EHR Adoption: The Tipping Point Has Been Reached

EHR Adoption: The Tipping Point Has Been Reached
Regardless of your feelings about the particular pros and cons associated with meaningful use—and you know that I have not been shy about expressing my opinions in that regard—it is impossible to deny the EHR Incentive Program’s positive impact on the implementation of healthcare IT. Meaningful Use has brought us to the tipping point, where EHRs are perceived as a necessity rather than an option for a successful medical practice. The enduring impact of ARRA is that it pushed the EHRs across the chasm, changing the profile of the EHR user from innovative, tech-savvy physician to mainstream physician.

We have reached the point where a critical mass has adopted EHRs, and paper charts are no longer acceptable. Practices that are not digital will find it hard to attract new physicians. Referrals will be affected as primary care physicians will prefer to deal with specialists in the community with whom they can share clinical data electronically, rather than bear the unnecessary costs incurred by the alternatives of faxing, printing, or mailing. These benefits can only be accomplished via an EHR, a fact reinforced by Stage 2’s increased emphasis on interoperability.

I still maintain that the decision to purchase an EHR should not be driven by potential government incentives but rather by the value delivered to a practice—improved patient care and service, productivity/efficiency gains, and cost savings. In fact, I would argue that participation in the meaningful use program is optional—but clearly, EHR adoption no longer is.

Meaningful Use Stage 2 Battle Lines Are Drawn

Meaningful Use Stage 2 Battle Lines Are Drawn
Interested stakeholders have submitted their comments regarding the Proposed Rule for Meaningful Use Stage 2. Providers and their professional organizations, vendors and HIT industry associations, and consumer groups advocating on behalf of patients have written detailed—and often lengthy—tomes for CMS and ONC to consider.

Sadly, the overly aggressive nature of the proposed requirements for Stage 2 is pitting providers against patients. Providers, with support from the EHR vendor community, express concern that the bar is being raised too high and too quickly to be practical, while consumer groups argue that we would be missing an opportunity by not raising it even higher. The pleas from both sides are equally passionate and well intentioned.

However, this should not be a battle—the fact that it has turned into one is most unfortunate. I believe that all stakeholders are truly committed to the same goal: higher quality, safer, and more convenient care for patients, provided efficiently and at a reasonable cost. Everyone agrees that meeting these goals requires moving towards increased interoperability and greater patient engagement, but it is the specifics of these requirements—as proposed for Stage 2—that are stirring up the controversy.

We need to advance at a reasonable pace, one that is challenging but not overwhelming. The risk of pushing providers to the point where the requirements are perceived to be unrealistic, unmanageable, and overly burdensome—particularly as incentives dwindle to insignificant levels—is that they will abandon the program as unachievable. If that happens, the continued success of the incentive program will be in jeopardy. No one’s goals will be met.

HIT Policy Committee Focuses on Physicians

HIT Policy Committee Focuses on Physicians
A very positive conversation took place at yesterday’s HIT Policy Committee meeting, and it put the focus squarely on the physicians—a focus that in the past seems to have gotten lost in the shuffle.

The Committee was reviewing and finalizing its comments for submission to CMS on the Proposed Rule for Stage 2. A healthy debate ensued regarding who should have to enter the orders into the EHR to satisfy the CPOE requirements—the physician or a designated clinical staff member. In response to a suggestion that there were reasons for requiring the physician to personally enter the orders into the system, Neil Calman, MD, raised the discussion to another level by asking about the entire purpose of EHRs and meaningful use. Dr. Calman challenged his fellow committee members to think about how an EHR should be expected to change the way physicians practice—and how it should not. He asked why we would want to bog physicians down with tasks that other staff were already doing instead of helping physicians focus on the work that utilizes their highest skills and expertise.

The EHR incentives are definitely encouraging EHR adoption, but we should not lose sight of why increased adoption is such an important goal. The value of an EHR to a physician is not the $44,000 incentives—it is the potential for increased productivity and efficiency, better and safer patient care, and the ability to share information. It’s easy to get caught up in creating comprehensive measures that ensure that the interests of all stakeholders are met, and in doing so, to lose sight of the practical impact on physicians’ workflow. In the case of yesterday’s CPOE debate, the committee came up with a recommendation that preserves the intention of the CPOE measure—and meaningful use in general—while respecting the value of the physicians’ time. I hope this conversation will set the tone for future meaningful use deliberations.

EHR Incentive Program Financed on the Backs of Physicians

I was shocked to read the following paragraph, buried on page 379 of the 455-page Proposed Rule for Stage 2 Meaningful Use, (page 13812 in the Federal Register). The paragraph also appears verbatim in the Final Rule for Stage 1:

Explanation of Benefits and Savings Calculations:

In our analysis, we assume that benefits to the [EHR Incentive] program would accrue in the form of savings to Medicare, through the Medicare EP payment adjustments [penalties]. Expected qualitative benefits, such as improved quality of care, better health outcomes, and the like, are unable to be quantified at this time.

While the second sentence is disappointing, I do respect CMS’s candor in acknowledging the ongoing paucity of hard data on the quantification of the assumed qualitative benefits of EHR adoption. The first sentence, however, left me short of breath because it points to the following inescapable, disheartening conclusion: The economics of the EHR Incentive Program is predicated upon physician failure!

EHR Incentive Program Financed on the Backs of Physicians

In fact, the government’s projections for physician participation from 2014 through 2019 are rather pessimistic. Meaningful use among Medicare EPs is estimated to grow, in the less optimistic (“low”) scenario, from 18% to a mere 36%, and in the most optimistic (“high”) scenario, only from 49% to 70%.¹ Even these high projections are low enough—incidentally—to give the Secretary of HHS the option to increase the penalties from the statutory 3% in 2017 to a potential 4% in 2018 and 5% in 2019.

What kind of program have we created that over a period of 9 years will likely take almost as much money from physicians as it gives them?

The government giveth and the government taketh away!

¹Source: Proposed Rule, Stage 2 Meaningful Use, page 13804, Table 19.

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.