I arrived home to the release of the results of a new MGMA study (conducted last month), which concluded that practices expect that the operational changes required to meet the proposed meaningful use criteria will cause a significant decrease in productivity. Nearly 68% of the respondents anticipate such a decrease, with 31% projecting that the decrease would exceed 10%—and this was likely based on only the impact of Stage 1 meaningful use criteria.

This productivity loss is what I described in last week’s EMR Straight Talk post, where ARRA meaningful use requirements compound the reduction in productivity that is already associated with the “point-and-click” EMRs themselves. Before ARRA, physicians estimated that traditional EMRs reduced their productivity by between 20% and 40%, as documented in testimonials posted on the Government’s FACA blog and included in the Voice of the Physician Petition. Others are speaking out about this issue as well; Paul Roemer reported that his cardiologist puts the productivity loss at 30%, due to the amount of time that he “wastes” performing clerical—i.e., data entry—tasks. (Read his comments in “Healthcare IT, How Good is Your Strategy: A Scathing Rebuke of EHR.”) Added together, this means that physicians face a 40% reduction in productivity at the outset. Imagine what will happen to productivity when the more stringent Stage 2 and 3 meaningful use criteria are implemented!

The conclusion is clear. Physicians should not be considering EHR adoption for the incentive money; they should be looking at what will help them address their business and patient-care needs. The HIMSS keynote address by chairman Barry Chaiken, M.D., charged the EMR industry with “creating healthcare IT solutions that are so compelling, so irresistible, that people just want to use them.” Systems like that already exist—they just don’t interest the government, which appears to be more interested in data collection than EHR adoption.

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Even if CMS were to agree to grant some general flexibility, the committee was adamant that CPOE remain mandatory right from the start, (i.e., not deferrable to 2013), and that the data entry be done directly by the ordering provider. Adding to the burden that the 25 measures already impose on physicians, the committee also recommended the reinstatement of some of the most onerous requirements—documenting a progress note; stratifying quality reports by race, gender, language, insurance class, etc.; and recording advance directives, just to name a few. This sends a strong signal to physicians about where their interests rank among those of the various other stakeholders.

It’s easy to get sidetracked by the details of meaningful use, but with that as a focus, one loses sight of the forest for the trees. The government continues to ignore the fundamental problem that has discouraged EHR adoption in the past, particularly for high-volume, community-based specialists—and that is the EHR products themselves. The government has created an unstable program, basing it on unproven, difficult-to-use, traditional EHRs, and then has imposed additional layers of complexity on top of these products. First, EHR vendors will have to rush to modify their products to meet HHS certification requirements, resulting in even more cumbersome EHR products. Then, over the next five years, they will have to constantly hustle to keep up with the continuously evolving meaningful use criteria, as well as implementing the Y2K-like conversion from ICD-9 to ICD-10. In the technology world, rushing development efforts to meet unrealistically aggressive timeframes typically results in unusable and clumsy software. Unfortunately for physicians, the government will expect them to use these more complex EHRs to meet onerous meaningful use requirements that become increasingly stringent from 2011 to 2013 and 2015.

Regardless of whether Stage 1 meaningful use is ultimately made a little harder or a little easier, the fact remains: trying to earn the government’s EHR incentives will severely impact physician productivity. High-volume physicians, who in the future will be expected to see more patients at lower reimbursement rates, need to identify and adopt productivity-enhancing—not productivity-sapping—EHR solutions.

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As a result, the Stimulus Legislation poses overwhelming challenges for specialists—challenges that outweigh any potential returns. This is hardly surprising given the lack of input from specialists in the decision-making process. With only one or two exceptions, the physicians involved are all primary-care or informatics experts, not specialists. It was not until October that the question of specialists was even discussed, and so the “meaningful use” criteria that emerged don’t fit the services that specialists routinely provide, nor do they fit the way specialists routinely practice medicine, at least not without major workflow disruptions.

The focus on primary care is indisputable. Look at the programs that have been announced and funded in just the last two weeks:

• February 2, 2010: ONC will survey 1,700 patients in 84 primary-care practices because it recognizes “an evidence gap about patients’ preferences and perceptions of delivery of health care services by providers who have adopted EHR systems.” (Notice in the Federal Register)

• February 12, 2010: The Department of Health and Human Services (HHS) announced $375 million in funding for Regional Extension Centers (RECs), which will “provide outreach and support services to at least 100,000 primary-care providers and hospitals within 2 years.” In describing the RECs, David Blumenthal stated, “Primary-care providers in small practices provide the great majority of services in the U.S. but have limited resources to implement, meaningfully use, and maintain EHR systems. On-site technical assistance for these priority-primary care providers will be a key service offered by the RECs.”

But the biggest obstacle for specialists remains the traditional EHR products themselves—the challenges posed by the government program only compound the fact that these EHRs are fundamentally so difficult for many physicians to use. Designed for primary-care practices, their success has been limited to that arena. Traditional EHRs are built around the creation of exam notes, not around workflow and physician productivity. The highly leveraged nature of specialists’ practices—where office visits lead to surgeries and other procedures—makes their economics highly sensitive to even small negative impacts on productivity. In addition, their high patient volumes make workflow-focused software critical, and note-focused software unusable. For example, a 10% reduction in productivity for the average specialist would result in an annual revenue loss of over $100,000. (Use our physician productivity calculator to estimate the cost to your own practice.) As a result, there are a very few large specialty practices that have successfully and fully adopted a traditional EHR.

The government should be up front about their interests and acknowledge their focus on primary care. Until they devote the same kind of resources to finding out what works in medical specialty practices, they should just leave the specialists out of the program—exempting them from both incentives and penalties.

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Those commenting identified several additional unintended consequences and voiced other concerns, including:

• Dissatisfaction with templates and the utility of the notes they generate;
• Failure of the government program to consider the needs of providers;
• Effect of traditional EHRs on physician productivity;
• Failure of physician organizations to speak out on behalf of their constituents; and
• Difficulty of finding the right EHR for a practice.

An interesting comment came from Paul Roemer, who directed concerned readers to his post on HealthsystemCIO.com, in which he suggests that the “meaningful use” dates will be pushed back. He maintains: “Washington created a $40 billion lottery and they are having trouble finding anyone able to purchase tickets.” His contention is that very few providers will be ready or able to take advantage of the incentives, including those who already have implemented a traditional, point-and-click EHR.

What do you think the government should do with its program that is clearly meeting significant and vocal resistance—particularly among specialists and other high-volume physicians? Submit your comments below, and let’s keep the conversation going.

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My curiosity is piqued! What are the unexpected consequences the government anticipates, and why is HHS so concerned? Awaiting the report from the panel of experts, I started thinking—and it didn’t take me long to create a list of my own.

My top three unintended consequences are the following: (If you’d like to suggest other potential unanticipated consequences—positive or negative—please submit a comment at the bottom of this page.)

• There will be more EHR failures than successes, particularly among high-performance specialists.
• “Certification” will stifle innovation.
• Productivity and physician-focused EHRs will lead the market among high-performance physicians.

More EHR Failures:

After an initial peak in implementations, long-term EHR adoption will slow—particularly among high-performance specialists—and the current failure rate will escalate. Many factors will contribute to this: (1) Some physicians will rush into EHR purchases without conducting proper due diligence. (2) Products that were overly complex and did not work in busy specialists’ practices in the past will surely not succeed now, particularly since these same products must now be used in an even more structured and demanding way. (3) Sorely needed implementation and training will be provided by inexperienced and rushed implementation teams, further reducing the likelihood of success with providers, many of whom are less technologically savvy than the early adopters. (4) Where there was never a convincing economic justification in the past, the addition of data-collection requirements will further lessen the economic feasibility of traditional, point-and-click EHRs. (5) Physicians will try to transfer data entry tasks to scribes and other lower-cost employees (assuming that the regulations allow CPOE to be done by other than the ordering provider), but this strategy will not make economic sense, either, since the additional costs will outweigh the government incentives. The result? The high failure rate will leave physicians “holding the bag” after investing large sums of money, failing to earn the anticipated incentives, and owning a system that doesn’t meet their needs.

“Certification” will stifle innovation:

Innovation will suffer, as it did in the past when many EHR vendors devoted all their development resources to complying with the long list of CCHIT-certification requirements. Forcing all vendors seeking certification to meet the same criteria will surely sap the drive for innovation. As vendors burn through precious development resources to meet evolving government standards instead of improving their core product, they will fail to respond to the interests of their customers, i.e., the physicians. Sales and marketing will drive physicians’ choices, rather than the EHR products themselves. Large companies, which have the largest sales organizations and marketing budgets, will be successful in the short term. Smaller vendors who follow the herd instead of their entrepreneurial and innovative instincts will be driven out of the market.

Productivity and physician-focused EHRs will lead the market:

The good news is that innovation will triumph in the end. Alternative solutions—like the hybrid EMR—will prevail as high-performance physicians find success with products that focus on their needs and enhance their productivity. It will take 4 to 5 years for physicians who have experienced government-program EHR failures to reapproach the market after amortizing their losses. These physicians will seek products that focus on clinical-workflow efficiency and physician productivity. The long-term winners in the EHR market will be those vendors who resist the temptation to chase the “windfall” stemming from the stimulus legislation, and instead focus on improving their products to deliver these benefits.

Please share your thoughts on other possible unintended consequences by submitting a comment below.

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Although it is anticipated that the vast majority of public comments will not be submitted until the final days of the 60-day comment period—i.e., in early and mid-March—individual physicians and others have begun formally registering their opinions. Not surprisingly, some of the initial comments reflect anger about the length and complexity of the rules themselves. Urging the government to keep the requirements simple was a common theme among comments from physicians and administrators:

“If the goal is to get the majority of clinics using EHRs and to provide incentive funds to help the economy, then the first step of incentive payments must be easy to obtain.” —Craig Brauer

“The ‘meaningful use’ criteria should provide incentives to encourage the implementation of the most essential features of an EHR, but it is imperative that the ‘meaningful use’ criteria not become a Christmas tree of features that becomes hugely expensive and unworkable. The ‘meaningful use’ criteria must not make perfect the enemy of the good.” —Robert Rauner, M.D.

Others talked about the limitations of traditional EHR products and issues of usability:

“I am concerned that the current emphasis, promoting adoption of existing EHRs, with little focus on the need to make EHRs better, will ultimately slow innovation. . . . Usability is the Achilles heel of current EHRs. An EHR may meet all of the functionality requirements and yet be so burdensome to use that patient care is made more difficult. . . . At this point we don’t need more EHRs, we need better EHRs.” —Christine Sinsky, M.D.

Objections to CPOE and the effect on physician productivity were also common:

“The process of entering orders is often inefficient and time consuming, with multiple screens, drop-down boxes, scrolls, and clicks. Assigning these clerical tasks to physicians results in a redirecting of limited physician resources away from clinical work, replacing direct patient care with low value added clerical work.” —Christine Sinsky, M.D.

To view these and other comments, or to submit your own recommendations, go to regulations.gov.

On a lighter note, a few days ago, I read a parody in HIStalk (a venerable healthcare IT blog) called “Marry in Haste, Repent at Leisure: Choose Your EMR Soul Mate Carefully.” It compared purchasing an EMR to getting married, and the analogy is a good one. Mr. HIStalk, the blog’s author, postulated that “the same handful of wrong reasons that convince people to marry unwisely also convince them to buy EMRs that will make them unhappy.” If you are interested in reading more, go to HIStalk.

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A consensus among physicians is growing. They rightly feel that the government’s expectations are overly complex, burdensome, confusing, arduous, etc., and that the adoption of a traditional EMR is fraught with peril. The following are two of the comments I received on last week’s EMR Straight Talk:

“I have been ‘paperless’ for 6 years. For most of that time when I have complained about the cost and the increased physician time I have been ridiculed even at the AMA level. The expense is astronomical and there is no way to recoup the cost. I have been in private practice for 35 years and EMR is the biggest mistake of my career. It is somewhat comforting to know that others are evolving to my way of thinking on EMR. I feel this is the brainchild of the IT industry with little or no input from those actually using the systems. Thanks.” —Lee Schoeffler M.D.

“There is another huge ‘cost’, which is the creation and then electronic perpetuation, ad infinitum, of incorrect medical information. I have yet to find a patient encounter spit out by an EHR in which I could easily understand what was wrong with the patient. The automatically generated reports are often in a new language, ‘digmedgib’, for digital medical gibberish. I have read reports from ‘excellent’ EHR systems (one of which is utilized by one of your sources quoted [in another of last weeks comments] which contain disastrous errors created by a 0.5 mm slip of the mouse pointer and a click. This is what happens when two opposite diagnoses differ by one consonant and are adjacent in the pull-down list. We are trying to treat the patient but we are really doctoring the EHR.” —Sandra Brown, M.D.

David Brailer, M.D., former “Health IT Czar,” whom I quoted last week regarding the likelihood that penalties for non-participation will be dropped, also forecasted that “we’ll be approaching the peak of the hype cycle” before a “real slide back to reality,” with CMS money coming “slower than everybody thinks.” Like me, he recognizes the challenges the legislation presents for physicians.

In light of the 556 pages of publicly available, detailed information about the “meaningful use” legislation, I find shocking the amount and level of misinformation being perpetuated by even the most reputable—or so one would expect—sources of healthcare information. I was appalled by the following ad that the Cleveland Clinic ran in the New York Times recently:

The fact is: EHRs are not required—not now and not in 2014! The legislation explicitly states (in section 3006 (a) (1)) that participation is VOLUNTARY. Shame on the Cleveland Clinic for such a flagrantly irresponsible ad!

Less unexpected is the perpetuation of other myths by vendors of traditional EHRs—those with the most to gain financially from the legislation—concerning the alleged ease with which their products will facilitate the achievement of “meaningful use.” The well-respected EMR blog, HISTalk, recently invited CEOs of EMR companies to address 6 questions related to “meaningful use”, and is currently running a series containing their answers. You can read Part 1, Part 2, Part 3, Part 4, and Part 5 of the series so far, and it will probably come as little surprise to you that my responses are strikingly different than those of the other 9 CEOs! But my opinions do not appear to be in the minority when it comes to how physicians view the legislation, as you can see by the following comments HISTalk received:

“Could not agree more, except perhaps to extend the ‘extremely burdensome’ costs considered as not only financial, but also temporal and operational. In our little office, the greatest bane is workflow adjustment. There are just so many hours in a day and, functionally, our primary focus during most of them is to care for patients, not figure out how to enter data, collect stats, tweak templates, and distribute meaningfully to the cloud.”

“Frankly I am surprised that a couple of these guys (namely Girish and Pead) seem to believe that the 80% CPOE adoption will be so easy. Either they have incredible confidence in their software and the ability of their staff to affect change management, or, they are incredibly out of touch with the culture of your average physician practice. Steele is correct is suggesting it will be a huge challenge and Skelton understands that the transition will be more difficult for private practices and specialists in general.”

And just yesterday on HISTalk Practice, Dr. Gregg Alexander, a self-proclaimed “grunt-in-the-trenches pediatrician and geek” agreed:

“It feels as if the voices which ring most true to my trench-weary ears are not the ones being heard most loudly nor echoed most frequently. Most of the big brains of the industry, be they governmental guiders or corporate cognoscenti, seem to be enraptured with the power and the glory of the Meaningful Use Criteria [MUC]. . .The majority of healthcare in the U.S. is provided by smaller players who have no I.T. team, who have techno-illiterati-filled staffs, and who really want to focus on doing what’s right for our patients, not our data centers.”

Your voice counts. On Tuesday, the voters in Massachusetts made their feelings known, and we will see the impact shortly. Keep speaking out, and I will too.

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Last week’s EMR Straight Talk attracted a great deal of attention and elicited a number of interesting comments, some of which I would like to quote and respond to here.

Erin Goshorn, M.D., wrote:

“We have an excellent EMR in our subspeciality ophthalmology and ENT practice, which consists of 50+ providers. I thought that eventually EMR would increase efficiency and the extra time required to input data would go away. However, after 3 years of putting up with the inefficiency in my clinic created by EMR; I finally conceded. I now schedule 6 less patients a day and had to hire an additional skilled technician at 37,500 per year.”

Dr. Goshorn’s experience is typical of what I hear from physicians in a wide range of specialties. Although I don’t know the particulars of her practice’s finances, I did a little digging about the economics of the average ophthalmology practice. A decrease of 6 patients a day could easily represent a loss of $150,000 in annual revenue ($750,000 over 5 years), assuming that she sees approximately 40 patients a day and generates $1 million in revenue—and that’s before she devotes the additional time required to try to meet and report on the 25 meaningful-use measures.

Nick Orlowski pointed out:

“Great post, but you forgot a major additional cost. The costs you quote are accurate if the rollout and purchase work without a hitch. If you implement an EMR product, only to find out that it is the wrong product or doesn’t do what it has promised, you are out at least double your initial purchase cost, probably more!”

This comment alludes to the historically high failure rate of the type of EMR the government is encouraging physicians to adopt. Despite all the evidence—lack of landmark studies showing positive benefits to physicians, negative feedback on the government’s FACA blog, and discouraging comments submitted in the Voice of the Physician Petition, the government expects physicians to take the risk of proceeding down a path that leads—50%-80% of the time, according to the author of a recent landmark study—to a failed adoption attempt.

Another physician—a surgeon—challenged my financial analysis, charging that the meaningful-use requirements really only affect his time in office visits.

Since the bulk of his income comes from surgeries and other procedures, he maintained that I had overstated the impact. Unfortunately, this is a common misunderstanding of the economics of medical practices and ignores the impact of “leverage.” Office visits generate all other revenues—if you reduce the number of these visits by half, then your surgeries or other procedures, diagnostic tests, injections, etc. are also cut in half. Therefore, changes in exam-room productivity—such as the effect of trying to meet each meaningful-use measure—result in large changes in total revenue. Among the most highly leveraged specialists are orthopaedists, for whom every hour in the exam room generates approximately $1,000 in total revenue.

Steven Finch questioned:

“These #’s are terribly inflated and seem pulled out of thin air. I am curious how you attained them or what research you did to find them. I work with physicians who have implemented EMR systems in their practices everyday and they all agreed that not only are your #’s way off, your reporting is irresponsible at best. I would suggest going back to the drawing board and making another attempt.”

Actually, I would argue that if I erred, it was on the low side, since the numbers quoted do not include the cost of lost physician productivity. However, let me address Steven Finch’s allegations. Most of the numbers come from the government’s own published estimates or from industry (MGMA) data. To review, here are the numbers I used in last week’s blog:

¹ The capital cost is stated in the CMS Proposed Rule on Meaningful Use, in the table on page 361, and includes all the acquisition and implementation costs.

² $10K/year for annual maintenance comes from the same table, and includes ongoing training and upgrades that will be necessary as vendors change their products to keep up with the increasingly stringent requirements for “meaningful use.”

³ In the same table, the government estimates that it will take physicians 9 hours/year to report and document their “meaningful use” for the government. Using MGMA estimates of average physician revenue, this comes to approximately $500 per exam hour for primary-care physicians, and considerably higher for specialists.

⁴ The cost of additional staff time is an estimate—I believe a conservative one—based on the anticipated need for one staff member for every three physicians to input the information a physician would typically not input, at a cost of approximately $15K/year/physician. Even if you took this number out of the calculation entirely, the costs far outweigh the potential incentives.

Add in the cost of lost productivity (use Productivity Calculator to estimate), and it is clear that the government’s EHR program is a losing proposition for high-performance physicians.

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The new meaningful use requirements are virtually the same as those recommended by the HIT Policy Committee back in July, which means that the requirements remain onerous and unreasonable in terms of the burdens placed on physicians hoping to earn the incentives. There are 25 meaningful-use objectives and related measures, and every one of them must be met every year for a practice to qualify for the incentive money.

Economics clearly do not support participation in the incentive program. A physician must incur the following costs in return for a potential $44,000 earned over five years:

This $201,000 five-year loss doesn’t even factor in the exorbitant costs of the lost physician productivity associated with the implementation of a traditional EMR. Nor does it account for the risk of a failed adoption attempt or the inability to achieve meaningful use to the satisfaction of the government.

My concerns are not unique—it is clear that skepticism and doubt abounds among industry stakeholders:

• The length of the document alone should give physicians pause. As A. Cavale, M.D., says in one of the first government blog posts related to the proposed rule:
  

  “If the ONC really wants practicing physicians to read and understand any such criteria, it has to be cognizant of the size of such documents. It would be nearly impossible for a clinician in private practice to dedicate that type of time to read a 556-page document, understand it and implement it.”

• William Jessee, M.D., CEO and president of the MGMA (Medical Group Management Association), wrote in a letter to CMS:
  

  “Overly burdensome requirements and needlessly complex administration will only discourage physician participation in the program and the implementation of EHRs.”

• HIMSS, the EMR-vendor association, issued a warning:
  

  There is still “much work to do within healthcare regarding simple adoption [of electronic health-record systems] well before we can achieve meaningful use of the IT. . . . This foundational work—while required—will likely result in provider uncertainty about which IT products to adopt, costs through adoption of ever-maturing IT over time, higher costs associated with a need to support multiple standards, and somewhat delayed improvements in patient outcomes and costs.”

• HISTalk (venerable healthcare IT blog, 1/4/10) summarized the level of concern:
  

  “Doctors were already avoiding EMRs because of cost and negative workflow impact. Providers are questioning whether they can qualify for the incentives and whether they trust the government to pay them. . . . If you’re a provider trying to decide whether the government money has too many strings attached, this might convince you that it does. And if you asked me how the odds of high EMR utilization changed with the release of these proposed requirements, I’d say they got worse.”

What physicians should focus on instead of the government incentives is implementing a proven product like the hybrid EMR, which helps them operate a highly productive practice where patient care and efficiency are key.

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The authors cite several reasons for the failures, similar to the points I have presented in past EMR Straight Talk posts. Among the major conclusions reported were the following:

• While secondary work like audit, research, and billing may be made more efficient by EHRs, primary clinical work is often made less efficient;

• The larger the project, the more likely it is to fail; and

• EHRs do not adequately capture the messiness and unpredictability of the real world.

In other words, legacy EHRs do not benefit physicians, but rather force them to change the way they practice medicine. They fail to give them the tools and flexibility to solve real world problems and to effectively deal with the realities of day-to-day practice. Legacy EHRs “straight-jacket” physicians—requiring them to point-and-click their way through the documentation of patient exams, produce robotic notes, shift their focus away from the patient, and decrease productivity. They do not distinguish the needs of primary care from those of specialists. It is no surprise that implementations fail, and that high-volume specialty practices face the greatest risk.

Like me, however, the authors are not anti-EHR. They realize the need for new strategies and suggest encompassing “imagination and flexibility to overcome the inherent limitations [of existing EHRs].” As readers of EMR Straight Talk know, I have been a proponent of this approach to addressing the needs of high performance physicians. Based on the unparalleled success that our company’s hybrid EMR has in making physicians digital, efficient, and able to provide better patient care, I am sharing our action plan with the EHR vendor community:

• Adopt a laser-like focus on the needs of physicians.

• Invest precious R&D dollars in developing those software features that digitize the medical practice and automate routine clinical processes—those that, in the paper world, create intractable workflow bottlenecks and sub-optimal patient care.

• Convert paper charts to efficient digital, shareable, and portable formats.

• Address the need for speed—count the number of clicks required to accomplish basic tasks and cut it in half.  Measure the amount of mouse movement it takes to do the same tasks and reduce that by half.

• Allocate 75% of your programming budget to features that the support and implementation teams want—if it makes a support technician or implementation specialist happy, it will no doubt make clients happy.

• Assure customers’ success—move on to the next implementation only after the current implementation is deemed a success by the client (no matter how much Wall Street or your investors are breathing down your neck for revenue growth).

• Implement an ‘open checkbook’ policy for your support department to hire as many employees as it takes to please your clients—happy clients are your best marketing.

• Hire only ETPs (“eager-to-please” employees) who will always go out of their way to please clients.

If we address the fundamental problems inherent in legacy EHRs and focus on the needs of physicians, adoption will flourish and meeting the goals of the other stakeholders—patients, government, payers, and vendors—will naturally follow.

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