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.

The End of the Consult Letter as We Know It

The End of the Consult Letter as We Know ItThe end is in sight for the consult letter as we know it today. This has the potential to be a significant benefit delivered by meaningful use standards—physicians will get the clinical information they want and need from other physicians, and they will get it faster and more efficiently. Gone will be the days of lengthy, unstructured notes sent by fax or mail from one provider to another.

In today’s world, specialists report to referring physicians (i.e., primary-care providers) via a dictated consult letter or transcribed exam notes. These tend to be text heavy and contain no discrete or importable data. Others send EHR-generated narratives—lengthy notes that most physicians find difficult to read, if not useless. Finding the impression and care plan buried in massive amounts of verbiage is frequently a frustrating and time-consuming process. Meaningful use addresses this challenge by requiring a discrete data-rich summary of care for transitions from provider to provider. A menu measure in Stage 1, these summaries become a core measure in Stage 2, with more robust and structured content and the requirement that at least some of them be transmitted electronically.

The required Summary of Care provides better-quality information to the receiving provider and is created with less manual effort by the sending physician. The receiving EHR assimilates all of the data, presenting it in a cogent manner. The Summary of Care will contain structured data and a concise, accessible impression and care plan that tells the referring physician exactly what he/she needs to know. The receiving physician will filter the data as desired and the data can then be incorporated into the patient’s chart in his/her EHR, since all certified EHRs will use standard vocabularies.

Ease and speed of communication, along with cost reduction, are significant benefits, too. The Summary of Care can be transmitted as quickly as the data is entered into the patient’s chart. An automated batch process sends the summaries from the specialist’s EHR directly to the PCP’s, eliminating the cost of printing, faxing, or mailing letters. Meaningful use Stage 2 provides for the exchange either directly from provider to provider via secure e-mail (the “Direct” messaging protocol) or through Health Information Exchanges (HIEs).

Meaningful use will mark an end to the transmission of consult letters devoid of discrete data and to the exchange of hard to read exam notes. The impact on physician and practice productivity is undeniable.

Physicians Benefit from CMS’ Harmonization of Program Rules

Physicians Benefit from CMS’ Harmonization of Program Rules width=Kudos to CMS for making good on its promise to align quality measure reporting and incentives across the various government programs with which physicians must contend. With the publication last week of the 2013 Medicare Professional Fee Schedule final rule, CMS delivered on the harmonization promised in the Meaningful Use Stage 2 final rule in August.

This is very good news for physicians. Without the compromises that CMS made in both rules, physicians would be confronted with the challenge of trying to participate in a minimum of 3 government programs that involve quality measure reporting—ePrescribing under MIPPA, meaningful use under ARRA, and PQRS—each with its own set of intricate requirements, timetables, populations on which to report, reporting mechanisms, and incentive/penalty schedules. Not only would this be incredibly complicated, but it could give rise to incongruous situations in which a physician might, for example, successfully ePrescribe as part of demonstrating meaningful use, and yet still be subject to a penalty for inadequately ePrescribing under MIPPA.

Among the key areas of alignment are the following:

  • Reporting for PQRS using the EHR reporting option (as opposed to claims or registry reporting) will satisfy the clinical-quality-measure-reporting component of meaningful use. PQRS EHR-based measures will be aligned with the measures available for reporting under the EHR incentive program.
  • Meaningful use clinical-quality-measure reporting via PQRS will only be on Medicare patients, while all other meaningful use measures will continue to apply to all patients, regardless of payer.
  • PQRS reporting will be done using the CEHRT (Certified EHR Technology) that is required for meaningful use, eliminating the current requirement to use a separately certified “PQRS-Qualified” system.
  • Successful ePrescribing under meaningful use will protect physicians from ePrescribing penalties under MIPPA.

The government programs remain complex—but there is no question that aligning them as the recent rules do will decrease the reporting burden on physicians, spare related administrative costs, and eliminate the costs associated with duplicate EHR certification requirements. Valuable physician resources will be better allocated to providing the quality of care these programs seek to measure.

Audit Risk: EHR Coding, Cloning, and Templated Notes

Audit Risk: EHR Coding, Cloning, and Templated NotesPhysicians beware: CMS recently expanded RAC audits (Recovery Audit Contractors) to include office visit (E&M) claims, with the goal of identifying inflated coding and aggressively pursuing fraud and abuse. A recent New York Times article, “Medicare Bills Rise as Records Turn Electronic”, alleged that “EHRs may be contributing to higher Medicare costs because they make it easier to bill more for services.” This is a natural outgrowth of the pre-meaningful use origins of many EHRs—they were typically designed to create a clinical note that would maximize reimbursement. The point-and-click, templated notes of many EHRs will also be subject to intense scrutiny—because the notes often include copied and pasted text and omit the nuanced information that is critical to truly meaningful documentation.

In a sternly worded letter to hospital and medical association executives on September 24, HHS Secretary Kathleen Sebelius and Attorney General Eric Holder warned that they “will not tolerate health care fraud” and will take steps “to ensure payment accuracy.” They expressed serious concerns that some providers are misusing EHRs to increase reimbursement by cloning medical record documentation and by upcoding visits.

This new focus on auditing E&M coding was spurred by the findings of a report by the OIG (Office of the Inspector General) issued in May 2012, “Coding Trends of Medicare Evaluation and Management Services.” Over the last 10 years, physicians have increased their billing of higher-level E&M codes and reduced their billing of lower-level codes. Therefore, the OIG recommended that CMS have its contractors review physicians’ billings for E&M services and that they review—for appropriate action—those physicians who bill higher-level codes.

One of Medicare’s administrative contractors, (National Government Services), recently announced that it will not accept cloned documentation. “Cloned documentation will be considered misrepresentation of the medical necessity requirement for coverage of services due to the lack of specific individual information for each unique patient. Identification of this type of documentation will lead to denial of services for lack of medical necessity and the recoupment of all overpayments.”

These audits pose a significant risk since auditors are paid based on the amount they recover from providers.

The Case for Centralized Quality Reporting: A Perfect Example

The Case for Centralized Quality Reporting: A Perfect Example’ TimeQuality measure reporting is one of the 3 basic tenets of the EHR Incentive Program—the other 2 being ePrescribing and data sharing (interoperability)—as identified in ARRA, the program’s defining legislation. It is a key component to improving the quality of patient care. In a recent EMR Straight Talk post—“A Waste of Physicians’ Money and Vendors’ Time”—I proposed a more cost-effective method of analyzing clinical quality measure (CQM) data that would deliver more useful information for quality improvement than the approach currently in place for meaningful use. I suggested that rather than requiring each of the 472 vendors of certified EHRs to program the same CQMs (no longer 125 as initially proposed, but still a burdensome 64), EHRs should simply collect and report the data, and CMS or its designate should provide the analytics. Such a centralized approach would not only be more efficient, but it would produce more consistent and reliable data. Most importantly, it would allow for the immediate implementation of any changes to measure specifications as necessitated by the availability of new medical information.

Recently, I confronted a perfect example of the ineffectiveness of the current system and the opportunities that a centralized approach would afford. A physician informed me that a new CVX (immunization) code was created for the influenza vaccine—CVX code 144. While I told this client that we could easily add this code to the EHR for his use in documenting vaccinations (which we did), these vaccinations would unfortunately still not be reflected in the numerator for NQF 0041 (Preventive Care and Screening: Influenza Immunization for Patients over Age 50)—a fact validated by CMS. New electronic specifications for CQMs will not be implemented until 2014, and the current specifications remain in force for 2012 and 2013.

As an EHR vendor, I certainly appreciate the fact that we are not subject to the expectation that we will reprogram measures off-cycle. That would wreak havoc with our development roadmap and resource planning. Furthermore, changing the calculations to accommodate the new codes would compromise data comparability. So now we have comparable—but incorrect—data that does not reflect actual vaccination status. Under this system, how will we ever stay current as medicine constantly evolves?

Just imagine if everyone could begin using the new CVX codes immediately because the electronic specifications were updated in one centralized location with one effort. This is just one example from a potential 64 CQMs. How much more value would we derive from all the work that we demand of physicians in capturing the CQM data? How can we accelerate healthcare improvement if we are always 2–3 years behind?

Meaningful Use Stage 2: Did CMS Hear the Physicians? (Part 2)

Meaningful Use Stage 2: Did CMS Hear the Physicians? (Part 2)’ TimeIn my last post, I commended CMS for responding positively to many of the comments that were submitted regarding the Proposed Rule for Stage 2 of meaningful use. However, there were also troublesome areas that were acknowledged in the Final Rule, but addressed in a way that remains problematic for physicians. This post will review some of those issues.

Most notable are the two measures that make physicians’ incentives dependent on actions by patients—actions over which the physician does not have control. The Final Rule requires that:

  • More than 5% of all patients seen by the physician during the reporting period actually view, download, or transmit their available health information, and
  • More than 5% of patients seen send a secure message to the physician (containing health information, not just a request for an appointment).

The proposed rule had set the threshold at 10% for each of these measures. The response from the provider community was almost universal, arguing that no matter how much education, encouragement, and cajoling the practice provides to encourage this form of patient engagement, the physicians could not guarantee patient compliance. Alternatives were offered—my company suggested having the physician be the source of the messages, or holding him/her responsible for responding to a minimum percent of the messages received from patients. However, CMS held firm in its belief that it is incumbent upon the physician to encourage patients by offering an attractive, patient-friendly portal. By way of compromise, the Final Rule reduced the threshold from 10% to 5%, but this solution does not address the principle involved—i.e., the inequity of making the physician’s incentive dependent on the actions of patients. Just imagine if after successfully meeting all of the Stage 2 requirements for the 1,000 patients a physician saw during the reporting period, only 49 of the patients (instead of 50) actually viewed their information on the portal that the physician installed—his entire year’s incentive payment would be lost.

The menu set of measures is intended to afford physicians some flexibility—there are 6 measures from which they must select 3. Part of the rationale for this structure is to make meaningful use more meaningful for specialists. Yet in Stage 2, the menu measures that a physician is eligible to exclude will no longer count as being met, so many specialists will be left with no real choices at all—the menu measures become de facto core measures. Many specialists will find 3, or even 4, of the menu measures to be in that category—CMS acknowledges that syndromic surveillance is still premature, cancer registry reporting is likely irrelevant to most physicians, diagnostic images are only relevant to a few specialties, and many others will find no viable specialty registry to which to report so CMS “does not expect every EP to select this measure.” An ophthalmologist, for example, will have to report on the family history measure and the electronic progress note—not a measure they would choose if the menu were truly a menu.

Patient reminders is another measure that may be problematic for specialists who provide episodic care. Stage 2 requires the physician to send an appropriate reminder for follow-up or preventive care to 10% of the patients seen during the prior 24 months. No exclusion is available for physicians who see patients two or three times to treat a particular problem, but have no reason to ever recall the patient.

The above are examples of where CMS may have listened to the physicians, but didn’t really hear them. I hope that some further guidance related to these issues will be forthcoming to ensure that physicians are able to successfully demonstrate meaningful use in Stage 2.