Test Your Meaningful Use IQ – Stage 2 and 2014

Meaningful Use Stage 2 IQ TestFor many physicians pursuing the EHR incentives, 2014 means moving on to Stage 2 of meaningful use. Stage 2 is much more complex than Stage 1, with higher thresholds for most Stage 1 measures; core (i.e., mandatory) requirements that were formerly menu (i.e., optional); and totally new measures related to interoperability and patient engagement that will require revised workflows. It’s not too early to start learning about Stage 2, and I would suggest that physicians and their staff members take advantage of the abundant educational opportunities that already exist. CMS has produced helpful tipsheets and guides for providers, and you should expect your EHR vendor to offer comprehensive training programs on Stage 2. Another good way to learn about the new requirements is to attend a webinar—there are many, and I invite you to attend one of my company’s webinars that will prepare you well for 2014.

In the meantime, test your basic knowledge of 2014 and Stage 2 by taking this quiz. If you have any questions of your own, please comment below and I will be happy to respond.

Meaningful Use Breathing Room Appears on the Horizon

Meaningful Use Breathing Room Appears on the HorizonAmid the abundant (and yet unanswered) pleas from all quarters to extend or delay Stage 2 comes some potential good news about the scheduling of Stage 3: It’s becoming clearer and clearer that Stage 3 won’t start for anyone before 2017—at the earliest.

Although I have not seen any formal announcements by CMS or ONC confirming this, a recent legislative update from the EHRA (the HIMSS EHR vendor association) reported that the proposed rule on Stage 3 is not expected until late 2014. There are many steps and a defined timeline that transpire between the release of a proposed rule and implementation of the final regulations in the field. First, there is a 90-day comment period, during which all stakeholders have the opportunity to express their support and/or concerns about every aspect of the proposed rule. Then, the government needs another 90 days or so to consider each comment and create the final rule, in which it responds to these comments. That takes us to mid-2015. To give the EHR vendors anything short of 18 months to complete product development, test usability, deploy their upgraded software, and train their clients would meet with overwhelming resistance. Implementation of Stage 3 before 2017 would be highly unlikely.

This breathing room is a good thing for physicians. As I have discussed in prior EMR Straight Talk blogs, meaningful use has essentially stifled innovation by driving EHR vendors to focus the lion’s share of their development efforts on government requirements. Now physicians will benefit from the vendors’ ability to deliver the innovative workflow enhancements that providers need, and they will have time to hone their workflows to more efficiently meet the government’s requirements.

The Metastasizing Complexity of Templated Exam Notes

The Metastasizing ComplexityThe problems associated with templated exam notes have been well documented. From the amount of time it takes to build the notes by entering every piece of data via pointing and clicking, to the sheer length of the output that makes it hard for physicians to find the information they need, to the challenges related to upcoding and cloning (factors that the government is actively investigating), templated notes have been tolerated as a necessary evil associated with EHRs. But there are better ways to capture, exchange, and analyze discrete clinical data with precision, and without adversely affecting physician productivity.

As government programs rapidly evolve, and the number of such programs increases, the need to capture and analyze data will change and grow—think: new stages of meaningful use, PQRS, and the impending switch to ICD-10. An interview with orthopaedic surgeon Scott W. Trenhaile, M.D. in AAOS Now illustrates the increasing template-related burdens associated with ICD-10, just as an example. “We’ve spent a considerable amount of time on templating and are adjusting our templates to address those issues. . . . We’re changing the EMR templates to ensure that ICD-10 issues are covered. Answering certain questions in certain ways opens other templates so we have the information needed for ICD-10 coding.”

Just this past week, the number of anti-template commentaries published in the media has exploded.

  • The problem was aptly described as “note bloat” in a recent presentation to attendees of CHIME’s CIO forum, where the problems associated with typical EHR documentation of a patient exam were lamented.
  • A recent survey conducted by the American Medical Association and reported by the RAND Corporation cited the prominent concern among physicians that EHR technology “requires physicians to spend too much time performing clerical work and degrades the accuracy of medical records by encouraging template-generated notes.”
  • Bill Cayley, Jr., M.D., a family-medicine physician, blogged, “With the increasing use of electronic medical records (EMRs) and their ever-so-helpful templates, smart sets, and forms for capturing information needed to support billing and guide protocols, I fear we are losing the narrative forest for the well-documented trees.” He goes on to say, “Far too often, doctors are being forced to re-gather the entire history with the patient themselves, because prior documentation fails to provide the nuance needed to understand what happened during the last visit.”

If physicians are struggling with templated notes now, their problems are bound to be exacerbated as EHRs layer more and more levels of complexity onto already bloated platforms to try to keep up with the government’s voracious appetite for data.

Physicians need nimble and flexible data platforms to support the data-capture needed to identify and reward quality of care while maintaining physician productivity. The metastasizing complexity of the templated exam note can only lead to its demise.

How Much More Evidence Does CMS Need?

I was glad to see that CMS was concerned enough about the 17% meaningful use dropout rate to do some research into this rather alarming statistic. Some of what they discovered lends credence to the arguments put forth in the large—and growing—number of recent letters from stakeholder organizations suggesting that the meaningful use train is simply moving too fast.

In a recent presentation, CMS accounted for half of the non-returning providers as follows: 5% retired, 17% switched to a practice without an EHR, and 28% claimed to have simply forgotten or missed the deadline to attest.

The remaining 50% of the non-returners cited a number of reasons—some identifying more than one—that are quite revealing and can only lead to future falloffs in participation. The reasons given are presented in the CMS chart below:

How Much More Evidence Does CMS Need?

What more evidence do we need that physicians simply find meaningful use too complex, too time-consuming, and too costly? And that is only their assessment of Stage 1. Many of the non-returners were unable to meet one or more Stage 1 objectives, yet many Stage 2 measures will be considerably more challenging—for reasons other than increased thresholds. The Stage 1 menu measures that had the highest exclusion or deferral rates—i.e., the measures that most physicians did not select because they considered them to be most difficult—become required core measures in Stage 2. Compounding that challenge is the addition of totally new measures related to interoperability and patient engagement, all of which will require completely new workflows, staff training, and massive patient-education efforts.

Given the experience to date, the associated explanations provided by physicians, and the volume and passion of the requests pleading for some relief—from the burden of the requirements and from the impending penalties—some flexibility is clearly called for. How about at least backing off from the all-or-nothing requirement? Doesn’t it make sense for the long-term success of the EHR Incentive Program to offer physicians some flexibility at this critical juncture?

The Meaningful Use Train is Simply Moving Too Fast

The Meaningful Use Train is Simply Moving Too FastAs 2014 draws closer and the realities of meaningful use Stage 2 set in, many stakeholders are experiencing an increasing and justifiable level of anxiety about the consequences of a program that is advancing too rapidly. Following on the heels of the letter from a group of senators to the secretary of HHS that suggested a “pause” in the meaningful use program, there has been a recent avalanche of pleadings for a delay of Stage 2. These have come from such venerable groups as the AMA and AHA, MGMA, AAFP, HIMSS (the Healthcare IT industry organization), and CHIME (College of Healthcare Information Management Executives), all of which represent sizeable and varied constituencies.

The proposals offer a range of suggestions, and their solutions vary in scope and complexity, but the message is clear, consistent, and undeniable: the meaningful use train is simply moving too fast, and the future success of the program depends on an application of the brakes.

Recommendations include variations on the following:

  • Delay the start of Stage 2.
  • Expand the period for Stage 2 compliance (attestation) by up to a year.
  • Suspend the penalties, at least for those physicians who have successfully attested to Stage 1.
  • Add some needed flexibility by relaxing the “all or nothing” requirements for demonstrating meaningful use.
  • Extend the schedule so that physicians have 3 years at each stage before moving to the next.

Some lay the blame on the EHR vendors, citing lack of preparedness. To some extent they are correct—the certification website reveals that only 15 complete ambulatory EHRs from 12 different vendors have been certified for 2014 and Stage 2 so far—that’s just 3% of the 472 EHRs that were available to physicians in Stage 1. While some physicians will be left without a certified EHR in 2014, it is likely that the remaining major vendors will manage to get their EHRs certified by the end of the year. The fact remains, however, that more time before deployment can only improve the (sorely lacking) usability of the final products. One only has to look at the low average KLAS scores—now in the mid-70s—to appreciate the effects of rushed software development and implementation. Without a relaxing of the timeline, many physicians will be left with EHRs that are certified, but unusable.

The EHR Incentive Program is suffering, and its long-term success is at stake. A full 17% of the physicians who attested for the first year of Stage 1 failed to attest for the second incentive payment. (See “Alarming Fact” EMR Straight Talk post.) They simply could not sustain the use of their certified EHR—with which they were already familiar—for a full year of compliance with the complex rules of meaningful use—with which they were also already familiar. Unless we stop and evaluate why this is happening and make the necessary adjustments, the dropout rate is guaranteed to rise with Stage 2.

We have to stop and assess where we are trying to go in light of where we are now. Stage 3 is hurtling toward the final proposal without the benefit of any experience in Stage 2. The measure of the program’s success cannot continue to be the number of dollars paid in incentives, but should rather be providers’ satisfaction with the EHRs that they have been encouraged to adopt.

 

17% Meaningful Use Dropout Rate—Just the Tip of the Iceberg

17% Meaningful Use Dropout Rate—Just the Tip of the Iceberg

My last EMR Straight Talk post, which addressed the alarming 17% meaningful use dropout rate, generated many comments and resulted in several subsequent media interviews. While CMS has acknowledged the facts regarding this program failure, it does not acknowledge the gravity of the implications for the future of the program. According to a Bloomberg News article, CMS attributes the fallout to many of the same reasons that I have identified from the outset—program complexity, lack of fit with specialty practices, cost, dissatisfaction with EHRs, and inability to meet the meaningful use requirements.

To evaluate the program’s future, it is necessary to understand why physicians participate in meaningful use to begin with, and what their motivation would be to continue to participate once they have purchased a certified EHR and recouped $18,000 of its cost. A simple financial analysis begs the question: Why would physicians do dramatically more work for significantly less money?

One only has to look at the math to predict the future. As the table below illustrates, the financial value of the incentives drops by a factor of 10 at the same time that the program requirements increase precipitously. If 17% of physicians abandoned the program when the incentives fell from $6,000 to $1,000 per month of meaningful use effort, what should we realistically expect to happen when the incentives drop even further and the complexity increases?

Total $ Value of Participating in the EHR Incentive Program


*Estimate based on annual Medicare revenue of $300,000. Penalty = 1% in 2015, 2% in 2016

I am certainly not saying that physicians are only motivated by money—of course they want to do the right thing and provide the best possible care for their patients. And shunning meaningful use does not preclude them from leveraging their certified EHRs to exchange clinical data with other providers. But physicians have been quite outspoken about their concerns from the beginning, expressing their perception of the program as overly burdensome, wasteful, and distracting from their mission to provide that care. Now, the evidence is in—they are not just speaking, but they are walking. Clearly, to ensure the ongoing success of meaningful use, the government must fundamentally reduce the program’s complexity.