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.

8 thoughts on “Dear Farzad Mostashari, M.D.:

  1. These kinds of complaints will go nowhere. As long as physicians cede authority to CMS, insurance providers, and large hospitals, EMR regulations, “hoops” and other unfunded mandates will only increase. Such programs are not intended to improve care or prolong patients’ lives or comfort; they are designed for 3rd party payers to monitor physicians’ activities in order to control and financial restrict our activities. Perhaps when CMS makes Medicaid participation a requirement for state licensure will US physicians wake up. Unfortunately, it would be too late by then.

  2. If 10% were positive or very positive then what’s the problem? There are good products in the marketplace for anyone willing to do due diligence in purchasing. Just finished attesting for 2nd year with my FlexMedical EMR. There are features I would have preferred my vendor work on before meaningful use but overall a nice improvement. I’m guessing most practices shot themselves in the foot by rushing to upgrade a poor EMR that only got worse after a rushed meaningful use implementation. ONC gave EMR vendors a set of requirements, not a plan for implementing it poorly. Let’s put the blame where it belongs.

  3. I agree with your comments, Mr. Steele. I believe that most commentators continue to miss the critical difference between EHR in an institution and EHR in a private practice. These are two very different situations that require very different solutions. CMS started with the (mostly) admirable goal of promoting the use of EHR. Financial incentives are one type of support, but they will become meaningless in a private practice setting if MU complexity increases since there will be a corresponding decrease in productivity and increase in overhead that will make the financial incentives meaningless.
    I believe that Dr. Neighbors is missing the point. 10% positive is a horrible positive number, and an 82% negative or very negative response will cause the incentive system to collapse. As an SRS user who has attested, I can say with great confidence that the problem in not in the EHR system in this discussion. It is in the MU system which is already questionable but about to get much worse.

  4. It is critical that physicians find an EMR meaningful for reasons beyond the incentives. IMHO, importing simple, productive and meaningful apps to a well developed EMR will attract physician interest and provide a positive ROI beyond incentive money. A patient portal is an example of an app (webpage) that can populate the history section of the EMR with a well designed history questionaire template that can contribute to billing requirements. Physician fatigue from using an EMR is greatly underestimated and can be markedly decreased by changing the EMR to a ‘networked application’. The more stakeholders that contribute to the EMR, the more the functionality. For example, the currently implemented up-to date med list (Surescripts/Allscripts) is a very beneficial EMR function/benefit. Other networked functionality such as evidence based recommendations or policy guidelines may be helpful for some users. Networked EMRs such as Athena Health with software as a service is the gold standard IMO. The physician should have the option of choosing some favorite subspecialty apps while other apps may be CMS required. An app competition for the SRS platform drawing ideas from the physician community and developed by SRS engineers may build an app store that may satisfy each physicians requirements/preferences. The Hypercard application that came bundled with the old Mac computers helped build the cult community. The novice user could now develop an application for the mac with minimal coding experience. Each EMR must develop a library of apps to serve the needs of subspecialities. In all cases, a simple and powerful SEARCH function is key to provide physician satisfaction, buy in and reduce community physician document creation fatigue.

  5. Change is always hard, and is always accompanied with resistance. I would love to read about more of the positive outcomes that are happening every day because of this change.

  6. Encounter visit note creation is highly specialty specific and burdened by multiple and unique user preferences. Custom interfaces and specific request demands may be practical for large groups but is impractical for small and solo practices. Striking a balance to appeal to all users is an exercise in compromises. An EMR company is anxious to please physicians but needs to consider ROI. A possible solution lies in a networked EMR with push and pull capability. Since the EMR is becoming a shared document, the physician must be willing to give up autonomy and the burden of note creation. If I were hired by an EMR company, I would offer ways to transition from traditional note creation by the physician. Productivity is a ratio of production output to what is required to produce it (inputs). Productivity measures of the labour to create and generate EMR notes need to be evaluated among EMRs. I would identify bottlenecks and any workflow obstacles and offer simple solutions. The appeal of a simple, affordable and effective EMR which is compliant with the evolving MU stages and truly enhances productivity, may convert frustrated physicians to willing and loyal participants.

  7. I think this is an important argument in the EMR discussion. I am an IT guy and the discussion I have with doctors defiantly agree with the survey results. There are lots of ideas and smart people discussing approaches but I would like to add this: I don’t feel that medicine is an information problem. More then any documentation the provider-patient relationship is a universe unto itself not unlike a marriage. If Washington D.C. decides there are too many divorces it doesn’t help reduce divorces to itemize, document, and price every transaction between the couple. It helps to empower people to invest in their marriages. The analogy is a little strained but this difference in approach could have a significant impact. Instead of requiring Physicians to meet seemingly arbitrary (and in our case totally ridiculous) eRx criteria in their emr and then get reimbursed give Providers account access to e-prescribing services and let them decide which to use. Tell companies you will pay them based on how many eRxs they get providers to use (using some complicated math to get the results you want). No proposal is perfect but the idea here is that providers are given tools, not rules and trust instead of presumption of intent to deceive. In this example the provider could use the eRx system that provides a kickback but really using a bad system over a good system is not worth any kickback and providers who cheat will cheat no matter the complicated rules. Complexity is no deterrent no matter what a committee of 22 people where each member wants input a rule (to own part of the process) recommends.

  8. In my opinion, medicine is an information problem and well executed data visualization tools will result in meaningful use.

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