The Law and EHRs in Medical Education: The ARRA World David Donnersberger MD, JD Clinical Assistant Professor of Medicine MS3 Site Director University of Chicago Pritzker School of Medicine Overview American Recovery and Reinvestment Act of 2009 (ARRA) The ARRA s Divisions The Applicability to UGME and GME CMS Incentives, Meaningful Use, & Medical School Grants Medical Student Notes Risks in Text Transcriptions of EHRs EHR, Med Ed & Professional Staff Dangers of Forced EHR Competency 1
Division A: Appropriation Provisions Title VIII: Funds to Labor, HHS (NIH), Education Title XIII HITECH = Federal Mandates to New or Existing Agencies Division B: Tax, Unemployment, Health, State Fiscal Relief, and Other Provisions Title IV: Medicare and Medicaid id Health Information Technology Subtitle A-Medicare Incentives Subtitle B-Medicaid Incentives Division A: Appropriation Provisions, Title VIII Direct Cash to Labor, HHS (NIH), & Education No mandates in regard to EHRs, but it grants $700M for Comparative Effectiveness Research, $400M for IT dedicated to that research $1.5M to IOM to study how electronic health data can be used for outcomes research $500M to replace National Computer Center $500M in IT acquisitions for Social Security to process disability and retirement t workloads $40M for Social Security to adopt disability claims IT systems to comport with future EHRs No Mention of Medical Education EHR not the same as HIT 2
Division A: Appropriation Provisions Title XIII, also known as HITECH mandates HHS and ONC HIT to implement HIT to Ensure safety of patient health info Improve quality, reduce errors, reduce disparity, advance delivery of patient-centered care Reduce costs, errors, inefficiencies, duplicative data and incomplete data Apply info to guide decisions of care Improve Public Health and Early Detection Division A: Appropriation Provisions Title XIII, also known as HITECH mandates HHS and ONC HIT to implement HIT to Improve coordination of care and accuracy of care Facilitate research and quality Promote early detection, prevention and management of chronic disease Promote more efficient i marketplace, greater competition and choice Reduce disparity in care 3
Absent from these mandates are any explicit Educational Goals The language of these goals are almost identical to the objectives outlined in the April 2005 Executive Order of President Bush that created ONC HIT Many of which are concepts brought to world attention ti by the September 1999 IOM Report, To Err is Human: Building a Safer Health System Division A: Appropriation Provisions Title XIII, also known as HITECH Establishes Mandates to New or Existing Agencies Creates Committees on HIT Standards and HIT Policy that have discrete goals and scopes, some of which involve EHRs Creation of New Center for HIT Enterprise Creation of New HIT Research Center and Regional Extension Centers Establishes Demonstration Project Funds for Developing Clinical Education Curricula and New Non-Clinical IT Degree Programs 4
Clinical Education Demonstration Project Funds (grants) for Clinical Education are intended to help Integrate Information Technology into Clinical Education Medical, Osteopathic, Nursing, GME Proposals must suggest demonstration projects to develop academic curricula integrating ti certified EHRs in the clinical i l education of health professionals Competition Based, Peer Reviewed Clinical Education Demonstration Project Funds for Clinical Education continued Must collect data No funds can be used to purchase hardware, software, or services Not to cover >50% of costs Must be aimed at HITECH s Strategic Plan Reduce errors, Increase access to prevention, Reduce chronic disease, or Enhance quality of care 5
Title XIII HITECH Non-Clinical Educational Grants Grants to Institutions of Higher Learning to create new degree and certification programs in Medical Health Information Undergraduate degrees Master level degrees Certifications More Division A, Title XIII HITECH HIT Policy Committee and HIT Standards Committee are created and have Required Responsibilities and Areas for Consideration No discussion of medical education Safety, Efficacy, Privacy paramount Creation and Implementation of Standards Achieve utilization of EHRs for all Americans by 2014 Center for Health Care Information Enterprise Integration is created Institutes of Higher Learning can apply for funds for study of Best Practices, Public Health, Interoperability 6
More Division A, Title XIII HITECH Federal Grants to States for HIT infrastructure and implementation Specific requirements and funding earmarked for study of Best Practices, silent on medical education National Regional HIT Centers are created and are to be associated with NFP Institutions or Organizations Not specific to medical education or institutions of higher learning No clinical educational goals specified Division A of ARRA 2009 Title VIII gives billions to Agencies to buy and implement and study HIT Title XIII HITECH sets broad aspirational expectations, creates committees, and provides very discrete Medical Education Grants for EHR-focused Curricula and Non- clinical education Absence of any MEANINGFUL USE language or logic 7
, Division B Division B: Tax, Unemployment, Health, State Fiscal Relief, and Other Provisions Subject to the succeeding subparagraphs of this paragraph, with respect to covered professional services furnished by an eligible professional during a payment year (as defined in subparagraph (E)), if the eligible professional is a meaningful EHR user (as determined under paragraph (2)) for the EHR reporting period with respect to such year, in addition to the amount otherwise paid under this part, there also shall be paid to the eligible professional.from the Federal Supplementary Medical Insurance Trust Fund.an amount equal to 75 percent of the Secretary s estimate (based on claims submitted not later than 2 months after the end of the payment year) of the allowed charges under this part for all such covered professional services furnished by the eligible professional during such year. (ii) NO INCENTIVE PAYMENTS WITH RESPECT TO YEARS AFTER 2016. Division B, Title IV Attention & Debate Follow the Dollars Medicare and Medicaid Incentives for Eligible Professionals who meaningfully use EHRs Who is an Eligible Professionals depends on Medicare or Medicaid pathway, but it is clinicians and not medical schools, GME programs, or CDIM/APM Meaningful Use to be defined by Secretary of HHS by Dec 31, 2009, but elements of: Use of Certified EHR technology E-Prescribing Connected in a way to provide care coordination Some reporting of quality measures 8
Meaningful Use Minimums (i) MEANINGFUL USE OF CERTIFIED EHR TECHNOLOGY The eligible professional demonstrates to the satisfaction of the Secretary.that during such period the professional is using certified EHR technology in a meaningful manner, which shall include the use of electronic prescribing as determined to be appropriate by the Secretary. (ii) INFORMATION EXCHANGE. The eligible professional demonstrates to the satisfaction of the Secretary.that during such period such certified EHR technology is connected in a manner that provides, in accordance with law and standards applicable to the exchange of information, for the electronic exchange of health information to improve the quality of health care, such as promoting care coordination. (iii) REPORTING ON MEASURES USING EHR. [.] the eligible professional submits information for such period, in a form and manner specified by the Secretary, on such clinical quality measures and such other measures as selected by the Secretary. The Secretary may provide for the use of alternative means for meeting the requirements of clauses (i), (ii), and (iii) Financial Incentives and Meaningful Use Medicare Incentives Up to $44,000 paid over five years if EHR is being meaningfully used in 2010 Penalties of reduced CMS reimbursement of 1% for failure to comply in 2015, 2% in 2016, 3% in 2017.. Hospital-based eligible professionals are not included in incentive scheme Anesthesiologist, Pathologists, Emergency doctors 9
Overview American Recovery and Reinvestment Act of 2009 (ARRA) The ARRA s Divisions The Applicability to UGME and GME CMS Incentives, Meaningful Use, & Medical School Grants Medical Student Notes Risks in Text Transcriptions of EHRs EHR, Med Ed & Professional Staff Dangers of Forced EHR Competency Student Notes in EHR As of yet, only one case where the actual HER is created in the courtroom for judge and djury to review Therefore, the printed text transcript of the EHR is the record What is in the printed text transcript is the decision of EHR administrations Originals of notes later addend Med student notes Record of orders subsequently deleted 10
Student Notes in EHR In the printed text transcript, notes and orders appear the same and tend to be bundled under note types rather than author type Progress Notes H&Ps Discharge Summaries Operative Reports Later review of the printed text transcript by payers or attorneys runs the risk of elevating the perceived importance of medical student observations or ideas by virtue of democratizing or normalizing all authors Student Notes in EHR The observations, impressions, opinions, recommendations, assessments and plans of medical students ARE NOT held to any Standard of Care. They are NOT doctors. Their ideas, even complicated medical ideas regarding diagnosis or treatment plan, are not subject to expert debate regarding Standards of Care. Attorneys may use the information or the story contained in student notes to contradict the plans of attendings and residents 11
Student Notes in EHR Recommendations Know who makes decisions at your Institution about which information is included in the text transcript of the EHR If faculty or residents electronically co-sign student notes, clearly document how the findings or plan differ from what the student outlined Read, edit and teach student note-writing, especially SOAP notes Professional Staff and EHRs Hospital administration requiring physician proficiency i in their EHR system Professional Staff enforcing this through bylaws and suspension of privileges Physicians who who have privileges at several hospitals resisting with arguments of restraint of trade, etc. (Ob/Gyne, Surgery, Psych) 12
Professional Staff and EHR Potential loss of off-site, ambulatory, and community clinical educators? Increased burden on clinical educators who use the same EHR or in the same hospital system? Loss of supervision and consistency of EHR training in other EHR system Different expectations ti across systems Different templates Different order sets and pathways Professional Staff and EHR Set school- or department- or program-wide expectations for trainee EHR learning Site visits by directors to observe EHR in practice with learners Voice concerns to Professional Staff and Administration leadership that good off-site educators my be burdened or lost by strict EHR requirements, as well as increased burden on in-system user-educators Discourage medicals student t exposure to templates, t order sets, and pre-set pathways Demand hardcopies of notes for your review 13