The Metastasizing Complexity of Templated Exam Notes

The Metastasizing ComplexityThe 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.

How Much More Evidence Does CMS Need?

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:

How Much More Evidence Does CMS Need?

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?

The Meaningful Use Train is Simply Moving Too Fast

The Meaningful Use Train is Simply Moving Too FastAs 2014 draws closer and the realities of meaningful use Stage 2 set in, many stakeholders are experiencing an increasing and justifiable level of anxiety about the consequences of a program that is advancing too rapidly. Following on the heels of the letter from a group of senators to the secretary of HHS that suggested a “pause” in the meaningful use program, there has been a recent avalanche of pleadings for a delay of Stage 2. These have come from such venerable groups as the AMA and AHA, MGMA, AAFP, HIMSS (the Healthcare IT industry organization), and CHIME (College of Healthcare Information Management Executives), all of which represent sizeable and varied constituencies.

The proposals offer a range of suggestions, and their solutions vary in scope and complexity, but the message is clear, consistent, and undeniable: the meaningful use train is simply moving too fast, and the future success of the program depends on an application of the brakes.

Recommendations include variations on the following:

  • Delay the start of Stage 2.
  • Expand the period for Stage 2 compliance (attestation) by up to a year.
  • Suspend the penalties, at least for those physicians who have successfully attested to Stage 1.
  • Add some needed flexibility by relaxing the “all or nothing” requirements for demonstrating meaningful use.
  • Extend the schedule so that physicians have 3 years at each stage before moving to the next.

Some lay the blame on the EHR vendors, citing lack of preparedness. To some extent they are correct—the certification website reveals that only 15 complete ambulatory EHRs from 12 different vendors have been certified for 2014 and Stage 2 so far—that’s just 3% of the 472 EHRs that were available to physicians in Stage 1. While some physicians will be left without a certified EHR in 2014, it is likely that the remaining major vendors will manage to get their EHRs certified by the end of the year. The fact remains, however, that more time before deployment can only improve the (sorely lacking) usability of the final products. One only has to look at the low average KLAS scores—now in the mid-70s—to appreciate the effects of rushed software development and implementation. Without a relaxing of the timeline, many physicians will be left with EHRs that are certified, but unusable.

The EHR Incentive Program is suffering, and its long-term success is at stake. A full 17% of the physicians who attested for the first year of Stage 1 failed to attest for the second incentive payment. (See “Alarming Fact” EMR Straight Talk post.) They simply could not sustain the use of their certified EHR—with which they were already familiar—for a full year of compliance with the complex rules of meaningful use—with which they were also already familiar. Unless we stop and evaluate why this is happening and make the necessary adjustments, the dropout rate is guaranteed to rise with Stage 2.

We have to stop and assess where we are trying to go in light of where we are now. Stage 3 is hurtling toward the final proposal without the benefit of any experience in Stage 2. The measure of the program’s success cannot continue to be the number of dollars paid in incentives, but should rather be providers’ satisfaction with the EHRs that they have been encouraged to adopt.

 

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

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%

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

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

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.