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.

Meaningful Use, ePrescribing, and PQRS: Need for Harmonization

While physicians are working feverishly to understand the complexities of meaningful use, their efforts are complicated by the demands of other government incentive programs that have similar goals but different rules. Two of the three cornerstones of ARRA are ePrescribing and reporting on quality measures, yet it is still necessary to comply separately with the regulations of EHR incentives (ARRA’s meaningful use), ePrescribing (MIPPA), and PQRS if physicians wish to maximize—or, in the near future, preserve—practice revenue.

EHR Incentive PaymentsThe chart to the right is taken from a 6-page CMS document that addresses the complicated interrelationships among EHR incentives, ePrescribing, and PQRS. For physicians, the challenge goes beyond understanding the potential payments; of greater significance is the administrative burden created by the discrepancies in reporting metrics and reporting periods among the three disparate programs. The following represent just a few of the inconsistencies inherent in the programs:

  • Under Medicare, physicians cannot receive both an EHR incentive and an ePrescribing (MIPPA) incentive in the same year. They can, however, receive both an EHR incentive and a PQRS incentive in the same year.
  • Future penalties for failure to demonstrate both meaningful use and PQRS will be additive. Whether cumulative penalties will apply for physicians who are not meaningful users and do not ePrescribe is not addressed in the CMS chart, but the prevailing understanding is that, instead, the harsher of the two penalties will prevail.
  • Because ePrescribing benchmarks differ, a physician could be deemed a successful ePrescriber under ARRA but not under MIPPA, and vice-versa.
  • Regardless of whether or not a physician receives incentives under ARRA, he/she must continue to comply with the MIPPA ePrescribing requirements (i.e., G-Coding) to avoid future MIPPA penalties. (Ironically, a physician could demonstrate meaningful use in 2011, receive an EHR incentive, but be penalized 1% under MIPPA in 2012 for failure to report G-Codes—a MIPPA, but not a meaningful use, requirement.)
  • Although many of the quality measures are common to both meaningful use and PQRS, separate reporting is required. Differences exist in the applicability of thresholds and in the reporting periods.

I am glad to see that the lack of program harmonization is being recognized—and I hope it will be successfully addressed in the next round of rule-making. Recently, the AMA distributed a survey “seeking physicians’ input on rules and regulations that increase their administrative costs and paperwork burden, or that interfere with patient care without a significant benefit to patients and/or the government.” Last week, the Government Accounting Office issued a recommendation to CMS that they eliminate overlapping ePrescribing requirements. Harmonizing the rules will go a long way toward encouraging widespread and successful participation in government programs that are aimed at increasing quality of patient care.

EMR Straight Talk’s 2nd Birthday—Over 100,000 Views and Counting

Thank you for making EMR Straight Talk the success that it is today. I was very enthusiastic when I started writing this blog, and am even more so now, having watched it grow and having had the opportunity to personally engage with a number of readers. Your support and ongoing interest are truly appreciated.

EMR Straight Talk was launched exactly two years ago today—February 17, 2009—at precisely the moment that President Obama launched the EHR incentive program. I vividly recall sitting in my office watching the news coverage of the fanfare surrounding the president’s signing of the Stimulus Plan (the American Recovery and Reinvestment Act). As he put his pen to paper, I pushed the “Send” button for the first post.

A lot has transpired since then, and EMR Straight Talk’s readership has boomed. Recently it surpassed 100,000 views, with a single-day traffic milestone of 1,197 readers on February 4, capping a record-breaking week that had 2,072 readers.

I enjoy sharing my thoughts and hearing comments from readers, whether or not they agree with me. It is particularly rewarding to find EMR Straight Talk posts referred to—and the conversation continued—in other industry blogs such as HIStalk, EMR and HIPAA, Health Data Management, and FierceHealth IT, to name a few. What that says to me is that the blog addresses issues of concern to a wide audience, offers a fresh perspective on these issues, and provides educational content that my readers seek.

Last year, I was identified as one of the “disruptive forces in healthcare,” a badge that I wear proudly. I like to think that EMR Straight Talk was responsible—at least indirectly—for stimulating conversation with the government that changed the playing field for physicians, and particularly for specialists.

I look forward to continuing the dialogue with you and welcome your suggestions of topics that you would like me to discuss in future posts.

Blumenthal and EHR Program: Time Will Tell

In the aftermath of Dr. Blumenthal’s departure announcement, he has received abundant praise for his accomplishments, his leadership, and his commitment to EHR adoption. There is a general consensus that the groundwork has been laid and that sufficient organizational structures are in place to move the EHR adoption program forward smoothly, despite the upcoming change in command at ONC.

Most writers have attributed Blumenthal’s departure to his need to return to Harvard—which had granted him its standard two-year leave of absence—since his option to retain a tenured position expires at the end of that period. According to Secretary Sebelius, this schedule was incorporated in the HHS plan from the outset.

Some people are more cynical regarding Blumenthal’s reasons for departing, like one of the commenters on last week’s EMR Straight Talk post, who suggested that he is getting out “before the roof collapses.” They cite recent studies that question the link between EHRs and quality of care, the loss of confidence among some providers regarding their ability to meet the meaningful use requirements, and the recent (albeit unsuccessful) attempt by House Republicans to repeal unspent funding that would have included the EHR incentive program. These commenters express doubt as to whether the momentum toward health IT adoption will continue.

Others say new leadership will be a good thing. John Moore of Chilmark Research posits that the EHR program is at a turning point—and that as it transitions from the development phase into the operational phase, it should be led by someone with operational experience rather than by an academician.

No doubt, top PR people were involved in the orchestration of the Blumenthal announcement. What still concerns me is why it was not accompanied by the naming of his replacement—a sentiment that has been echoed by many industry pundits, (Ken Terry, for example). This begs the question: What does it really mean? Time will tell.