Meaningful Use Stage 2: What’s Wrong With This Picture?

It’s been said that a picture is worth a thousand words. The following summary of the proposed regulations for Stage 2 meaningful use and certification says it all—literally and figuratively!

Thanks goes to the Advisory Board Company for reviewing the proposed rules and “simplifying” the requirements for public consumption. (Of course, this poster can be blown up and printed in a readable size . . . if you have 24 square feet of wall space available!) You will see that the requirements for Stage 2 are even more numerous and complex than those for Stage 1. Don’t be fooled by the fact that providers would still have to meet only the same number of measures (20)—many of these measures now have multiple components and subcomponents that incorporate additional requirements that used to be counted as measures in their own right.

Why does meaningful use have to be so complicated and over-specified? How did we go from the original intent of the HITECH Act—encourage EHR adoption to facilitate the three goals of ePrescribing, reporting on quality measures, and exchanging clinical information—to the over-engineered chart above? We have surely lost sight of the forest for the trees.

Physicians cannot be expected to understand the requirements of a program that is so complex that it takes 455 pages to explain. The government is inviting their input on the proposed regulations, but how can busy physicians be expected to comment on a rule that they cannot possibly even have time to read?

I am not denying that the program is the product of a lot of time and hard work on the part of many very smart people who represent the interests of the multitude of stakeholders in the healthcare industry. However, the explosion of requirements is going to frustrate providers and ultimately undermine the success of the entire program, and this is particularly true given the large number of IT-related programs that physicians must comply with now and in the next few years. We have created an administrative nightmare for physicians, and spawned an industry of consultants who are paid by physicians to interpret meaningful use and other complicated incentive programs.

Physicians want to do the right thing—provide better care, improve outcomes, and reduce costs. But they can be pushed only so far before they justifiably start to push back. On March 28, the AMA sent a letter to the Department of Health and Human Services, signed by 61 professional associations and all 51 state medical societies, that describes the situation as an “imminent storm” creating an “extraordinary financial and administrative burden as well as mass confusion for physicians.”

It’s time to speak up. Submit your comments on the proposed Stage 2 meaningful use rule.

Most EHRs Disappoint Specialists

The vast majority of EHRs are outright failing the specialists. Is this news? Surely not to those physicians suffering EHR implementation disasters, but thanks to KLAS, we now have hard data to confirm the anecdotal evidence. It is provided in the recent KLAS report, and eloquently described by Ken Terry in his recent article in Information Week. His title, however, “EHR’s Aren’t Specialist-Friendly Enough,” underestimates the seriousness of the problem. And the problem will only get worse as more specialists rush to purchase EHRs under the pressure of impending meaningful use deadlines.

In an industry where the EHR satisfaction scores by specialty range from a paltry high of only 7.6 (on a scale of 10) for internal medicine and family practice to an embarrassing low of 5.8 for oncologists and ophthalmologists, most specialists rate their EHRs in the barely passing range between 6.2 and 6.8.

Source: KLAS as reprinted in HIStalk

Let’s look at these scores as grades—the best EHRs are only earning a C (76%); orthopedists are trying to make a go of EHRs that are squeaking by with a D (65%); and some specialists are saddled with EHRs that are simply flunking out (58%).

And these scores are averages. Assuming a normal distribution of responses (see example of bell curve for ophthalmology, below), there are many physicians who rate their EHRs considerably lower than the average—giving scores of 48%, 38%, or even lower. (Readers who are physicians know what happens to students who get a 38% on an organic chemistry final exam: dreams of medical school quickly disappear as these students are weeded out of the candidate pool!)

Of course, just as there are some specialists who rate their EHRs below the average, there are also some who score theirs at the high end of the bell curve (in the orange section). Oh, and guess where a vendor is going to take a prospective customer for a site visit?

So, what’s a specialist to do to increase the chance of EHR success? Play it safe and go with a name brand, generic EHR? Clearly not! That strategy is anything but safe. The legacy EHRs are all built to support the needs of primary-care physicians—it is no surprise that internists and family practitioners are less dissatisfied with their EHRs than their specialist colleagues are.

Here are some tips:

  • Start with the KLAS report, “Ambulatory EMR by Specialty Study 2012: Finding the Fit”, and identify those EHRs that have high ratings in your specialty.
  • Make sure that these vendors have a large network of providers in your specialty.
  • Perform comprehensive due diligence, calling physicians that you select.
  • Beware of vendor-selected site visits—these physicians should not be expected to be representative of the majority experience.

You can’t cheat when it comes to selecting an EHR. After all, it may be the EHR that gets the bad grade, but it’s you who is going to have to pay.

Meaningful Use Stage 2: Speak Now, or Forever Hold Your Peace

Meaningful Use Stage 2: Speak Now, or Forever Hold Your PeaceYesterday, the Proposed Rule defining Meaningful Use Stage 2 was officially posted in the Federal Register. This means that the clock has begun ticking on the 60-day comment period, and the opportunity to influence the decision makers will end on May 6. It is critical that physicians speak up, particularly now that some will be able to respond from the perspective of their experiences in—or familiarity with—Stage 1.

In upcoming posts (after we have had the time to read, re-read, and analyze the lengthy Proposed Rule), I will discuss specific measures that I believe require modification due to their limited practicality and/or potentially adverse impact on physician workflows. Today I want to provide some high-level observations drawn from an initial evaluation of the Rule and highlight a few major implications that immediately come to mind:

  • The bar has definitely been raised! The emphasis on interoperability, patient engagement, and more extensive quality measure reporting impose very demanding requirements that represent a huge step up in capability and effort. The term “more stringent”—which is used in the ARRA legislation to characterize successive stages of meaningful use—does not begin to describe the relative intensity of Stage 2.
  • Expectations are very high, despite the fact that a vast number of physicians have not even begun to participate in Stage 1. Although CMS claims that the number of core and menu measures remains steady at a total of 20 (through some sleight-of-hand counting magic!), the actual requirements have expanded in number, complexity, and depth.
  • The proposed leap forward in the exchange of clinical data is monumental in scope. Although this is an important long-term program goal, it must be reconsidered in light of the dismal experience in this area in Stage 1. The requirement to simply test the ability to exchange clinical data met with such confusion and failure that the measure has been retroactively eliminated for 2013—the second year of Stage 1.
  • Patient engagement is another area of focus in Stage 2. Again, this is a noble goal, and physicians should be rewarded for doing everything possible to encourage patient and family involvement in care. The Proposed Rule, however, defines meaningful use to include specific patient actions, such as e-mailing their physician and accessing their information on a portal. It is unacceptable to make a provider’s incentive payment dependent upon actions by patients over which he or she has no ultimate control.
  • The Rule proposes some appealing options for streamlining clinical quality measure (CQM) reporting and harmonizing the various CMS programs that involve CQMs. However, the number of measures has exploded, and the administrative aspects of the various options will be very difficult for providers to discern.

Those are my first impressions. I will follow up with more information on these and other issues and on the procedure for submitting comments to CMS. In the meantime, I am interested in hearing your thoughts and/or concerns about the Proposed Rule and how it could impact your practice.

Why Superior EHR Customer Service is Critical to Your Practice’s Success

In today’s increasingly complex environment, superior service and support from your EHR vendor are critical to long-term practice viability. Reliable customer service can no longer be viewed as just a box to be checked on the EHR scorecard during the selection process—it is vital to success.

Why Superior EHR Customer Service is Critical to Your Practice's SuccessThe EHR industry is characterized by fairly poor customer satisfaction—the average KLAS score for service sits at a low 73% (Ambulatory EMRs for 11–75 Physicians). Physicians who cannot rely on their EHR company for excellent support will find their productivity and success jeopardized. No longer is the impact of an EHR limited to its use in managing charts—the increasing demands of government and other payer programs have extended the reach of an EHR beyond the four walls of the practice, and success or failure now has increasingly significant financial implications. Physicians must be able to successfully share information, connect to HIEs, and report on clinical data. In the future, they will need to respond to new reimbursement models such as ACOs. All of these communications are complicated and fraught with potential technical challenges—even with the best EHR solutions—making access to the highest quality customer support vital.

Meaningful use incentives are foremost on the minds of most physicians right now, and the program’s requirements are complex, confusing, and challenging. Physicians rely on their EHR vendors not only for the technical support necessary to achieve meaningful use, but also for the educational resources required to successfully navigate the program. Unfortunately, this kind of support is not universally available within the industry. The findings of a recent survey presented to the HIT Policy Committee revealed that physicians cite vendors—in particular, the lack of adequate support and training and unresolved technical problems—as a major obstacle to achieving meaningful use.

Physicians want to know that their EHR company will be in business for the long term. In a recent post, “The EHR Bubble Will Pop—To the Victor Go the Spoils,” I maintained that significant market consolidation is inevitable, and that many, if not most, of the 472 EHR companies currently offering certified EHRs will not survive the shakeout. Customer service is a distinguishing feature among EHR companies that will be important in ensuring a vendor’s future viability.

So, what constitutes excellence in EHR customer service and support, and how do you see through the promises made by vendors during the sales process to ensure that you will receive the level of support that you need? The highest quality customer support requires a sufficiently large team of highly skilled, well-trained, eager-to-please employees, who are easily reachable and accountable for responding within a defined and appropriate amount of time. Where possible, they should be proactive, not just reactive. Such a team requires oversight by senior management, which is really only possible if the support department is not outsourced or sent overseas. You should rely on the real experience of colleagues—review the KLAS ratings and then validate them by doing your own due diligence.

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.

The EHR Bubble Will Pop – To the Victor Go the Spoils

Like the dot-com bubble, the EHR bubble—nurtured by the government incentives—will not last. As I look at what’s happening in the market, it becomes apparent that at some point in the not-too-distant future, the EHR bubble will pop and many vendors will face financial challenges that will lead to their demise.

Several market factors will come into play, including:

  • Physician dissatisfaction with their choice of EHR, which likely was selected in haste to meet the government’s incentive timetable and was delivered by an overwhelmed vendor;
  • Physician disenchantment with the EHR Incentives Program, as financial rewards decrease while requirements intensify;
  • An overabundance of EHR vendors  competing in a market dominated by a small number of major players. (Currently there are 472 EHR vendors offering certified “Complete EHRs”)

To understand how these factors will affect EHR vendors, it is important to understand how such companies typically raise money and what kind of “hockey-stick” growth projections they made to attract investors.

EHR Revenue

Missed growth projections; continued expenses for implementation, support, and ongoing upgrades; and diminishing government incentives will leave many companies unable to find investors willing to fund their future growth.

There will be market consolidation, and financially strong companies will acquire distressed companies for pennies on the dollar.

…To read the full story, see HIStalk Readers Write.

Stage 2 Meaningful Use Delayed to 2014: What’s It Really About?

HHS has made it official—Stage 2 of meaningful use will be pushed back to 2014. The announcement by HHS Secretary Sebelius came as no surprise, following as it did the recommendation made by the HIT Policy Committee and the endorsement by ONC head Farzad Mostashari. The change only affects providers whose first incentive payment year is 2011, since they are the only providers who would be subject to Stage 2 regulations in 2013 had the delay not been implemented—everyone was already entitled to 2 years of meaningful use at Stage 1.

What I find interesting about all the hoopla that has accompanied the announcement is the spin the government put on the decision. According to the press release from HHS, “To encourage faster adoption, the Secretary announced that HHS intends to allow doctors and hospitals to adopt health IT this year, without meeting the new standards until 2014. Doctors who act quickly can also qualify for incentive payments in 2011 as well as 2012.”

Isn’t it a bit late for a provider to decide to adopt health IT this year? In reality, this announcement is too last-minute to change any adoption-related behavior or to accelerate EHR adoption. The announcement continued, “Perhaps most importantly, we want to provide an added incentive for providers attesting to meaningful use in 2011.” Apparently, the goal is to accelerate attestation rather than adoption—to encourage physicians who were already using certified EHR technology in a “meaningful way” to attest and to collect an incentive payment this year, instead of holding off attesting until 2012. This would create a potential PR benefit for the incentive program, which currently boasts nearly 115,000 registered providers, but reports that only 10,155 (9%), have successfully attested.

The benefit of the schedule delay accrues only to the early adopters, who now can earn 3 years of incentives under the less stringent requirements of Stage 1 (only, however, if they are willing to forego their 2011 Medicare ePrescribing bonuses—not a worthwhile trade-off for high-revenue physicians with large Medicare volumes). In its statement, HHS acknowledged the pushback from providers regarding how challenging even the Stage 1 requirements are. Perhaps, it would truly spur program participation and EHR adoption if all providers—not just the early adopters—were entitled to 3 years of meaningful use under Stage 1 rules. Also, if CMS has so little confidence that physicians will succeed at Stage 2, shouldn’t it reconsider how much it plans to raise the bar?