed the generation of a medicine list, the provision of alternative medications, authorization requirements, and a printed or electronic submission of each prescription.19
American Recovery and Reinvestment Act (ARRA) of 2009. This act included the HITECH Act, establishing a $19.2 billion program to meet goals of increased EHR use by 2014 through the reduction of barriers to EHR installation and implementation.2,3 The legislation also established Medicare and Medicaid EHR Incentive Programs to aid and financially incentivize physicians to incorporate HIT services before 2015 (see Table 3). These programs focus primarily on increasing use of EHRs, CPOE, and CDS.1-4 Penalties begin to kick in if approved EHRs are not implemented within the program’s prescribed timeline.
The Affordable Care Act (ACA) of 2010. This law requires the development of standards and protocols intended to make data protection and patient education about health care options easier.20 Important examples include setting quality reporting requirements, grants for community-based collaborative care networks, grants for technical assistance, grants for EHR purchase, and bonus payments for physicians meeting Medicare HIT guidelines. The law also requires the Agency for Healthcare Research and Quality to expand HIT adoption and use.21
The rewards and penalties associated with each program are listed in Table 3.
To qualify for the eRx incentive payment, physicians must be able to electronically prescribe. Information regarding incentives can be found at this site.
All physicians and hospitals are eligible to register for HIT implementation benefits with Medicare. Physicians only can register with Medicaid if more than 30 percent of their patients are Medicaid enrollees and the program is offered in their state.1,4 To qualify for financial incentives under either program, physicians and hospitals must demonstrate meaningful use (MU) of a certified EHR platform.1,4 In the first year of participation in the Medicaid version of the program, physicians and hospitals must only demonstrate that they have “adopted, implemented, or upgraded a certified EHR.”22 Further instructions and details for the Medicaid plan can be found at the CMS website.
Certified EHR and MU are defined as follows:
Certified EHR: EHR technology that has been tested and certified by Office of the National Coordinator.2 A list of certified EHR platforms is available at http://onc-chpl.force.com/ehrcert. EHR systems, in combination with other HIT platforms, may be purchased separately or integrated with a choice of local or Web-based data storage. There is no evidence of a cost benefit when adopting a single integrated platform or multiple stand-alone platforms.1
MU: Physicians must report annually that they are successfully using EHR to qualify for financial incentives. MU criteria define what needs be reported to prove successful application of HIT. The current MU criteria, known as Stage 1, focus on basic HIT implementation including data capture, assistance in clinical decision making, and using stored data to track certain clinical conditions. Stage 2 and Stage 3 criteria will be introduced sequentially and will expand on Stage 1, increasing criteria requirements and patient self-management tools, and will add focus to overall population health and HIT data sharing.4 After each MU stage is passed, physicians must update how they report to reflect the current stage. Each MU stage comprises three lists of objectives. To meet MU in Stage 1, physicians must annually meet all 15 Core Set Objectives (see Table 4), five of 10 Menu Set objectives (see Table 5), and, if applicable, keep track of up to six clinical quality measures (see Table 6).15,23
Obstacles and concerns
Since the release of the Stage 1 MU criteria, surgeons have raised several concerns. One issue centers on the fact that MU criteria related to patient information collection are too specific to primary care, making them difficult for surgeons to meet. The American College of Surgeons (ACS) is currently pushing to make criterion exceptions for specialists to prevent surgeons from being forced to track patient data that are irrelevant to their practice. The ACS also is advocating surgical registry participation through HIT as an optional criterion. This change would effectively provide another non-required, surgeon-friendly option that could replace any other requirement.24,25
Another concern is that required participation in quality improvement programs may slow HIT adoption, as practices may need to make major changes in management techniques. The ACS advocates that involvement in quality improvement programs, although important, should be optional so as to increase rate of HIT implementation.5,6
The proposed expansion of MU criteria in Stage 2 requirements has also sparked concern. The ACS maintains that the new requirements are too aggressive and may be too difficult for many surgeons to meet. The proposal also includes troubling provisions, such as applying the Medicare penalty to the physicians and hospitals that have met the first year requirements of the Medicaid Incentive Program, and the large time gap between the year that the Medicare EHR penalty is applied and the year in which CMS assesses whether the physician has met the program requirements.26
Ongoing advocacy for surgeons is especially important as the MU criteria are expected to evolve over the next few years to correct problems and inequalities. The next generation of MU criteria, known as Stage 2, is slated to take effect in 2013 and will become mandatory in 2014 for physicians and hospitals that have already completed at least one year of the EHR incentive program under Stage 1. These proposed changes were available for public commentary until May 7, 2012.27 Many of the proposed changes, if they become effective, will directly affect surgical specialties. For example: (1) lab and radiology orders will count towards CPOE use, making the core set objective 1 more applicable to surgeon practice; (2) recording more than 50 percent of advanced directive discussions will be mandatory, potentially affecting how surgeons, patients, and patient primary care physicians coordinate care; (3) sending reminders to at least 10 percent of all unique patients for follow-up will become a core requirement, potentially altering how surgeons interact with patients; and (4) providing accessible lists of all members of a patient’s care team will be mandatory, which may affect surgeons working in institutions, such as academic centers, that have large, rotating teams.27
Although some of these changes do respond to the College’s concerns, they by no means cover all issues, and may in fact produce new ones. Therefore, the ACS will continue to advocate for surgeon-friendly criteria. Furthermore, as more surgeons implement HIT, it is important that they report the issues they encounter to the ACS, so that the College can identify new, pertinent issues and help shape future incentive requirements to be more relevant to surgical practice.
Recent federal legislative efforts are slowly bringing American medicine to levels of HIT implementation seen in other economically developed nations. It is vital that surgeons remain actively involved in reporting concerns about MU criteria. By engaging in this challenge directly, surgeons will help themselves and their patients to ensure that MU is “meaningfully useful” to surgeons and all the other key stakeholders.
- Bisantz A. Karsh BT, Wears RL, Lewis VR, Ancker J, Fairbanks RJ. Health information technology: Can there be meaningful use without meaningful design? Proceedings of the Human Factors and Ergonomics Society Annual Meeting. 2011;55(9):1724-1728.
- Healthcare Information and Management Systems Law and rules: Meaniful use. Available from: http://www.himss.org/asp/topics_focusdynamic.asp?faid=402.
- Blumenthal D. Stimulating the adoption of health information technology. W V Med J. 2009;105(3):28-29.
- Centers for Medicaid & Medicare Services. EHR Incentive Program. 2011. Available at: http://www.cms.gov/EHRIncentivePrograms. Accessed May 8, 2012.
- Russell T. American College of Surgeons Letter to Congress. March 30, 2009. Available at: http://www.facs.org/ahp/medicare/bonomack033009.pdf. Accessed May 18, 2012.
- American College of Surgeons. Health information technology. 2011. Available at: http://operationpatientaccess.facs.org/issues/health-information-technology. Accessed May 18, 2012.
- National Institutes of Health. Electronic health records overview. 2006. The Mitre Corporation. McLean, Virginia. Available at: http://portal.ahrq.gov/portal/server.pt/gateway/PTARGS_0_898095_0_0_18/Electronic%20Health%20Records%20Overview.pdf. Accessed May 18, 2012.
- Furukawa MF, Raghu TS, Spaulding TJ, Vinze A. Adoption of health information technology for medication safety in U.S. Hospitals, 2006. Health Aff (Millwood). 2008;27(3):865-875.
- Hsiao CJ, Hing E, Socey TC, Cai B. Electronic health record systems and intent to apply for meaningful use incentives among office-based physician practices: United States, 2001–2011. NCHS data brief, no 79. Hyattsville, MD: National Center for Health Statistics; 2011.
- MedPac. Report to the Congress: New approaches in Medicare. Information technology in healthcare. Chapter 7. 2004. Available at: http://www.medpac.gov/publications%5Ccongressional_reports%5CJune04_ch7.pdf. Accessed May 8, 2012.
- Indiana Network for Patient Care. Regenstrief Institute, Inc. Available at: http://www.regenstrief.org/medinformatics/inpc. Accessed May 8, 2012.
- Underwood WS, Brookstone AJ, Barr MS. (2011) The correlation of training duration with EHR usability and satisfaction: Implications for meaningful use. AmericanEHR. Available at: http://americanehr.com/. Accessed May 8, 2012.
- Byrne CM, Mercincavage LM, Pan EC, Vincent AG, Johnston DS, Middleton B. The value from investments in health information technology at the U.S. Department of Veterans Affairs. Health Aff (Millwood). 2010;29(4):629-638.
- Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E, Morton SC, Shekelle PG. Systematic review: Impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med. 2006;144(10):742-752.
- U.S. Department of Health and Human Services. Agency for Healthcare Research and Quality. Costs and benefits of health information technology. Available at: http://www.ahrq.gov/downloads/pub/evidence/pdf/hitsyscosts/hitsys.pdf. Accessed May 8, 2012.
- RAND health. Health information technology: Can HIT lower costs and improve quality? Available at: http://www.rand.org/pubs/research_briefs/RB9136/index1.html. Accessed May 18, 2012.
- Bates DW, Leape LL, Cullen DJ, Laird N, Petersen LA, Teich JM, Burdick E, Hickey M, Kleefield S, Shea B, Vander Vliet M, Seger DL. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;280(15):1311-1316.
- Garg AX, Adhikari NK, McDonald H, Rosas-Arellano MP, Devereaux PJ, Beyene J, Sam J, Haynes RB. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: A systematic review. JAMA. 2005;293(10):1223-1238.
- Burley C. Electronic prescribing in 2011. Bull Am Coll Surg. 2011;96(6):6-11.
- U.S. Department of Health and Human Services. The Office of the National Coordinator for Health Information Technology. Electronic eligibility and enrollment. Available at: http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3161. Accessed May 18, 2012.
- Healthcare Information and Management Systems Society. The Patient Protection and Affordable Care Act: Summary of key health information technology provisions. June 1, 2010. Available at: http://www.himss.org/content/files/PPACA_Summary.pdf. Accessed May 8, 2012.
- American College of Surgeons. Medicare vs. Medicaid. Available at: http://www.facs.org/ahp/ehr/medicarevsmedicaid.html. Accessed May 17, 2012.
- American College of Surgeons. Division of Advocacy and Health Policy. Final Criteria—Stage 1. Available at: http://www.facs.org/ahp/ehr/finalcriteria.html. Accessed May 18, 2012.
- Detmer DE. Statement of the American College of Surgeons to the Health Information Technology Policy Committee. Meaningful Use Workgroup. 2011. Available at: http://bit.ly/KLGVXl. Accessed May 8, 2012.
- Opelka FG. Statement of the American College of Surgeons to Health Information Technology Committee. Available at: http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_10741_907456_0_0_18/Opelka-specialistsQA.pdf. Accessed May 17, 2012.
- American College of Surgeons. Division of Member Services. ACS response to major categories of concerns. 2010 Board of Governors survey. Available at: http://www.facs.org/about/governors/bogresponse.html. Accessed May 8, 2012.
- U.S. Department of Health and Human Services. Centers for Medicare & Medicaid Services. Electronic Health Record Incentive Program—Stage 2 proposed rule. Available at: http://www.gpo.gov/fdsys/pkg/FR-2012-03-07/pdf/2012-4443.pdf. Accessed May 8, 2012.