Question: What do you get when you try to retrofit a primary-care-focused government program to be relevant to specialists?
Answer: Unintended consequences.
In response to the outcry from specialists about the primary-care nature of meaningful use, CMS implemented some exclusions to make the program more workable for them—but these changes did little to make it more “meaningful.” In fact, there were some significant—and, I have to believe, unintended—consequences that will actually create challenges for many specialists:
- Some physicians will have to add what they consider non-relevant vital signs to their workflow. Acknowledging that vital signs are not within the scope of practice for some specialties, CMS provided a potential exclusion for this measure. However, to take advantage of the exclusion, providers must attest that all three vital signs (height, weight, and blood pressure) do not apply to their practice. This leaves physicians who routinely record just one or two of the vital signs without a way to satisfy the measure, other than to add the non-relevant measurement, too—blood pressure for orthopaedists, height and weight for ENT specialists, etc. (For an explanation, read The All 3 Vital Signs Dilemma.)
Is it the government’s intention that orthopaedists take blood pressure on every patient? Perhaps—but if so, are these physicians then responsible for treating this condition? Some would argue that orthopaedists need to know their patients’ blood pressure if they are going to perform surgery—likely true, but why should this requirement also apply to non-surgical patients? It should not, but let’s remember: this is a primary-care-focused program, designed by primary-care physicians, and this type of analysis was never performed.
- Some specialists will have to report on clinical quality measures (CQMs) that have no relevance to their practices—and in doing so will provide meaningless data. The accommodation for specialists in regard to reporting on CQMs was originally intended to allow them to identify non-relevant measures by reporting zero as the denominator. However, the meaningful use measure requires physicians to report CQMs using data that is directly generated by the EHR. This results in the inclusion of patients in the denominator of CQMs that are outside the scope of the reporting physicians’ specialties. Physicians will be forced to report on problems for which they did not treat the patients, reporting zeros as the numerators, but not the denominators. (For further details, see Clinical Quality Measures: Who Defines Relevance?)
This raises several issues. First, physicians are reluctant to go on record as not addressing a known problem, even when that problem is outside their specialty. In this litigious medical environment, this is not an unreasonable concern. Second, the data generated in this manner will be meaningless since numerous specialists will provide data on the same patients and on the same problems as are being treated by primary-care physicians—making it will appear that, on average, very little care is being provided for these problems. Some physicians will be trapped into providing data on measures that are not relevant to their practice, even though valid measures exist. For example, any pediatrician with even a few patients over 18 will have to report on those few older patients—using the core measures meant for adult populations—rather than report on his/her entire pediatric patient base, using the alternate core measures that were specifically added to capture valuable information regarding the pediatric population.
CMS acknowledges that the purpose of this particular requirement during Stage 1 is merely to get people comfortable with automated reporting—specifically stating that the government is not looking to gain valuable information about medical practices or the state of care being delivered. I am concerned, however, that the discussions to date about reporting on CQMs in Stage 2 do not advance us towards producing data that will be any more meaningful. To accomplish that, the entire structure would have to look more like PQRS, where physicians report only on measures directly relevant to their practices.
For meaningful use to be meaningful to specialists—beyond the financial value of the incentive money—the program needs to be restructured to fit their needs and practices. It is quite evident that trying to apply primary-care requirements to specialists is not effective.