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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Risky Business

June 10th, 2009 by EMR Straight Talk

Watching the stock market’s gyrations over the past few months has made me reconsider investment strategies. I thought about the thousands of people who have won the million dollar lottery. These people have made a lot of money and swear by the lottery because it has changed their lives, and they would recommend lottery tickets as a great investment. Yet, I know for myself and for most people, we would not spend a significant portion of our assets on lottery tickets because we assess the risk and conclude that the likelihood of success makes betting the nest egg on the lottery an unsound investment.

So, little surprise, my thoughts turned to EMR and, specifically, the realization that in evaluating EMRs, the issue of risk is too often overlooked. EMRs are purchased after speaking to a few of the vendor’s success stories (i.e., lottery winners), which blinds the buyer from assessing the true, underlying risk.

When calculating expected return on any investment, one needs to account for the likelihood of achieving that return. Everyone who purchases an EMR enters into the process with the expectation that they will be successful. Unfortunately, history has shown that this is not the reality; the chances of failure with a traditional, point-and-click EMR are relatively high. Depending on the physician’s specialty, traditional EMRs carry a 50%-90% failure rate which explains why, according to a New England Journal of Medicine study, only 4% of physicians are using a fully functional EMR.

My business school Finance professor would insist that the expected financial returns resulting from any investment must be decreased by the chance of failure. So, for example, if you are a physician who expects $44,000 in EMR incentives from the government, you must decrease that expected windfall by at least 50%, to $22,000. Furthermore, you may be successful in implementing an EMR, but not in convincing CMS that you are using the EMR in a meaningful way, so you must adjust the $22,000 further downward to reflect this additional reality.

Unfortunately, when purchasing an EMR, payments to the vendor are not tied to the success of the product, so physicians must pay full freight and then hope that the ROI materializes—a lot like buying a lottery ticket. Don’t buy a dream! Consider all of the potential returns, realistically assess the likelihood that your physicians will actually use the EMR successfully, and adjust your expected ROI accordingly. You can make a sound business decision only by including “risk” in your analysis.

From EMR Vendors: Fact or Fiction?

June 3rd, 2009 by EMR Straight Talk

The Economic Stimulus legislation has presented an incredible opportunity for EMR vendors. Unfortunately, it seems that some of them are taking advantage of it by giving out misleading information and applying scare tactics so that practices will purchase their EMRs. Below is a sampling of such statements, which have been forwarded to me by physicians asking whether they are “fact or fiction.”

Have you had similar experiences? Please share them by submitting a comment at the bottom of this post.

What some EMR reps are saying:

  • “The government is requiring you to buy an EMR.” This one is a scare tactic since participation is voluntary.Section 3006 of the American Recovery and Reinvestment Act specifically states “…nothing in such Act or in the amendments made by such Act shall be construed to require a private entity to adopt or comply with a standard or implementation specification adopted under section 3004.”
  • “Your EMR must be CCHIT-certified to qualify for the incentive payments.” I hate to use the word “lying” but this statement comes close since the legislation neither identifies standards nor mentions any particular credentialing body, including CCHIT. The HIT Standards Committees, which just had its first meeting on May 15, is charged with recommending an initial set of certification standards by December 31, 2009. Recently, there has been a surge of rhetoric in the media expressing dissatisfaction with CCHIT, so it is by no means a foregone conclusion that CCHIT certification will be required.
  • “Simply buy a CCHIT-certified product, and you will qualify for the Stimulus money.” This remark is similar to “I have a great stock to sell you”—because EHR incentive payments are not guaranteed. Simply purchasing a “certified” EHR is not sufficient; the incentives require you to demonstrate “meaningful use” of the EHR every year, and to do so in the manner specified by and to the satisfaction of the government. “Meaningful use” has not yet been fully defined, and the legislation states that the requirements are to become more stringent over the period covered by the law.
  • “You must act now—buy an EHR now because in order to get the money from the government, you must be using the EMR by 2011.” As with used-car salesmen, “buy now” is always popular, but you actually have until 2013 to implement and potentially qualify for the lion’s share of the incentives. Even if you do not implement until 2014 (5 years from now), you would still be eligible for almost 80% of the money.

Have you heard any of these statements of “fact”? My advice: Do your due-diligence. Make sure you understand the real facts about the legislation and find an EMR that meets the needs of your practice. Have you heard other statements of “fiction?”—Please share them by submitting a comment at the bottom of this post.

Putting the Cart before the Horse

May 27th, 2009 by EMR Straight Talk

The vice-chair of the HIT Standards Committee, John Halamka, MD, opened the first Standards Committee meeting by charging the committee with “recommending standards, implementation specifications, and certification…in support of meaningful use.” But “meaningful use” has not yet been defined, which begs the question—Are we putting the cart before the horse?

In fairness, the Standards Committee, as well as the other planners and implementers of the EHR provisions, are under significant time pressure to meet the ambitious deadlines contained in the Economic Stimulus legislation. The initial set of standards for EHR certification is due by December 31, yet “meaningful use” has yet to be clarified—David Blumenthal “hopes to provide a direction and some specifications in the late spring, early summer.” Therefore, in the interest of time, all parties are discussing “meaningful use” and standards concurrently.

To compound matters, it appears that the certification/standards decision has essentially been made already—underlying the conversations is the ubiquitous assumption that CCHIT will be the government’s standards for EMR qualification. Perhaps this is driven by the need for expediency in the face of the looming deadlines, or perhaps it stems from the recommendation made by HIMSS. (See last week’s blog below.) In either case, how can we already know what standards are necessary to ensure meaningful use before we have a clear and complete definition of “meaningful use”? How do we make certain that the standards are applicable to all physicians, including high-performance, private-practice specialists, when CCHIT standards are primary-care focused? Do we need another set of standards for specialty practices? In any case, isn’t this a classic example of putting the cart before the horse?

The Machinery Behind Health-Care Reform

May 19th, 2009 by EMR Straight Talk

This weekend, The Washington Post published an investigative report entitled “The Machinery Behind Health-Care Reform: How an Industry Lobby Scored a Swift, Unexpected Victory by Channeling Billions to Electronic Records.” The reporter, Robert O’Harrow Jr., clearly hit a nerve when he exposed the origins of the EHR funding portion of the Economic Stimulus Bill—The Washington Post received so many comments that it had to stop accepting responses! I am sharing my comments here, along with the original article.

Dear Mr. O’Harrow:

Thank you for exposing the behind-the-scenes efforts that led to the creation and funding of the Economic Stimulus Plan’s EHR incentives program. Industry insiders have long-recognized these inherent conflicts of interest, but have been reluctant to make them public.

It is important to understand that the situation is being perpetuated—the people now charged with developing the specific regulations regarding how the money is to be dispersed and the standards which will determine to whom it will be given are the very same stakeholders who were behind the legislation. One has only to listen to the recent “meaningful use” hearing in Washington and look at the appointments to the HIT Policy and Standards Committees for evidence.

First, to clarify your premise—it is not the entire industry that lobbied. It is the traditional EMR vendors who are positioning themselves to receive the benefits. Only the big, CCHIT companies have been invited to the table to be part of the conversation in any significant way other than through very limited opportunities for public comment. No vendors of alternative technologies, i.e., non-CCHIT-certified products, have been given any formal role, regardless of their successful adoption rates and greater physician satisfaction.

It is no wonder that CCHIT is the presumed set of standards which will be used to qualify EMR software for Stimulus Plan payments. The legislation was rushed through with such a short timetable for implementation that it is hard to dispute the conclusion that there is no time to develop new standards. The HIT Policy and Standards Committees are predisposed to CCHIT—the vendor community representatives on each committee are from large, CCHIT companies, and at least one committee member is a CCHIT commissioner. It does not seem to be of concern that these EMRs are the very ones that have experienced miserable adoption track records, (see Landmark EMR Studies), particularly among specialists, nor that evidence does not exist to show that CCHIT certification has improved this adoption record.

In an effort to push the implementation along, the interests of high-performance, private-practice physicians are not represented in the process. There are no full-time, private-practicing physicians on the Standards Committee, who can appreciate first-hand the impact the wrong EMR can have on a provider. The seven physician members spend most, if not all, of their time in informatics-focused positions at their respective institutions. Furthermore, the needs of non-primary care physicians are being ignored. By virtue of its composition, the Committee will focus on primary care—of the physicians on the Committee, five are internal medicine-certified, one is a pathologist, and the vendor representative trained as a neurologist. For primary care physicians, CCHIT-type software may be more usable than it is for specialists.

In the era of transparency, it is important that all of these issues be understood and then addressed before the enormous sums of money are dispersed with limited potential to achieve the desired outcomes.

Legislation without Representation

May 12th, 2009 by EMR Straight Talk

The 21 members of the HIT Standards Committee have been appointed, and unfortunately I was not among those selected. However, HHS Secretary Kathleen Sebelius and National Coordinator for Health Information Technology David Blumenthal did assemble a highly credentialed, very impressive group of health IT experts who will contribute much time and extensive experience toward the recommendation of the qualification criteria for EHRs under the Economic Stimulus Plan.

My concerns remain as anticipated—that the Committee, as impressive as it is, will not represent the interests of high-volume private practitioners, particularly the specialists, who are on the front lines of delivering patient care on a daily basis to the majority of Americans.

  • There are no full-time, private-practicing physicians on the Committee. The seven physician members spend most, if not all, of their time in informatics-focused positions at their respective institutions.
  • By virtue of its composition, the Committee will continue the focus on primary care—of the physicians on the Committee, five are internal medicine–certified, one is a pathologist, and the vendor representative trained as a neurologist. There is no one with first-hand experience regarding the vastly different issues facing specialists. Who will make sure that EHR use will be defined “meaningfully” for them?
  • Committee members are associated with large, closed-loop medical institutions, (albeit venerable ones, such as the Mayo Clinic and Kaiser Permanente.) Their environments facilitate utilization of EMRs in ways that are typically beyond the reach of independent, community practices.
  • The Committee appears predisposed toward CCHIT—one member is a CCHIT Commissioner and the vendor community representative is from a CCHIT EMR company (as is the vendor on the HIT Policy Committee). No alternative EMR technologies are represented—i.e., there are no alternative voices to broaden the Committee’s perspective regarding other EMR solutions with successful adoption track records.

Rest assured that, although I am not a Committee member, I will participate as a member of the public via Web access to the meetings. SRS Government Affairs will monitor both the HIT Standards and the HIT Policy Committees’ meetings, and I will keep you informed in future blogs. Stay tuned.

No Use = No “Meaningful Use”

May 6th, 2009 by EMR Straight Talk

On Day 2 of the Government’s Hearing on Meaningful Use, there was finally some recognition of the need for physicians to be able and actually willing to use their EMRs. Three speakers from the audience, including SRS, presented testimony reminding Committee members of the dismal track record of traditional EMRs to date, and warning that different results should not be realistically expected simply because financial incentives are offered. It was clear from the concerned looks and head-shaking by the Committee members that they were starting to acknowledge that CCHIT was not the easy answer they had expected to the complex issues surrounding adoption and meaningful use of an EMR.

Dr. David Classen, from the University of Utah and Computer Sciences Corporation gave very interesting testimony in which he suggested that the focus must be on finding EMRs that anticipate the needs of users and are easy to use. While some standard criteria should be established, he maintained that the issue is implementation and use, not criteria alone. In fact, he shared results from a study in which a number of major CCHIT-certified products did not fare very well in meeting several test measures of improvement in quality of care. When asked about the correlation between performance on these measures and specific product criteria, he responded that he did not find any.

While no specific alternatives were put forth, “usability” was identified as an important criteria. This means more than simply adding a usability measure to existing CCHIT criteria. It means ensuring that the EMRs included in the legislation add value to physicians’ practices, and maintain or enhance, rather than decrease, their productivity. It also means “usable” by all physicians, not just primary-care physicians—the providers around whom the “meaningful use” discussion continues to be based. Our testimony, which was echoed by the other speakers, emphasized that the only way enduring adoption and true meaningful use will occur is if physicians themselves deem their EMR usable. There can be no “meaningful use” without actual use, and we will not see any of the anticipated quality-of-care and cost benefits if physicians are not using the EMRs we incent them to buy.

Is Obama Listening to Physicians? Report from Day 1 of Government Hearing on “Meaningful Use”

April 29th, 2009 by EMR Straight Talk

Two SRS representatives are currently in Washington, D.C., attending the Hearing on “Meaningful Use” of Health Information Technology. They are listening to (and will provide) testimony to the government on what should constitute “meaningful use” of an EHR that would qualify physicians to receive the potential EHR incentive payments.

Noticeably absent from the testimony and discussion at the Hearing, so far, is any consideration of the impact that “meaningful EHR use” requirements would have on physicians. The proposed definitions all supported admirable goals of improved quality of care and better outcomes, interoperability, and reduced costs—all of which well represent the interests of varied healthcare system stakeholders. But the physicians are the ones who will be asked to take on the incremental burden of collecting the data in the required formats at the point of care. The result will be a decrease in productivity that will have financial implications for physicians, but will also impact their ability to take care of the increasing number of patients entering the healthcare system. As the population ages, and if President Obama is successful in his plan to extend healthcare coverage to the uninsured, the already existing physician shortage will be exacerbated. (Read “Shortage of Doctors Proves Obstacle to Obama Goals” in this past Monday’s New York Times).

Another concern is that medical specialists were not mentioned even once during the course of the day’s testimony—all of the discussion centered on primary care. The focus should be on primary care, since they are responsible for the management of most chronic illness; however, high-performance specialists have different workflows and EMR requirements. There must be a separate set of criteria and requirements for their demonstration of “meaningful use.”

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