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

June 19th, 2013

A recently published assessment of the government’s April EHR attestation data revealed that 17% of the providers [...]

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MU-dropouts

Physicians Spooked by Failure Stories—EHR Adoption Suffers

May 10th, 2013

A 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 [...]

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spooked-blog

Senators Say Meaningful Use Program Needs Rebooting

April 19th, 2013

Yesterday, six senators released a white paper, Reboot: Re-examining the Strategies Needed to Successfully Adopt Health IT, that argues that there is no evidence [...]

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reboot-blog

“Dear President Obama”

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April 1st, 2009

Last week, I talked about one of the defining characteristics of hybrid EMRs—that they are designed for high-performance, high-volume, and high-revenue practices. They are successful in these practices because physicians find them highly “usable.” I am sending the following letter to President Obama because this critical attribute, usability, has been overlooked in the design of the government’s plan to encourage EMR adoption.

Dear President Obama:

Like you, I place a high value on improving the quality and reducing the cost of health care for all Americans. As the CEO of a successful hybrid EMR company for the past 12 years, I clearly agree that bringing EMR technology to physicians will help accomplish these goals, but it must be the right technology—technology that front-line physicians, who provide the bulk of care to millions of patients each day, will find usable. I and others are deeply concerned that if the failure to align the interests of the government with those of practicing physicians is not addressed, it will prevent the Economic Stimulus Plan’s EHR incentive program from accomplishing its commendable goals.

As the first president to make use of social media to communicate with constituents, you are no doubt aware of the groundswell of concern being expressed by physicians. These front-line physicians are filling the Internet with comments about their failed attempts to implement CCHIT-type, traditional EMRs. They detail the negative impacts these EMRs have had on their productivity and on their ability to preserve the physician-patient relationships that are critical to providing high quality care.

Before spending $19.2 billion to encourage the purchase of failure-prone traditional EMRs, why not first spend a mere $1 million to $2 million of this money to determine which types of EMRs physicians find usable and adoptable? A reading of the CCHIT criteria reveals that “usability” was never a consideration. There are studies that show the positive impact of EMRs on other stakeholders, but numerous landmark studies have documented the negative impact traditional EMRs have on physicians. Even your Budget Director, Peter Orszag, testified before Congress last July that “Office-based physicians in particular may see no benefit if they purchase such a product—and may even suffer financial harm.”

There are EMR models, such as the hybrid EMR, which front-line, high-performance, high-volume physicians have embraced and find highly usable. They deliver the same quality of care benefits and facilitate the reporting of valuable clinical data without burdening physicians with the responsibility of collecting it themselves.

If usability is not one of the fundamental characteristics upon which EHRs are evaluated, the incentive program is doomed to failure. Either physicians will take the bait and buy an EHR, only to find they cannot “meaningfully use” it, or they will ignore the legislation and not implement an EHR. In either case, our goals will not be accomplished.

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Comments

What Is a Hybrid EMR?

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March 25th, 2009

The continued success of hybrid EMR has prompted extensive debate about what actually constitutes one. While the Internet is now filled with discussions about EMRs, the number of conversations regarding hybrid EMRs has exploded. People are always asking me what it is that makes hybrid EMRs work so well and how they are different from traditional (CCHIT-type) EMRs. This is the first in a series of 3 discussions that will address this subject.

A hybrid EMR is a high-performance EMR that is successful in high-performance practices.

In 1997, SRS created the first hybrid EMR, concentrating on performance-driven practices, where high-volume physicians demanded unencumbered productivity. As others have followed our lead, hybrid EMRs continue to be designed with efficiency and speed in mind. This emphasis on performance criteria contrasts sharply with traditional EMRs. As a reading of the CCHIT criteria reveals, traditional EMRs are constructed for lower-volume, primary care practices where speed is not a primary driver.

SRS has built the largest national network of high-performance practices that successfully use an EMR. Our development process is driven by these practices and we work to facilitate the sharing of best practices among them.

In the next segment of the series, I will share my thoughts on a key defining characteristic of high-performance hybrid EMR—high usability.

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ePrescribing—A Great First Step

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March 16th, 2009

In contrast to the concerns I have expressed in prior posts about the government’s EHR incentives plan, the Medicare ePrescribing program is an example of the appropriate way to reconcile the goals of the government with the needs and motivations of practicing physicians, on whose participation the success of the program depends.

The ePrescribing program should serve as a model for other government plans. It aligns the interests of all parties, delivering the healthcare-reform benefits the government has targeted—interoperability, sharing of data, cost savings, and improved quality of care through reduction of errors and adverse drug interactions—while simultaneously offering added value to physicians. The latter is the missing link in the proposed EMR incentives program.

With the right ePrescribing software, physicians improve practice workflow by using office staff more efficiently and by writing prescriptions in less time. At the same time, they make better-informed Rx decisions, reduce their malpractice exposure, and eliminate repeat patient calls that tie up staff unnecessarily—patient satisfaction increases.  All of these factors lead to increased revenue and greater opportunities for practice growth. In addition to the benefits that accrue to physicians, pharmacies receive accurate, legible scripts that eliminate the need for clarification calls, and insurance companies see fewer claims for multiple-sourced prescriptions. ePrescribing is a win-win-win program for all parties.

Clearly, ePrescribing is inherently less complicated than adoption of a complete EHR. Unlike dealing with all the complexities and nuances of the human condition and its maladies, prescribing drugs electronically is easy because it deals with a finite set of data that is perfectly suited for a digital solution.

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A Physician’s Voice

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March 9th, 2009

It is one thing for me to describe the limitations of traditional (CCHIT-type) EMRs. After all, I have a vested interest in a hybrid EMR. I have devoted 12 years of my life to developing a type of EMR that reflects the physician’s voice and that offers benefits for workflow and quality of patient care. I could be accused of being biased. I would therefore like to share with you an opinion piece published last week in the New York Times, “The Computer Will See You Now,” in which Dr. Anne Armstrong-Coben, a clinical professor of pediatrics at Columbia, shares her personal experiences with a traditional EMR. This one user has hit the nail on the head when she concludes that “the computer depersonalizes medicine.” Her comments support the conclusions presented in the New England Journal of Medicine article, “Avoiding the Pitfalls of Going Electronic.”

Dr. Armstrong-Coben struggles to keep the computer from interfering with her ability to connect with her patients. “I find myself apologizing often, as I stare at a series of questions and boxes to be clicked on the screen and try to adapt them to the patient sitting before me.” She describes a chart produced by her traditional EMR as “a generic outline, screens filled with clicked boxes.” She recognizes that these charts are incapable of capturing the nuances that are so important to high-quality diagnosis and treatment. Dr. Armstrong-Coben suggests that alternatives like a hybrid EMR might be a better solution.

I maintain that the computer is a wonderful tool, but for most users it requires a conscious effort. Dictating an exam or writing on a piece of paper is more intuitive and efficient for most doctors. Computers force physicians to tear themselves away from their patients, shift their focus to a computer screen and interface with a keyboard and mouse. Doing so requires deliberate effort to navigate oftentimes-complex screens containing a myriad of dropdowns, check boxes and text boxes. The computer distracts the physician and dilutes the physician-patient encounter—unless the EMR is designed to allow physicians to practice and document exams as they have always done and are comfortable doing. That is what distinguishes the hybrid EMR from traditional EMRs.

With precision, Dr. Armstrong-Coben has identified the crux of the EMR-adoption problem.

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Challenge EMR Vendors to “Put Your Money Where Your Mouth Is”

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March 2nd, 2009

Change has arrived. The government, through the Department of Health and Human Services (HHS), will provide an incentive if you purchase and meaningfully use a “government” EMR. The problem is that the HHS incentive will only pay for the type of systems that have a dismal track record with busy, high-volume physicians.

Landmark studies have demonstrated that government EMRs, (traditional, CCHIT-style EMRs), impose financial hardship on physicians. There does not exist a single landmark study that concludes otherwise. Just ask any government EMR vendor to prove otherwise with any landmark study that meets the “smell test”:

  • The study is either large in scale or by a venerable, nationally recognized institution.
  • The study is not vendor funded.
  • The study must specifically address physician productivity. Studies that claim benefits of EMR accruing to other industry stakeholders are not relevant.

Before embarking on an expensive and risky venture into the world of government EMRs, you owe it to yourself to be 100% sure that the system is usable and adoptable for your unique practice. If you are not able to prove to CMS that you are a “meaningful user” of the EMR technology, the entire cost of an expensive EMR purchase will rest on your shoulders.

How do you make sure that your investment in a government EMR will perform just as the sales rep promises and bring your practice into the digital world, while receiving payments from the government? Easy. Insist that the vendor puts its money where its mouth is.

Before investing heavily in a government EMR, know ahead of time whether or not you will be successful. Have the vendor prove to you that they can get 2 physicians in your practice live on their system. To be fair, no money should exchange hands—only time. The two physicians and their staff will invest their valuable time learning the system and the vendor will invest its valuable time implementing and training. If, after a 30-day trial period, you are happy and can see that practice-wide implementation of the government EMR is feasible, then you sign a contract with the confidence that the investment is worthwhile. If you feel that the government EMR is not right for you, then the government EMR vendor removes the system from your office and a financial disaster is averted.

The power of this arrangement is that the government EMR vendor, whose sales rep promises the world, actually has to back up its claims with a fair trial by you, the “real-world user.” If the product does not perform as you expect, then you will not suffer the loss of a substantial investment. Go ahead and make the government EMR vendor “put its money where its mouth is.”

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The Voice of the Physician

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February 24th, 2009

I’ve gone through the $19 billion healthcare IT Stimulus Plan with a fine-toothed comb. Incentives will be paid to physicians who meet “meaningful use” requirements set by the government. To show “meaningful use,” physicians must purchase a “government EMR” which means that the government dictates the features and functions that the software package must have.

Unfortunately, the government does not have the wherewithal to create standards that will allow EMRs to be usable, effective, and fast.

The starting point for government EMR standards under the Stimulus Plan will likely be the Commissioners on the Certification Commission for Healthcare Information (CCHIT). It is a travesty that the 21 member CCHIT commission is devoid of busy, high-volume, front-line, private-practice physicians. (For a list of the 21 commissioners, see: http://cchit.org/about/commission).

Moving past CCHIT, the Stimulus Plan creates a newly formed HIT Policy Committee that is charged with setting overall policy and overseeing the distribution of the Stimulus Plan funds. The committee will consist of a partisan group of 20 politically charged individuals with only one physician representative. The probability that the one physician will be a busy, high-volume physician in private practice is near zero. The “cast of characters” comprising the committee is worth noting:

  • 3 members appointed by the Secretary of the Department of Health & Human Services (at least one from HHS and at least one public health official)
  • 1 appointed by the majority leader of the Senate
  • 1 appointed by the minority leader of the Senate
  • 1 appointed by the Speaker of the House
  • 1 appointed by the minority leader of the House
  • 13 appointed by the Comptroller General which shall include:
    • 3 advocates for patients or consumers
    • 2 members representing health care providers, one of which shall be a physician
    • 1 from a labor organization representing healthcare workers
    • 1 having expertise in health information privacy and security
    • 1 having expertise in improving the health of vulnerable populations
    • 1 from the research community
    • 1 representing health plans or other third-party payers
    • 1 representing purchasers or employers
    • 1 having expertise in health care quality measurement and reporting
  • “Such other members as shall be appointed by the President and representatives of other relevant Federal agencies.”

In addition to the HIT Policy Committee, the government formed the HIT Standards Committee that will set EMR standards. By law, this committee will consist of consumers, ancillary healthcare workers, purchasers, health plan representatives, technology vendors, researchers, members of relevant Federal agencies, providers and individuals with technical expertise on health care quality, privacy, security, and on the electronic exchange and use of health information.

The private-practice physician’s voice will barely be heard and the standards will be set by non-physician bureaucrats. Instead of incorporating the voice of physicians, the new standards will incorporate a cacophony of voices from a variety of industry stakeholders—most of whom have agendas that oppose those of physicians.

EMRs from the makers of Medicare and Medicaid will not succeed. Only hybrid EMR systems that listen to the one, unified voice of physicians would be adopted on a mass scale.

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President Obama signed the American Recovery and Reinvestment Act of 2009 today, which includes funding for Health Information Technology.

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February 17th, 2009

Despite all of the buzz surrounding the creation of this legislation, its impact on medical practices should be minimal. The Economic Stimulus Package offers a limited financial incentive to physicians who purchase a “government EMR.” To qualify for the government’s offer, practices will have to purchase the type of EMR which history has shown to be unusable, costly, and a drain on productivity, and will then have to endure the inevitable protracted implementation process. Then, before receiving each (or any) of the portions of the promised funding, the physician will have to demonstrate to the government that he/she is using the EMR in the way and to the full extent demanded by the Department of Health and Human Services. Physicians stand to gain at most $44,000 by participating in this program, or an average of $8,800 per year, but risk losing considerably more in productivity, efficiency and quality of patient care, as well as capital. There are better opportunities available elsewhere to achieve a much higher financial return as well as other benefits.

The following are a few facts about the legislation for you to consider:

1) There is no government requirement to purchase EMR technology.

This is a voluntary program only. The government is not requiring physicians to purchase an EMR of any type, “certified” or not. The law 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.” [Sec.3006 (a) (1)] The program is purely optional, offering a relatively small incentive payment to those who can comply with the onerous and continually evolving requirements. Therefore, practices should feel free to purchase the product which they feel delivers the greatest workflow benefits to its physicians and improves patient care, rather than letting the government make this important choice for them.

2) $44,000 in “potential” incentive payments pales in comparison to the cost of purchasing an EMR/EHR which is expensive, difficult to implement, and not easily adoptable.

The $44,000 is not awarded at the time of EMR purchase, but rather is paid out over 5 years, (averaging $8,800 per year), beginning in 2011 as follows, contingent upon demonstration of “meaningful use:”

  • Year 1: $15,000 or $18,000
  • Year 2: $12,000
  • Year 3: $ 8,000
  • Year 4: $ 4,000
  • Year 5: $ 2,000

The types of EMRs that are designed the way the government wants, i.e. traditional, point-and-click EMRs, do not have a track record of success. Historically, only 50% of the implementations of traditional EMRs have resulted in successful adoption and the literature and blogs are replete with testimony from disillusioned and frustrated traditional EMR users. The reasons have been repeatedly documented in studies by well-respected institutions:

The government has created this legislation without the benefit of any comparable studies to demonstrate the value and effectiveness of traditional EMRs in accomplishing the lofty goals itemized in the “purpose” section of the Act. When you factor in the physician’s costs related to the purchase, lost productivity, tedious and risky implementation, and effect on patient/physician relationships of this type of EMR, $8,800 per year is trivial. The full burden of risk sits squarely on the shoulders of the physicians. Purchase a “government” EMR and find it unusable, then what?

3) Policy recommendations regarding the implementation of nationwide healthcare IT will be made by a large committee that includes only one practicing physician.

Of significant concern is the issue of who is going to be designing the “government” EMR. The legislation assigns this responsibility to the Health Information Technology (HIT) Standards Committee, a group of varied stakeholders, only a small minority of whom will be “providers.” The Standards Committee is to be established by the HIT Policy Committee, a group with a membership of over 20 mostly political appointees, only one of whom is a physician. Can these committees be relied upon to represent the best interests of practicing physicians?

4) Incentive payments are not guaranteed and the risk is entirely borne by physicians; if you cannot show “meaningful use” the way the government demands, you will not qualify for any incentive payments. The government is trying to encourage the purchase of a “government” EMR through a conditional “IOU.”

If you do purchase a “certified” EMR but find that you are unable to demonstrate “meaningful use” of all of the required functionality to the extent demanded in any of the 5 payment years, you forfeit the incentive for that year. To compound the issue, the Secretary of HHS is charged with revising the standards to become more stringent over time. According to a study published in the New England Journal of Medicine, only 4% of physicians are currently able to make full use of an EMR. Given this track record, the purchase of a certified product by no means guarantees receipt of the incentive.

The hybrid EMR will give you what the Stimulus Plan won’t—easy-to-use software that works! Manage your practice more efficiently, increase physician productivity, enhance revenue in many other ways, and get your money from the government painlessly through ePrescribing. Rewards without risk.

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