Beyond Meaningful Use Lies a Game Changer for Specialists

 Beyond Meaningful Use Lies a Game Changer for SpecialistsI have frequently said that meaningful use is a primary-care program, and I still maintain that it was designed with primary-care physicians and their patients in mind. But I believe that specialists will be the greatest beneficiaries of Stage 2’s shift in focus to interoperability. If EHR vendors expand upon the groundwork laid by meaningful use, they will provide physicians with not only a reliable way to get information about their patients’ clinical history, but also an efficient way to reconcile that information and incorporate it into their charts.

As increasing amounts of discrete clinical data is shared between physicians—Stage 2 adds new elements to the Stage 1 required data set—many physicians will find themselves subject to significant workflow disruptions as they struggle to incorporate all of this data into their patient charts. The workflow impact is clearly greatest when the physician sees a new patient, so specialists—for whom new patients typically constitute 25–35% of their office visits—will feel the impact more intensely than primary-care physicians, who may see only a few new patients a week.

How does the physician get this data into the patients’ chart, and where should the data come from? While patients are a good source of demographic data, the primary-care physician is the best source of an authoritative and vetted record of the patient’s health history. Stage 2 of meaningful use creates standards that facilitate the transport of this clinical data from the primary-care physician to the specialist via the “Direct” messaging protocol—a secure e-mail-like exchange process. The data is sent in a standard format called the CCDA (Consolidated Clinical Document Architecture). But this is where meaningful use ends, leaving it up to the recipient of the data to incorporate it into the patient’s digital chart, and this can be time-consuming and disruptive to workflow if the process is not automated.

For physicians, having the tools to accomplish these tasks in an efficient, productivity-focused manner will be a veritable game changer. It will not be sufficient for an EHR to merely display the data from the primary-care physician. Rather, it will be critical for vendors to provide physicians with an efficient means of reconciling this data and automating the process of entering the approved discrete clinical data elements into the patients’ charts. The key for EHR vendors will be to go above and beyond the requirements specified by meaningful use.

Meaningful Use Attestation Data Points to Future Vendor Success/Failure

CMS just released the December 2012 attestation data, and one thing is abundantly clear—many EHR vendors will not be around to see Stage 2.

Of the 472 EHR vendors offering certified “Complete EHRs” in early 2012, many lacked even a single physician who had attested to meaningful use by the end of the year. And while it is not surprising that large vendors dominate the EHR market, they do so to a far greater extent than the 80/20 rule would predict. The top 24 EHR companies (just 6% of the 392 ambulatory EHRs with attestations) account for 80% of the total attestations to date—only 19 companies have delivered over 1,000 attestations and only 32 have exceeded 500. At the other end of the spectrum, 112 of the vendors produced only 1 to 5 attestations and a full 252 report 50 or fewer.

Meaningful Use Attestation Data Points to Future Vendor Success/Failure

So what does this mean for the future? Consider why so many vendors have so few attestations. It could be that they are small companies, new to the market, with limited revenue, resources, and staffing—which suggests they likely lack the significant development resources required to meet the increasingly complex certification requirements of Stages 2 and/or 3. Or it could be that their software is challenging to use and their physicians were unsuccessful at demonstrating meaningful use. In either case, these vendors will not survive in the long run—if lucky, they will be acquired by one of the large vendors. The survivors will most likely be those who have already established themselves in the top tier, and whose physicians experience only minimal disruption in the process of satisfying the government’s requirements. Was it the intention of CMS and ONC to force market consolidation? Or is the demise of small, innovative EHR companies an unintended consequence of the complexity of the EHR incentive program?

My Thoughts on the New York Times Article

My Thoughts on the New York Times ArticleI woke up Tuesday morning excited to see a lead story about EHRs in the New York Times. I had expected to read about the impact that meaningful use is having on the EHR industry and the practice of medicine, because that was the subject of the 45-minute interview I had with the author 3 weeks ago. Instead, I was rather surprised to see the article’s title: “A Digital Shift on Health Data Swells Profits in an Industry.

The article focused on the politics behind the funding of the EHR Incentives Program— aka “meaningful use”—which is a very important story but one that was already covered in 2009 in a Washington Post expose titled “The Machinery Behind Health-Care Reform: How an Industry Lobby Scored a Swift, Unexpected Victory by Channeling Billions to Electronic Records.” (For more information, see my EMR Straight Talk post on that article.)

The New York Times article went on to castigate EHRs with the following statement, backed up by a quote from a physician:

. . .these systems also have many critics, who contend that they can be difficult to use, cannot share patient information with other systems and are sometimes adding hours to the time physicians spend documenting patient care.

“On a really good day, you might be able to call the system mediocre, but most of the time, it’s lousy.”

The online version of the article had 495 highly charged negative comments, which are worth perusing to understand the current sentiment among physicians.

I have not been shy about expressing my concerns about the effect of the typical point-and-click EHR on physician productivity, and about the sapping of innovation brought about by the complexities of the meaningful use regulations. However, I do see a silver lining in the meaningful use cloud, and that is the establishment of standards that are already having profound and positive effects on interoperability. In my interview with the author, we talked at length about the problems of EHR-siloed information and the benefits that certification will bring to the sharing of clinical data among providers, HIEs, and patients. Painful and costly as the certification process has been for EHR vendors, this standardization is advancing the industry and addressing many of the concerns expressed in the comments.

I hope that the New York Times will consider future stories about the progress being made towards EHR interoperability and about the differences among EHRs that distinguish the physicians who are reaping the benefits of their EHRs from those who are suffering from the negative impact of theirs.

EHR Vendors on Meaningful Use: Enough is Enough!

EHR Vendors on Meaningful Use: Enough is Enough!Physicians, professional societies, and EHR vendors are now aligned against the complexity and pace of the meaningful use program. In my last two EMR Straight Talk posts, I shared my concerns about the future of the meaningful use program. My letter to Farzad Mostashari relayed the rampant dissatisfaction expressed by physicians about the program’s complexity, the government’s unrealistic expectations, and the impact on physician productivity. In my last post, Physicians Are Crying “Uncle!”, I discussed how physicians and the professional societies that represent them are demanding that the runaway meaningful use train be slowed. Of paramount concern to physicians is the fact that the EHR usability they crave is being sacrificed in the pursuit of certification.

EHR vendors collectively expressed their concerns in a comment letter from the HIMSS EHRA (Electronic Health Record Association) to the HIT Policy Committee about the initial proposal for Stage 3, and their message was in synch with that of the physicians and their societies. The vendors focused on the government’s interference with their ability to innovate, and they expressed their frustration over being unable to creatively address the needs and demands of physicians for new capabilities:

The needs of such experienced and often sophisticated [physician] users will best be met by market innovation, while extensive and detailed standardized requirements dictated by the federal government are not only unnecessary but may actually interfere with the pace and direction of needed innovations.

Vendors advocate, as I do, for the government to limit its focus to overarching issues like ensuring interoperability, and they argue against the government simply piling on more new measures. The opportunity to innovate is being thwarted by government programs that force vendors to devote all available resources to an ongoing chase after continually changing certification requirements.

Rarely do we see such close alignment between physicians and vendors on any matter. If CMS and ONC continue plowing ahead, ignoring the pleas of these major stakeholders, history will deem them to have been woefully negligent stewards of a program that started out with such laudable goals.

Physicians Cry “Uncle” Over Meaningful Use

Physicians Cry 'Uncle' over Meaningful UseThe increasingly unrealistic demands of meaningful use are leading to a groundswell of resistance. While 96,000 physicians have demonstrated meaningful use and earned EHR incentives, the majority did so while complaining about the negative impact that the Stage 1 “minimal” set of requirements had on their practice workflows. (See the results of a physician survey and read physicians’ comments in my last EMR Straight Talk post.) As Stage 2 approaches, those who have previewed the increasingly complex and demanding requirements are consumed by trepidation. Many are already considering abandoning meaningful use after they collect their $30,000 for Stage 1. Despite the fact that no one has yet had experience with the Stage 2 requirements, the Stage 3 proposal from the HIT Policy Committee is already out for public comment. Physicians and the professional organizations that represent them—already close to the breaking point—are crying “Uncle!”

The following is only a partial list of organizations that have commented: the American Medical Association, American Academy of Family Practice, College of Healthcare Information Management Executives, American College of Physicians, and the American Hospital Association. You can read their comments by googling the organization name and “Stage 3 comments” or “Letter to Mostashari.”

Although they phrase it in slightly different ways, all of these organizations are pleading with the powers that be to slow down what is perceived as a runaway train. Their comments center around several problems: lack of EHR usability, unrealistic and excessively complex requirements, the undue speed with which they are being imposed, and a lack of evidence of the program’s success. Physicians see the program as a massive data collection and reporting project with no proven quality improvement outcomes attached to it. Unless the government pays heed to the concerns and recommendations being voiced, the EHR incentive program is doomed to failure. Physicians will simply toss in the towel.

The following is a description of the most common sentiments expressed in the letters and formal comments:

  • Stage 3 should not even be considered until the experience of Stages 1 and 2 can be evaluated to see what was actually accomplished and what the cost is to physicians. Many are calling for an independent assessment of the program. It is not sufficient to merely gloat about how successful the successful meaningful users were—an analysis must be conducted to investigate why other physicians were either not successful or chose not to even attempt to achieve meaningful use.
  • In addition, Stage 3 should not occur until at least 3 years after Stage 2, giving physicians and vendors sufficient time to move forward.
  • EHR usability is identified as a major issue in every set of comments. EHR de-installs are increasing in number as physicians abandon legacy systems. The impact of a lack of usability is compounded when physicians attempt to use an already challenging system to meet an overwhelmingly challenging set of requirements. When workflow is negatively affected, the costs to physicians can quickly exceed the benefits.
  • The AMA suggests that the government conduct user-satisfaction surveys—by practice type, size, and specialty—and incorporate the results into the certification requirements going forward.
  • Meaningful use remains a primary-care program that, despite the addition of a few specialist-focused measures, does not adequately recognize specialists’ unique workflows. They resent being asked to report on measures that have minimal, if any, value to their practices.
  • As the requirements become increasingly complex, it may be time to modify the “all or nothing” approach, and reward physicians for reasonable levels of success. Penalties should be eliminated, or at a minimum, significantly delayed.

Don’t sit back and wait for the Stage 3 rules to be finalized. Express your opinions either by writing to your professional organization or directly to Dr. Farzad Mostashari. It is critical to keep up the pressure on the decision makers.

Dear Farzad Mostashari, M.D.:

I am writing to express my deep concern about the future of the EHR incentive program. I am alarmed to see that the program is plagued by rampant dissatisfaction among physicians. My fear is that at your level of involvement—as the very passionate but national leader at the top of the program—you may be insulated from what physicians in the trenches are saying. As lofty and admirable as the goals identified in the initial legislation are, I worry that the regulations are evolving in a way that will lead to the program’s undoing.

You were recently quoted as wanting physicians to “really embrace meaningful use as not just one more thing that they’re doing. . .now that the financial barriers [to EHR adoption] have largely been removed.” However, for the program to accomplish its long-term goals, it is critical that physicians find it meaningful for reasons beyond the incentives. Financial incentives alone cannot sustain meaningful use—particularly as they diminish sharply over the next few years. One would expect that physicians’ initial objections to the meaningful use requirements would soften a bit as they cash their $18,000 EHR incentive checks. But the results of a recent survey show the opposite. Physicians are angry—and if their anger is tempered at all, it is only by the fact that they are receiving significant reimbursement for their Stage 1 efforts.

The voice of the ambulatory physician is not being heard. To understand what is really on the minds of front-line physicians, I commissioned a reputable, independent survey firm to investigate. 684 physicians responded to an open-ended question regarding their perceptions about meaningful use. The physicians’ comments are disheartening, and must be viewed as a wake-up call to ONC, CMS, and the advisory committees to rethink where the program is heading.

I urge you to read the comments yourself—they are presented uncensored, exactly as submitted. The vehement tone does not bode well for the future of the program. The tables below summarize the prevailing sentiments. First, the comments were categorized according to the messages conveyed. The results speak for themselves.

Dawn of a New and Improved Consult Letter

  • Nearly one third of the physicians cited wasted time and unnecessary work, with an additional 11% mentioning unrealistic expectations and extreme difficulty. This was based on their experience in Stage 1—the increased complexity of Stage 2 will cause these numbers to increase.
  • 12 physicians described the requirements as “hoops” through which they are being required to jump.

To quantify the qualitative data, a relative rating was assigned to each comment using a scale of 1 to 5 (from very negative to very positive).

Dawn of a New and Improved Consult Letter

  • Only 10% offered positive responses, and most of those cited the financial compensation as the reason.
  • 82% provided negative comments, the majority of which used terms similar to those summarized in the first table above.
  • A common complaint was the perceived disconnect between entering data and improving care and outcomes.
  • Specialists commented on the lack of relevance to their practices.
  • Responders felt that the requirements were created without sufficient input from practicing physicians.

Meaningful use has overstepped its intended mission. Exploding complexity, along with a corresponding lack of physician support, will result in the failure of the program. I fear that this downward spiral will be accelerated by the increased complexity of Stage 2 and what is being envisioned for Stage 3. Private practice physicians see this program very differently than academic and informatics-driven physicians do. The average physicians are drowning in the details and feel that their ability to practice is being hampered, rather than enhanced. They will likely abandon what they perceive to be a distracting, box-checking exercise after Stage 1, once they have earned the first—and “easiest”—$30,000.

All is not lost—there is a path toward success. The requirements must be simplified! Focusing on the three initial goals as stated in ARRA—ePrescribing, quality reporting, and interoperability—rather than presenting a complex maze of 23 separate measures on which physicians have to report, would go a long way toward making meaningful use meaningful to physicians.

Dawn of a New and Improved Consult Letter

Dawn of a New and Improved Consult LetterMy last blog clearly touched a nerve, as evidenced by the number of comments (14 in 5 days) and their spirited tone. Clearly—and we agree on this—the consult letter is a key part of patient care. The issue is how to get useful information efficiently transferred from the specialist to the primary-care physician without compromising the nuanced content and without reducing the patient encounter to a series of data points—the fear voiced by many of those who commented.

The question at the heart of this matter is what constitutes a consult letter in today’s medical practice and what it should be in the future. Currently, it may be a well-worded letter that ideally is concise and to the point; however, at the other end of the spectrum, an EHR-generated exam note is increasingly serving as the consult letter. My previous blog was really an indictment of the templated notes that more and more physicians are sending in lieu of consult letters. These are often bloated, undecipherable multipage notes that physicians find useless in communicating or identifying the impression and care plan. (This is the fundamental objection expressed in the comments from Drs. Dugger, Franc, Werner, Raulston, Kuhl, and others.)

The new Summary of Care document—a creation of the meaningful use program—replaces the EHR-generated exam note. While its emphasis is on transmitting discrete data, there is nothing that precludes physicians from incorporating narratives that convey the desired nuance. The Summary of Care can accommodate a long list of data, but it does not have to be a “data dump”—data that the sending physician feels is not relevant can be omitted. What physicians typically find most valuable in the summary is a limited set of data—diagnosis, medications, procedures, lab test results, and immunizations, along with a care plan. Descriptive text can be inserted/appended if the physician feels it would add value.

The value of the Summary of Care format is its simplicity, consistency, and data-rich content, which together enable the receiving physician to easily identify the information that is important to him or her (typically, the impression and care plan), and to incorporate that information into the patient’s chart. The data is subsequently available to the physician and can be retrieved and/or reported as needed. This stands in stark contrast to the templated exam note that currently functions as a consult letter.

Designed correctly, the Summary of Care will serve as a new and improved consult letter, delivering system-wide efficiencies while preserving the personal “art of diagnosis” (to quote Christian Wertenbaker’s comment). Nothing prevents a physician who crafts well-constructed consult letters from continuing to send them along with the Summary of Care. But it is my prediction that as EHR software continues to evolve and to develop more content-rich Summaries of Care, fewer and fewer physicians will find it necessary to supplement them in this manner. And given how overburdened and harried so many doctors already are, that will be a good thing.