The rules for Stage 1 meaningful use and EMR certification are final. The primary-care focus is indisputable; it is widely acknowledged that applicability to specialists is minimal at best. All that specialists and their medical societies can do now is make their recommendations known and advise their members accordingly—as AAOS recently did, for example—and hope that the government will define meaningful use for specialists in a meaningful way in the future.

However, based on the HIT Policy Committee’s recent action on August 24, it does not appear that the government is hearing their voice—as I discuss in a more detailed article on HIStalk. The Committee appointed 24 members of a new Quality Measures Workgroup, tasked with prioritizing quality measures for Stage 2 meaningful use and analyzing gaps in the current criteria. All 18 physicians on the committee are primary-care providers—internists, family practice, and pediatricians—only two of whom have a subspecialty, neither of which is surgical.

Many specialists have decided to pass on the government’s EMR incentives program, and they will move forward by making EMR decisions that they feel are in the best interest of their practices and their patients.

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Despite the ongoing and concerted advocacy efforts by medical specialty societies to influence the final meaningful use regulations, it is clear that the rules still do not offer much for specialists. I am glad to see that professional organizations are speaking out—issuing statements and providing advice to their members about the particular challenges that the current meaningful use rules pose for specialists. They agree that the right EMR offers physicians and their patients undeniable benefits and they encourage EMR adoption, but the growing consensus is that the government’s program is still defined in a way that is only meaningful for providers of primary care.

The latest group to document its concerns is the American Academy of Orthopaedic Surgeons (AAOS). Discussing the EMR Position Statement, published in the August issue of AAOS Now, EMR Project Team leader, Thomas C. Barber, M.D., warns that “Orthopaedic surgeons will have great difficulty in meeting the current 25 meaningful use standards.” The Statement maintains that “it is essential for the successful development of meaningful use standards and EHR systems certification….to recognize the different needs and uses of EHR by disparate medical specialties, especially the differences between surgical specialties and primary care specialties,” implying that to-date this has not been accomplished.

I expect that other medical societies have issued—or will issue—similar statements. As I have mentioned in previous posts, the problem for specialists is not just that the meaningful use measures are primary-care-related, but also that the EMR certification criteria are primary-care-driven. AAOS has it right when it concludes in its Position Statement that “Many systems are geared toward primary care medical practice, which can limit the utility of EHRs for specialty surgical practice.” Such systems are not productivity-focused and don’t address the specific needs of specialists. The bottom line is exactly what the academies are advising, and what I have been encouraging physicians to do all along: evaluate and adopt an EMR based on its ability to help your practice accomplish your specific goals.

Related posts:

1. Stage 2 Meaningful Use: Specialists Still Left Out
2. The rules for Stage 1 meaningful use and EMR certification...
3. Specialists and the Final Rule on Meaningful Use
4. The Final Rule on Meaningful Use has erased any lingering...
5. The EMR Equation: Break-even Point for Meaningful Use
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For the second year in a row, people were spotted at the Allscripts User Conference sporting a “No Hybrid EMR” button (as reported in HISTalk.) This begs the question: What are they afraid of?

Could it be that Allscripts—a giant in the traditional EMR industry—is afraid of the hybrid EMR? Why would that be? Perhaps it is because:

• The hybrid EMR forces physicians to think about their fundamental reasons for wanting to purchase an EMR—it changes the conversation from meaningful use to business improvement, from the interests of government and other stakeholders to the needs of physicians. In contrast, vendors of traditional EMRs have spent the last year-and-a-half marketing government certification and potential meaningful use incentives.
• Physicians are continuing to buy hybrid EMRs despite government subsidies for traditional EMRs because they recognize the greater value of the hybrid EMR to their businesses.
• The hybrid EMR increases physician productivity and does not require any downtime, even during implementation. Users of traditional EMRs often experience long periods of decreased productivity (low-end estimates from MGMA peg this at 15%, usually lasting a year or more).
• Mid- to large-size specialty groups, in particular, find the hybrid EMR more suitable to their practice needs; traditional EMRs do not successfully compete in this arena.
• The hybrid EMR works—because it is easy to use and flexible, it is quickly and universally embraced by users, virtually all of whom become enthusiastic references.

It’s true that the hybrid EMR challenges the traditional EMR model, but in a market characterized by a disturbingly low rate of EMR adoption, and by needs that differ significantly by practice type, surely there is room for a variety of solutions.

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The Final Rule on Meaningful Use has erased any lingering doubts about the government’s lack of interest in the participation of specialists. As HIT Policy Committee member Gayle Harrell pointed out during the July 21 committee meeting, CMS has made it more—rather than less—difficult for many specialists to comply with meaningful use. Gayle is the committee member who first identified—last spring as the rules were being created—the lack of attention to the needs of specialists, and she was a primary force behind the convening of specialist panels last October to address the issue.

When I look at some of the core [meaningful use] measures, they don’t fit into what a lot of specialists do…. I don’t know a lot of surgeons who take body mass [indices], or ophthalmologists who take blood pressure or weight. These kinds of things are really requiring an additional burden on a lot of specialists.

She was clearly disappointed with the final rule, as are the specialists, who understand that meaningful use has clearly not been defined with them in mind.

In addition to the meaningful use measures, the core clinical quality measures in the final rule are all primary-care related—the basic three are blood pressure measurement, tobacco use/tobacco cessation intervention, and adult weight screening and follow-up. The alternative core measures, which can be selected from in case not all of the first set apply, are also all primary-care related—weight assessment and counseling for children and adolescents, influenza immunization for patients over 50, and childhood immunization status. In addition, the Final Rule replaced the Proposed Rule’s specialty-specific measures with a set of 38 other measures, from which physicians are expected to report on three. Many specialists will be hard-pressed to find any measures in this set, as well, that fall within the scope of their practices.

So what will specialists do? They will recognize that the government’s current definition of meaningful use is not meaningful for them; they will not sacrifice their time and productivity attempting to meet irrelevant requirements; and they certainly will not add non-billable, primary-care functions to their patient exams for the sake of compliance. Knowing that participation is voluntary, and already skeptical about the likelihood of actually receiving any incentives—based on past PQRI experience and given the lack of recourse available to them in the meaningful use rule—the vast majority of specialists will elect not to participate.

What they should do is to revive the interest they were beginning to show in electronic medical records a year-and-a-half ago, before the government got involved, and select a system that will best address the specific needs of their own practices as they themselves identify them, rather than as other stakeholders define them.

Related posts:

1. Stage 2 Meaningful Use: Specialists Still Left Out
2. The rules for Stage 1 meaningful use and EMR certification...
3. Specialists’ Societies Speak Up about Meaningful Use
4. Despite the ongoing and concerted advocacy efforts by medical specialty...
5. Readers Respond: The Exorbitant Cost of Meaningful Use
6. As anticipated, the release of the proposed rules on “meaningful...

The publication of the anxiously awaited final rule on meaningful use was announced Tuesday at a press conference featuring a cast of dignitaries. HHS Secretary Sebelius; newly appointed head of CMS, Donald Berwick, M.D.; ONC head David Blumenthal, M.D.; and Surgeon General Regina Benjamin, M.D. unanimously and vociferously extolled the virtues of a paperless medical practice. I could not agree more, as I’ve stated in prior EMR Straight Talk posts. Where we disagree is in considering the impact on physician productivity and revenue. There was not one mention at any point during this “EMR pep rally” of the impact on productivity that is associated with pursuing meaningful use.

Uncertainty has been removed from the market, and the most common excuse for inaction is now gone. The government’s intentions are crystal clear, and physicians know exactly what will be required if they want to pursue the EHR incentives. Physicians who want to become digital and reap the extensive benefits of a paperless office must now make a choice—pursue the productivity path or follow the meaningful use path.

As expected, most of the initial response to the release of the rule involved identification and analysis of the differences between the proposed rule and the final version. For those of us who have followed meaningful use closely for the past year and a half, this is an interesting topic of conversation, but for physicians, the only relevant issue is what the current requirements mean to their practice—how would they respond if this was the first they ever heard of meaningful use? The sheer length of the rule (864 pages) will no doubt raise valid concerns regarding the complexity and challenges involved. Physicians must take the time to read the matrix of objectives and measures for themselves to estimate the impact on their time that trying to demonstrate meaningful use will have. The data collection and reporting requirements are significant, and they will become even more so in Stages 2 and 3. High-performance physicians/specialists, in particular, will find that the cost of lost productivity far outweighs the potential incentives.

In pursuing the meaningful use path, productivity will be affected not only by the meaningful use requirements, but also by the very nature of the type of EMRs that must be used to successfully satisfy the measures. Historically, point-and-click EMRs have been rejected by high-performance physicians because, by design, they focus on data collection and note creation rather than on usability and physician productivity. Nothing has really changed in this regard, and I don’t foresee a sea change in physician behavior resulting from the promise of a potential $44,000.

But the waiting is over, and the time has come for physicians to choose their EMR path.

Related posts:

1. The EMR Equation: Break-even Point for Meaningful Use
2. Paul Roemer, a frequent and knowledgeable participant in the ongoing...
3. Readers Respond: The Exorbitant Cost of Meaningful Use
4. As anticipated, the release of the proposed rules on “meaningful...
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