Rome Wasn’t Built in a Day

In my last EMR Straight Talk post (Stage 2 Clinical Quality Measures—More Is Not Better), I maintained that simply adding a large number of new quality measures without addressing the underlying flaws in the reporting process will do little to advance the program towards its goals. So I was very interested in reading Joseph Goedert’s blog the following week in Health Data Management: “Why Must CMS Overreach on Rules?”

In discussing the proposed rule regarding Accountable Care Organizations (ACOs), Joe makes a similar argument to mine. He questions CMS’s proposal that, to share in an ACO’s savings, providers would have to report on 65 quality measures—including 28 new measures—when CMS will not even be ready in 2012 to electronically accept the considerably smaller number of quality measures associated with meaningful use.

In both cases, CMS is trying desperately to accomplish a long-term vision, albeit a noble one, in too short a timeframe. While formulating its proposal for Stage 2 meaningful use, the HIT Policy Committee had several intense discussions about the trade-off between (1) aggressively moving toward the end goal and losing people along the way because they were overwhelmed and feared failure, and (2) accepting a slower pace, but with a greater chance of success. The foundation of the programs have to be solid, or real progress will not be achieved.

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Reader’s Correction/Clarification:

In my EMR Straight Talk post on August 10, (“HIE’s and Information Sharing—Physicians Feel the Pressure”), I incorrectly stated that without membership in NYU’s UPN (University Physicians Network), “physicians do not have access to the group’s favorably negotiated reimbursement rates.” I received a comment from Robert Goff, Executive Director of NYU’s UPN, stating that “UPN does not negotiate with any payer or health plan outside of fully compliant shared risk arrangements,” and that the requirement regarding physician information technology “is part of a broad initiative to promote enhanced quality and the delivery of more efficient health care.”

I apologize for the misstatement.

Stage 2 Clinical Quality Measures—More Is Not Better

Serious time and effort is being devoted to the development of the clinical quality measure (CQM) reporting requirement for Stage 2 of meaningful use, with the intention of accelerating progress toward the program’s end goals. Sadly, however, the old joke keeps coming to mind about an airplane pilot who announces to his passengers that he has good news and bad news. The bad news is that he has no idea where they are, but the good news is that they are making great time!

Moving forward in Stage 2 without first addressing the fundamental flaws and omissions that plague Stage 1 is not the right approach. CMS has acknowledged that the CQM reporting requirement in Stage 1 is no more than that—a reporting requirement meant to get physicians comfortable with the process of reporting. CMS is under no illusions that the data collected will be meaningful as a measure of the level or quality of care being provided. Many physicians will be reporting on problems for which they are not treating the patients, which means that measure numerators will be zero (or very low) and that duplicate data will be submitted by different physicians for the same patients for the same conditions, which will result in an underestimation of the true care being delivered.

The Stage 2 recommendations for CQM reporting that the HIT Policy Committee has forwarded to CMS significantly expand on the Stage 1 measures in an attempt to address a broader set of factors that affect quality, as well as to be relevant to a wider set of physicians, including specialists. These are important goals, but premature. The model that was created—shown in this graphic—requires the addition of an extensive “library” of measures for each of the 6 menu “domains”.

Adding a large number of measures will be challenging on a practical front—it will involve development and testing by specialty societies and NQF, implementation by EHR vendors, training for providers, etc.—but more importantly, it does not address the basic issues related to the value of the data submitted. The problems identified above remain, no target thresholds exist, and no meaningful baseline data will be established to monitor progress over time. This is clearly a case where more is not better.

HIEs and Information Sharing: Physicians Feel the Pressure

The exchange of clinical data is one of the three pillars of the EHR incentives program, and the legislation was intended to serve as a stimulus (pun intended!) for the creation of health information exchanges (HIEs) by including significant funding earmarked for their establishment. The stage 1 meaningful use requirements provide further support by requiring physicians to take a first step towards information sharing. EHR adoption was expected to be the impetus for the development and flourishing of HIEs.

HIE and Information Sharing - Physicians Feel the Pressure

It appears that it may be just the opposite—interest in HIEs may be driving adoption of EHRs, rather than the other way around. Growth in the HIE arena is coming from private HIEs—those sponsored by health care systems to connect their own providers and facilitate the effective sharing of clinical information about their mutual patients. The growth in private HIEs is far outstripping the growth in community HIEs, according to KLAS, and physicians are facing new and stepped-up pressures to participate.

It is no longer just the carrot of the meaningful use incentives at play. The following are just two examples that have recently been brought to my attention where sticks are being used to “encourage” physician participation in information sharing. The University Physicians Network (UPN) at NYU is making participation in its information-sharing network a requirement for membership in the UPN, without which physicians do not have access to the group’s favorably negotiated reimbursement rates. A similar physician group in Massachusetts is making membership in its network a prerequisite for patient referrals.

I’m interested in hearing from readers about the development of HIEs and other information-sharing networks in your markets, and the carrots and/or sticks associated with participation.

EMR Straight Talk Centennial Blog—It’s Still About Productivity

This is my 100th EMR Straight Talk post, and a lot has changed in the EHR world since the blog’s inception—but some things have not. Productivity is still the name of the game in EHRs, especially for specialists.

There is no question that the government incentives have stimulated interest in EHR adoption, but according to a recent physician survey, that is not the primary reason that providers are looking to implement one. “Quality and efficiency” ranked higher than the EHR incentives as the goal of EHR implementation, according to this report by CapSite—a healthcare technology research company. Heightened interest in efficiency is not surprising, given that in another study (by MGMA), physicians identify rising operating costs as a tremendous challenge.

Although the above data was not cut by specialty, I know from my experience in the field that these issues are magnified in specialty practices. MGMA found that of all physicians, orthopaedists face the greatest challenge in successfully implementing EHR systems. Ophthalmologists have such distinct needs that the American Academy of Ophthalmology took the time to publish an article defining the specific characteristics that an ophthalmology EHR must have to be valuable in their members’ practices.

When you read through the list of requirements, they all tie into the impact on productivity and efficiency—factors critical to both of these specialties given their particularly high patient volumes. The implications for EHR selection are significant, and have not changed since I wrote my first EMR Straight Talk post.

Thank you for reading and commenting!

EHR Success: What is the Reality?

With the constant barrage of meaningful use success stories in the media—number of providers enrolled, dollars of incentives earned, and case studies about practices that have already received their money—it pains me to see that the experience on the ground quite often does not reflect this reality. Although they are only anecdotal, let me share two recent personal stories that I fear are representative of all too common EHR implementation failures.

I recently visited my dermatologist, whose practice purchased an EHR approximately 2 years ago (not my company’s product). When I arrived, I saw to my dismay that the office looked and operated exactly as it had before they bought the EHR—there were walls of charts; no computers in or around the exam rooms; and my physician walked in grasping my paper chart in his hand, with loosely assembled documents protruding from the edges. When I asked why they were still using paper charts, I was told that “it takes a long time to switch over to computers!” No one in the office—not the front desk staff, not the clinical staff, and not my physician—could even tell me the name of the EHR they had purchased. Clearly, little—if any—progress had been made on the implementation front in the 2 years since the purchase decision, and yet they seemed to think this lack of a transition was normal. All that money invested, and no return!

A visit to my primary care physician was equally disturbing, but from another perspective. His practice had implemented an EHR (also not my company’s product), and several of the physicians were, in fact, using the software—but not happily. He complained that he was seeing fewer patients each day, as well as staying a half hour longer to catch up on his documentation. Will he earn a meaningful use incentive? Likely yes, but at what cost?

I have always maintained that government incentives should not be the motivation for adopting an EHR. Practice improvement—cost reduction, increased productivity, and better patient care—should be the driver. With the rapidly increasing demand for care and the growing shortage of physicians, the need for easily implementable, productivity-enhancing EHR technology is indisputable, and yet so many EHR implementations are still failing. How do we as an industry address this shortcoming?

Physician EHR Productivity: Vital to Meet Spike in Demand for Care

Half of the physician group practices recently surveyed expected to buy an EHR system within the next 2 years. In the rush to purchase, however, it is imperative that physicians take the time to carefully assess how each of the EHRs they are considering will impact their productivity. Productivity has always been a major concern in EHR adoption, but demographics and financial factors now conspire to make it increasingly critical. Physicians can no longer afford even the slightest decrease in productivity. Consider the following projections that affect specialists:

  • The demand for joint replacement surgery will soon outstrip the supply of orthopaedic surgeons available to provide it, according to studies presented to AAOS. This is partly the result of an aging population with increasing rates of obesity and arthritis, but the growing demand will also come from a younger population. A full 50% of joint replacements will be sought by people under 65—the physically active baby boomer generation with a high level of physical activity. Not only will first-time joint replacements increase astronomically (rising 673% to 3.48 million knee replacements, and 174% to 572,000 hip replacements by 2030), but the demand for revision joint replacements, (i.e., repair or replacement of artificial joints) will also increase—doubling by 2015.
  • The situation is similar for ophthalmologists. Higher life expectancy will create a demand for 30 million cataract surgeries by 2020. Combined with the downward pressure on Medicare reimbursement rates that will lead some ophthalmologists to limit their practices to medical ophthalmology, the result will be a greater caseload for the remaining surgeons—but these physicians will need a high-volume, highly productive practice to remain financially viable.
  • Dermatologists will see a two- to three-fold increase in skin cancer patients as the population ages, and the demands for their medical services will grow rapidly. Not only will dermatologists be called upon to perform more surgical procedures in their offices, but increased awareness will lead to a higher demand for screening and preventive-care services.

Physician productivity will be critical in the office as well as the operating room, since the number of surgeries performed is directly proportional to the number of office visits conducted. A physician-focused, specialist-oriented, efficient EHR will be key to a physician’s ability to meet the increased demands, satisfy patient needs, and run a financially successful practice. Given the above statistics, it would be fiscally and socially irresponsible to implement an EHR that negatively impacts physician productivity. Now, more than ever, productivity is king.

EHR Usability – Let Physicians Decide

Usability has become the focus of a great deal of attention in the EHR world. The HIT Policy Committee has talked about making usability a component of meaningful use—recognizing that spending $36 billion to incentivize and support physicians to adopt EHRs means that we can no longer close our eyes to the historically high rate of EHR failures. Fears about lack of usability, and the resulting impact on productivity, have contributed to physicians’ reluctance to move forward with implementation, and EHR incentives will not sustain adoption beyond the first payments if physicians find their EHRs unusable.

To address these issues, the Committee held a day-long hearing on usability, and on June 7, NIST (National Institute for Standards and Testing) convened a workshop to discuss the state of EHR usability. Significant work is being done by NIST, as well as by academic institutions, research and trade groups, and vendors, to determine how to measure, evaluate, and improve the usability of EHRs.

I hope that those involved in the efforts to advance EHR usability will consider the following points:

  • The only people who can truly define usability are the users—i.e., physicians and other providers. Usability relates to the comfort, ergonomics, and acceptability of a particular application interface to its users. As such, it is the experiences and feedback provided by those users that must be the driving force behind any shift toward greater usability.
  • Usability can be measured, but not legislated. Because personal subjectivity will always be an important factor in each individual user’s judgment about what is ergonomic, comfortable, and generally acceptable, there will always be room for a variety of approaches. Attempts to legislate the best way will inevitably accommodate only a narrow range of users, leaving those with varying preferences and workflows without software to satisfy their usability requirements.
  • Usability must be evaluated not only from the perspective of primary care physicians, but also that of specialists. Specialists provide different types of care and have very different expectations of their EHRs. Treating specialists as an afterthought—as happened in the initial formulation of the meaningful use requirements—would be a major disservice and undermine the serious work being done to define usability.

There is a great opportunity here for the government to provide advice and education regarding EHR usability—this could go a long way to furthering successful EHR adoption. It would be a major mistake, however, for the government’s role to extend to legislating or mandating usability standards. That would sap innovation, push creative vendors out of the market, and turn EHR adoption back to where it was before the meaningful use incentives.