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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MUS2-IQ

EHR Coding Dreams Shattered by the Evidence

July 12th, 2012 by EMR Straight Talk

The automated E&M coding feature of most EHRs has traditionally been highly valued by physicians in search of the Holy Grail. But, apparently this key EHR selling point is a myth! According to a report released by the Office of the Inspector General (OIG) of the Department of Health and Human Services (HHS), absolutely no one actually uses this highly touted feature.
EHR Coding Dreams Shattered by the Evidence
The survey concluded that physicians do not trust their EHRs to assign billing codes. Of the 2,000 physicians surveyed, 88% manually assign the codes for E&M services and the remaining 12% use professional billers to do so.

Perhaps the message has finally gotten out! As part of its 2012 work plan, OIG has specifically targeted billing fraud perpetuated by reliance on EHR coding/documentation. Physicians are scared. But the caution regarding automated coding should not come as news to anyone. It has long been known that EHR coding—along with templated notes—does not stand up well in an audit. An article in the well-regarded Medical Economics journal exposed these dangers several years ago.

Yet EHR sales reps continue to entice physicians by appealing to their desperate search for the Holy Grail of coding, offering an easy way to ensure that they will maximize reimbursement. I hope that the results of this study will redirect physicians to search for an EHR based instead on the potential to deliver improved practice productivity and efficiency and enhanced levels of patient care.

Stage 2 Meaningful Use: The Public Has Spoken

June 27th, 2012 by EMR Straight Talk

CMS asked for comments on its Proposed Rule for Stage 2 Meaningful Use, and it got them—1,131 of them, to be exact. While the comments that have drawn media attention are those from major stakeholder organizations, the vast majority of comments were submitted by individuals—and CMS is obligated to read and consider each and every one of them as they formulate the Final Rule.

 

I thought it would be interesting to see whether the comments from those in the trenches—those whose everyday lives are impacted by the meaningful use regulations—are in line with the sentiments expressed by groups like the AMA, AHA, MGMA, EHRA, etc. In a review of the first 25% of the comments by individuals, (over 250 comments), a consensus clearly evolved around a few major points, and the results remained fairly consistent as we read. The graph above illustrates the prevailing sentiments.

  • By far, the predominant concern is that the proposed requirements are far too demanding, i.e., the bar is being set too high. An overwhelming 82 of the comments identified the sheer number of measures and components, challenging thresholds, the cost of compliance, and overly aggressive timetables—even in light of the delay to 2014—as being unrealistic.
  • On a similar note, another 14 addressed the complexity of the requirements, describing them as difficult to understand, ambiguous, and overly complicated. When combined with the above, approximately 40% of the 250 comments reviewed maintained that the Stage 2 requirements are simply too demanding.
  • As anticipated, there was a resounding concern (56 comments) about holding physicians responsible for actions by any third parties over whom they have no real control. Most comments referred to the requirement that patients view or download their charts and communicate to the physician by secure e-mail, but some asked that providers be insulated from any failure by vendors to meet the requirements or the client upgrade schedules.
  • The limited relevance for specialists remains an issue in Stage 2, as the program is still viewed as primary-care focused. There were 23 comments that addressed the paucity of meaningful use measures and clinical quality measures that are relevant to specialists, and some went so far as to claim that trying to meet requirements that are geared towards primary care could actually distract specialists from their own priorities and be detrimental to the quality of care they would be able to deliver.
  • Some comments addressed the penalties and suggested that the rules provide for a broader range of exemptions and more leeway. The suggestion that the first year of Stage 2 only require 90 days of reporting—which was suggested for other reasons as well—was supported by providers concerned with the penalties.
  • In response to a plea from CMS that people report what they like in the proposal, in addition to what they don’t, some commenters expressed general support for the Stage 2 recommendations, and a small number argued that the bar wasn’t raised high enough. Some—likely specialists—applauded the change in exclusions for reporting of vital signs; several approved of ensuring patient access to their clinical information; and there was support for the proposed harmonization of clinical quality measure reporting under the various government programs (meaningful use and PQRS).

Perhaps what is most interesting about the comments is the emotion and passion behind many of them—whether expressing favorable or unfavorable opinions. If you would like to browse through the public comments yourself, go to www.regulations.gov and enter “CMS-2012-0022” in the search bar.

The Future of Meaningful Use

June 14th, 2012 by EMR Straight Talk

The Future of Meaningful Use
This week, I came upon two blog posts that I thought were interesting in light of my last EMR Straight Talk post, which suggested that EHR adoption was being driven to the tipping point by the meaningful use incentives. Increasing numbers of physicians—many of whom were initially motivated by the government’s incentives—are beginning to question the real value of complying with the program’s ever-more-demanding requirements. Whether or not meaningful use thrives as the program progresses will ultimately be determined by the physician market, but sentiment is clearly mounting that too much is being demanded.

In a recent post on the venerable HIStalk blog, Dr. Jayne reminds physicians of why they went into medicine, and she challenges the government to justify new requirements by “providing concrete evidence that jumping through the hoops you’re holding in front of us will actually help patients in a truly meaningful way.” Analyzing the trade-off between the incentives and productivity, she worries about not only the impact on physician income, but also the impact on the number of patients who can receive care. I particularly appreciated her conclusion that what we should be seeking is “evidence-based Meaningful Use.”

An editorial published on the AMA’s American Medical News website, titled “Meaningful Use’s Stage 2: A Recipe for Failure,” highlights the AMA’s concerns about the Proposed Rule, concluding that the requirements are simply “too demanding” and will turn physicians into cynics, rather than participants in the EHR program.

EHR Adoption: The Tipping Point Has Been Reached

May 31st, 2012 by EMR Straight Talk

EHR Adoption: The Tipping Point Has Been Reached
Regardless of your feelings about the particular pros and cons associated with meaningful use—and you know that I have not been shy about expressing my opinions in that regard—it is impossible to deny the EHR Incentive Program’s positive impact on the implementation of healthcare IT. Meaningful Use has brought us to the tipping point, where EHRs are perceived as a necessity rather than an option for a successful medical practice. The enduring impact of ARRA is that it pushed the EHRs across the chasm, changing the profile of the EHR user from innovative, tech-savvy physician to mainstream physician.

We have reached the point where a critical mass has adopted EHRs, and paper charts are no longer acceptable. Practices that are not digital will find it hard to attract new physicians. Referrals will be affected as primary care physicians will prefer to deal with specialists in the community with whom they can share clinical data electronically, rather than bear the unnecessary costs incurred by the alternatives of faxing, printing, or mailing. These benefits can only be accomplished via an EHR, a fact reinforced by Stage 2’s increased emphasis on interoperability.

I still maintain that the decision to purchase an EHR should not be driven by potential government incentives but rather by the value delivered to a practice—improved patient care and service, productivity/efficiency gains, and cost savings. In fact, I would argue that participation in the meaningful use program is optional—but clearly, EHR adoption no longer is.

Meaningful Use Stage 2 Battle Lines Are Drawn

May 14th, 2012 by EMR Straight Talk

Meaningful Use Stage 2 Battle Lines Are Drawn
Interested stakeholders have submitted their comments regarding the Proposed Rule for Meaningful Use Stage 2. Providers and their professional organizations, vendors and HIT industry associations, and consumer groups advocating on behalf of patients have written detailed—and often lengthy—tomes for CMS and ONC to consider.

Sadly, the overly aggressive nature of the proposed requirements for Stage 2 is pitting providers against patients. Providers, with support from the EHR vendor community, express concern that the bar is being raised too high and too quickly to be practical, while consumer groups argue that we would be missing an opportunity by not raising it even higher. The pleas from both sides are equally passionate and well intentioned.

However, this should not be a battle—the fact that it has turned into one is most unfortunate. I believe that all stakeholders are truly committed to the same goal: higher quality, safer, and more convenient care for patients, provided efficiently and at a reasonable cost. Everyone agrees that meeting these goals requires moving towards increased interoperability and greater patient engagement, but it is the specifics of these requirements—as proposed for Stage 2—that are stirring up the controversy.

We need to advance at a reasonable pace, one that is challenging but not overwhelming. The risk of pushing providers to the point where the requirements are perceived to be unrealistic, unmanageable, and overly burdensome—particularly as incentives dwindle to insignificant levels—is that they will abandon the program as unachievable. If that happens, the continued success of the incentive program will be in jeopardy. No one’s goals will be met.

HIT Policy Committee Focuses on Physicians

May 3rd, 2012 by EMR Straight Talk

HIT Policy Committee Focuses on Physicians
A very positive conversation took place at yesterday’s HIT Policy Committee meeting, and it put the focus squarely on the physicians—a focus that in the past seems to have gotten lost in the shuffle.

The Committee was reviewing and finalizing its comments for submission to CMS on the Proposed Rule for Stage 2. A healthy debate ensued regarding who should have to enter the orders into the EHR to satisfy the CPOE requirements—the physician or a designated clinical staff member. In response to a suggestion that there were reasons for requiring the physician to personally enter the orders into the system, Neil Calman, MD, raised the discussion to another level by asking about the entire purpose of EHRs and meaningful use. Dr. Calman challenged his fellow committee members to think about how an EHR should be expected to change the way physicians practice—and how it should not. He asked why we would want to bog physicians down with tasks that other staff were already doing instead of helping physicians focus on the work that utilizes their highest skills and expertise.

The EHR incentives are definitely encouraging EHR adoption, but we should not lose sight of why increased adoption is such an important goal. The value of an EHR to a physician is not the $44,000 incentives—it is the potential for increased productivity and efficiency, better and safer patient care, and the ability to share information. It’s easy to get caught up in creating comprehensive measures that ensure that the interests of all stakeholders are met, and in doing so, to lose sight of the practical impact on physicians’ workflow. In the case of yesterday’s CPOE debate, the committee came up with a recommendation that preserves the intention of the CPOE measure—and meaningful use in general—while respecting the value of the physicians’ time. I hope this conversation will set the tone for future meaningful use deliberations.

EHR Incentive Program Financed on the Backs of Physicians

April 19th, 2012 by EMR Straight Talk

I was shocked to read the following paragraph, buried on page 379 of the 455-page Proposed Rule for Stage 2 Meaningful Use, (page 13812 in the Federal Register). The paragraph also appears verbatim in the Final Rule for Stage 1:

Explanation of Benefits and Savings Calculations:

In our analysis, we assume that benefits to the [EHR Incentive] program would accrue in the form of savings to Medicare, through the Medicare EP payment adjustments [penalties]. Expected qualitative benefits, such as improved quality of care, better health outcomes, and the like, are unable to be quantified at this time.

While the second sentence is disappointing, I do respect CMS’s candor in acknowledging the ongoing paucity of hard data on the quantification of the assumed qualitative benefits of EHR adoption. The first sentence, however, left me short of breath because it points to the following inescapable, disheartening conclusion: The economics of the EHR Incentive Program is predicated upon physician failure!

EHR Incentive Program Financed on the Backs of Physicians

In fact, the government’s projections for physician participation from 2014 through 2019 are rather pessimistic. Meaningful use among Medicare EPs is estimated to grow, in the less optimistic (“low”) scenario, from 18% to a mere 36%, and in the most optimistic (“high”) scenario, only from 49% to 70%.¹ Even these high projections are low enough—incidentally—to give the Secretary of HHS the option to increase the penalties from the statutory 3% in 2017 to a potential 4% in 2018 and 5% in 2019.

What kind of program have we created that over a period of 9 years will likely take almost as much money from physicians as it gives them?

The government giveth and the government taketh away!

¹Source: Proposed Rule, Stage 2 Meaningful Use, page 13804, Table 19.

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