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!
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.
Will not buy the type of EMR that is difficult to use and has not worked for other physicians in their specialty;
Will not risk the costs of a failed implementation;
Cannot tolerate the decrease in productivity—seeing fewer patients and generating less revenue;
Have established as a priority improving the quality of patient care they deliver, rather than collecting and reporting data that the government wants;
Cannot afford to take on unnecessary additional administrative burdens in the face of declining reimbursements;
Are not worried about potential penalties that will be relatively small, if they are even imposed at all; and
Are not interested in the government’s program, the benefits of which accrue primarily to other stakeholders, and not to their practice.
So why are these physicians, who have determined that government incentives are not relevant or achievable, still on the fence about adopting an EMR solution that will deliver measurable benefits? Staying with paper charts is not a good business strategy because there is nothing more inefficient!
The costs associated with the excess staff needed to manage these medical records are massive and wasteful—these positions can be eliminated or the employees can be more effectively used in revenue-generating or patient-care roles.
Paper charts hinder practice growth because adding physicians requires a proportional increase in support staff—medical records, billing, nurses, and medical assistants—and because physicians can’t see more patients without lengthening their work hours.
Slow responsiveness to primary care physicians limits referral volume.
Profitability is further affected by billing bottlenecks that delay revenue collection.
The chaos associated with trying to manage paper charts has a damaging effect on staff morale and creates rampant frustration among patients, physicians, and staff.
Paper charts are a malpractice nightmare—prescriptions are not consistently documented, orders are not easily tracked, and medical decisions are often made without complete clinical information.
You cannot afford to maintain the status quo.
Physicians can transform their practices without the government—there are excellent EMR solutions available, such as the hybrid EMR. It’s time to become digital. It’s time to get off the fence!
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.
Last week’s EMR Straight Talk, “Government EHR Program: Potentially Harmful Unintended Consequences,” seems to have struck a nerve with readers—based on the number, source, and intensity of the comments. The elevated level of concern is palpable. What I find rewarding is that blogs like EMR Straight Talk are creating a community of physicians who find support for their concerns—concerns that they might have thought were unique to themselves. Several of last week’s comments came from physicians who are not even on our mailing list, which means that their colleagues are sharing the blog, seeking to build support for their beliefs. Most of the comments were submitted by specialist physicians who are getting our message and beginning to speak up about why they do not consider the government’s EHR program relevant for their practices.
Those commenting identified several additional unintended consequences and voiced other concerns, including:
Dissatisfaction with templates and the utility of the notes they generate;
Failure of the government program to consider the needs of providers;
Effect of traditional EHRs on physician productivity;
Failure of physician organizations to speak out on behalf of their constituents; and
Difficulty of finding the right EHR for a practice.
An interesting comment came from Paul Roemer, who directed concerned readers to his post on HealthsystemCIO.com, in which he suggests that the “meaningful use” dates will be pushed back. He maintains: “Washington created a $40 billion lottery and they are having trouble finding anyone able to purchase tickets.” His contention is that very few providers will be ready or able to take advantage of the incentives, including those who already have implemented a traditional, point-and-click EHR.
What do you think the government should do with its program that is clearly meeting significant and vocal resistance—particularly among specialists and other high-volume physicians? Submit your comments below, and let’s keep the conversation going.