Proposed SGR Fix – It’s Different This Time

February 8th, 2014

Year after year, physicians live for months with the uncertainty and angst of threatened, often draconian, Medicare reimbursement cuts born out of the Sustainable Growth Rate (SGR) budgeting formula.  And every year, intense lobbying and complex negotiations lead to short-term [...]

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Healthcare costs

Ominous Outlook for Meaningful Use

January 30th, 2014

I believe that 40% of past attesters will give up on meaningful use. To understand the troubling trends that lead to this conclusion, read my Readers Write column on HIStalk [...]

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Test Your Meaningful Use IQ – Stage 2 and 2014

November 11th, 2013

For 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 [...]

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MUS2-IQ

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

July 15th, 2013

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.

Alarming Fact: Meaningful Use Dropout Rate at a Staggering 17%

June 19th, 2013

Alarming Fact: Meaningful Use Dropout Rate at a Staggering 17%Here’s an alarming fact: the meaningful use dropout rate is already 17%.

A recently published assessment of the government’s April EHR attestation data revealed that 17% of the providers who earned an $18,000 EHR incentive in 2011 did not earn the $12,000 second incentive in 2012. Although the analysis was performed by the venerable Wells Fargo, my immediate response was, “That’s impossible! They must have miscalculated the data.”

So I crunched the numbers for myself, and to my astonishment, the conclusion is absolutely correct. A staggering 17% of the providers who succeeded at demonstrating meaningful use for 90 days were unable to sustain that performance for a full year—the second required reporting period—despite the fact that the program’s requirements remained exactly the same and the providers already had the necessary workflows in place to support those requirements. What makes this fact even more troubling is that the 2011 attesters were typically the early EHR adopters and therefore most experienced in the use of the technology.

A 17% loss rate in any business is wholly unacceptable, and this failure does not portend well for the future of the EHR Incentive Program. If $12,000 proved to be insufficient motivation for physicians with meaningful use experience to meet the relatively low requirements of Stage 1 on an ongoing basis, it would be foolish to expect physicians to muster the wherewithal to meet the increasingly demanding requirements of Stage 2. The incentive for a year’s performance at that point will be a mere $4,000.

Compounding this finding is the fact that 14% of physicians who attested to Stage 1 have already stated that they have no intention of attesting to Stage 2, according to another recent survey. And we can be sure that this number will rise as physicians begin to familiarize themselves with the labyrinthine requirements. If physicians are not motivated by the remaining incentives, it’s equally clear that the imposition of penalties for noncompliance will yield no better results. There is already a groundswell of objections to the penalties, including a bill introduced in the House seeking numerous exemptions, letters from AMA and AHA, etc.

So, is this the beginning of the end of meaningful use? What is keeping physicians from continuing to participate in the program? Are they bailing or failing? In either case, it is just too complicated—physicians are demonstrating that they are not willing to divert their attention from treating patients to consistently devoting the time necessary to keep track of the myriad measures on which they must successfully report. Instead of making meaningful use increasingly complex, we need to simplify it—focus on interoperability and leave the physicians and their clinical staffs to practice medicine. If we do not, the entire program will go down the drain. Let’s not throw the baby out with the bathwater!

Physicians Spooked by Failure Stories—EHR Adoption Suffers

May 10th, 2013

Physicians Spooked by Failure StoriesA significant portion of the physician market has still not adopted an EHR, despite the lure of government incentives and the fear of the penalties looming on the horizon. The stock prices of most publicly traded ambulatory EHR companies are down sharply, as sales are lower and earnings projections have not been met throughout the industry. How can this be, when the EHR incentive program has successfully increased EHR adoption and was expected to be such a boon to EHR vendors?

I know why, and it is not—as commonly thought—because the initial EHR-adoption rush fostered by the incentives has ended. Rather, it is because of rampant physician dissatisfaction that has reached a more-than-palpable level. I have noticed a dramatic change in the tenor of conversations with physicians, most recently at professional society conferences, where physicians who have not yet purchased an EHR are frozen in their tracks. They are worried by the horror stories they hear from colleagues—even from those who have succeeded at meaningful use—because many of those physicians continue to experience major workflow disruptions and significant productivity losses from which they see no potential to rebound. Recent surveys point to the number of physicians looking to replace their EHRs, and based on my company’s experience in the replacement market, that number is growing. A recent article summarized the findings of a large study on EHR satisfaction and presented an insightful analysis of the potential reasons for these disappointing results.

This heightened level of frustration has resulted from frantic, insufficiently researched EHR purchase decisions by physicians and rushed, inadequate implementations conducted by resource-strapped vendors. Massive EHR failures are exactly what I predicted in an EMR Straight Talk post on the unintended consequences of the EHR incentive program in February 2010:

After an initial peak in implementations, long-term EHR adoption will slow—particularly among high-performance specialists—and the current failure rate will escalate. Many factors will contribute to this: (1) Some physicians will rush into EHR purchases without conducting proper due diligence. (2) Products that were overly complex and did not work in busy specialists’ practices in the past will surely not succeed now, particularly since these same products must now be used in an even more structured and demanding way. (3) Sorely needed implementation and training will be provided by inexperienced and rushed implementation teams, further reducing the likelihood of success with providers, many of whom are less technologically savvy than the early adopters. (4) Where there was never a convincing economic justification in the past, the addition of data-collection requirements will further lessen the economic feasibility of traditional, point-and-click EHRs. . . . The result? The high failure rate will leave physicians “holding the bag” after investing large sums of money, failing to earn the anticipated incentives, and owning a system that doesn’t meet their needs.

So, what can physicians do to avoid falling victim to EHR failure, and to instead reap the benefits of successful EHR adoption—government incentives and practice productivity? I have written extensively about the importance of physicians doing thorough and objective reference checking—that advice is as valid now as when I first wrote about it, and perhaps is even more critical today. For guidance on how to conduct a thorough and fair evaluation of an EHR, read EMR Selection: How to Uncover the Truth or 100% EHR Success – A Clinical Approach.

Senators Say Meaningful Use Program Needs Rebooting

April 19th, 2013

Senators Say Meaningful Use Program Needs RebootingThis week, six senators released a white paper, Reboot: Re-examining the Strategies Needed to Successfully Adopt Health IT, that argues that there is no evidence that the $32 billion in taxpayers’ money being spent on meaningful use is returning the results it was designed to deliver. Although it would be naïve to discount the political motivation of the authors—all six being Republicans—they raise some of the same criticisms and concerns that I have written about in the past. They also make some claims that I feel compelled to dispute.

The senators have it right on these issues:

  • The success of the EHR incentives program should not be measured by the amount of money spent, yet every month CMS issues a report boasting how many billions of dollars have been paid in incentives. This is, of course, a proxy for EHR adoption and meaningful use attestations, but it says nothing about the impact on quality or cost of care—the motivation behind supporting EHR adoption.
  • The program is being propelled forward too quickly. It was the right move to delay Stage 2 for a year, but the requirements were set in stone long before a detailed evaluation could be made of the successes, challenges, and failures of Stage 1.
  • Program sustainability will be a challenge. The costs of participation are increasing for providers, given the added demands of Stage 2; for example, they will have to pay for interfaces to registries and HIEs and they will need to purchase a portal, if one is not provided by their EHR. As out-of-pocket costs rise, incentives decrease. This, combined with the challenges posed by the program moving too fast, will cause many physicians to abandon participation, which will threaten the program’s ability to deliver results.
  • There is no question that the proliferation of government programs with which physicians must contend has made compliance a challenge. The legislation is so complex and the requirements so cumbersome that they are diverting physicians’ attention from patient care.

I vociferously disagree, however, with the senators’ criticism regarding interoperability. Of course, we are not there yet—and clearly they are frustrated by that fact—but progress is underway toward that universally supported goal. Contrary to their claim that there are no meaningful use measures that require interoperability, there are in fact several in Stage 2, including the requirement that physicians electronically send a patient care summary for 10% of patients transitioned to the care of another physician or provider. This exchange is facilitated by the fact that all certified EHRs must communicate using the same formats.

Not only does interoperability relate to provider-to-provider communication, but it also allows for easy integration between products of different vendors, without requiring additional programming. I was recently speaking with another HIT vendor about a potential partnership arrangement, and we both talked the same language—XDR Direct for transport protocol and CCDA or HL7 in terms of content. This conversation would neither have been possible, nor would we be able to create a tight, simple interface between our products, were it not for the standards promulgated by the EHR incentive program. This kind of interoperability will ultimately be better for physicians and for their patients. The EHRA (EHR vendor association of HIMSS) hit the nail on the head: the appropriate role for government is to set the standards, but then the vendors should be free to innovate and let the market take over from there.

Beyond Meaningful Use Lies a Game Changer for Specialists

April 4th, 2013

 Beyond Meaningful Use Lies a Game Changer for SpecialistsI have frequently said that meaningful use is a primary-care program, and I still maintain that it was designed with primary-care physicians and their patients in mind. But I believe that specialists will be the greatest beneficiaries of Stage 2’s shift in focus to interoperability. If EHR vendors expand upon the groundwork laid by meaningful use, they will provide physicians with not only a reliable way to get information about their patients’ clinical history, but also an efficient way to reconcile that information and incorporate it into their charts.

As increasing amounts of discrete clinical data is shared between physicians—Stage 2 adds new elements to the Stage 1 required data set—many physicians will find themselves subject to significant workflow disruptions as they struggle to incorporate all of this data into their patient charts. The workflow impact is clearly greatest when the physician sees a new patient, so specialists—for whom new patients typically constitute 25–35% of their office visits—will feel the impact more intensely than primary-care physicians, who may see only a few new patients a week.

How does the physician get this data into the patients’ chart, and where should the data come from? While patients are a good source of demographic data, the primary-care physician is the best source of an authoritative and vetted record of the patient’s health history. Stage 2 of meaningful use creates standards that facilitate the transport of this clinical data from the primary-care physician to the specialist via the “Direct” messaging protocol—a secure e-mail-like exchange process. The data is sent in a standard format called the CCDA (Consolidated Clinical Document Architecture). But this is where meaningful use ends, leaving it up to the recipient of the data to incorporate it into the patient’s digital chart, and this can be time-consuming and disruptive to workflow if the process is not automated.

For physicians, having the tools to accomplish these tasks in an efficient, productivity-focused manner will be a veritable game changer. It will not be sufficient for an EHR to merely display the data from the primary-care physician. Rather, it will be critical for vendors to provide physicians with an efficient means of reconciling this data and automating the process of entering the approved discrete clinical data elements into the patients’ charts. The key for EHR vendors will be to go above and beyond the requirements specified by meaningful use.

Meaningful Use Attestation Data Points to Future Vendor Success/Failure

March 18th, 2013

CMS just released the December 2012 attestation data, and one thing is abundantly clear—many EHR vendors will not be around to see Stage 2.

Of the 472 EHR vendors offering certified “Complete EHRs” in early 2012, many lacked even a single physician who had attested to meaningful use by the end of the year. And while it is not surprising that large vendors dominate the EHR market, they do so to a far greater extent than the 80/20 rule would predict. The top 24 EHR companies (just 6% of the 392 ambulatory EHRs with attestations) account for 80% of the total attestations to date—only 19 companies have delivered over 1,000 attestations and only 32 have exceeded 500. At the other end of the spectrum, 112 of the vendors produced only 1 to 5 attestations and a full 252 report 50 or fewer.

Meaningful Use Attestation Data Points to Future Vendor Success/Failure

So what does this mean for the future? Consider why so many vendors have so few attestations. It could be that they are small companies, new to the market, with limited revenue, resources, and staffing—which suggests they likely lack the significant development resources required to meet the increasingly complex certification requirements of Stages 2 and/or 3. Or it could be that their software is challenging to use and their physicians were unsuccessful at demonstrating meaningful use. In either case, these vendors will not survive in the long run—if lucky, they will be acquired by one of the large vendors. The survivors will most likely be those who have already established themselves in the top tier, and whose physicians experience only minimal disruption in the process of satisfying the government’s requirements. Was it the intention of CMS and ONC to force market consolidation? Or is the demise of small, innovative EHR companies an unintended consequence of the complexity of the EHR incentive program?

My Thoughts on the New York Times Article

February 22nd, 2013

My Thoughts on the New York Times ArticleI woke up Tuesday morning excited to see a lead story about EHRs in the New York Times. I had expected to read about the impact that meaningful use is having on the EHR industry and the practice of medicine, because that was the subject of the 45-minute interview I had with the author 3 weeks ago. Instead, I was rather surprised to see the article’s title: “A Digital Shift on Health Data Swells Profits in an Industry.

The article focused on the politics behind the funding of the EHR Incentives Program— aka “meaningful use”—which is a very important story but one that was already covered in 2009 in a Washington Post expose titled “The Machinery Behind Health-Care Reform: How an Industry Lobby Scored a Swift, Unexpected Victory by Channeling Billions to Electronic Records.” (For more information, see my EMR Straight Talk post on that article.)

The New York Times article went on to castigate EHRs with the following statement, backed up by a quote from a physician:

. . .these systems also have many critics, who contend that they can be difficult to use, cannot share patient information with other systems and are sometimes adding hours to the time physicians spend documenting patient care.

“On a really good day, you might be able to call the system mediocre, but most of the time, it’s lousy.”

The online version of the article had 495 highly charged negative comments, which are worth perusing to understand the current sentiment among physicians.

I have not been shy about expressing my concerns about the effect of the typical point-and-click EHR on physician productivity, and about the sapping of innovation brought about by the complexities of the meaningful use regulations. However, I do see a silver lining in the meaningful use cloud, and that is the establishment of standards that are already having profound and positive effects on interoperability. In my interview with the author, we talked at length about the problems of EHR-siloed information and the benefits that certification will bring to the sharing of clinical data among providers, HIEs, and patients. Painful and costly as the certification process has been for EHR vendors, this standardization is advancing the industry and addressing many of the concerns expressed in the comments.

I hope that the New York Times will consider future stories about the progress being made towards EHR interoperability and about the differences among EHRs that distinguish the physicians who are reaping the benefits of their EHRs from those who are suffering from the negative impact of theirs.

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