CMS asked for comments on its Proposed Rule for Stage 2 Meaningful Use, and it got them—1,131 of them, to be exact. While the comments that have drawn media attention are those from major stakeholder organizations, the vast majority of comments were submitted by individuals—and CMS is obligated to read and consider each and every one of them as they formulate the Final Rule.
I thought it would be interesting to see whether the comments from those in the trenches—those whose everyday lives are impacted by the meaningful use regulations—are in line with the sentiments expressed by groups like the AMA, AHA, MGMA, EHRA, etc. In a review of the first 25% of the comments by individuals, (over 250 comments), a consensus clearly evolved around a few major points, and the results remained fairly consistent as we read. The graph above illustrates the prevailing sentiments.
- By far, the predominant concern is that the proposed requirements are far too demanding, i.e., the bar is being set too high. An overwhelming 82 of the comments identified the sheer number of measures and components, challenging thresholds, the cost of compliance, and overly aggressive timetables—even in light of the delay to 2014—as being unrealistic.
- On a similar note, another 14 addressed the complexity of the requirements, describing them as difficult to understand, ambiguous, and overly complicated. When combined with the above, approximately 40% of the 250 comments reviewed maintained that the Stage 2 requirements are simply too demanding.
- As anticipated, there was a resounding concern (56 comments) about holding physicians responsible for actions by any third parties over whom they have no real control. Most comments referred to the requirement that patients view or download their charts and communicate to the physician by secure e-mail, but some asked that providers be insulated from any failure by vendors to meet the requirements or the client upgrade schedules.
- The limited relevance for specialists remains an issue in Stage 2, as the program is still viewed as primary-care focused. There were 23 comments that addressed the paucity of meaningful use measures and clinical quality measures that are relevant to specialists, and some went so far as to claim that trying to meet requirements that are geared towards primary care could actually distract specialists from their own priorities and be detrimental to the quality of care they would be able to deliver.
- Some comments addressed the penalties and suggested that the rules provide for a broader range of exemptions and more leeway. The suggestion that the first year of Stage 2 only require 90 days of reporting—which was suggested for other reasons as well—was supported by providers concerned with the penalties.
- In response to a plea from CMS that people report what they like in the proposal, in addition to what they don’t, some commenters expressed general support for the Stage 2 recommendations, and a small number argued that the bar wasn’t raised high enough. Some—likely specialists—applauded the change in exclusions for reporting of vital signs; several approved of ensuring patient access to their clinical information; and there was support for the proposed harmonization of clinical quality measure reporting under the various government programs (meaningful use and PQRS).
Perhaps what is most interesting about the comments is the emotion and passion behind many of them—whether expressing favorable or unfavorable opinions. If you would like to browse through the public comments yourself, go to www.regulations.gov and enter “CMS-2012-0022” in the search bar.
The vast majority of EHRs are outright failing the specialists. Is this news? Surely not to those physicians suffering EHR implementation disasters, but thanks to KLAS, we now have hard data to confirm the anecdotal evidence. It is provided in the recent KLAS report, and eloquently described by Ken Terry in his recent article in Information Week. His title, however, “EHR’s Aren’t Specialist-Friendly Enough,” underestimates the seriousness of the problem. And the problem will only get worse as more specialists rush to purchase EHRs under the pressure of impending meaningful use deadlines.
In an industry where the EHR satisfaction scores by specialty range from a paltry high of only 7.6 (on a scale of 10) for internal medicine and family practice to an embarrassing low of 5.8 for oncologists and ophthalmologists, most specialists rate their EHRs in the barely passing range between 6.2 and 6.8.
Source: KLAS as reprinted in HIStalk
Let’s look at these scores as grades—the best EHRs are only earning a C (76%); orthopedists are trying to make a go of EHRs that are squeaking by with a D (65%); and some specialists are saddled with EHRs that are simply flunking out (58%).
And these scores are averages. Assuming a normal distribution of responses (see example of bell curve for ophthalmology, below), there are many physicians who rate their EHRs considerably lower than the average—giving scores of 48%, 38%, or even lower. (Readers who are physicians know what happens to students who get a 38% on an organic chemistry final exam: dreams of medical school quickly disappear as these students are weeded out of the candidate pool!)
Of course, just as there are some specialists who rate their EHRs below the average, there are also some who score theirs at the high end of the bell curve (in the orange section). Oh, and guess where a vendor is going to take a prospective customer for a site visit?
So, what’s a specialist to do to increase the chance of EHR success? Play it safe and go with a name brand, generic EHR? Clearly not! That strategy is anything but safe. The legacy EHRs are all built to support the needs of primary-care physicians—it is no surprise that internists and family practitioners are less dissatisfied with their EHRs than their specialist colleagues are.
Here are some tips:
- Start with the KLAS report, “Ambulatory EMR by Specialty Study 2012: Finding the Fit”, and identify those EHRs that have high ratings in your specialty.
- Make sure that these vendors have a large network of providers in your specialty.
- Perform comprehensive due diligence, calling physicians that you select.
- Beware of vendor-selected site visits—these physicians should not be expected to be representative of the majority experience.
You can’t cheat when it comes to selecting an EHR. After all, it may be the EHR that gets the bad grade, but it’s you who is going to have to pay.
This is my 100th EMR Straight Talk post, and a lot has changed in the EHR world since the blog’s inception—but some things have not. Productivity is still the name of the game in EHRs, especially for specialists.
There is no question that the government incentives have stimulated interest in EHR adoption, but according to a recent physician survey, that is not the primary reason that providers are looking to implement one. “Quality and efficiency” ranked higher than the EHR incentives as the goal of EHR implementation, according to this report by CapSite—a healthcare technology research company. Heightened interest in efficiency is not surprising, given that in another study (by MGMA), physicians identify rising operating costs as a tremendous challenge.
Although the above data was not cut by specialty, I know from my experience in the field that these issues are magnified in specialty practices. MGMA found that of all physicians, orthopaedists face the greatest challenge in successfully implementing EHR systems. Ophthalmologists have such distinct needs that the American Academy of Ophthalmology took the time to publish an article defining the specific characteristics that an ophthalmology EHR must have to be valuable in their members’ practices.
When you read through the list of requirements, they all tie into the impact on productivity and efficiency—factors critical to both of these specialties given their particularly high patient volumes. The implications for EHR selection are significant, and have not changed since I wrote my first EMR Straight Talk post.
Thank you for reading and commenting!
With the constant barrage of meaningful use success stories in the media—number of providers enrolled, dollars of incentives earned, and case studies about practices that have already received their money—it pains me to see that the experience on the ground quite often does not reflect this reality. Although they are only anecdotal, let me share two recent personal stories that I fear are representative of all too common EHR implementation failures.
I recently visited my dermatologist, whose practice purchased an EHR approximately 2 years ago (not my company’s product). When I arrived, I saw to my dismay that the office looked and operated exactly as it had before they bought the EHR—there were walls of charts; no computers in or around the exam rooms; and my physician walked in grasping my paper chart in his hand, with loosely assembled documents protruding from the edges. When I asked why they were still using paper charts, I was told that “it takes a long time to switch over to computers!” No one in the office—not the front desk staff, not the clinical staff, and not my physician—could even tell me the name of the EHR they had purchased. Clearly, little—if any—progress had been made on the implementation front in the 2 years since the purchase decision, and yet they seemed to think this lack of a transition was normal. All that money invested, and no return!
A visit to my primary care physician was equally disturbing, but from another perspective. His practice had implemented an EHR (also not my company’s product), and several of the physicians were, in fact, using the software—but not happily. He complained that he was seeing fewer patients each day, as well as staying a half hour longer to catch up on his documentation. Will he earn a meaningful use incentive? Likely yes, but at what cost?
I have always maintained that government incentives should not be the motivation for adopting an EHR. Practice improvement—cost reduction, increased productivity, and better patient care—should be the driver. With the rapidly increasing demand for care and the growing shortage of physicians, the need for easily implementable, productivity-enhancing EHR technology is indisputable, and yet so many EHR implementations are still failing. How do we as an industry address this shortcoming?
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.
The evidence is indisputable: the fear of lost productivity associated with EHR implementation is uppermost in the minds of physicians, and their fears are justified by the actual experience of the majority of EHR adopters to date. The titles of two articles about the recently released MGMA EHR survey say it all: “Survey: EHRs Often Don’t Increase Doc Productivity” (Health Data Management) and “HITECH Drives Docs to EHRs, but Cost, Productivity Issues Remain” (Healthcare IT News).
MGMA is to be commended for the size and scope of this important survey (4,588 practices representing 120,000 physicians), for the multiple ways it segmented the survey population, and for the detailed analysis of the results. One important segmentation was missing, however—that of physician specialty, or, at a minimum, of primary care versus specialist. The EHR experience of orthopaedists or ophthalmologists, who may see as many as 60 patients a day, is dramatically different from that of a family practice physician who sees 20.
Productivity was the pervasive issue. The only group that reported some productivity gains was the 16.3% self-proclaimed “optimized users” of EHRs—those who have had sufficient time following implementation to master the EHR. (The report did not define “sufficient time.”) Among this group, 41% reported that physician productivity has increased. What is disturbing about this statistic, however, is the implication of the converse—that even among these most accomplished EHR users, the majority of physicians (59%) are seeing a decrease, or at best no increase, in productivity. For the total population studied, 43% have just worked their way back up to where they were before implementation, and 31% of respondents are experiencing an actual productivity decrease.
Productivity was the major factor accounting for why 8% of survey participants are in the process of replacing their EHR with another, while anticipated productivity loss was reported as the most significant barrier to EHR implementation for physicians still using paper charts. Among these paper users, 78% fear productivity loss during implementation and 67% worry about the effect even after the transition to an EHR.
This data confirms past experience regarding productivity loss and raises these critical questions:
- Why do only 16.3% of EHR owners categorize themselves as “optimizing their use of an EHR”?
- While government incentives will certainly address the financing concerns expressed by small practices, how will this money address the productivity obstacle for all adopters?
- What accounts for the loss of productivity?
- When technology has replaced an antiquated paper process in other industries, it has always brought increases in productivity. How do we deliver the same results in healthcare?
The MGMA report did not tie satisfaction and productivity to the particular EHR being used, but there were clearly some successes, so it is important to understand what differentiates these implementations. It all comes down to usability. According to a recent HIMSS Task Force Report on why adoption has been so slow, “A key reason, aside from initial costs and lost productivity during EMR implementation, is lack of efficiency and usability of EMRs currently available.” I maintain that lost productivity and lack of usability are one and the same.