Electronic Health Records in Oncology
Why Meaningful Use Matters
By Peter Paul Yu, MD
The problems that face our national health care delivery systems
include fragmentation of the provider base, poor communica-
tion among providers and with patients, misaligned incentives
among stakeholders, lack of a common governance structure,
and insufficient financial and expert resources for instituting
and managing change even where the will to do so exists.
Although widespread adoption of electronic health records
(EHRs) is frequently and correctly cited as necessary tomeet the
challenge of doing better with less, technology alone will not
accomplish this. Societal change within both the medical sys-
tem and the population that themedical establishment interacts
with must accompany the adoption of health information tech-
nology (HIT). The reliance on financial incentives and disin-
centives to control medical behavior, improve value, and bend
the rising burden of health care on the nation’s economy will
fail unless physicians and their professional societies are in-
cluded as meaningful partners in health care reform. We will
begin to advance health care only if we succeed in creating a new
socio-technologic ecosystem that includes providers, patients,
and payers.
The meaningful use (MU) criteria that unlock the American
Recovery and Reinvestment Act (ARRA) stimulus dollars mat-
ter because these criteria are the tangible first efforts to redesign
how health care is delivered while acknowledging the central
role of HIT and EHRs. The underlying principles on which
these criteria were constructed define the priorities and goals for
national health and health care delivery redesign.
The Origins of MU
MU combines technology adoption by providers and hospitals,
health information exchange, practice redesign, and consumer
engagement in order to improve outcomes and efficiency of
health care delivery. The Institute of Medicine (IOM) has been
instrumental in laying out the underlying principles for the
design of a more efficient health care delivery system capable of
increasing value by simultaneously improving the quality of
care delivered and reducing resources expended. Five overarch-
ing goals to achieve this have been identified by IOM and were
subsequently adopted by the Office of the National Coordina-
tor for Health Information Technology (ONC) as the under-
lying basis for MU1:
1. Improve quality, safety, efficiency, and reduce health care
disparities.
2. Engage patients and families.
3. Improve care coordination.
4. Improve population and public health.
5. Ensure adequate privacy and security protections for per-
sonal health information.
The importance of first two objectives of MU is understood
by medical oncologists. HIT has a major role to play in enhanc-
ing the quality, safety, and efficiency of chemotherapy admin-
istration.2,3 Although engagement of patients and families in
shared decision making happens daily in oncology practice, the
use of HIT can greatly facilitate this by sharing information on
diagnosis, staging, treatments, and expected outcomes. The
process of shared decision making and the influence of families
and social networks in that process will need to be better un-
derstood so that cancer-relevant HIT tools can be developed.
These first twoMUobjectives illustrate that the EHRs is not the
passive documentation tool of the paper medical record, but
instead amore dynamic instrument that actively assists the phy-
sician in patient care.
The third MU objective is improved care coordination.
Cancer care requires multidisciplinary coordination between
primary care, medical specialties, and allied health professionals
to achieve optimal outcomes and efficiencies. Fundamental to
the third MU objective is that patient-centered care necessitates
that health information follow the patient as he or she moves
through the medical system.
The fourth MU objective, improving patient and popula-
tion health, is a novel concept for most oncologists, accustomed
as we are to focusing on health care one patient at a time. The
office-based paper chart was meant for the personal use of the
recording physician in providing care to an individual patient.
It sufficed if the information contained within the paper chart
complemented the knowledge stored in the physician’s mem-
ory and provided documentation of services for reimburse-
ment. This method of recording health data has become
inadequate to support emerging heath care systems that require
actionable guidelines that support a complete episode of cancer
care and define and measure health and economic outcomes. A
new generation of clinical practice guidelines will be created
with EHR implementation planned from the outset using clin-
ical decision support tools. To write and validate these new
guidelines will require data capture, aggregation, and reporting
from the real-world patient experiences of practices as we begin
to assemble new knowledge bases.
The fifth MU objective can be seen as a technical issue, but
it is one that oncologists ignore with substantial medical legal
risk. Maintaining the integrity of health data, restricting access
to personal health data, and ensuring the secure exchange of
data are often dependent on human actions and less so on the
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206 JOURNAL OF ONCOLOGY PRACTICE  VOL. 7, ISSUE 4 Copyright © 2011 by American Society of Clinical Oncology

underlying EHR’s design. Policy and procedures need to be in
place and followed.
Over the next 5 years, if the MU goals are achieved, we will
have an established digital infrastructure for our nation’s health
care system. Looking to the future, the IOM has advanced
concepts to build on the foundation of MU. The use of patient
data to feed into a rapid cycle of knowledge creation and quality
and outcomes improvement could speed the process of trans-
lating clinical research into routine care. A Rapid Learning
Health Care System (RLHS) is based on the use of every pa-
tient’s medical experience to contribute data, which when ag-
gregated and analyzed can generate new insights into disease
mechanisms and treatment approaches. This is an iterative pro-
cess; as new knowledge is generated, it will feed back to inform
and revise best practices of patient care. An IOM workshop in
2009 examined how a RLHS for oncology might take shape.4
RLHSs will be heavily dependent on electronic capture and
transmission of patient data and presuppose the implementa-
tion of a national system for exchanging health data between
patients, providers, and entities engaged in public health. Thus
viewed, MU is not merely a government incentive program to
induce physicians to exchange paper for a digital version of the
medical record. Misunderstanding this is to risk expending a
minimum effort to meet the regulatory requirements to qualify
for the MU incentive dollars without instituting the lasting
changes needed to prepare for the models of health care delivery
that will follow.
Setting up MU
ARRA became law on February 19, 2009. Title IV of Division
B of ARRA established incentive payments to eligible profes-
sionals, hospitals, critical access hospitals, andMedicare Advan-
tage Organizations to promote the adoption and meaningful
use of interoperable HIT and qualified EHRs. Title IV of Di-
vision B and Title XIII of Division A of ARRA together are also
referred to as the Health Information Technology for Eco-
nomic and Clinical Health Act or HITECH Act. ONC was
charged with establishing a Health Information Technology
Policy Committee and a Health Information Technology Stan-
dards Committee to respectively recommend criteria for the
meaningful use of EHRs by providers and establish technical
standards for EHRs. Although ONC through its Policy Com-
mittee makes recommendations on MU criteria, the final deci-
sion on MU criteria is determined by the Centers for Medicare
& Medicaid (CMS). ONC does determine the certification
standards and testing process for EHRs to be designated as
“certified EHR technology.” Physicians and hospitals can
choose one certified EHR that meets all technical requirements
or can cobble together individual components or modules that
are each certified to perform a portion of the certification re-
quirement. As of the end of 2010, one of the certifying bodies,
the Commission for the Certification of Health Information
Technology, had certified 92 EHR technical products for eligi-
ble providers, of which 73 were complete systems and 19 were
EHR modules.5 Providers qualify for the MU incentive only if
they are using certified EHR technology and can demonstrate
that their use of it fulfills the MU performance criteria. If both
are achieved, the physician qualifies for up to $44,000 under
Medicare rules or $63,750 under Medicaid rules over a 5-year
period. Providers participating under the Medicaid program
have one extra year of incentive payments, and in the first year
do not need to demonstrate meeting MU performance criteria.
To qualify under theMedicaid program, providers need to have
at least 30% of their patient volume under Medicaid. Providers
may begin participation in MU in 2011, but there is no loss of
incentive dollars for starting in 2012. Starting after that reduces
the total incentive package. However, the first year’s participa-
tion requires only a 90-day period; thereafter, full year partici-
pation is required (Table 1).
The MU requirements will be rolled out in three stages, the
first in 2011, second in 2013, and third anticipated in 2015,
with the introduction of new criteria and higher performance
standards with each successive stage. In 2015, providers who do
not meet MU requirements will be penalized, starting at 1% of
CMS reimbursement, increasing to 2% in 2016, 3% in 2017,
and thereafter as the Secretary of Health and Human Services
deems necessary to ensure widespread adoption of an electronic
infrastructure for health care. The focus of stage 1 requirements
is capturing health information in a structured format, tracking
key clinical conditions, coordinating care, supporting clinical
decision making, engaging patients and families, and reporting
quality measures and public health information. Stage 2 will
“encourage the use of health IT for continuous quality im-
provement at the point of care and the exchange of information
in the most structured format possible . . . and the expectation
that providers will electronically transmit patient care summa-
ries to support transitions of care across unaffiliated providers,
settings and EHR systems.”6(p35) Stage 3 will focus on “promot-
ing improvements in quality, safety, and efficiency leading to
improved health outcomes, focusing on decision support for
national high-priority conditions, patient access to self-man-
agement tools, access to comprehensive patient data through
robust, patient-centered health information exchange and
improving population health.”6(p36)
The Final Rule defining stage 1 of MU was published on
July 28, 2010, after extensive public hearings and comment
period in which ASCO actively participated. The Final Rule
establishes MU criteria and the threshold levels of performance
that must bemet to qualify for incentive dollars. A core set of 15
objectives must bemet, and from amenu set of an additional 10
items, five must be selected, including at least one of the two
population and public health measures.7 The core set of MU
objectives requires eligible providers to submit three clinical
quality measures from a list of six core or alternate core quality
measures (Table 2) and any three additional ones from a menu
of 38 quality measures.6 Of these, the ones most likely to be
useful to medical oncologists are listed in Table 3. There are no
threshold quality performance levels that are required; this is a
reporting activity only. Note that for 2011, providers will attest
to meeting the MU measures, and in 2012, CMS plans to be
capable of receiving electronic transmission reporting of the
clinical quality measures.
Electronic Health Records in Oncology
JULY 2011  jop.ascopubs.org 207Copyright © 2011 by American Society of Clinical Oncology