Kudos to CMS for responding positively and reasonably to many of the comments submitted by physicians and/or their professional organizations regarding the Proposed Rule for Stage 2 meaningful use. Of course, there were also a number of issues that could have been addressed more favorably from the providers’ perspective—and I will address those in my next EMR Straight Talk post—but I was pleasantly surprised to see the changes and the compromises that CMS did make that will benefit physicians.
The most significant concession was related to timing: in 2014, physicians will only report for a 90-day calendar quarter—rather than a full year, as originally intended. This should result in higher-quality, more-usable EHRs as vendors will have more time to develop, test, and certify their new versions. It also eliminates the fiasco that surely would have ensued for providers were they all to require upgrading by their vendors within a very small window of time. This new schedule also ensures that physicians will have the time they need to implement, and sufficiently train on, the new versions of their software, enhancing the likelihood that they will be able to successfully demonstrate meaningful use. The 90-day reporting period also provides some flexibility for those unfortunate physicians who hastily purchased an EHR in a rush to meet meaningful use and now find themselves dissatisfied with their decision—they will have down time that will make the replacement process easier.
I was also pleased to see several changes that address the reporting burden for physicians. Stage 2 offers a batch-reporting option—however, providers must still individually meet all of the meaningful use requirements—and it attempts to harmonize clinical quality measure reporting across the various government programs. These were two proposed concepts that physicians strongly endorsed in their comments.
Specialists particularly appreciate the Final Rule’s successful resolution to the challenges posed by the vital-signs measure currently in force—the new requirement unlinks the reporting of height and weight from the reporting of blood pressure. Beginning in 2013 (i.e., a year before Stage 2 even takes effect), physicians who find height and weight relevant to their practices (but not blood pressure) will be able to report the former while attesting to an exclusion for the latter. This will remove an irrelevant step in the workflow for many specialists.
While CMS did hear the physicians on these important issues, there are other areas that the Final Rule did not sufficiently address. I will discuss these in my next post.
EHR vendors are facing the arduous task of programming as many as 125 clinical quality measures (CQMs)—in addition to the development challenges presented by all the other new meaningful use requirements for Stage 2—and to do this in a relatively short period of time. To compound matters, the calendar is rapidly advancing and the specifications for these quality measures are not even available yet.
Is there a better way to approach quality measure reporting? I think so—and it seems so obvious to me! EHRs should not be doing all of the analysis—they should simply collect and report the data, and CMS or its designate should provide the analytics. A centralized approach would be much more efficient and would produce more consistent and reliable data.
Think of the time and resources being wasted. Why should each of the 472 vendors offering certified EHRs have to program the same 125 clinical quality measures—that’s the programming of a total of 59,000 measures—when they should not have to program any at all? This unnecessary cost will ultimately be passed on to physicians. And what about the effect on standardization and comparability of the data produced? Despite the certification requirements for each of the quality measures, minor variances in calculations are inevitable, and this compromises the value of the data for comparative purposes. Centralization would also allow changes to be implemented in a nimble and timely manner. With a centralized registry, new measures could be introduced, and changes to measure specifications that result from new research could be programmed and released immediately, without having to wait what could be years for each of the 472 vendors to develop, upgrade, and deploy the changes to the hundreds of thousands of physician-EHR users.
A model already exists for such an approach, and the infrastructure for data exchange is in place using one or more of the standards that are accepted in the industry today. Registries are already analyzing clinical data and identifying areas for quality improvement. It is critical that we think outside of the box to find opportunities like the above that eliminate unnecessary duplication of effort and free vendors to focus on areas of keen interest—like EHR usability and physician productivity.
I recently came upon some unsettling information about the current state of HIEs (Health Information Exchanges). It was disturbing in light of the increasingly important role that interoperability plays in healthcare and because expectations are already being placed on many physicians regarding clinical data exchange. Much is written about the problems that HIEs face—the challenges most commonly being attributed to funding, business sustainability, and, in a recent post, insufficient EHR penetration. But what I discovered in conversations with a major HIE reveals an even bigger shortcoming.
A nationally known hospital system in a major metropolitan area has implemented an HIE operated by one of the biggest names in the world of health information exchange. One would expect this large company to be on the forefront of this emerging area of technology. However, this HIE vendor is incapable of accepting clinical data in the current, standard format (CCD—Continuity of Care Document), despite the fact that CCD has been recognized as the “new” standard since 2008. CCD was selected by the Healthcare Information Technology Standards Panel (HITSP), recognized by the Secretary of HHS, and named as the standard for clinical data exchange in the Meaningful Use regulations. This major HIE told us that CCD is “on their development roadmap,” and that they currently accept clinical data only in HL7 format.
The problem this creates is that, once again, physicians are left holding the bag! At this particular hospital, many of the independent physicians are members of an organization that represents their interests. They are implementing EHRs—which is a good thing—and are expected to participate in the HIE and to exchange data by the end of this year. However, their respective EHR vendors will have to maintain multiple standards to satisfy all of the various participants, and this will incur higher costs, which will ultimately be borne by the physicians.
How can we expect true sharing of data when not all parties that participate in information sharing are being held to the same standards—standards that have been established specifically for this purpose? Perhaps HIEs should be regulated to ensure compliance, just as EHRs and the physicians who implement them are.
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.
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.
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.
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.
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.