Physicians: Don’t Count on EHR Support from Hospitals

Anthony Guerra, noted HIT industry blogger and editor of HealthSystemCIO, has written extensively about the pressures and stresses facing hospital Chief Information Officers (CIOs) due to the myriad government programs making demands on their skills and their time. His recent survey revealed that a mere 16% of CIOs manage to maintain a relatively normal workweek of 40–49 hours, while 35% report working over 60 hours per week. In my opinion, the current level of stress extends throughout all levels of the IT staff—a sentiment echoed at today’s HIT Policy Committee meeting as they evaluated the recommendations for Stage 2 meaningful use.

This is not surprising. In the midst of upgrading to meet meaningful use requirements—a bigger challenge for many hospitals than originally anticipated—IT departments are expected to simultaneously prepare their facilities to comply with the impending 5010 requirements and convert their systems from ICD-9 to ICD-10. Also looming in the not-too-distant future are the newly defined Accountable Care Organizations (ACOs), which will require significant and expanded data and reporting capabilities. All of this is compounded by a shortage of IT professionals in the healthcare arena.

So how does this relate to private-practice physicians—the constituency on whom I typically focus? I’ve cautioned in a previous post, One Size Does Not Fit All, about the mismatch between the EHR needs of hospitals and of physicians in private practice. Physicians should also be wary of adopting their hospital’s EHR if they are doing so with the expectation that the hospital’s IT resources will be at their disposal. They will be sadly disappointed—supporting private practice physicians, particularly specialists, will be low on the list of priorities for IT staff when their plates are already overflowing.

Usability: Can Every EHR Be Above Average?

Usability is the key differentiator between the long-term success and failure of an EHR implementation. The findings of the recent MGMA study lead to the inescapable and troubling conclusion that too many physicians do not consider their EHRs “usable.” A bad EHR choice is costly for the particular physician(s) and, while it might suffice in the short term for the purpose of earning meaningful use incentives, it will do nothing in the long run to foster sustained EHR adoption. Recognizing this, the HIT Policy Committee’s Adoption and Certification Workgroup convened an 8-hour hearing last week on the subject of how to define and measure usability. Recommendations were offered that mirrored my EHR reform proposal, and various groups/studies are already working on usability testing. One such group is CCHIT, which has introduced a usability rating tool into its commercial certification (not to be confused with government-certification) process. In her testimony, Karen Bell, M.D., Chair of CCHIT, discussed the results (Chart 1) and her recommendations.

So what’s wrong with this picture?

What’s wrong is that, to be useful to physicians, it has to look like this:

This is not meant as an indictment of CCHIT—the organization is to be commended for having taken an important first step in defining usability and creating a process for measuring it. The problem—which Karen Bell did acknowledge when challenged about it—is that if this rating scale were an accurate reflection of usability, there would be many fewer complaints about EHRs and, in my opinion, many fewer failures.

To provide physicians with the objective information that will be valuable to them in EHR purchase decisions, the ratings must be comparative and follow a normal distribution, as illustrated in Chart 2 above. Because achieving this distribution would require more aggressive usability criteria, it would distinguish those EHRs that have the greatest positive impact on productivity and cost savings from those that have a lesser, or negative, impact in these areas.

Even more important, this more challenging evaluation will create a market in which vendors are forced to compete on usability and how to better meet the needs of physicians. Physician satisfaction levels will increase. It will elevate quality across the board and raise the level of the entire EHR industry. Perhaps, as Dr. Ross Koppel testified at the Usability Hearing, if health IT were more usable, we wouldn’t even need incentives to spur EHR adoption!

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.

MGMA Study Reveals #1 Reason Physicians Fear EHRs

The evidence is indisputable: the fear of lost productivity associated with EHR implementation is uppermost in the minds of physicians, and their fears are justified by the actual experience of the majority of EHR adopters to date. The titles of two articles about the recently released MGMA EHR survey say it all: “Survey: EHRs Often Don’t Increase Doc Productivity” (Health Data Management) and “HITECH Drives Docs to EHRs, but Cost, Productivity Issues Remain” (Healthcare IT News).

MGMA is to be commended for the size and scope of this important survey (4,588 practices representing 120,000 physicians), for the multiple ways it segmented the survey population, and for the detailed analysis of the results. One important segmentation was missing, however—that of physician specialty, or, at a minimum, of primary care versus specialist. The EHR experience of orthopaedists or ophthalmologists, who may see as many as 60 patients a day, is dramatically different from that of a family practice physician who sees 20.

Productivity was the pervasive issue. The only group that reported some productivity gains was the 16.3% self-proclaimed “optimized users” of EHRs—those who have had sufficient time following implementation to master the EHR. (The report did not define “sufficient time.”) Among this group, 41% reported that physician productivity has increased. What is disturbing about this statistic, however, is the implication of the converse—that even among these most accomplished EHR users, the majority of physicians (59%) are seeing a decrease, or at best no increase, in productivity. For the total population studied, 43% have just worked their way back up to where they were before implementation, and 31% of respondents are experiencing an actual productivity decrease.

Productivity was the major factor accounting for why 8% of survey participants are in the process of replacing their EHR with another, while anticipated productivity loss was reported as the most significant barrier to EHR implementation for physicians still using paper charts. Among these paper users, 78% fear productivity loss during implementation and 67% worry about the effect even after the transition to an EHR.

This data confirms past experience regarding productivity loss and raises these critical questions:

  • Why do only 16.3% of EHR owners categorize themselves as “optimizing their use of an EHR”?
  • While government incentives will certainly address the financing concerns expressed by small practices, how will this money address the productivity obstacle for all adopters?
  • What accounts for the loss of productivity?
  • When technology has replaced an antiquated paper process in other industries, it has always brought increases in productivity. How do we deliver the same results in healthcare?

The MGMA report did not tie satisfaction and productivity to the particular EHR being used, but there were clearly some successes, so it is important to understand what differentiates these implementations. It all comes down to usability. According to a recent HIMSS Task Force Report on why adoption has been so slow, “A key reason, aside from initial costs and lost productivity during EMR implementation, is lack of efficiency and usability of EMRs currently available.” I maintain that lost productivity and lack of usability are one and the same.

From EHR Vendors: New Facts or More Fiction?

Meaningful use is complex enough without having to sort fact from fiction when it comes to the rules, regulations, and requirements. It irks me when I hear the misinformation being disseminated by some EHR vendors in their attempts to sell their products to physicians who are not fully steeped in the nuances of the program.

The distribution of meaningful use misinformation for marketing purposes is not new. I wrote an EMR Straight Talk post titled “From EMR Vendors: Fact or Fiction?” on exactly this subject almost two years ago, when the program was still in its formative state. Sadly, unsavory marketing tactics remain the same—only the purported “facts” have changed.

The following are what I consider the most notorious misstatements about meaningful use:

  • It is not true that “You must demonstrate meaningful use in 2011 to qualify for the full $44,000 in incentives.”
    As the incentives chart illustrates, physicians can earn the full $44,000 over a 5-year period even if they start meaningful use in 2012. In fact, there are compelling reasons not to start in 2011. The first is that physicians can maximize their total revenue by focusing on earning the 1% ePrescribing bonus in 2011 and postponing meaningful use to 2012. Unfortunately, few vendors are alerting physicians that because they cannot collect both ePrescribing and EHR incentives in 2011, they would be leaving money on the table by pursuing meaningful use this year. The second advantage of waiting until 2012 is that physicians will not have to advance to the more stringent requirements of Stage 2 meaningful use until 2014 (instead of 2013), allowing more time to implement required upgrades.
  • It is not true that If you wait until 2012, you will have to report on a full year’s data, rather than only 90 days.”
    The 90-day reporting period applies to the individual physician’s first payment year—it is not tied to calendar years. Therefore, physicians can actually start as late as October 1, 2012 and still earn the maximum incentives.
  • It is not true that “Providers have already received money for meaningful use of an EHR.”
    No one has yet demonstrated meaningful use. The incentive money distributed so far has been awarded under Medicaid, which provides first-year incentives for A/I/U (Adoption, Implementation, or Upgrading of EHR technology) and does not require the demonstration of meaningful use. In fact, although the first potential 90-day reporting period concludes at the end of March, the attestation portal (through which providers document meaningful use) will not be operational until April 18th.
  • It is not true that “Generating a structured, point-and-click, templated note is the only way to capture meaningful use data.”
    Most EHRs are built on a note-driven platform, where the design of the software traps physicians into capturing meaningful use data through over-engineered, click-heavy templates. It is disingenuous of the sales representatives of these vendors to suggest that a structured note is a requirement of meaningful use. When all you own is a hammer, every problem looks like a nail.

Caveat Emptor!

Meaningful Use Stage 2–Physicians’ Opinions Count Most

The HIT Policy Committee’s Meaningful Use Workgroup met this week to begin discussing the question that I posed at the end of my EMR Straight Talk post last week, i.e., how to reconcile the various stakeholders’ positions regarding Stage 2 meaningful use. Most of the feedback received by the workgroup in response to its request for comments relate to issues surrounding timing, with providers and vendors urging restraint, and consumer groups (representing patients and payers) pushing for more aggressive timelines.

Given the statutory constraints (i.e., changes to the law itself would require Congressional action, a path the workgroup will not pursue), the options are limited—and each carries consequences for the program’s long-term goals. The workgroup acknowledged the concerns of vendors regarding the time needed to adequately and safely develop and deploy any new required functionality. They also appreciated the impact on providers of the implementation and training demands associated with upgrading technology, particularly at a time when providers are facing other IT challenges such as ICD-10 and HIPAA 5010. The workgroup considered the following options:

  • Option 1: Slow down the program’s pace by not adding any new measures and functionalities to Stage 2, but merely increasing the thresholds related to Stage 1 measures.
  • Option 2: Delay the start of Stage 2 by allowing each provider more time at Stage 1 or by basing the initiation of Stage 2 on the overall level of provider compliance/success in Stage 1.
  • Option 3: Shorten the first year’s reporting period to 90 days when providers progress to Stage 2.

The workgroup identified the following as the problems associated with each of the above proposals:

  • Option 1 (no new measures) will not get the program where it needs to be rapidly enough. It does not advance the program past data capture and towards the program’s goals: interoperability; “advancing clinical processes” (the goal of Stage 2); or improving outcomes (the goal of Stage 3).
  • Option 2 (delay Stage 2) raised the concern that extending Stage 2 will set a precedent for delaying Stage 3. The dwindling financial incentives and the lack of positive incentives after 2016 could reduce interest in Stage 2 or make it difficult for the program as a whole to ever progress past Stage 2, given that there are no positive incentives available after 2016.
  • Option 3 (90-day reporting period) does nothing to resolve the vendors’ concerns about the timeline for development.

Another critical issue to be addressed is how to increase the relevance of the EHR program to specialists, which will be the subject of a special hearing on May 13—similar to the hearing that solicited their input for Stage 1. Of all of the stakeholders, physicians are the most critical to the attainment of the EHR program’s goals. Physicians—primary care and specialists alike—are the cornerstone of the program, and their participation beyond Stage 1 will depend on the development of a set of reasonable and achievable requirements.

Meaningful Use Stage 2—So Many Opinions

While providers are still struggling with the details of meaningful use Stage 1—and as of yet, no one has actually demonstrated meaningful use of their EHR—plans for defining Stage 2 requirements are moving ahead at full speed. A preliminary set of recommendations was released by the Meaningful Use Workgroup of the HIT Policy Committee in January, along with a Request for Comment by February 25. And comment they did!

Major organizations representing the various stakeholders submitted lengthy letters detailing their recommendations. While the specific concerns they express differ slightly, a clear consensus is emerging:

  • Rushing providers to do too much too quickly in the next stage will be counterproductive to the end goal of successful and widespread EHR adoption, as well as have a negative effect on patient care.
  • The proposed timelines are too aggressive in several areas.
  • Expectations should not exceed the existence of a sufficient information-exchange infrastructure, e.g., syndromic surveillance is identified as unrealistic.
  • Stage 2 requirements should be based on an objective evaluation of the experience in Stage 1 and the value of individual measures.

The last point above reveals a sense of frustration over the fact that the existing timetables create pressures that do not allow for this approach. Without taking into consideration the successes, failures, and physician participation rate in Stage 1—including, I would add, the rate of participation by specialists—Stage 2 could lay the groundwork for failure.

The AMA’s letter on behalf of 39 medical societies reiterates those societies’ initial concern about the excessive burden being placed on physicians. The letter argues for increasing flexibility, expanding the ability to opt out of measures that are not relevant to a physician’s routine practice, retaining a menu set rather than making all measures core and therefore required, and limiting physicians’ responsibility to what is within their control and not subject to compliance by other parties (e.g., patients’ use of portals for access to health information).

MGMA identified many of the same concerns, adding a request for harmonization of government programs to eliminate duplication of effort. (See discussion of this topic in my last EMR Straight Talk post.) Premier, Inc., a provider alliance, urged that new no clinical quality measures should be added until Stage 1 performance can be evaluated.

From the IT industry, AHIMA (an organization of healthcare IT professionals) cautioned about the impact of the overwhelming number of complex initiatives that practices will have to incorporate at the same time—ICD-10, Healthcare Reform, and meaningful use. EHRA, the EHR vendor trade organization, not surprisingly expressed its concern about the time needed to develop the software updates that will be required, particularly in light of the impending regulations identified by AHIMA. It therefore recommended that Stage 2 be limited to increased thresholds for Stage 1 measures with no addition of new measures. EHRA specifically identified clinical decision support as an area in which the government’s expectations go well beyond the scope of an EHR. As an overarching recommendation, EHRA urged a delay in the start of Stage 2 and the extension of certification to three years instead of two.

A somewhat different perspective comes from consumer organizations. The Consumer Partnership for eHealth and the Campaign for Better Care, on behalf of a number of other groups such as AARP and several unions, argue for a significant raising of the bar and accelerating of the program. For example, they ask that all menu measures become core measures, patient and family engagement via use of portals be emphasized, and clinical decision support rules be defined and adherence required. Deborah C. Peel, MD, Founder and Chair of Patient Privacy Rights, submitted a letter expressing her disappointment that “the current MU Stage 2 criteria and schedule for MU Stage 3 criteria completely ignore/omit privacy rights and protections in existing privacy law . . .“ It is not surprising that these groups would take a more aggressive stance and have higher expectations—these are the people who are paying for this program.

How will all of the above positions be reconciled? Based on the experience of Stage 1, in which the HIT Policy Committee and CMS revised the initial requirements to make meaningful use more achievable, I believe that they will do the same for Stage 2 and create a set of rules that are beneficial to the overall healthcare system and patients, while not overly burdening physicians.