Electronic Health Records - Thoughts Beyond "Meaningful Use"



Healthcare reform issues have frequently dominated the headlines over the past year.  There are many new changes yet to roll out depending on the final regulations of the bill still being debated by our legislators. One major change has been in full swing and has captured the attention of healthcare organizations across the country.

The need for an electronic health record (EHR) is obvious and ties to issues of privacy, efficiency, medical errors and duplication of tests to name a few. The healthcare industry has clearly lagged behind when you acknowledge the fact that we have had ATM cards for several decades that allow us to perform banking transactions all over the world.

Although the federal government is not always the leading edge innovator of change, in the case of the electronic health record, they have actually led the pack as evidenced by the system that has existed in their Veteran's Administration (VA) network for many years. Recognizing the value of such a system, the government developed an incentive program as part of the American Recovery and Reinvestment Act (ARRA) of 2009.

Under this act, provisions were developed for a program known as the Health Information Technology for Economic and Clinical Health (HITECH) Act. The final rules of this program were released in July of 2010 and offers financial incentives under Medicare and Medicaid to hospitals and eligible professionals who demonstrate "meaningful use" certified Electronic Health Records technology.  

Although clearly an important step, health care leaders must look beyond meaningful use to implement a solution that will fit seamlessly into the process of patient care and provide value rather than turmoil.

Electronic Health Records "Meaningful Use"

There has been an enormous amount of attention placed on these two words and information is available from a variety of sources. A prudent approach is to go right to the source and gain information regarding rules and regulations from the Centers for Medicare and Medicaid Services (CMS).

Demonstrating meaningful use is the key to receiving the incentive payments but it is not the driver of the key objectives of the program which relate to achieving health and efficiency goals. The recovery act specifies three main components of meaningful use:

  • The use of a certified EHR in a meaningful manner (e.g.: e-Prescribing);
  • The use of certified EHR technology for electronic exchange of health information to improve quality of care; and
  • The use of certified EHR technology to submit clinical quality and other measures.

Once established, providers must demonstrate meaningful use of their installed system for 3 months prior to becoming eligible for any financial incentives. For hospitals there are a total of 24 meaningful use objectives.

There are 14 core objectives that are required and a remaining 5 that may be chosen from the list of 10 menu set objectives. Facilities that are on the leading edge of this change process may become eligible for the financial incentives beginning in mid 2011.

The Real Objectives

Although the government is providing financial objectives to incentivize providers to develop an EHR solution, the real objectives of the program are as follows:

  • To improve the quality, safety and efficiency of care while reducing disparities;
  • To engage patients and families in their care;
  • To promote public and population health;
  • To improve care coordination; and
  • To promote the privacy and security of EHR's

In practical terms those goals relate to such things as reducing medication errors due to the inability to read a physician's handwriting, or eliminating duplication of tests because the results of previous tests do not easily follow the patient as they seek care in multiple locations.

Health care leaders must meet the criteria to qualify for the incentive payments but then clearly focus on how an EHR can improve quality and lower costs in their organizations.

The Change Process

Health care executives must realize that implementing an Electronic Health Record requires understanding of the change process as well as a commitment to a "total solution" and not just software implementation. The acceptance of this major change by the end users; physicians, nurses and other clinical professionals is critical to the process.

Physicians want to know, how easy will it be for me to locate information, make rounds on my patients, order medications and establish routine order sets, etc. Nurses have their own issues related to availability of computer terminals, ease of documenting nurse's notes and accessing test results. Intimate involvement of the key stakeholders in the evaluation and implementation process is a major factor in success or frustration.

One Size Does not Fit All

Clearly there are differences in capabilities and resources in a 25 bed critical access hospital and a 700 bed medical center. The former often has very little on site information technology (IT) personnel and support unless they are part of a larger health system. Larger institutions often have a full complement of IT support and have different needs when it comes to EHR implementation.  

For this reason, when evaluating vendors, health care executives should look for a total solution which has a menu of options to choose from that can be customized to the specific needs of the client. This could range from a total outsourced solution for smaller hospitals to working in a support capacity utilizing existing resources in a larger facility.

Choosing the Best Option

There are a number of qualified companies with viable EHR solutions to pick from. When choosing a vendor it is important to consider these meaningful thoughts beyond meaningful use.

  • The software must be certified;
  • The vendor must have an efficient process of meeting meaningful use criteria;
  • System costs should be structured to minimize total costs while taking advantage of positive adjustments in Medicare Cost Reports (for critical access hospitals) or enhancing payments to larger facilities;
  • Total costs of the implementation should be calculated. Is this an all inclusive package deal for a defined period of time, or will there be ongoing maintenance and upgrade costs?  Beware of a low acquisition cost followed by expensive upgrades;
  • Are financing options available that meet your needs? and;
  • How will your system be supported and maintained and how will it interface with existing systems?

Avoiding the "CEO Nightmare"

As we enter the age of EHR we are moving into a scenario of dependence on technology that we have not experienced to this point. The typical issues that a CEO worries about have historically related to things such as patient safety, quality measures, financial performance, medical staff relations and employee satisfaction.  

The CEO did not have to be concerned about how orders would be processed or patient documentation achieved because it was accomplished via people and paper. This might be a good system based on "up time" but as described earlier it does not offer the safety, efficiencies and portability of data advantages that an EHR provides.  

The most critical issue that CEOs should ask is, "how will our EHR system be maintained and supported and by who?" Making sure that you have a clear, professional, cost effective answer to that question will avoid the CEO nightmare of frustrated physicians and staff complaining about not being able to care for their patients.


We are entering a major era of change in the healthcare industry as it relates to implementation of EHR. It is important to meet meaningful use criteria and qualify for financial incentives offered by the federal government as soon as possible.

It is equally important however to engage in a process that takes in account the change process with the users as well as the need for a total solution that that is cost effective and meets your ongoing system support needs. Healthcare leaders that recognize these key elements will provide the best environment for serving their patients while enhancing the satisfaction of their clinicians.

About The Author

Kevin Shrake is an experienced Health Care CEO. He is a Fellow in the American College of Healthcare Executives as well as an accomplished author and public speaker. He currently serves as the Executive Vice President and Chief Operating Officer of M*D Resources, Inc. based in Fresno, California.