Just What the Doctor Ordered

The government is hearing the voice of the specialists.

Since the inception of the EHR incentive program in February 2009, specialists have been concerned about their role in a program that is clearly focused on primary care. As I have pointed out before, the legislation’s primary-care focus is borne out by the composition of the decision-making committees, the allocation of funding for associated programs, and the fact that specialists were not even a topic of conversation in the deliberations until late in the game.

I have tried to advocate for the physicians—specialists, in particular—by representing their special issues via the Voice of the Physician Petition, blog postings, letters to Dr. Blumenthal and Secretary Sebelius, and by sending staff to Washington to speak on their behalf. In the last few months, specialists, their medical societies, and industry pundits such as David Kibbe and Vince Kuraitis have speculated that many specialists will not participate in the program.

Apparently, the government is worried and is taking steps to reach out to specialists to assuage their concerns. Last week, David Blumenthal confirmed publicly that specialists will not be expected to add primary-care clinical workflows to their practices to satisfactorily demonstrate meaningful use, and that they can exclude select measures that don’t apply to their practices. (See my HIStalk Practice post for more information.) While nothing in the regulations has changed since the release of the final rule in July, Dr. Blumenthal’s recent statements should dispel physicians’ initial skepticism about the potential exclusions—skepticism that had roots in disappointing PQRI experiences.

Having heard Dr. Blumenthal speak before an audience of ophthalmologists at the recent AAO meeting, I find it refreshing to see a move to a more inclusive program.

Specialists: Square Pegs in the Government’s Round EHR Holes?

It has been abundantly clear to me that the government’s EHR program is not relevant for specialists and other high-volume physicians. It was evident from the outset that specialists were never the focus of the legislation, but recent program-funding announcements dispel—once and for all—any doubts about the government’s intentions in this regard. Furthermore, the type of EHRs that are designed to meet the government’s criteria are not responsive to the particular needs of specialist physicians. The comments I continue to receive, and those posted elsewhere, are adamant on that point.

As a result, the Stimulus Legislation poses overwhelming challenges for specialists—challenges that outweigh any potential returns. This is hardly surprising given the lack of input from specialists in the decision-making process. With only one or two exceptions, the physicians involved are all primary-care or informatics experts, not specialists. It was not until October that the question of specialists was even discussed, and so the “meaningful use” criteria that emerged don’t fit the services that specialists routinely provide, nor do they fit the way specialists routinely practice medicine, at least not without major workflow disruptions.

The focus on primary care is indisputable. Look at the programs that have been announced and funded in just the last two weeks:

  • February 2, 2010: ONC will survey 1,700 patients in 84 primary-care practices because it recognizes “an evidence gap about patients’ preferences and perceptions of delivery of health care services by providers who have adopted EHR systems.” (Notice in the Federal Register)
  • February 12, 2010: The Department of Health and Human Services (HHS) announced $375 million in funding for Regional Extension Centers (RECs), which will “provide outreach and support services to at least 100,000 primary-care providers and hospitals within 2 years.” In describing the RECs, David Blumenthal stated, “Primary-care providers in small practices provide the great majority of services in the U.S. but have limited resources to implement, meaningfully use, and maintain EHR systems. On-site technical assistance for these priority-primary care providers will be a key service offered by the RECs.”

But the biggest obstacle for specialists remains the traditional EHR products themselves—the challenges posed by the government program only compound the fact that these EHRs are fundamentally so difficult for many physicians to use. Designed for primary-care practices, their success has been limited to that arena. Traditional EHRs are built around the creation of exam notes, not around workflow and physician productivity. The highly leveraged nature of specialists’ practices—where office visits lead to surgeries and other procedures—makes their economics highly sensitive to even small negative impacts on productivity. In addition, their high patient volumes make workflow-focused software critical, and note-focused software unusable. For example, a 10% reduction in productivity for the average specialist would result in an annual revenue loss of over $100,000. (Use our physician productivity calculator to estimate the cost to your own practice.) As a result, there are a very few large specialty practices that have successfully and fully adopted a traditional EHR.

The government should be up front about their interests and acknowledge their focus on primary care. Until they devote the same kind of resources to finding out what works in medical specialty practices, they should just leave the specialists out of the program—exempting them from both incentives and penalties.