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Tuesday, December 21, 2010

Meaningful Use and the Devil in the Details: A Reader's View

A reader, Dr. Scott Monteith, a psychiatrist, shared his thoughts on government-mandated 'Meaningful Use' of Electronic Medical Records ('MU') with me after reading a number of my EHR posts, and asked if he could share his thoughts via Healthcare Renewal.

Dr Monteith is a graduate of the University of Michigan and Michigan State University where he was chief resident. He is a board certified psychiatrist, clinical assistant professor in the departments of psychiatry and family medicine at Michigan State University, and has worked in the same community health center for 20 years serving people suffering from severe and persistent mental illness. His interest in Health Information Technology goes back over 20 years. He has served as a CCHIT Juror, was appointed by Michigan’s Governor Granholm to the Controlled Substances Advisory Commission which has an oversight role for the Michigan Automated Prescription System, and was a member of the Business Operations group of the Michigan Health Information Network.

Dr. Monteith writes:

From Medical Economics:

“While 85% of physicians were aware of the financial incentives for implementing an electronic health record (EHR) system, more than 35% did not know that they face government-assessed financial penalties for not complying, according to a survey of more than 500 physicians by Physicians' Reciprocal Insurers, a New York-based medical liability insurance company. The penalties are equal to a 1% reduction of the physician's annual Medicare payments per year up to 5%. However, those penalties do not seem to be having the intended effect, as more than 65% of physicians who were unaware of the financial penalties said this would not cause them to implement system."

The above Medical Economics article reflects a reality that is consistent with what we are seeing in the clinical ‘trenches.’

Eligible Providers (EPs) are realizing that Meaningful Use (MU) incentives are not as simple as…using a certified EHR + being part of Medicare and/or Medicaid + applying for MU + attesting to MU.

Receiving $44k (or $64k) in incentives seems not only increasingly elusive, but of questionable benefit even if some or all of the incentives are realized.

The ‘carrot & stick’ of Meaningful Use (MU) seems to increasingly be viewed as ‘meaningless and useless’ by at least some clinicians. Some are asking if ‘MU’ will stand for ‘meaningless and useless’ in the future.

There seems to be a long list of reasons why MU is so challenging. From what I have gleaned, there appear to be two main issues:

1. the cost to meet MU may be too high (and, said another way, the ROI might be too low); and

2. there are too many uncertainties associated with MU (largely stemming from the risk of burdensome bureaucratic entanglement – an unknown and potentially huge “cost”).

As we know, MU reimbursement flows through two streams: Medicare and Medicaid.

And one’s incentive dollars and/or penalties are based on Medicare/Medicaid volume.

So small Medicare/Medicaid volume means small incentives/penalties. With the perception of inevitable Medicare and Medicaid cuts, these two funding streams become increasingly irrelevant for more and more providers.

Another issue stems from the fact that MU and the associated EHR “certification” are losing credibility because they do not address “usability.” My users simply want EHRs that “work,” and “work” well (like their iPhones).

Users ultimately want and expect usability. They hoped that certification would help guide them in this important respect, but they are finding that is not the case.

To the extent that certification is not meaningfully addressing ‘usability,’ therefore, MU is viewed as ‘useless’ in guiding purchasing decisions.

Further, many are simply not confident that they will meet MU.

Other challenges I’ve encountered include:

  • One big problem with MU is that many people believe that wedding one’s self to MU (ARRA) will open a can of bureaucratic worms (and they might be correct)
  • MU is 864 pages of details. How many users will read all 864 pages of the government’s final rule for MU? (And of those few who do, how many will understand it?). If one doesn’t know the MU rules, how will one prepare for MU? Hire consultants and IT experts? How much will this cost?
  • How will one establish that one is MU-certified? In year one there will be self-attestation. But who/what will certify users as to whether or not users are meeting MU in the other years? How much will it cost (direct costs to pay above certification organization/entity)?
  • How much will it cost users to become certified (indirect costs to prepare for your certification)?
  • Currently it appears that one must recertify every year for incentives. But how often will one have to recertify to avoid penalties? What will be the ongoing cost in terms money, time, energy, business flow? Will the ROI be positive or negative (and how positive or negative)?
  • To what future governmental audits might one be subjected if one gets incentive dollars and/or wants to avoid penalties (especially after the inevitable celebrated cases of abuse)? It is not hard to imagine receiving a letter from the government that says, in essence: “You self attested that you met MU in year one. You are now being audited to substantiate your attestation.”
  • How many people will be audited after receiving ARRA dollars? How much time will the audit take? For how long will you need to keep records? What records?
  • What will Congress (and the FBI) do when someone gets ARRA dollars through the “incentives” (or avoids “penalties” in the penalty phase), but they haven’t properly completed the MU certification process, or properly/fully documented it (perhaps no fault of their own)?
  • What liability does one incur by claiming to meet MU, but then later discovering that someone in the government says that you have not met MU?
  • Given that one needs to do things for MU that establish X percent of a given function (e.g., Rxs) are accomplished through an EHR, one needs both a numerator and denominator to establish the percentage. But how does one capture the data to establish MU percentages for Rxs (and other tasks) that are done on paper?
  • Are incentive dollars taxable? The answer appears to be “yes.” But many doctors are already “signing over” their dollars to institutions. Unfortunately, neither the doctors nor the institutions are making accommodations for the tax implications. That is, what happens when institutions get the dollars, but because the dollars flow through the clinician, the clinician gets the tax bill?
  • What happens if you change EHRs, for example, due to moving to new practice? Will you have to start all over again? Will you have to reimburse the government?
  • Today there are over 400 EHR vendors. In five years, it is expected that at least 350 will ‘go under’ (no longer exist). What then? Recertify? Give back ARRA dollars?
  • Will the goal line (either in terms of criteria or time) for MU be moved? (It might move; some say it definitely will move.) How often will this occur? What are the implications for your MU and any ARRA dollars that you have received?
  • The Republican “Pledge” is calling for no incentives be spent (including related to HIT).

Of course, my own opinion is that setting standards for "meaningful use" implies that use of EHR's can be meaningful to the doctor & patient (rather than to the government and to payors); the literature is conflicting on this point.

Further, doing do at a time when HIT is widely acknowledged to be of poor usability (even by HIMSS itself) is putting the cart before the horse, as I wrote at my post "
Cart before the horse, again: IOM to study HIT patient safety for ONC; should HITECH be repealed?"

We report; you decide.

-- SS

6 comments:

  1. I have a solo Family Medicine practice, using an EMR since 1997. My solo started in 2004; I bill about $15,000/year straight Medicare.

    I checked with the outreach folks that are to "help" me with MU; and confirmed that the penalty of 1% will never justify to me the rework and horrendous possibilities of "fully" computerizing my practice -- this is incredibly amazing since:

    1) I construct and give a typed note for each visit to each pt, including typed lists of meds, tests, dx.

    2) I use an online scheduler, so I can tell almost instantaneously when I'll be seeing pts and coordinate their care between my 2 offices.

    3) I access the local hospital I admit patients to through their database.

    4) I use a secure portal for patient communications.

    5) I use a commercial grade ePrescribing tool that works reasonably well for refills, but is hideous for new prescriptions.

    This is usable for me, limited hardware and software investment, but it as of now does not qualify for MU -- I doubt I will, but the vendor probably will get to MU before the "penalty phase" kicks in.

    Personally, I don't care, as the system works well (I do outsource billing, BTW).

    I'll take the "hit" as the cost to do MU would be 100x the cost of the penalty.

    Matt in Western PA
    matlev@comcast.net

    ReplyDelete
  2. I have a solo Family Medicine practice, using an EMR since 1997. My solo started in 2004; I bill about $15,000/year straight Medicare.

    I checked with the outreach folks that are to "help" me with MU; and confirmed that the penalty of 1% will never justify to me the rework and horrendous possibilities of "fully" computerizing my practice -- this is incredibly amazing since:

    1) I construct and give a typed note for each visit to each pt, including typed lists of meds, tests, dx.

    2) I use an online scheduler, so I can tell almost instantaneously when I'll be seeing pts and coordinate their care between my 2 offices.

    3) I access the local hospital I admit patients to through their database.

    4) I use a secure portal for patient communications.

    5) I use a commercial grade ePrescribing tool that works reasonably well for refills, but is hideous for new prescriptions.

    This is usable for me, limited hardware and software investment, but it as of now does not qualify for MU -- I doubt I will, but the vendor probably will get to MU before the "penalty phase" kicks in.

    Personally, I don't care, as the system works well (I do outsource billing, BTW).

    I'll take the "hit" as the cost to do MU would be 100x the cost of the penalty.

    Matt in Western PA
    matlev@comcast.net

    ReplyDelete
  3. WSJ Blogs
    HEALTH BLOG

    December 21, 2010, 10:14 AM ET

    Recommended Reading for Health-Care Executives

    “In “Reengineering Health Care: A Manifesto for Radically Rethinking Health Care Delivery,” business writer Jim Champy and Harry Greenspun, chief medical officer of Dell Inc., draw on lessons used by companies like Texas Instruments, Campbell’s Soup and Wal-Mart to offer solutions for health care.

    The book argues for the widespread adoption of new information technology, but warns that technology alone can’t improve health care: The clinicians have to be comfortable with it and engaged in its adoption. At MultiCare Health Systems in Tacoma, Wash., the authors say, it took 10 years to implement an electronic health record. Many lessons were learned the hard way, such as the importance of understanding exactly how the technology will work in the physician’s exam room before installing it.”

    There appears to be the beginning of recognition of the complexities of installing HIT by those who do not have a financial interest in the immediate adoption and sale of this product.

    Steve Lucas

    ReplyDelete
  4. Associated with poor usability are errors. When the focus of attention is on a user unfriendly device, the creativity and pattern recognition cognitive energy, ie intellectual power, is depleted or diverted to the CPOE or EMR device. Mistakes happen via this insidious mechanism.

    Thus, there is errorgenicity of these devices, even if they pass as meaningfully useful.

    What you have in reality are two diseases that are being treated, the patient and her/his disease and the EMr and its disease, clickorrhea and data hide and seek (aka where's Waldo?).

    ReplyDelete
  5. Steve Lucas wrote:

    At MultiCare Health Systems in Tacoma, Wash., the authors say, it took 10 years to implement an electronic health record. Many lessons were learned the hard way, such as the importance of understanding exactly how the technology will work in the physician’s exam room before installing it

    Steve,

    as in my earlier post about Detroit Hospital - these lessons should and could be learned in a library, or through better talent management (e.g., hiring of people into leadership roles who actually know what they're doing as a result of education and experience in medicine and medical informatics).

    Learning these lessons by experimenting on live patients is simply unethical and unacceptable at this point in time.

    -- SS

    ReplyDelete
  6. Anonymous December 22, 2010 4:20:00 PM EST wrote:

    What you have in reality are two diseases that are being treated, the patient and her/his disease and the EMR and its disease

    I quite agree.

    Clinical IT cannot "reform healthcare" until the IT itself, its culture and its artifacts, are themselves reformed.

    -- SS

    ReplyDelete