What does ‘meaningful use’ mean for pediatrics?

The American Recovery and Reinvestment Act of 2009 authorizes the Centers for Medicare and Medicaid Services (CMS) to provide reimbursement incentives for eligible professionals and hospitals who become ‘meaningful users’ of certified electronic health record (EHR) technology. The Office of the National Coordinator for Health Information Technology (ONCHIT) published a Notice of Proposed Rule Making that defines meaningful use. The goal of this rule is to assure that EHR technology is used to improve the quality of patient care. Children’s needs demand specific consideration when health information technology is developed and implemented. The different stages of growth, development and socialization of childhood require different meaningful use criteria that must be developed carefully for the diverse pediatric patient population. The American Academy of Pediatrics (AAP) suggests a number of principles for meaningful use in pediatrics.

The American Recovery and Reinvestment Act of 2009 (Stimulus Bill) authorizes the CMS to provide reimbursement incentives for eligible professionals and hospitals who become meaningful users of certified EHR technology. The ONCHIT published a Notice of Proposed Rule Making that defines meaningful use [101] and we are currently awaiting the final ruling. The goal of this rule is to ensure that EHR technology is used to improve the quality of patient care. In the words of the National Coordinator David Blumenthal: “The […] Act makes clear that the adoption of records is not a sufficient purpose: it is the use of EHRs to achieve health and efficiency goals that matters.”

Children’s needs demand specific consideration when health information technology is developed and implemented [1–3]. Children are a diverse and complex group. Their physiology, metabolism, size, development and special legal, educational and social needs result in unique vulnerabilities and special requirements that must be considered when planning and implementing EHRs. Children are at higher risk for adverse drug events than adults [3]. In children (unlike in adults) the change between two consecutive measurements (e.g., weight and height, or developmental milestones) are often more important than the actual measurement.

Children and adolescents also include many subgroups with unique medical needs. It is easy to recognize that children are not just little adults when you picture a 180 lb adolescent and a 2 lb premature infant. Their activities, metabolism, nutritional needs, anticipated development, preventive care needs, privacy and confidentiality, name or family history changes, anticipatory guidance, metabolism, response to medications, and risks for specific infections could not be more different. The different stages of growth, development and socialization of childhood require different meaningful use criteria. The Notice of Proposed Rule Making recognizes that meaningful use criteria for an orthopedic surgeon should be different from those of an internist. But, these two physicians have more in common in their daily practice than a neonatologist and an adolescent medicine physician.

Meaningful use criteria for the diverse pediatric patient population must be developed carefully. The AAP suggests that it be done with the following principles in mind.

Rule 1: meaningful use criteria & quality measures must be tailored to the scope of practice

Meaningful use and quality measures must be tailored to the scope of pediatric practice, and to specific patient populations. A pediatrician specializing in the treatment of obesity should be able to select quality reporting measures that reflect the nature of his/her practice. Reporting and retrieving newborn screening data and tracking follow-up should be quality measures for physicians who care for newborns. Adolescents are in a critical stage of their life, where not all sensitive information is shared with their parents. Meaningful use in this age group must acknowledge the need for privacy and support the ability of adolescents to determine when and how parents or guardians have access to their clinical information. Using the same measurements of meaningful use across the spectrum of pediatric care would not make sense.

Rule 2: all meaningful use criteria must be based on valid quality measures

Any meaningful use criterion should be based on evidence that its implementation will lead to improvement in quality of care. In addition, tested and valid quality measures should be available so that it can be determined whether goals are actually being achieved. The AAP supports the use of quality measures that have been vetted, evaluated, and endorsed by organizations such as the National Quality Forum or the Ambulatory Care Quality Alliance.

Rule 3: meaningful use must encourage & endorse the patient-centered medical home

The AAP advocates the primary care patient-centered medical home as a model of delivering primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate and culturally effective. The goal of the medical home includes a community-based system focused on a family-centered partnership and the provision of high-quality, developmentally appropriate, healthcare services that continue uninterrupted as the individual moves along and within systems of services and from adolescence to adulthood. For the first time in history, technology offers the opportunity to make the medical home a reality through the shared use of information by various providers, the patient, caregivers and supporting services through EHRs. Meaningful use must be a driver in the implementation of the medical home.

Rule 4: meaningful use must mean that no pediatrician is left behind

Meaningful use legislation will be more likely to make a positive impact on child health if pediatricians are able to participate in the incentive program. Approximately 46% of pediatricians are forced to limit their Medicaid panel to below the 20% threshold in order to stay in business [102]. These pediatricians may have financial difficulties in purchasing EHRs. Pediatricians generally do not care for those with Medicare, either. Thus, a significant proportion of pediatricians will be excluded from eligibility from the The American Recovery and Reinvestment Act incentive program. We urge that the Children’s Health Insurance Program (CHIP) and uninsured patients be included in the 20% calculation, at least until the impact of the Health Care reform bill is felt [103]. In addition, future ONCHIT initiatives should include strategies and incentives that further disseminate EHRs in pediatric practices that do not meet the Medicaid threshold.

Rule 5: meaningful use must mean the same thing in every Medicaid program

Unlike the meaningful use program for adult patients that will be designed and structured by the federal government though CMS, the incentive programs tied to medical incentives are shaped and implemented by the State and Territorial Medicaid programs. The risk of generating 57 different programs and 57 different definitions of meaningful use for children is high. Varying definitions would discourage health information technology vendors from implementing meaningful use criteria for children, because the potential buyers for each measure may be limited to one or two states. In order to be successful in pediatrics, meaningful use criteria must be standardized and harmonized across states and territories.

Rule 6: meaningful use regulation should include incentives for partial implementation

Meaningful use has been divided into stages, and stage one requires the physician to use an EHR that contains all the required elements. Failure to comply in even one category will lead to a failure to qualify for incentives. However, many smaller practices and hospitals will face challenges and obstacles that may make 100% compliance with all measures impossible. To generate the most benefit for children, the AAP believes it is in the best interest of children to support and encourage both full and partial implementation by physicians to qualify for full or partial participation in the incentive process.

One goal of the 2009 American Recovery and Reinvestment Act is to infuse money into the economy as fast as possible. ONCHIT’s meaningful use accomplishes this goal and at the same time advances health information technology in medicine in a dramatic way. However, this regulation was produced under an enormous time pressure, and even though the AAP recognizes the strong leadership and excellent work of the ONCHIT, the AAP believes that there are opportunities for improvement.

Children have a lot to gain from this meaningful use regulation – their specific needs put them at high risk for adverse events and medical errors. EHRs promise increased safety, more data sharing, advanced clinical decision support, reduction of care duplication, and a higher quality of care for children. Children could gain even more from improved regulation. The AAP supports the goals of meaningful use, and looks forward to collaborating with the Office of National Coordinator to improve on the details of this important regulation.