Survey on Meaningful Use

Project Synopsis

The federal “meaningful use” program was implemented to improve the safety, quality, and efficiency of patient visits through the adoption of electronic health records (EHRs). This program was designed with the idea if physicians were incentivized to perform and then enter the steps (criteria) that were needed for a typical patient visit into an EHR then EHRs would be more quickly adopted. However, the program has not gone as planned. Complaints by American Academy of Family Physicians (AAFP) members seemed to fall into one of two categories:

  1. Documentation of meaningful use reduces the amount of time spent interacting with a patient;
  2. Review and documentation of some meaningful use criteria is not an efficient use of already limited face-to- face time with the patient.

A large scale project has been designed to evaluate the effect of “meaningful use” in the three phases. Phase I was approved for funding by the AAFP by the board and executed over a period of six months and was designed to evaluate the effect on what is arguably the most valuable time during a patient visit to a clinic, the face-to-face physician-patient time. Our goal was to understand the physician’s role in documenting and using the criteria, the effort involved in that role, and are there any perceived barriers for use. A goal that was achieved, allowing collection of tangible evidence (data) regarding the effect of “meaningful use” criteria on the everyday physician’s practice beyond just an opinion by defining prevalence, impact, and benefit or detriment.

Objective

To evaluate the benefit of meaningful use criteria during the face-to-face physician-patient time during a clinic visit by completing the following aims:

Aim 1
Define benefit of meaningful use criteria based on the average patient visit

Goal: tTo answer the question, is the criteria useful when seeing a patient, and if so, should the criteria be labeled as meaningful use.

Aim 2
Define the effort and ease of documentation of each criterion

Goal: To understand the physician’s role in documenting or using the criteria, the effort involved in that role, and if there are any perceived barriers for use.

Methodology

The research framework was a reducing model that utilized a Delphi approach of using the experts to develop a survey based on the project objectives. The overall approach was to first develop all information specifically with detail and then combine that information by consensus where detail is traded-off for global understanding of concept. The milestone describe survey development to execution.

Milestone 1
Define the work/tasks associated with each meaningful use criteria that are required for review and/or documentation during a patient visit based on program stage (1-2013, 1-2014, 2). This process will utilize five expert teams of physicians, engineers, and experts who are currently practicing and/or working in the day-to-day treatment of patients. Five teams were decided upon so practices would be represented regionally from around the United States. Refinement of criteria occurred through a series of focus groups. The idea is that first teams create their own list initial task-to-criteria list(s) based on their region, after all lists were combined into one consensus list by the panel.

Expert Panel
Expert Panel:

Steven Waldren, MD, MS  (Midwest)

Tosha Wetterneck, MD, MS  (North)

Expert Panel:

G. Talley Holman, PhD, MBA   (Midwest)

John Beasley, MD  (North)

Expert Panel:

Heidi Roberson-Cooper  (Midwest)

Jenna Marquard, PhD  (Northeast)

Expert Panel:

Deborah (Deb) Cohen, PhD (West Coast)

Chet Fox, MD  (Northeast)

Expert Panel:

Ryan Mullins, MD  (Texas)

Joy Rivera, PhD  (Southeast)

Expert Panel:

Charles North, MD, MS  (Southwest)

Matt Rafalski, MD  (Southeast)

Expert Panel:

Lawrence Dardick, MD  (Southwest)

 

Milestone 2
Using the information gained from milestone 1, an online survey metric was developed to evaluate the usefulness of the criteria during a patient visit and the effort or ease involved in documenting in the EHR. The survey was piloted and refined for a target time of 30 minutes. A target population of 15,000 randomly selected primary care physicians who had attested to meaningful use (got paid for participating) was identified. Multiple levels of confidence were calculated based on population statistics with the lowest level needing roughly 1000 respondents to yield findings based on demographics of interest. This milestone ended with IRB approval by the AAFP.

Milestone 3
Execute the survey utilizing the AAFP marketing research division and evaluate the data. The survey was executed over a three-week period. The approach use a pre-release email asking participants to make time, a lease email 48-hours later, and two reminders (one email, one post).

Findings

The findings shown here represent 439 primary care physicians (PCPs) from across the U.S. who responded to a survey of the impact of meaningful use on practice from the summer of 2015. This survey measured the benefit and burden of each criterion based on the follow definitions:

  • Burden def. Not just relative to time, it is mental or physical effort including interrupts
  • Compliance def. The minimum action, thought, or task to complete the objective          
  • Useful def. Likely to improve diagnosis, treatment, patient satisfaction, or safety   
  • Patient episode def. Events or tasks dedicated to preparing, executing or documenting a patient visit  

Table 1 shows the meaningful use criteria distributed into 4 categories by stage based on high versus low burden (difficulty) and utility during the PCP’s face-to-face time with a patient. Comparison of the groups of criteria allows estimation of the overall impact of a stage on a practice and how stages vary. 

Table 1. Benefit and Burden Based on Physician Face-to-Face Time
 Zone 1Zone 2Zone 3
Zone 4
 Zone 1: (Criteria useful and not difficult to complete)Zone 2: (Criteria useful but difficult to complete)Zone 3: (Criteria less useful but not difficult to complete)Zone 4: (Criteria less useful and difficult to complete)
Stage 1:
Core
Zone 1:
  • Record and chart vitals
  • Record smoking status
  • Maintain active allergy list
  • Perform Drug-Allergy checks
  • Peform Drug-Drug checks
  • Generate and transmit scripts electronically
Zone 2:
  • Use computerized Physician Order Entry (CPOE)
  • Maintain current problem list
  • Maintain active medication list
  • Protect electronic health information
Zone 3:
  • Record Demographics
Zone 4:
  • Provide patients with electronic copy of health information
  • Provide clinical summaries for each office visit
  • Implement one trackable clinical decision support rule

Stage 1: Menu
Zone 1:
  • Incorporate clinical lab-test results into EHR
Zone 2:
  • Perform medication reconciliation when receiving patient from another setting/provider
Zone 3:
  • Submit electronic data to immunization registries
  • Submit syndromic surveillance data to public health agencies
Zone 4:
  • Generate lists of patients by specific conditions
  • Use EHR technology to ID patient-specific education
  • Provide summary care record for each transition of care or referral
  • Send patient reminders preventive/follow-up care
  • Perform drug formulary checks
Stage 2: Core
Zone 1:
  • Record and chart vitals
  • Record smoking status
  • Generate and transmit scripts electronically
  • Incorporate clinical lab-test results into EHR
Zone 2:
  • Use computerized Physician Order Entry (CPOE)
  • Protect electronic health information
  • Perform medication reconciliation when receiving patient from another setting/provider
Zone 3:
  • Record Demographics
  • Submit electronic data to immunization registries
Zone 4:
  • Provide patients with electronic copy of health information
  • Provide clinical summaries for each office visit
  • Implement one trackable clinical decision support rule
  • Generate lists of patients by specific conditions
  • Send patient reminders preventive/follow-up care
  • Use EHR technology to ID patient-specific education
  • Provide summary care record for each transition of care or referral
  • Use secure electronic messaging
Stage 2: Menu
Zone 1:
  • Record patient family health history
Zone 2:
  • Record Electronic notes in patient records
Zone 3:
  • Submit syndromic surveillance data to public health agencies
    ID and report cancer cases to registry
    ID and report specific cases to a specialized registry
Zone 4:
  • Imaging results accessible through CEHRT

Figure 1 below shows each criterion of stage one plotted in relation to each other relative to use (benefit) and difficult to complete (burden).

Figure 2 below shows each criterion of stage two plotted in relation to each other relative to use (benefit) and difficult to complete (burden).

Figure 1. Stage 1 Criteria: Click to Enlarge

Figure 2. Stage 2 Criteria: Click to Enlarge