HCIT: Don’t Underestimate the Power of CMS’ Carrots and Sticks

Anyone who knows even a little bit about behavior modification theory intuitively understands that offering rewards and/or punishments is an effective way to encourage people to do what you want them to do. The government clearly understands this principle and has been using incentives and penalties to motivate physicians to participate in its programs—PQRS, ePrescribing, and, most recently, the EHR incentives.

The EHR incentives have already prompted a great deal of EHR activity, but the program is too new to quantify cause and effect yet. A direct correlation between government policy and provider behavior, however, is evidenced by the history of my company’s ePrescribing license purchases, so I thought EMR Straight Talk readers would find the analysis of my company’s experience interesting.

As illustrated above, ePrescribing sales tracked the MIPPA legislation as follows:

  • 2009 was the first year of ePrescribing bonuses, and the requirements (a 50% threshold) made it important to start ePrescribing early in the year. As you can see, this created a huge demand for ePrescribing licenses during the first half of 2009.
  • Sales continued in late 2009 and early 2010—although at a more moderate rate—as later adopters decided to take advantage of the last year of 2% bonuses and as the easier-to-meet threshold of 25 ePrescribing encounters was introduced.
  • Imminent penalties caused a spike in sales in the beginning of 2011, when providers first learned that 2012 penalties would be based on ePrescribing activity—or lack thereof—in the first 6 months of 2011.

Another interesting observation that can be made is that, for some providers, penalties are a much more effective behavior modification tool than incentives, regardless of the relative amounts of money at stake. My experience with ePrescribing—illustrated by the 2011 surge in licenses—was that many physicians who had not been persuaded by the 2% bonuses in 2009 and 2010 felt compelled to move ahead when faced with a 1% penalty for 2012. Regardless of whether a particular physician attributes more weight to the carrot or to the stick, the data above—although not unexpected—confirms the effectiveness of the government’s strategy.

Stage 2 Meaningful Use: What Do You Think?

At this week’s HIT Policy Committee meeting, the Meaningful Use Workgroup presented its Stage 2 thinking to date, based on the 422 comments they received on their initial proposal. As discussed in a previous EMR Straight Talk post, the issue at the forefront is timing—with providers and vendors expressing significant practical concerns, and consumer groups pushing for rapid advancement.

The workgroup presented the following options for consideration by the Policy Committee. (I invite you to voice your opinion by responding to the poll below.)

  1. Maintain current timeline. Stage 2 would begin in 2013 for providers who demonstrate meaningful use in 2011. Providers who first demonstrate meaningful use in 2012 would have until 2014 to meet the Stage 2 requirements.
  2. Maintain the current timeline (as above), but allow a 90-day reporting period, instead of a full year, when providers are first governed by Stage 2 requirements. This would give providers until October 1 to begin their first year at Stage 2, instead of January 1—a nine-month delay.
  3. Delay Stage 2 by one year, allowing providers 3 years instead of 2 years at Stage 1. This means that the earliest any provider would have to meet Stage 2 expectations would be 2014.
  4. Phased-in approach separating existing from new functionalities:
    – Stage 2a (2013) would increase thresholds for measures for which the functionality already exists, (required to meet Stage 1), adding only new clinical quality measures.
    – Stage 2b (2014) would add new measures that require new EHR functionalities .

The responses from various HIT Policy Committee members covered the gamut.

  • Some were in favor of moving aggressively at all costs, presenting various arguments such as: (a) If we don’t pressure providers now, we will face the exact same issues at the next stage; (b) More extensive data capture does nothing to move us towards Stage 3 goals; and (c) We cannot just address the physicians’ workflow problems and ignore the challenges patients face in dealing with the current, difficult-to-navigate healthcare system.
  • Other Committee members, like Gayle Harrell, cautioned against trying to do too much too quickly—as she has from the outset—and stressed the long-term value to the program of setting providers up for success. Pushing them too hard could cause them to drop out after they earn the bulk of the incentives associated with Stage 1.
  • The phased-in approach was perceived as creative, but I was surprised that there was not much discussion about the administrative complexities this plan creates—to say nothing of the challenge of conveying it to providers.


Blumenthal’s Departure: Odd Timing

Yesterday morning, in a podcast interview with Neil Versel, a respected HIT journalist, I was asked to compare the mood at last year’s HIMSS meeting with my expectations for this year’s assembly. In 2010, I listened as David Blumenthal, head of ONC, spoke to a standing-room-only crowd, whipping up a frenzy of excitement about ARRA and its EHR incentives in what I can only describe as a pep rally. I told Neil that I anticipate a more subdued and somewhat anxious atmosphere at this year’s meeting, since the practical realities and challenges associated with the complexities of meaningful use have set in. A recent survey of hospital CIOs, for example, revealed reduced confidence in the ability of their respective institutions to successfully meet the requirements within the allotted timeframes, and a resulting skepticism about whether they would earn the incentives. Similarly, at the recent 2-day hearings conducted by the Adoption and Certification Workgroup, the generally positive sentiment was tempered by concerns about operational issues, timing, IT workforce challenges, and the multitude of government programs on the plates of practices.

Then, yesterday afternoon, the news broke that David Blumenthal is stepping down from his post as the national leader of the EHR adoption and incentives program. Although we all know that no single individual is ever indispensible, the timing of his departure struck me as quite odd. The program is at the precipice—its launch is just underway and the first attestations of meaningful use are expected in April. Initial success or failure will be evidenced imminently. One would think that this would be the time to demonstrate stability and unwavering commitment from the top down—a time to rally all of the forces to ensure the program’s success.

I cannot help wondering the following:

  • Why is Blumenthal stepping down now, when the program is at such a critical juncture?
  • Why is HHS Secretary Sebelius just now “conducting a national search for the right successor” even though she reports that it was always the plan that Dr. Blumenthal would end his term at this point?
  • What are the implications for the EHR incentives program?
  • Will his departure affect the likelihood of its success?
  • How will provider confidence in the program be impacted?
  • Should we expect changes in the program? What kind of changes?

Please share your thoughts on David Blumenthal’s departure by commenting below.

Meaningful Use IQ Test Results

The response to last week’s Meaningful Use IQ Test revealed a tremendous thirst for information and a fair amount of confusion about the facts and realities of meaningful use. Neither was terribly surprising, given the recent hype surrounding the program’s launch and the complexity of the regulations.

Since the quiz was posted last week, 534 people have taken the test. The average score was 56% (see chart below and the breakdown of responses at the bottom of the page). These results mean that physicians will need a great deal of assistance from consultants, Regional Extension Centers, and vendors to succeed in their pursuit of the EHR incentives. If that aid is not forthcoming, there could be a large number of very disappointed providers when the incentives are distributed.

Meaningful Use IQ Test Results

The following are some observations:

  • Only a small minority of our test-takers (9%) appear to truly understand the regulations and the requirements in their entirety. (Inga, from HIStalkPractice.com is one of the few who just might—based on her perfect score!)
  • Many people find the intricacies of the regulations baffling—as indicated by more than half of the respondents (300 of 534) knowing half or less of the information.
  • The fact that over one-third of the respondents did not know that providers cannot collect Medicare EHR incentives and Medicare ePrescribing incentives in the same year—no “double dipping” allowed—means that they have likely not analyzed their options to maximize the total revenue from the two incentive programs.
  • I thought it was interesting that nearly half of the respondents thought that the program requires reporting on only Medicare and Medicaid patients, when, in reality, the government is requiring providers to submit data on all patients.
  • Clearly, the message has come through that the program has been made more specialist-friendly, as physicians will be able to exclude measures that are not relevant to their practices. However, many do not understand how these exclusions factor into the demonstration of meaningful use.

The Meaningful Use IQ Test is still active, so if you haven’t accepted the challenge yet, you can still do so. I’m glad that it is raising awareness and providing valuable education. That was precisely its purpose!

Meaningful Use IQ Test Results

Test Your Meaningful Use IQ

Meaningful Use IQ TestNow that the EHR incentive program has officially begun, physicians and practice managers are taking a closer look at the meaningful use requirements and the rules for participation. At my company, we have been fielding an increasing number of questions about meaningful use, and it is clear that the complexity of the regulations has created a fair amount of confusion.

See how well you understand meaningful use. Challenge yourself: Check your knowledge by taking this quiz, and learn some important information in the process. Comments are welcome.

Make It Happen!

The message is clear—physicians are concerned that their interests are being ignored, and they want their voices heard.

SRS is making that happen. We hear the voice of the physician and we will be broadcasting it to President Obama, HHS Secretary Kathleen Sebelius, Dr. David Blumenthal, the HIT Policy Committee, the HIT Standards Committee, and leading industry blogs.

Following last week’s post, entitled “The Silent Majority is Being Heard – Let’s Be Louder,” we invited SRS clients and non-clients alike to let us represent their voices in Washington. The response from physicians and practice administrators has been tremendous—not only have we already received an unprecedented number of signatures to our letter to government officials, but we are being deluged with individual comments to be forwarded along with the letter…and they are still pouring in.

There is still time to join the campaign:

  • Sign our letter and/or add your own comments.
    Click below to read and then sign:

SRS Client Petition Non-Client Petition

  • Share this with your colleagues—physicians and practice administrators—and encourage them to let us speak for them.

Whether your practice is using SRS, has another EMR, or is still on paper charts, this is about you. Will you be able to meet the increasingly stringent “meaningful use” requirements currently under consideration by the government? The following are just a few of the voices that your peers have already asked us to share with Washington:

  • “We support efforts to reduce the cost of healthcare without reducing quality, and we recognize the value of a computer-based health record for quickly sharing patient information with other providers and avoiding duplication of services. However, the methodology for doing so should not be so burdensome as to change how a physician practices medicine, particularly if it interferes with patient-doctor interaction.”
  • “We have implemented an EMR system in our practice and are leaders in our area in implementation of new technology. However, despite numerous attempts, we have failed to find an EHR system for entering clinic notes and orders that improves efficiency. Instead we have found it only makes us more inefficient, less productive, and more frustrated. The right technology is not here yet. We cannot be forced to implement a flawed system.”
  • “I am a primary care doctor. Point-and-click does not work for us either. The vast array of problems that we handle requires a more flexible way to document a visit. We handle usually 3 different issues on average per visit. Point-and-click falls apart if there is more than one chief complaint or if the patient tells us something that has not been considered by the point-and-click software. The documentation is forced to become less accurate. There is also an impact on the relationship with the patient since the doctor spends more eye contact with computer rather than the patient. I am not a doctor who is afraid of technology. I have a degree from M.I.T. in electrical engineering and worked as an engineer for years before changing careers. If point-and-click EMRs were useful, my practice would have had it years ago. Electronic prescribing has benefits and we have been doing that for years. We have a hybrid system that we currently use and will add other features when it makes sense. I do not believe we will ever use a point-and-click system even with incentives.”

The AMA is expressing the same concerns that we have been voicing—they formally came out against the planned penalties in the federal stimulus plan at their annual meeting this month.

Please add your own voice now, and let us make sure that you are heard.

The Silent Majority Is Being Heard – Let’s Be Louder

The tide appears to be changing as the voices of the silent majority are finally being recognized in Washington. I have been repeatedly and emphatically expressing my concern that the needs of physicians—particularly high-performance physicians—are being ignored as the government attempts to encourage EHR adoption.

  • Last week, Gayle Harrell, an HIT Policy Committee member, made many of the same points that I have been making, as the Committee reviewed the initial set of recommendations on “Meaningful Use” and considered EHR certification. (Read the highlights in the post below, Finally, A Voice of Reason!)
  • In recent months, many of you have been speaking out on Straight Talk and other blogs. To the question asked in last week’s poll—is the government putting too much of a burden on physicians?—a resounding 90% of respondents answered “Yes.”
  • Physicians are voting with their pocketbooks, continuing to base their EMR purchase decisions on the best way to help their practices deliver the highest quality care in the most efficient manner, rather than on the promise of potential government incentives.
  • Even CCHIT (Commission for Certification of Healthcare Information Technology) has acknowledged these and other voices of reason. Just recently, CCHIT backed down on its all-or-nothing stance and proposed broadening its certification program to include alternative paths to EMR certification.

Comments like those of Dr. Boss (below) attest to the value of alternative, innovative solutions, such as the hybrid EMR, and to the importance of including them in the government’s plans for widespread EHR adoption:

“The best EHR system out there without a shadow of a doubt is SRS, even though it is not yet CCHIT certified. It is cost effective, user friendly to those of us who are not computer ‘geeks,’ and the company is extremely responsive to any needs of ours that arise. If the entire country was on SRS, a lot of our current difficulties would go away.”

Richard S. Boss, M.D.
Pine Medical Group, Fremont, MI
20-Physician Multi-Specialty Group

We will be sending you an e-mail tomorrow, giving you the opportunity to join us and have your voice heard before the final decisions are made in Washington.