Meaningful Use Stage 2: Speak Now or Forever Hold Your Peace

A preliminary set of recommendations for defining Stage 2 meaningful use was released by the Meaningful Use Workgroup of the HIT Policy Committee earlier this month in the form of a Request for Comment—the deadline for comments is February 25. The decision-makers in Washington clearly realize the value of securing buy-in from providers, having received over 2,000 comments to the proposed Stage 1 rule when it was issued last year. As a result of those lobbying efforts, which included the Voice of the Physician Petition that we circulated on EMR Straight Talk, CMS made changes that accommodated the specialists and made participation realistic for them.

This is the opportunity for physicians to have a voice in Stage 2 before the final recommendations are submitted to CMS this summer. This request comes very early in the process of developing and finalizing the requirements—the workgroup will consider the comments and then present its recommendations to the HIT Policy Committee, which will review and revise and then forward them to CMS, which will issue the final rule. So for this stage, providers have the chance to provide input well before recommendations become set in stone.

Since most providers haven’t even embarked on Stage 1, and many are not yet conversant in the rules and requirements for that stage (as evidenced by the results of the Meaningful Use IQ Test), the following are highlights of the proposed recommendations. Note that clinical quality measures are not discussed—they will be the subject of a separate set of recommendations.

  • The proposal does not address the excludability of non-relevant measures. I assume its retention is implied, but it is important to comment on the need to keep these options in place. This was a very valuable modification added to Stage 1, particularly for specialists.
  • Disappointingly, Stage 2 still does not define meaningful use in a way that adds value for many specialists, and a way that will keep them engaged once the significant portion of the incentives have been collected.
  • Menu measures will become core measures, so the measures physicians choose to defer in Stage 1 will be mandatory in Stage 2. Some of these measures pose challenges for specialists, e.g. sending reminders to 20% of patients may not be reasonable for certain specialists such as orthopaedists or ENT physicians, because they provide episodic care.
  • Most of the changes involve increased thresholds for satisfying the measures, e.g., CPOE increases from 30% to 60%, ePrescribing from 40% to 60%, etc. These changes should not present a challenge since the software and relevant workflows will already be in place from Stage 1.
  • There are several new measures, such as adding lab or radiology to CPOE and including online secure patient messaging.

To voice your thoughts on this initial set of recommendations, go to www.regulations.gov and click “Submit a Comment”. Don’t say they didn’t ask!

An Open Letter to HHS Secretary Sebelius

We are very encouraged that the Voice of the Physician Petition has been acknowledged at the highest levels of government. After HHS (Department of Health and Human Services) Secretary Kathleen Sebelius received the petition that SRS sent to her—and simultaneously hand delivered to the HIT Policy Committee—Secretary Sebelius asked Dr. Blumenthal to respond to me. As head of the Office of the National Coordinator for Health Information Technology, Dr. Blumenthal chairs the HIT Policy Committee and, together with Secretary Sebelius, will accept or modify the recommendations on “meaningful use” and EHR certification that come from that committee and from CMS (Centers for Medicare & Medicaid Services). In the interest of continuing this conversation, I am extending the following invitation to Secretary Sebelius, as I already have to Dr. Blumenthal:

Dear Secretary Sebelius:

I received Dr. Blumenthal’s letter and was glad to hear that you appreciate the input provided in the Voice of the Physician Petition. The ability of the EHR incentives to successfully encourage widespread adoption of EHRs is inextricably linked to the belief by physicians that EHR technology is of benefit to them, as well as to all the other stakeholders in the healthcare delivery system.

I would like to arrange a brief meeting with you to discuss these very important issues in person. As the CEO of SRS, with 12 years of experience listening to and working with front-line physicians, I can offer you some valuable insights into what community-based physicians are looking for and how they perceive the legislation—likely a different perspective than that being presented by committee members.

SRSsoft was recently named to the Inc. 5000 list of most rapidly growing companies, and was identified as one of the top 100 healthcare companies. Our success and growth is directly attributable to the fact that our EMR development is driven entirely by the needs of private-practice physicians.

As the representative of thousands of physicians who want their voices heard—SRS clients and non-clients alike—I would be happy to come to Washington to talk with you. I am confident that you would find the conversation valuable.

Lost Opportunity: EMR Reform Was within Our Grasp

In October of 2007, the government (or specifically, CMS—the Centers for Medicare and Medicaid Services) had a great idea: It announced a 5-year EHR demonstration project. The project had goals similar to the EMR Reform concept detailed in last week’s EMR Straight Talk. The government set about to scientifically investigate whether “investing time and money to convert . . . to EHR is worthwhile [for physicians] or not.” The project would also specifically measure physician satisfaction, exploring how EHRs affect workflow and identifying which functions physicians actually use. The goal was to “examine practices’ experience in implementing and using EHRs” and to evaluate “providers’ perceptions of the effects on their practice and patients.” This was a great start at a sorely needed objective evaluation of the efficacy of EMR in physician offices.

Why did the government fund this program to the tune of $150 million? My guess is that it was because they recognized that no study existed to support the commonly held—but undocumented—assumptions regarding the value of EMRs to physicians. The few landmark studies that have been conducted have focused on the value to other stakeholders—insurance companies, the government, etc.—but not to physicians.

The demonstration project had a start date of June 1, 2009, and will encompass 5 years of data collection. Yet on February 17, 2009, in a rush to push through legislation, and encouraged by special interest groups, President Obama signed the Stimulus Bill before the first demonstration test site was even operational. The government will now spend $36 billion supporting the very same EHRs they had wanted to study, but without the benefit of the potentially valuable information that the demonstration project could have provided. Nor will they have heard from physicians about what actually works in the real world of medical practice.

So here we are, embarking on a massive government program enticing physicians to invest in and implement software that the government itself has acknowledged is unproven in value—and urging physicians strongly that the time to do so is now—despite the fact that the demonstration project’s Phase I is just beginning and preliminary results will not be available until 2014.

Don’t we have a responsibility to provide physicians with at least the level of decision support to which they have access when they buy a car? Regrettably, this failure represents a lost opportunity to produce an EMR report card that would let physicians see what is really going on “under the hood”—before we expect them to invest their hard-earned money. Never before has the argument for EMR Reform been so compelling.

Challenge EMR Vendors to “Put Your Money Where Your Mouth Is”

Change has arrived. The government, through the Department of Health and Human Services (HHS), will provide an incentive if you purchase and meaningfully use a “government” EMR. The problem is that the HHS incentive will only pay for the type of systems that have a dismal track record with busy, high-volume physicians.

Landmark studies have demonstrated that government EMRs, (traditional, CCHIT-style EMRs), impose financial hardship on physicians. There does not exist a single landmark study that concludes otherwise. Just ask any government EMR vendor to prove otherwise with any landmark study that meets the “smell test”:

  • The study is either large in scale or by a venerable, nationally recognized institution.
  • The study is not vendor funded.
  • The study must specifically address physician productivity. Studies that claim benefits of EMR accruing to other industry stakeholders are not relevant.

Before embarking on an expensive and risky venture into the world of government EMRs, you owe it to yourself to be 100% sure that the system is usable and adoptable for your unique practice. If you are not able to prove to CMS that you are a “meaningful user” of the EMR technology, the entire cost of an expensive EMR purchase will rest on your shoulders.

How do you make sure that your investment in a government EMR will perform just as the sales rep promises and bring your practice into the digital world, while receiving payments from the government? Easy. Insist that the vendor puts its money where its mouth is.

Before investing heavily in a government EMR, know ahead of time whether or not you will be successful. Have the vendor prove to you that they can get 2 physicians in your practice live on their system. To be fair, no money should exchange hands—only time. The two physicians and their staff will invest their valuable time learning the system and the vendor will invest its valuable time implementing and training. If, after a 30-day trial period, you are happy and can see that practice-wide implementation of the government EMR is feasible, then you sign a contract with the confidence that the investment is worthwhile. If you feel that the government EMR is not right for you, then the government EMR vendor removes the system from your office and a financial disaster is averted.

The power of this arrangement is that the government EMR vendor, whose sales rep promises the world, actually has to back up its claims with a fair trial by you, the “real-world user.” If the product does not perform as you expect, then you will not suffer the loss of a substantial investment. Go ahead and make the government EMR vendor “put its money where its mouth is.”