Emergency Departments and Meaningful Use

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Role of ED in patient care

The Emergency Department is often the first point of contact with the health care system. ED practice is a complex mixture of ambulatory and inpatient care. Large amounts of clinical data are gathered in the ED, all of which must be passed along the continuum of care. Much intensive and critical care is provided in the ED setting. In 2006, the CDC estimated that there were over 119 million ED patient visits in the US, of which about 13% resulted in hospital admission[ ]. Overall, about 45% of all hospital admissions arrive through the ED. For the key medical service lines including internal medicine and its subspecialties, seven out of 10 admissions start in the ED[1].

State of computerization in U.S. ED

Emergency Departments are somewhat more computerized than the inpatient services of general acute-care hospitals, but they are far from complete EHR adoption. A recent study estimated that only 17% of Emergency Departments in the US are adequately computerized to meet a “basic” definition of meaningful use[2], defined as managing demographic information, computerized provider order entry, and lab and imaging results. In the same study 46% (95% CI 39–53%) of US EDs reported having adopted some portion of an EMR. Computerized provider order entry was present in 21% (95% CI 16–27%).

By comparison, a 2009 paper in the New England Journal of Medicine showed that only 1.5% of U.S. hospitals have a comprehensive electronic-records system (i.e., present in all clinical units), and an additional 7.6% have a basic system (i.e., present in at least one clinical unit). Computerized provider-order entry for medications has been implemented in only 17% of hospitals[3]. Larger hospitals, those located in urban areas, and teaching hospitals were more likely to have electronic-records systems. Respondents cited capital requirements and high maintenance costs as the primary barriers to implementation, although hospitals with electronic-records systems were less likely to cite these barriers than hospitals without such systems.

Meaningful Use applied to the ED

The details of the proposed rules for Meaningful Use are explored elsewhere. There are separate programs for physician practices and for hospitals.

Hospital-based physicians were excluded from any physician incentive payments under the original ARRA/HITECH act. CMS has proposed that a hospital-based Eligible Physician (EP) be defined as an EP who furnishes 90 percent or more of his/her allowed services in a hospital, including all hospital inpatient, outpatient, and emergency department settings. (The only exception to this rule is for those practicing predominantly in an FQHC or RHC). Section 1848(o)(1)(C)(ii) of the Act defines the term hospital-based eligible professional to mean an EP, such as a pathologist, anesthesiologist, or emergency physician, who furnishes substantially all of his or her Medicare-covered professional services during the relevant EHR reporting period in a hospital setting (whether inpatient or outpatient) through the use of the facilities and equipment of the hospital, including the hospital's qualified EHRs. Thus emergency physicians appear to be statutorily excluded from any of the physician incentive payments.

The HITECH Act is less clear on what work products and work locations qualify for hospital incentive payments. CMS has proposed that only orders placed at the time of admission or thereafter should qualify for the CPOE threshold. This rule, if upheld, would discount any orders placed in the Emergency Department. However, in other areas of the Interim Final Rule, Emergency Departments are mandated to collect and report data.


In response to concerns that the incentive program unfairly excluded outpatient physicians and practices based at hospital-based clinics, on April 15, 2010, the Continuing Extension Act of 2010 (the Act) was passed by the U.S. Congress and signed into law by President Obama. Among other things, the Act extended the availability of Medicare and Medicaid incentive payments for the meaningful use of certified electronic health record (EHR) technology to physicians and certain other health care professionals who furnish substantially all of their services in hospital-based outpatient locations, other than an emergency department[5]. Hopes of extending physician incentives to ED physicians were dashed.

Position of Emergency Medicine Societies: ACEP

On March 1, 2010, the American College of Emergency Physicians submitted its public comments [6]to CMS on the Notice of Proposed Rule Making (NPRM)[7]. ACEP expressed its concern that the NPRM is ambiguous with respect to adoption and use of EHRs in emergency departments (EDs). “Even though all other care settings (ambulatory and hospital) are heavily dependent on the ED document products, the proposed rules de-incentivize ED adoption and instead encourage continued use of paper templates and hand written orders, which must somehow merge "electronically" with the rest of the health care system.”

The ACEP commentary included the following key points:

1. CPOE that takes place in the ED (POS 23 - emergency room, hospital) should be included in the hospital’s CPOE Meaningful Use numerator and denominator, at least for patients who are subsequently admitted. Care starts in the ED, and it is often the site of the most intensive care and the greatest data-gathering of the patient encounter.

2. ACEP recommends that hospitals be incentivized to deploy clinical care systems (i.e. EHR, CPOE, etc.) in the ED that are specifically engineered to improve the emergency care process. Inpatient tools may not be appropriate for ED workflow.

3. Excluding key patients (i.e. ED patients) from EHR incentive schemes creates disincentives to adoption, and may cause some hospitals to remain with paper charts and paper orders.

4. ACEP strongly agrees with the inclusion of ED throughput measures in the proposed clinical quality measures for electronic submission by eligible hospitals for payment year 2011–2012. This will focus attention on boarding (the common practice of holding admitted patients in the ED).

5. ACEP strongly supports the Stage 1 criteria that hospitals test their capability to provide electronic syndromic surveillance data to public health agencies; EDs will be a key collection point.

Similar supportive comments were submitted by the eHealth Initiative[8], advocating inclusion of ED orders for calculation of he hospital’s CPOE Meaningful Use numerator and denominator. “The ED is often the most time and resource intensive care setting, and, as a result, it is often the site of the largest volume of CPOE. Many hospitals might be able to reach the threshold of 10% CPOE required of EHs only by leveraging the CPOE that takes place in their ED.”

Regardless of the outcome of the CMS rule making process, advocacy for IT incentives in Emergency Medicine will likely continue by political means.


 [1]Emergency Department Visits, CDC Fastfacts, http://www.cdc.gov/nchs/fastats/ervisits.htm accessed 05/22/10
 [2]The Emergency Department as Admission Source. Healthcare Financial Management November 1 2007 http://www.allbusiness.com/health-care/medical-practice-orthopedics/5504499-1.html  
 [3]Geisler BP, Schuur JD, Pallin DJ (2010) Estimates of Electronic Medical Records in U.S. Emergency Departments. PLoS ONE 5(2): e9274. oi:10.1371/journal.pone.0009274
 [4]Jha AK, DesRoches CM, Campbell EG, Donelan K, Rao SR, Ferris TG, Shields A, Rosenbaum S, Blumenthal D. Use of electronic health records in U.S. hospitals. N Engl J Med 2009;360:1628-38.
 [5]United States: HITECH Definition of Hospital-Based Eligible Professional Amended in Response to Industry Outcry. 10 May 2010. http://www.mondaq.com/unitedstates/article.asp?articleid=100070
 [6]ACEP comments to CMS on NPRM.  http://www.regulations.gov/search/Regs/home.html#documentDetail?R=0900006480ab5875
 [7]Meaningful Use Notice of Proposed Rule Making http://edocket.access.gpo.gov/2010/pdf/E9-31217.pdf
 [8]eHealth Initiative comments to CMS. http://www.medeanalytics.com/pdfs/eHealth%20Initiative%20Letter%20to%20CMS%20(03-08-10).pdf

Submitted by David English