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.

HCIT: Don’t Underestimate the Power of CMS’ Carrots and Sticks

Anyone who knows even a little bit about behavior modification theory intuitively understands that offering rewards and/or punishments is an effective way to encourage people to do what you want them to do. The government clearly understands this principle and has been using incentives and penalties to motivate physicians to participate in its programs—PQRS, ePrescribing, and, most recently, the EHR incentives.

The EHR incentives have already prompted a great deal of EHR activity, but the program is too new to quantify cause and effect yet. A direct correlation between government policy and provider behavior, however, is evidenced by the history of my company’s ePrescribing license purchases, so I thought EMR Straight Talk readers would find the analysis of my company’s experience interesting.

As illustrated above, ePrescribing sales tracked the MIPPA legislation as follows:

  • 2009 was the first year of ePrescribing bonuses, and the requirements (a 50% threshold) made it important to start ePrescribing early in the year. As you can see, this created a huge demand for ePrescribing licenses during the first half of 2009.
  • Sales continued in late 2009 and early 2010—although at a more moderate rate—as later adopters decided to take advantage of the last year of 2% bonuses and as the easier-to-meet threshold of 25 ePrescribing encounters was introduced.
  • Imminent penalties caused a spike in sales in the beginning of 2011, when providers first learned that 2012 penalties would be based on ePrescribing activity—or lack thereof—in the first 6 months of 2011.

Another interesting observation that can be made is that, for some providers, penalties are a much more effective behavior modification tool than incentives, regardless of the relative amounts of money at stake. My experience with ePrescribing—illustrated by the 2011 surge in licenses—was that many physicians who had not been persuaded by the 2% bonuses in 2009 and 2010 felt compelled to move ahead when faced with a 1% penalty for 2012. Regardless of whether a particular physician attributes more weight to the carrot or to the stick, the data above—although not unexpected—confirms the effectiveness of the government’s strategy.

EMR Straight Talk Centennial Blog—It’s Still About Productivity

This is my 100th EMR Straight Talk post, and a lot has changed in the EHR world since the blog’s inception—but some things have not. Productivity is still the name of the game in EHRs, especially for specialists.

There is no question that the government incentives have stimulated interest in EHR adoption, but according to a recent physician survey, that is not the primary reason that providers are looking to implement one. “Quality and efficiency” ranked higher than the EHR incentives as the goal of EHR implementation, according to this report by CapSite—a healthcare technology research company. Heightened interest in efficiency is not surprising, given that in another study (by MGMA), physicians identify rising operating costs as a tremendous challenge.

Although the above data was not cut by specialty, I know from my experience in the field that these issues are magnified in specialty practices. MGMA found that of all physicians, orthopaedists face the greatest challenge in successfully implementing EHR systems. Ophthalmologists have such distinct needs that the American Academy of Ophthalmology took the time to publish an article defining the specific characteristics that an ophthalmology EHR must have to be valuable in their members’ practices.

When you read through the list of requirements, they all tie into the impact on productivity and efficiency—factors critical to both of these specialties given their particularly high patient volumes. The implications for EHR selection are significant, and have not changed since I wrote my first EMR Straight Talk post.

Thank you for reading and commenting!

Meaningful Use, ePrescribing, and PQRS: Need for Harmonization

While physicians are working feverishly to understand the complexities of meaningful use, their efforts are complicated by the demands of other government incentive programs that have similar goals but different rules. Two of the three cornerstones of ARRA are ePrescribing and reporting on quality measures, yet it is still necessary to comply separately with the regulations of EHR incentives (ARRA’s meaningful use), ePrescribing (MIPPA), and PQRS if physicians wish to maximize—or, in the near future, preserve—practice revenue.

EHR Incentive PaymentsThe chart to the right is taken from a 6-page CMS document that addresses the complicated interrelationships among EHR incentives, ePrescribing, and PQRS. For physicians, the challenge goes beyond understanding the potential payments; of greater significance is the administrative burden created by the discrepancies in reporting metrics and reporting periods among the three disparate programs. The following represent just a few of the inconsistencies inherent in the programs:

  • Under Medicare, physicians cannot receive both an EHR incentive and an ePrescribing (MIPPA) incentive in the same year. They can, however, receive both an EHR incentive and a PQRS incentive in the same year.
  • Future penalties for failure to demonstrate both meaningful use and PQRS will be additive. Whether cumulative penalties will apply for physicians who are not meaningful users and do not ePrescribe is not addressed in the CMS chart, but the prevailing understanding is that, instead, the harsher of the two penalties will prevail.
  • Because ePrescribing benchmarks differ, a physician could be deemed a successful ePrescriber under ARRA but not under MIPPA, and vice-versa.
  • Regardless of whether or not a physician receives incentives under ARRA, he/she must continue to comply with the MIPPA ePrescribing requirements (i.e., G-Coding) to avoid future MIPPA penalties. (Ironically, a physician could demonstrate meaningful use in 2011, receive an EHR incentive, but be penalized 1% under MIPPA in 2012 for failure to report G-Codes—a MIPPA, but not a meaningful use, requirement.)
  • Although many of the quality measures are common to both meaningful use and PQRS, separate reporting is required. Differences exist in the applicability of thresholds and in the reporting periods.

I am glad to see that the lack of program harmonization is being recognized—and I hope it will be successfully addressed in the next round of rule-making. Recently, the AMA distributed a survey “seeking physicians’ input on rules and regulations that increase their administrative costs and paperwork burden, or that interfere with patient care without a significant benefit to patients and/or the government.” Last week, the Government Accounting Office issued a recommendation to CMS that they eliminate overlapping ePrescribing requirements. Harmonizing the rules will go a long way toward encouraging widespread and successful participation in government programs that are aimed at increasing quality of patient care.

Meaningful Use IQ Test Results

The response to last week’s Meaningful Use IQ Test revealed a tremendous thirst for information and a fair amount of confusion about the facts and realities of meaningful use. Neither was terribly surprising, given the recent hype surrounding the program’s launch and the complexity of the regulations.

Since the quiz was posted last week, 534 people have taken the test. The average score was 56% (see chart below and the breakdown of responses at the bottom of the page). These results mean that physicians will need a great deal of assistance from consultants, Regional Extension Centers, and vendors to succeed in their pursuit of the EHR incentives. If that aid is not forthcoming, there could be a large number of very disappointed providers when the incentives are distributed.

Meaningful Use IQ Test Results

The following are some observations:

  • Only a small minority of our test-takers (9%) appear to truly understand the regulations and the requirements in their entirety. (Inga, from HIStalkPractice.com is one of the few who just might—based on her perfect score!)
  • Many people find the intricacies of the regulations baffling—as indicated by more than half of the respondents (300 of 534) knowing half or less of the information.
  • The fact that over one-third of the respondents did not know that providers cannot collect Medicare EHR incentives and Medicare ePrescribing incentives in the same year—no “double dipping” allowed—means that they have likely not analyzed their options to maximize the total revenue from the two incentive programs.
  • I thought it was interesting that nearly half of the respondents thought that the program requires reporting on only Medicare and Medicaid patients, when, in reality, the government is requiring providers to submit data on all patients.
  • Clearly, the message has come through that the program has been made more specialist-friendly, as physicians will be able to exclude measures that are not relevant to their practices. However, many do not understand how these exclusions factor into the demonstration of meaningful use.

The Meaningful Use IQ Test is still active, so if you haven’t accepted the challenge yet, you can still do so. I’m glad that it is raising awareness and providing valuable education. That was precisely its purpose!

Meaningful Use IQ Test Results

Government EHR Program: Potentially Harmful Unintended Consequences

I am really intrigued by the latest creation from the Department of Health and Human Services (HHS). Last week, HHS announced a contract to set up a group of experts to identify and attempt to fix any “undesirable” and “potentially harmful unintended consequences” that result from the stimulus legislation’s EHR incentives. According to the announcement, which was posted on the Federal Business Opportunities website: “Historical experience, as well as mounting evidence of unexpected problems, demands that we consider potential downsides.”

My curiosity is piqued! What are the unexpected consequences the government anticipates, and why is HHS so concerned? Awaiting the report from the panel of experts, I started thinking—and it didn’t take me long to create a list of my own.

My top three unintended consequences are the following: (If you’d like to suggest other potential unanticipated consequences—positive or negative—please submit a comment at the bottom of this page.)

  • There will be more EHR failures than successes, particularly among high-performance specialists.
  • “Certification” will stifle innovation.
  • Productivity and physician-focused EHRs will lead the market among high-performance physicians.

More EHR Failures:

After an initial peak in implementations, long-term EHR adoption will slow—particularly among high-performance specialists—and the current failure rate will escalate. Many factors will contribute to this: (1) Some physicians will rush into EHR purchases without conducting proper due diligence. (2) Products that were overly complex and did not work in busy specialists’ practices in the past will surely not succeed now, particularly since these same products must now be used in an even more structured and demanding way. (3) Sorely needed implementation and training will be provided by inexperienced and rushed implementation teams, further reducing the likelihood of success with providers, many of whom are less technologically savvy than the early adopters. (4) Where there was never a convincing economic justification in the past, the addition of data-collection requirements will further lessen the economic feasibility of traditional, point-and-click EHRs. (5) Physicians will try to transfer data entry tasks to scribes and other lower-cost employees (assuming that the regulations allow CPOE to be done by other than the ordering provider), but this strategy will not make economic sense, either, since the additional costs will outweigh the government incentives. The result? The high failure rate will leave physicians “holding the bag” after investing large sums of money, failing to earn the anticipated incentives, and owning a system that doesn’t meet their needs.

“Certification” will stifle innovation:

Innovation will suffer, as it did in the past when many EHR vendors devoted all their development resources to complying with the long list of CCHIT-certification requirements. Forcing all vendors seeking certification to meet the same criteria will surely sap the drive for innovation. As vendors burn through precious development resources to meet evolving government standards instead of improving their core product, they will fail to respond to the interests of their customers, i.e., the physicians. Sales and marketing will drive physicians’ choices, rather than the EHR products themselves. Large companies, which have the largest sales organizations and marketing budgets, will be successful in the short term. Smaller vendors who follow the herd instead of their entrepreneurial and innovative instincts will be driven out of the market.

Productivity and physician-focused EHRs will lead the market:

The good news is that innovation will triumph in the end. Alternative solutions—like the hybrid EMR—will prevail as high-performance physicians find success with products that focus on their needs and enhance their productivity. It will take 4 to 5 years for physicians who have experienced government-program EHR failures to reapproach the market after amortizing their losses. These physicians will seek products that focus on clinical-workflow efficiency and physician productivity. The long-term winners in the EHR market will be those vendors who resist the temptation to chase the “windfall” stemming from the stimulus legislation, and instead focus on improving their products to deliver these benefits.

Please share your thoughts on other possible unintended consequences by submitting a comment below.

Planning for the Flood

I spent the last few days attending the annual conference of the Medical Group Management Association (MGMA) in Denver, where there was a lot of talk about the financial challenges practices are facing and about the government’s EHR incentives.

Robert Tennant, MGMA’s Senior Policy Advisor, acknowledged that few groups will be eligible for the incentives when the government’s program begins in 2011. According to William Jessee, M.D., President and CEO, the vast majority of practices do not currently have any type of EHR, and despite being pressured by vendors that the time to purchase and implement one is now, physicians are reluctant to commit the resources necessary to do so. He attributed this to the financial effects of the recession—an unprecedented negative growth in practice revenue that is resulting in decisions to postpone capital investments. Add to this the pervasive confusion surrounding the incentives themselves, and the forecast is for wholesale inaction.

All of this has reinforced my belief that it is more important than ever for physicians to make good business decisions, and to do everything they can to enhance—or at a minimum, preserve—productivity. Not only will practices be faced with the financial pressures and declining reimbursements cited by the MGMA, but additional factors will make productivity critical. The impending flood of aging baby-boomers and the newly insured (through healthcare reform legislation)—coupled with a growing physician shortage—will swamp the healthcare system. This increased demand for care creates an opportunity, but only physicians who can leverage EHR technology to boost their productivity will really keep their heads above water.