Meaningful use

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Meaningful use is prominently used in Health Information Technology Economy and Clinical Health Act (HITECH) provisions of the American Recovery and Reinvestment Act (ARRA) [1]. It was further defined by the Center for Medicare and Medicaid Services in a way that describes the use of health information technology for use among professionals.

The American Recovery and Reinvestment Act of 2009 authorized the Centers for Medicare & Medicaid Services (CMS) to provide financial incentives to providers and hospitals for adopting meaningful use of certified electronic health record (EHR) technology.

Under this authority the Office of the National Coordinator for Health Information Technology (ONC) has begun to setup standards, implementation specifications, and certification criteria for electronic medical record technology. The final rules should be completed by the end of 2010.


The Office of the National Coordinator for Health Information Technology (ONC) has listed the following goals as a guide [2]:

  1. Promote interoperability and where necessary be specific about certain content exchange and vocabulary standards to establish a path forward toward semantic interoperability.
  2. Support the evolution and timely maintenance of adopted standards
  3. Promote technical innovation using adopted standards
  4. Encourage participation and adoption by all vendors, including small businesses
  5. Keep implementation costs as low as reasonably possible
  6. Consider best practices, experiences, policies, frameworks, and the input of the HIT Policy Committee and HIT Standards Committee in current and future standards
  7. Enable mechanisms such as the Nationwide Health Information Network (NHIN) to serve as a test-bed for innovation and as an open-source reference implementation of best practices
  8. To the extent possible, adopt standard that are modular and not interdependent.

The standards to be adopted are based on current industry practices and rely on the following: Health Level 7, Inc (HL-7); National Institute of Standards and Technology (NIST) and Integrating the Health care Enterprise (IHE); SNOMED CT; International Statistical Classification of Diseases (ICD), LOINC, NCPDP and RxNorm.

You may view the entire proposed Electronic Health Record Incentive Program by opening the following pdf file[3] or link[4].


In order for eligible providers and hospitals to qualify for federal stimulus dollars, they must use certified electronic health technology in order to measure clinical quality. The United States federal government outlined the proposed criteria to achieve meaningful use in the Medicare and Medicaid Programs; Electronic Health Record Incentive Program; Proposed Rule of January 13, 2010. [5] Most health care organizations are trying to achieve meaningful use although there are struggles. [6] [[7]

Measures of clinical quality

The 25 measures involved in using health information technology for physicians, are separated into 5 initiatives. In order to qualify for stimulus dollars, the eligible provider must meet all the targets specified in the rule during a 90 day reporting period.


The Centers for Medicare and Medicaid Services (CMS) has stated meaningful use is can reform the health care system and improve health care quality, efficiency, and patient safety in three stages. [8]

Stage 1

  1. Electronic capture of health information in a coded format
  2. Tracking key clinical conditions
  3. Effective communication and care coordination
  4. Reporting of clinical quality measures
  5. Reporting public health information

Stage 2

will expand on the above by focusing on disease management, clinical decision support, medication management, support for patient access to their health information, transitions in care quality measurement and research and direct communication with public health agencies.

Stage 3

achieving improvement in quality, safety and efficiency, focusing on decision support for national priority conditions, patient access to self management tools, access to comprehensive patient data and improving health outcomes.

As of August 2009 the HIT Policy Council has provided a Matrix defining the time-line and recommendations of Meaningful Use. [9]. They have also recommended that systems be certified, currently the only recognized certification body is the Certification Commission for Health Information Technology (CCHIT).

First Initative: Improve quality, safety, efficiency, and reduce health disparities

  1. Use CPOE for all orders for 80% of orders
  2. Enable drug based alerts
  3. Maintain an up-to-date problem list of current and active diagnoses for 80% of patients
  4. E-prescribe for 75% of prescriptions
  5. Maintain an active medication list for 80% of patients
  6. Maintain an active allergy list for 80% of patients
  7. Record structured demographic data for 80% of patient
  8. record vital signs in the EMR for 80% of patients
  9. Record smoking status of 80% of patients
  10. Incorporate laboratory testing as structured data 50% of the time
  11. Generate a list of patients for quality improvement or outreach
  12. Report ambulatory quality data to the Center for Medicaid and Medicare services
  13. Send reminders to patients per their preference for 50% of patients
  14. Implement 5 clinical decision support rules
  15. check insurance eligibility electronically for 80% of patients
  16. Submit claims electronically for 80% of patients

Second initiative: Engage patients and their families

  1. Provide 80% of patients who request it, a copy of their health information within 48 hours
  2. Provide 10% of all patients with electronic access to to their health data within 96 hours of its availability.
  3. Provide 80% of patients a clinical summary of their visit

Third initiative :Improve care coordination

  1. Demonstrate the ability to electronically share clinical information between organizations
  2. Perform medication reconciliation for 80% of encounters
  3. Provide a summary of care record for 80% of referrals and transitions in care

Fourth initiative: Improve Population and Public Health

  1. Demonstrate electronic submission of immunization to state immunization registries
  2. Demonstrate the ability to exchange information with public health agencies

Fifth Initiative: Ensure Adequate Privacy and Security Protections for Personal Health Information

  1. Protect electronic health information by implementing appropriate technologies.

The interim rule goes on to state that physicians will be required to report on a subset of 90 clinical quality measures related to specialty.(5) The exact quality measures to be selected, and modifications to the use metrics will be available late in the spring of 2010 when the final rule is published.

The Impact of Meaningful Use

Many eligible healthcare professionals are scrambling to meet the meaningful use criteria and deadlines for many reasons; primarily to maximize Medicare and Medicaid reimbursements, leverage technology to provide better patient care and create efficiencies in prescribing, registry reporting, transition of care and medical records management.4

Knowing full well that implementing an electronic health record system and consequently proving meaningful use will require resources to accomplish, with the focus on the implementation factor, the impact to healthcare support services such as the medical records department, has been overlooked or, if known, ignored.

Meaningful use definition

“Meaningful use is ultimately linked to achieving measurable outcomes in patient engagement, care coordination, and population health.”1 Meaningful use is being defined by the Centers for Medicare and Medicaid Services as “how to best frame (these) measures including measurement of key public health conditions, measuring health care efficiency, and measuring the avoidance of certain adverse events.” 1

Meaningful use measures with impact on support services Measure: Record Advance Health Care Directive (AHCD) Stage 1: 50% (hospital requirement only). Make core requirement. For EP and EH: 50% of patients >=65 years old have recorded in the electronic health record (EHR) the result of an advance directive discussion and the directive itself if it exists. 2


Advance health care directives are legal documents, which allow the patient to chose his or her end-of-life decisions ahead of time.3 50% of all admitted patients 65+ should have documented in their health record that there was a discussion about, or documentation of, an advance directive. Hospitals have been actively pursuing this meaningful use criteria as it is seems to be an easy goal to accomplish because the time and effort to implement this procedure electronically appears minimal with low impact to the workflow. However, the unexpected consequence of implementing this criterion without full workflow process analysis proved to negatively impact clinical support services at healthcare facilities. Colleena Kirby, the legal documents processor in the medical records administration department at a large health maintenance organization in Hawaii reports that there was an average of 10 AHCD per day pre-meaningful use. Post-meaningful use implementation about 60 AHCD per day arrives for processing.5 The AHCD workflow consists of filtering for errors, rejecting erroneous AHCD, sending out rejection letters, scanning, indexing and documenting the AHCD. This process took approximately two hours a day for 10 AHCD. With the number increasing to 60 per day, the processing of AHCD was creating a backlog of all other documentation processing and was requiring resources which were not available to the medical records administration department. Consequently all legal documents processing started backlogging, which impacted patient care, revenue cycle and legal departments.5

How clinical information systems can help: The use of the EHR can be used by healthcare providers to document that a conversation regarding AHCD was discussed with the patient, which also qualifies as part of the 50% of AHCD for meaningful use. However, many providers and facilities will accept the paper document and send to the medical records administration, or scanning department, to process and scan in the document itself as proof of discussion of the AHCD. Document management systems which utilize a scan-on-demand function, which can feed scans into the EHR via fax or PDF, can help integrate the paper and electronic records, alleviating the impact to support services departments while not requiring more full-time resources to complete the work and also fulfilling meaningful use criteria.

References: 1. U.S. Department of Health and Human Services The Office of the National Coordinator for Health Information Technology. Meaningful use: a definition. 2009. Available from URL: Accessed 2011 May 21. 2. U.S. Department of Health and Human Services The Office of the National Coordinator for Health Information Technology. Meaningful use matrix. 2009. Available from URL: Accessed 2011 May 21. 3. Medline Plus. Advance directives. Available from URL: Accessed 2011 May 21. 4. Healthcare Information and Management Systems Society. The consequences of not pursuing meaningful use. 2010. Available from URL: Accessed 2011 May 21. 5. Kirby C. [Personal interview, 15 May] Honolulu; 2011 (unpublished).

Submitted by: Lari Anne Kamei


  1. Stimulus : American Recovery and Reinvestment Act of 2009 Public Law 111-5 Official Text. Lanham, MD: Government Institutes / Bernan Press; 2009.
  2. CMS. Medicare and Medicaid Programs; Electronic Health Record Incentive Program. Proposed Rule. Fed Regist; 2010. p. 1844-2011
  3. Lewis P. "Meaningful Use" takes time (HIMSS 2010 conference). In: amednews: American Medical News; 2010.
  4. Kennedy D. [10] Small, Mid-Sized, Physician practices Could Face Barriers in Meeting 'Meaningful Use' Criteria. iHealthBeat 2010:1.
  5. Heubusch. [11] Clinical Quality Measures for Providers. J AHIMA 2010.