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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Putting the Cart before the Horse

May 27th, 2009

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

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

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

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

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.”

The Risk of Automated EMR Coding

April 22nd, 2009

A frequent topic of conversation is how to improve the claims-coding process. If you are intrigued by the automated E&M coding offered by an EMR, I suggest caution. This feature has high marketing appeal—promising that office visits will be coded to the highest level of reimbursement possible. Unfortunately, however, EMR coding has led to severe financial and legal repercussions for practices, as reported in a recent study in the venerable Medical Economics journal.

An increase in average coding levels raises a red flag with payers, and EMR documentation does not stand up well in the resulting audits. According to the authors, who assisted several practices during Medicare audits, the danger is that EMRs automatically guide physicians to create records that document high levels of care, and the result can be a statistically significant (and noticeable) increase in the percentage of claims with level-4 and level-5 codes. The templated chart notes created by traditional (CCHIT-type) EMRs all tend to look the same and do not contain the information necessary to justify these higher levels of coding.

In a claims audit, typically between 20 and 100 charts per physician are reviewed, and the results are then extrapolated to the entire set of claims for that payer. For the practices discussed in this article, between 20% and 95% of the EMR-generated claims failed the audit, and the physicians were assessed penalties and subject to repayments to Medicare that ranged from $50,000 to $175,000 each.

Life After De-installing CCHIT

April 15th, 2009

Our recent announcement regarding a practice that has decided to de-install their existing CCHIT-certified EMR and replace it with the SRS hybrid EMR has been referred to as “gutsy” in the HISTalk blog and has generated a tremendous amount of interest. The determination to move away from a CCHIT-certified product may seem surprising in light of the Economic Stimulus Plan, but this is just the most recent in a series of de-installs/conversions that we have successfully completed.

SRS has been approached by an increasing number of practices interested in replacing their traditional EMRs with a hybrid EMR. This trend is dominated by high-performance, high-volume practices, even in the face of the government’s apparent interest in CCHIT-type EMRs.

These practices share a number of common experiences. They selected and purchased their EMR with high expectations and confidence that it would be implemented successfully throughout their practice and deliver a substantial ROI in a reasonable timeframe. Despite their best efforts to make it work, they have been frustrated by the inability to achieve universal adoption and to realize the anticipated benefits.

Although individual physicians within the practice may have been successful in using the CCHIT EMR, the majority have not embraced the technology. In almost all cases, the practice has not eliminated its transcription costs or changed its coding, which had been the driving forces for the purchase of an EMR initially. Physicians are still dictating their notes, refusing to be forced into productivity-sapping templating of patient exams.

In addition, practices are experiencing one of two things. They are either running simultaneous paper and EMR chart systems, experiencing the worst of both worlds, or they are using their EMR as a crude document management system. In many cases, they are still overrun with paper and the accompanying costly filing demands. Anticipated ROI has not materialized.

As our clients who found themselves in this position have testified, transitioning to a hybrid EMR can be accomplished relatively quickly and easily. Our hybrid EMR is built on a non-proprietary, OpenPath™ foundation, which allows for an easy, one-time transfer of data from the CCHIT EMR to the hybrid EMR. The transition to the hybrid EMR can be accomplished without repeating the protracted implementation process experienced by these practices with their first (and sometimes second) CCHIT EMR. Physicians quickly adopt the hybrid EMR and the practices quickly move toward realizing a true ROI.

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