Which Components of Health Information Technology Will Drive Financial Value? | Page 2

We added internal ratings for the additional functionalities and additional domains. We also had 7 national experts review the ratings in detail and suggest possible edits. Suggestions were reviewed and reconciled through consensus by 3 authors.

Identifying Top-Scoring Functionalities

For each functionality, we summed scores across the 6 domains, for a possible score of 6 to 18 points. We determined the distribution of scores for each technology-setting combination. None of the distributions were clearly bimodal with obvious cut-points for the highest scoring functionalities. Thus, we selected and applied the cutoff that would yield approximately 10 high-scoring functionalities for each technology-setting combination. We also used 2-tailed t tests to compare the average score for EHR functionalities with the average score for HIE functionalities. We used analysis of variance (ANOVA) to compare the average scores across healthcare settings.

Comparing With the Final Stage 1 Meaningful Use Criteria

We compared the top-scoring functionalities with the final Stage 1 meaningful use criteria. Stage 1 includes 15 “Core” measures that are required for all eligible providers and hospitals, such as “record patient demographics,” “record vital signs and chart changes,” and “use computerized order entry for medication orders.”1 In addition, Stage 1 includes 12 “Menu” measures, from which eligible providers and hospitals are expected to choose 5.1 Examples of Menu measures include “implement drug formulary checks” and “perform medication reconciliation between healthcare settings.” We calculated the percentage of top-scoring functionalities from our framework that are part of meaningful use and analyzed the content of those that are not yet part of meaningful use, in order to identify opportunities for future meaningful use measures.

Final Validation

We presented the top-scoring functionalities to experts again in August 2011. They validated the final set and recommended no changes, as they believed that it was consistent with and went beyond Stage 1 meaningful use.

RESULTS

We identified 105 unique functionalities enabled by EHRs and HIE and 233 functionality-setting combinations (Appendix). We identified a total of 84 functionalities for ambulatory care, 80 for inpatient care, and 69 for ED care. We identified a total of 160 functionality-setting combinations for EHRs and 73 for HIE. Overall and within each setting, there were more functionalities for EHRs than HIE.

Overall, the average summary score for each functionality in each setting was 12.5 (median 13, standard deviation [SD] 2.6) on a scale from 6 to 18, in which higher scores represented a higher likelihood of having a measurable positive financial effect. The average functionality for EHRs scored significantly higher than the average functionality for HIE (13.0 vs 11.3, P <.0001). There were no differences in average scores across healthcare settings (P = .33).

The distribution of scores is shown in Figure 1 for EHRs and Figure 2 for HIE. The cut-point that yielded approximately 10 high-scoring functionalities per technology-setting combination was a score of >16 for EHRs and >13 for HIE. Using this threshold, there were a total of 31 unique high-scoring functionalities and a total of 54 high-scoring functionality-setting combinations (Table). For EHRs, the high-scoring functionalities had scores ranging from 16 to 18, with a mean of 16.5 (SD 0.7). For HIE, the high-scoring functionalities had scores ranging from 13 to 16, with a mean of 13.9 (SD 1.0).

For EHRs in particular, there were 15 unique high-scoring functionalities and 27 high-scoring functionality-setting combinations (Table). Examples of high-scoring EHR functionalities included: providing alerts for expensive medications (ambulatory and inpatient care), providing alerts for redundant lab orders (inpatient and ED care), and displaying imaging results (ED). For HIE, there were 16 unique high-scoring functionalities and 27 high-scoring functionality-setting combinations (Table). Examples of high-scoring HIE functionalities included: sending and receiving imaging reports (ambulatory, inpatient, and emergency care), receiving laboratory results (ambulatory and emergency care), and enabling structured medication reconciliation.

All of the Stage 1 meaningful use measures reflect functionalities that were scored in our framework. Of the 15 Core meaningful use measures, 4 were ranked highly in our framework as having the most potential for driving financial value: use computer provider order entry (CPOE) for medication orders, implement drug-drug interaction checks, implement the capability to electronically exchange key clinical information among providers and patient-authorized entities, and report clinical quality measures to the Centers for Medicare & Medicaid Services or the states. Of the 12 Menu meaningful use measures, 4 were ranked highly in our framework: implement drug formulary checks, incorporate clinical laboratory test results into EHRs as structured data, perform medication reconciliation between care settings, and provide summary of care record for patients referred or transitioned to another provider or setting.

Of the 54 high-scoring functionality-setting combinations in our framework, 25 (46%) are represented in Stage 1 meaningful use (Table). Thus, nearly half of the functionality- setting combinations in our framework align with Stage 1 meaningful use and represent the portion of Stage 1 meaningful use that is most likely to yield financial benefits. Of the functionality-setting combinations that were not represented in Stage 1, some may be implemented as prerequisites to the formal definition of Meaningful Use but are not stated as measures per se, such as default drug dosages and alerts for preventive services. Many others are distinct and represent measures directed squarely at utilization and costs rather than at healthcare quality: provide alerts regarding generic substitution, provide rules-driven financial and administrative coding assistance, provide alerts for expensive medications, provide alerts for laboratory charges, and provide alerts for redundant lab orders.

DISCUSSION