HIT Policy Committee Focuses on Physicians

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.

Rome Wasn’t Built in a Day

In my last EMR Straight Talk post (Stage 2 Clinical Quality Measures—More Is Not Better), I maintained that simply adding a large number of new quality measures without addressing the underlying flaws in the reporting process will do little to advance the program towards its goals. So I was very interested in reading Joseph Goedert’s blog the following week in Health Data Management: “Why Must CMS Overreach on Rules?”

In discussing the proposed rule regarding Accountable Care Organizations (ACOs), Joe makes a similar argument to mine. He questions CMS’s proposal that, to share in an ACO’s savings, providers would have to report on 65 quality measures—including 28 new measures—when CMS will not even be ready in 2012 to electronically accept the considerably smaller number of quality measures associated with meaningful use.

In both cases, CMS is trying desperately to accomplish a long-term vision, albeit a noble one, in too short a timeframe. While formulating its proposal for Stage 2 meaningful use, the HIT Policy Committee had several intense discussions about the trade-off between (1) aggressively moving toward the end goal and losing people along the way because they were overwhelmed and feared failure, and (2) accepting a slower pace, but with a greater chance of success. The foundation of the programs have to be solid, or real progress will not be achieved.

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Reader’s Correction/Clarification:

In my EMR Straight Talk post on August 10, (“HIE’s and Information Sharing—Physicians Feel the Pressure”), I incorrectly stated that without membership in NYU’s UPN (University Physicians Network), “physicians do not have access to the group’s favorably negotiated reimbursement rates.” I received a comment from Robert Goff, Executive Director of NYU’s UPN, stating that “UPN does not negotiate with any payer or health plan outside of fully compliant shared risk arrangements,” and that the requirement regarding physician information technology “is part of a broad initiative to promote enhanced quality and the delivery of more efficient health care.”

I apologize for the misstatement.

Stage 2 Clinical Quality Measures—More Is Not Better

Serious time and effort is being devoted to the development of the clinical quality measure (CQM) reporting requirement for Stage 2 of meaningful use, with the intention of accelerating progress toward the program’s end goals. Sadly, however, the old joke keeps coming to mind about an airplane pilot who announces to his passengers that he has good news and bad news. The bad news is that he has no idea where they are, but the good news is that they are making great time!

Moving forward in Stage 2 without first addressing the fundamental flaws and omissions that plague Stage 1 is not the right approach. CMS has acknowledged that the CQM reporting requirement in Stage 1 is no more than that—a reporting requirement meant to get physicians comfortable with the process of reporting. CMS is under no illusions that the data collected will be meaningful as a measure of the level or quality of care being provided. Many physicians will be reporting on problems for which they are not treating the patients, which means that measure numerators will be zero (or very low) and that duplicate data will be submitted by different physicians for the same patients for the same conditions, which will result in an underestimation of the true care being delivered.

The Stage 2 recommendations for CQM reporting that the HIT Policy Committee has forwarded to CMS significantly expand on the Stage 1 measures in an attempt to address a broader set of factors that affect quality, as well as to be relevant to a wider set of physicians, including specialists. These are important goals, but premature. The model that was created—shown in this graphic—requires the addition of an extensive “library” of measures for each of the 6 menu “domains”.

Adding a large number of measures will be challenging on a practical front—it will involve development and testing by specialty societies and NQF, implementation by EHR vendors, training for providers, etc.—but more importantly, it does not address the basic issues related to the value of the data submitted. The problems identified above remain, no target thresholds exist, and no meaningful baseline data will be established to monitor progress over time. This is clearly a case where more is not better.

EHR Usability – Let Physicians Decide

Usability has become the focus of a great deal of attention in the EHR world. The HIT Policy Committee has talked about making usability a component of meaningful use—recognizing that spending $36 billion to incentivize and support physicians to adopt EHRs means that we can no longer close our eyes to the historically high rate of EHR failures. Fears about lack of usability, and the resulting impact on productivity, have contributed to physicians’ reluctance to move forward with implementation, and EHR incentives will not sustain adoption beyond the first payments if physicians find their EHRs unusable.

To address these issues, the Committee held a day-long hearing on usability, and on June 7, NIST (National Institute for Standards and Testing) convened a workshop to discuss the state of EHR usability. Significant work is being done by NIST, as well as by academic institutions, research and trade groups, and vendors, to determine how to measure, evaluate, and improve the usability of EHRs.

I hope that those involved in the efforts to advance EHR usability will consider the following points:

  • The only people who can truly define usability are the users—i.e., physicians and other providers. Usability relates to the comfort, ergonomics, and acceptability of a particular application interface to its users. As such, it is the experiences and feedback provided by those users that must be the driving force behind any shift toward greater usability.
  • Usability can be measured, but not legislated. Because personal subjectivity will always be an important factor in each individual user’s judgment about what is ergonomic, comfortable, and generally acceptable, there will always be room for a variety of approaches. Attempts to legislate the best way will inevitably accommodate only a narrow range of users, leaving those with varying preferences and workflows without software to satisfy their usability requirements.
  • Usability must be evaluated not only from the perspective of primary care physicians, but also that of specialists. Specialists provide different types of care and have very different expectations of their EHRs. Treating specialists as an afterthought—as happened in the initial formulation of the meaningful use requirements—would be a major disservice and undermine the serious work being done to define usability.

There is a great opportunity here for the government to provide advice and education regarding EHR usability—this could go a long way to furthering successful EHR adoption. It would be a major mistake, however, for the government’s role to extend to legislating or mandating usability standards. That would sap innovation, push creative vendors out of the market, and turn EHR adoption back to where it was before the meaningful use incentives.

EHRs and Productivity Loss: How Can This Be Acceptable?

The purpose of automation is to increase efficiency and productivity. Every industry that has undergone the transformation from paper to digital has realized these benefits immediately . . . every industry, that is, except the EHR industry. Why is this acceptable?

Even the AMA acknowledges this failure—and yet seems to accept it. Toward the end of its newly released, and otherwise very helpful, video on how to select an EHR is the test question: “What is the ‘best practice’ in terms of the number of patient visits to schedule during the first week of operation with your new EHR?”

Why does the AMA think that the correct answer “A”?:  “Reduce the number of patient visits by up to 50% for the first week to allow you and your staff to learn how to use your new EHR.”

Why isn’t it “D”?:  “Your new EHR was carefully selected to fit into your practice smoothly and seamlessly. There should be no impact on patient volume that first week.”

Why does the typical EHR implementation follow the bottom line of the graph below, when it should look like the top one? Dr. Jacqueline Fincher’s testimony at last week’s HIT Policy Committee’s hearing on “Experience from the Field” is representative of the all-too-common experience.

Dr. Fincher reported an “absolute requirement to drop patient volume by half for the first three months [due to] an exponential learning curve,” and that she and her partners “have never gone back to the previous volume of patients,” even after 5 years of EHR use.

Some argue that the medical business is different from other industries like banking and shipping. That is very true. The type of data collected is different, and the level of employee responsible for inputting much of the data is also very different. In most industries, it is the lower-level, less costly employees (such as bank tellers and UPS truck drivers) who input data, while in medical practices, it’s actually the CEOs (i.e., the physicians) who do it. This makes productivity all the more critical for an EHR. According to the recent MGMA study on EHR adoption, fear of productivity loss is the primary barrier to EHR adoption—a concern justified by reports from experienced users, as illustrated below.

For the EHR industry to evolve as necessary for widespread adoption to become a reality, choice “A” must be rejected as totally unacceptable by physicians and the professional organizations that represent their interests. Physicians should expect more from their EHRs—they should demand that vendors deliver productivity, not merely fancy features and functionality. The truth is, they can get both, but only if they do their due diligence.

Stage 2 Meaningful Use: What Do You Think?

At this week’s HIT Policy Committee meeting, the Meaningful Use Workgroup presented its Stage 2 thinking to date, based on the 422 comments they received on their initial proposal. As discussed in a previous EMR Straight Talk post, the issue at the forefront is timing—with providers and vendors expressing significant practical concerns, and consumer groups pushing for rapid advancement.

The workgroup presented the following options for consideration by the Policy Committee. (I invite you to voice your opinion by responding to the poll below.)

  1. Maintain current timeline. Stage 2 would begin in 2013 for providers who demonstrate meaningful use in 2011. Providers who first demonstrate meaningful use in 2012 would have until 2014 to meet the Stage 2 requirements.
  2. Maintain the current timeline (as above), but allow a 90-day reporting period, instead of a full year, when providers are first governed by Stage 2 requirements. This would give providers until October 1 to begin their first year at Stage 2, instead of January 1—a nine-month delay.
  3. Delay Stage 2 by one year, allowing providers 3 years instead of 2 years at Stage 1. This means that the earliest any provider would have to meet Stage 2 expectations would be 2014.
  4. Phased-in approach separating existing from new functionalities:
    – Stage 2a (2013) would increase thresholds for measures for which the functionality already exists, (required to meet Stage 1), adding only new clinical quality measures.
    – Stage 2b (2014) would add new measures that require new EHR functionalities .

The responses from various HIT Policy Committee members covered the gamut.

  • Some were in favor of moving aggressively at all costs, presenting various arguments such as: (a) If we don’t pressure providers now, we will face the exact same issues at the next stage; (b) More extensive data capture does nothing to move us towards Stage 3 goals; and (c) We cannot just address the physicians’ workflow problems and ignore the challenges patients face in dealing with the current, difficult-to-navigate healthcare system.
  • Other Committee members, like Gayle Harrell, cautioned against trying to do too much too quickly—as she has from the outset—and stressed the long-term value to the program of setting providers up for success. Pushing them too hard could cause them to drop out after they earn the bulk of the incentives associated with Stage 1.
  • The phased-in approach was perceived as creative, but I was surprised that there was not much discussion about the administrative complexities this plan creates—to say nothing of the challenge of conveying it to providers.


The Elephant in the Room

The search for the perfect EMR involves an extensive list of criteria related to features and functions, cost, hardware requirements, certification, references—and since February, the potential to obtain government incentive money. Search committees are assembled, consultants are engaged, RFPs are solicited, presentations are made, and references are checked. But there is a big elephant in the room that everyone is ignoring—physician productivity.

The effects of productivity are enormous. Changes in physician productivity dramatically and directly impact the practice’s bottom line. You can calculate the cost for yourself using the Productivity Calculator discussed in a prior blog. Physician productivity has broader societal impacts as well. Decreased productivity means fewer patients seen in the face of higher demand for care by aging baby boomers and the massive numbers of newly insured patients under proposed health care reform legislation. This is further compounded by the shortage of physicians.

Why is no one looking at productivity? Why aren’t physicians and medical societies insisting that productivity information be made available and be the focus of the EMR selection process? Why do RFPs—typically written by consultants—contain no questions about productivity? CCHIT certification has never included any evaluation of productivity, and neither does the government’s “meaningful use” matrix. Even at the recent MGMA Annual Conference there was no mention of productivity in a session on implementing EHR technology. A reasonable explanation might be that objective information about comparative productivity is not available. However, this problem could be remedied by EMR Reform—but that proposal is meeting with resistance within the industry.

Some of the answers to the questions above are less surprising than others. I believe that vendors are afraid of what comparative benchmarking would reveal about their products’ performance under close scrutiny of productivity. It is not in the vendors’ interest to yield control of the EMR evaluation process—not when scripted presentations permit skirting the productivity issue entirely. Consultants don’t feel confident that they have the tools to effectively compare productivity, particularly if vendors are not supportive of productivity measurement. What confounds me, however, is the lack of concern being expressed by physicians and their representative professional groups. I can only assume that it is due to the fear-based marketing efforts to which they are being subjected. Physicians are being told that they must buy an EMR because the government requires it and because everyone else will buy one—neither of which is true. What physicians should be fearful of is the loss of productivity that they will suffer if they do not consider productivity as a primary factor in the EMR selection process.

At next week’s HIT Policy Committee meeting, defining “meaningful use” for specialists will be a primary agenda item. We will advocate that meeting the government’s goals for widespread EHR adoption requires that physician productivity—the elephant in the room—be addressed.