After 17 years as the founder and CEO of SRS, I am transitioning to the role of Senior Advisor. I am extremely proud of the position that SRS has come to occupy in the healthcare technology industry, and as I hand the company reins over to Scott Ciccarelli, a seasoned executive with extensive healthcare experience, I am confident that SRS will continue to make its mark.
Writing the EMR Straight Talk blog has been one of my passions since its launch on February 17, 2009, as President Obama signed the Economic Stimulus Package making “meaningful use” a household term. The purpose of the blog has always been to educate readers and to stimulate critical thinking about the issues that impact physicians, so the number and intensity of comments from readers has been particularly rewarding.
For more information about the transition at SRS, read today’s press release. I hope you will continue to read EMR Straight Talk as the blog undergoes its own transition.
Thank you for reading.
Best wishes for your continued success,
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 patches that maintain or slightly increase reimbursement rates—these solutions are commonly referred to as the Doc Fix. This year’s fix is set to expire at the end of March, which would leave physicians facing a 23.7% reduction—but on Thursday, a bipartisan piece of legislation proposed a repeal of the SGR and the creation of a new payment model that would reward quality, rather than volume of care provided. All that’s left now is to figure out how to fund the $128 billion price tag over the next 10 years.
Although I haven’t read the 200-page bill, the following is a summary of its major provisions:
- The SGR fix would increase Medicare physician reimbursement rates by 0.5% annually for the next 5 years, i.e., through 2018. This would provide income predictability and stability for providers.
- 2018 rates would be maintained through 2023.
- From 2024 on, physicians who participate in Alternate Payment Models would see a 1% annual increase; non-participants would receive 0.5% increases.
- It would create a new payment system called MIPS (Merit-Based Incentive Payment System) by 2018, which would roll up meaningful use, PQRS, and the Value-Based Payment System into one program that would tie physician reimbursement to quality and cost. Physicians would be assessed in 4 areas:
- Quality: based on current and future quality measures from the PQRS and Meaningful Use programs
- Resource use: assessment of cost structure using a method similar to that currently in use in the Value-Based Payment Program
- Meaningful Use: satisfying current meaningful use requirements demonstrated by use of a certified EHR
- Participation in practice improvement activities: a new area of measurement related to clinical improvement.
- Physicians would receive a composite score on all of the above. Based on total score relative to other physicians, they would receive either:
- A negative adjustment of up to 4% in 2018, 5% in 2019, 7% in 2020, and 9% in 2021
- No adjustment
- A positive adjustment of as much as 3 times the maximum negative adjustment for that year.
- The new payment system would provide additional incentives (5% per year from 2018 to 2023) to providers who derive a substantial part of their income from alternative payment models that base payment on quality assessment and financial risk sharing rather than volume of services provided, (e.g., ACOs, Medical Homes, or other new healthcare delivery models).
- It would encourage cost savings by incentivizing care coordination and adherence to Clinical Decision Support (CDS) mechanisms and Appropriate Use Criteria (AUC) aimed at reducing unnecessary testing—specifically in the area of advanced diagnostic imaging:
- Effective 2017, physicians would be paid for advanced diagnostic imaging only if the claim shows consultation with CDS mechanisms and AUC.
- Effective 2020, the 5% of physicians with the lowest adherence rates would require prior authorization for such tests.
- Beginning in 2015, patients would have access to quality and cost data regarding individual physicians that would be made available on the Physician Compare Site.
MIPS would rely heavily on quality measurement, data sharing, and interoperability, so one thing is abundantly clear: Robust EHRs and extensive data management capabilities will be critical tools for physician success in the future, even more so than they are today.
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.
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, 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.
Amid 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 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.
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:
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?