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Michael S. Barr, MD, MBA, FACP (ACP)
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Dr. Peter Basch posted an interesting response to this Archives of Internal Medicine article on the Health Affairs Blog at: http://healthaffairs.org/blog/2011/02/11/the-case-for-meaningful-use-strengthened-not-weakened/. Entitled, "The Case for Meaningful Use Strengthened, Not Weakened," Dr. Basch states, "The implications of this 2009 paper for EHR research are abundantly clear. EHRs developed and used within the current “vicious cycle” can all but be guaranteed to show no improvement in quality. The technology was not designed to improve quality, but rather to support documentation and billing." He then goes on to point out that, "...rather than calling into question the meaningful use program, this study actually supports its use." The post by Dr.Basch puts the Archives article into perspective and highlights the challenges ahead...never mind changing the payment system to anchor those changes - the closing point of his article.
The lack of a clear, positive clinical effects of CDS on quality has been shown in other studies, too - which raises several questions. Assuming the evidence-basis for the CDS recommendations is well-represented by the clinical decision support system, we should ask: 1) How are CDS recommendations presented to clinicians and their teams? 2) Are the CDS recommendations sufficiently adjusted to account for the unique clinical needs of an individual patient and his/her preferences? If so, are the metrics of quality also modified to measure outcomes based on the adjusted and individualized priorities? 3) Are our measures of quality adequate to discern the effectiveness of the CDS guidance? 4) Is there a way to appropriately involve patients (and their families/caregivers when appropriate) in the review/implementation of guidance provided by CDS? This post is the personal opinion of the author and does not necessarily reflect the official policy or position of the American College of Physicians (ACP). ACP does not endorse a specific EHR brand or product and ACP makes no representations, warranties, or assurances as to the accuracy or completeness of the information provided herein.
The specific wording in the final rule regarding computerized provider order entry (CPOE) is as follows: (1)(i) Objective. Use computerized provider order entry (CPOE) for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines. (ii) Measure. Subject to paragraph (c) of this section, more than 30 percent of all unique patients with at least one medication in their medication list seen by the EP have at least one medication order entered using CPOE. (iii) Exclusion in accordance with paragraph (a)(2) of this section Any EP who writes fewer than 100 prescriptions during the EHR reporting period. CMS was careful to limit CPOE to electronic prescribing for Stage 1 because of the challenges many practices would have had if the metric also included laboratory & test ordering. The other key point is that the 30% goal is based on a denominator which only includes those patients for whom a medication has been added to their medication list – not the entire patient population served by the eligible professional. However, the final rule already states that Stage 2 will raise the threshold from 30% to 60%. We can probably expect future Stages to also include objectives for laboratory and other test ordering. Therefore, practices should definitely inquire about the capability of EHR systems being considered to connect with the laboratories, radiology centers, and hospitals in their community through standardized interfaces. [This post is the personal opinion of the author and does not necessarily reflect the official policy or position of the American College of Physicians (ACP). ACP does not endorse a specific EHR brand or product and ACP makes no representations, warranties, or assurances as to the accuracy or completeness of the information provided herein.]
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Jun 1, 2010