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DrLyle’s Take on the Meaningful Use Rules 7/30/10

July 30, 2010 News 10 Comments

In mid-July, the government released the final rules on MU and EHR certification. I was actually at the perfect place for this — the annual meeting of AMDIS (Association of Medical Directors of Information Systems). So we had 200 CMIO-type docs and a panel of speakers ready to talk about this topic. HIT geek heaven!

From my bias of focusing on ambulatory EMRs, here is what I learned at this meeting from listening and talking to some very smart people on the topic and reflecting on everything the past few weeks:

Big picture stuff

MU Rules are reasonable. The government listened to the end users and decreased the expectations on the "Core Rules" (decreased the percentage of eRx required), while putting other rules in an optional "Menu" (i.e. choose five of 10). But be aware, anything optional you don’t do in Phase 1 will be required in Phase 2 in 2013 (i.e. you’ll need to do 10/10 from the Menu)… and they will likely think of more things to add by then.

MU Rules are still not a slam dunk. Even for mature users, there will be work that needs to be done. It is hard to believe that a non-mature user, or users without a lot of resources will be able to easily accommodate everything.

The government seems to think this will really work well and we will see over 50% adoption by 2015. I would love that, but am less optimistic. Best quote I have heard is that MU incentives are like giving someone money to have a baby. You will have a baby if you want a baby. The money is a nice extra, but not the main driver. Change is hard, so I am hoping that while we keep asking vendors and users to add functionality, we consider how we can improve usability at the same time. 

I do hope the government is at least working on a secret Plan B in case 2015 comes and we are only at a fraction of where we need to be (e.g. maybe they give money to innovation think tanks to figure out better EMR user interfaces). If you want to read more about the rationale behind having a Plan B, check out the great Kuraitis/Kibbe blog on this topic.

Per John Glaser, we need to think about MU not as a simple, one-time incentive, but rather as a stepping stone to bigger reimbursement reform. In other words, it helps groups create the HIT foundation for alternative care models and payment reform of the future (e.g. Medical Homes, ACOs). In that future, an EMR is no longer a competitive differentiator, but rather how we use our EMRs will be the differentiator (e.g. care efficiency and improvement, use of clinical decision support, secondary use of data, and patient engagement).

Some details that popped out at me

  1. The denominator is now "unique patients" rather than patient visits. So if a patient is seen three times in a year, you just have to fulfill the rule at least once for that patient.
  2. Scoring will be done on an individual physician basis, not on a group-wide analysis.
  3. To correctly measure many of these details (e.g. give clinical summary to 50% of those who ask) we would need to figure out a way to keep track of who "asks". That seems like a strange request for structured data and certainly should not be what a doctor is spending his time doing. So either we need to make it an easy administrative chore or consider doing it for 100% of people automatically.
  4. For patient reminders (for patients over 65), physicians can decide content and format. For example, we can decide to just do colonoscopy reminders and only do it via mailers to patients — it does not have to be electronic. The point is to just prove we can identify patients by age and communicate with them in some way.
  5. Patient education: we need to figure out a way to document when we provide these handouts. Some EMR systems may have that built in, but even then, just for the handouts they have. What if I go online and print something else out? Or give them a special handout I have created? We may need to create a special patient education section to document this, but it is again more busy work for physicians (which I am not a fan of!).
  6. EMR vendors are on the hook. They are required to ensure some level of MU reporting from their EMRs to get certification. The result will likely be that they will be spending a lot of extra time and money preparing their EMRs and then trying to get everyone to take those upgrades. They will then likely just certify the most recent version of their system.
  7. EMR users need to upgrade, due to above point. It is unclear how all current EMR users are going to be able to quickly upgrade their systems in the coming 6-12 months. That takes a lot of planning, time, resources, and money. I wonder if users of "older versions" will band together to try and get their older versions certified, or if the vendor will help at all?

Some good resources

 

Lyle Berkowitz, MD is a practicing internal medicine physician, a healthcare IT consultant (www.DrLyle.com) and founder of the Szollosi Healthcare Innovation Program (www.TheSHIPHome.org). He blogs regularly at The Change Doctor (http://drlyle.blogspot.com/).

Comments 10
  • Superb post, Lyle.

    Only thing I’d mention is that, sadly, I do know some families who conceive babies just for the extra monthly government monies they’ll receive. (I have been told that, directly, by the parents.) I suspect the same will be true for at least some providers, doing it for the money, not because they are really ready for their new “baby.”

    To be raised well, both types of babies take lots of time, love, attention, work, and will dramatically change your day-to-day life! As we’ve all seen for either situation, without the necessary “parental” sacrifice, both have much lower odds for a successful life.

  • Excellent thoughts! Keep ’em coming please!

    Would also appreciate it if you’d elaborate on your comment below:

    MU Rules are still not a slam dunk. Even for mature users, there will be work that needs to be done. It is hard to believe that a non-mature user, or users without a lot of resources will be able to easily accommodate everything.

    What exactly were you thinking?

  • To RustBeltFan… Nothing cryptic in those comments, just stating what I think is pretty obvious- this is not a turn-key, 10 minute application to fill out. Our group has been live for over 7 years, and while I think we have 80% of MU covered, there is the other 20%… For example, we still need to add in a few things (eg how to better document smoking in a structured way, move to full EDI eRx- since we just print them now), create new workflows (eg start offering/giving clinical summaries to our patients, contact pts over 65 with preventive care info), figure out how to track strange things we’ve never formally tracked before (eg specifics on handing out pt ed materials, tracking who asks for their record electronically) and finally, we need to report on all these measures- and even though a certified EMR is supposed to have those reporting tools… I think they will only get us part of the way there. And oh yeah, we need to do a full upgrade to the latest version to make sure we are using a certified EMR! And again, we are mature EMR users with a great group of IT staff… so that does make me think a smaller group with less experience and less staff has an awful lot to do.

  • DrLyle, as one of those in “a smaller group with…less staff” you described it succintly and completely in that we absolutely have “an awful lot to do.” We’re experienced, but as you note, this is no small Mount MU to climb.

  • Lyle,
    My reaction to

    … add functionality, we consider how we can improve usability at the same time. ..

    is strongly YES, there’s strong, broad agreement there.

    My reaction to

    … (e.g. maybe they give money to innovation think tanks to figure out better EMR user interfaces) …

    is strongly NO. The innovation think tanks, as well as vendors as well as home grown sites like Partners have all done concrete work to substantially improve GUIs and the user experience, while adding functionality. Funding, combined with the ARRA/Cert/MU mandates killed every single one of those initiatives.

    How much is the government funding of AHRQ to put resources freely in everyone’s hands speeding up EMR translation and reducing costs?

    The fix, IMHO, is to tune the policy so that it doesn’t squelch innovation.

  • So how many will fulfill the meaningful use challenge?

    I doubt that it’ll be the 50% that is expected by 2015. The way I see it, we’ll see physicians drop Medicaid/Medicare en masse and the MU uptake will be no more than 20%, and possibly it’ll be much less.

    Currently, according to CDC’s report which came out on 12/2009, only 6.3% of physicians have an EHR and are using it in a meaningful way. All I see is an all-or-nothing HITECH Act set of rules that currently hover at an open-book 864 pages which will expand as it enters into the more onerous phase 2 then phase 3. It reimburses physicians not unlike that of computer parts venders that employ “rebates” which notoriously pay out at a 17% level, using 3rd parties. The past P4P Medicare experiments likewise paid out poorly, at a 20% level in one and at a 40% level in another but those that got paid in the latter one averaged only $600 for their troubles over the course of a whole year. Medicare will likewise rely on 3rd parties to administer their HITECH program.

    It’s just much simpler to get rid of all of one’s Medicaid and Medicare patients and either go cash only or see younger HMO and PPO patients. If we’re not allowed to do that, many physicians that I know of will simply retire and go on into alternative careers. End of story…

    Al

  • The way I see it, we’ll see physicians drop Medicaid/Medicare en masse and the MU uptake will be no more than 20%, and possibly it’ll be much less……….It’s just much simpler to get rid of all of one’s Medicaid and Medicare patients and either go cash only or see younger HMO and PPO patients.

    While that is certainly the route some will choose, I doubt it will be en masse. This statement also presumes that HMOs and PPOs don’t jump on the bandwagon and require their providers to be meaningful users of EHR.
    And from I’m hearing, that is NOT the direction Health Plans are going. Honestly, it’s time ALL healthcare clinicians “get over it” and start using tools that benefit patient care. I know they’re not perfect yet, but we are at least moving forward. The sooner we can all work together (that means vendors, providers, health plans, consultants, government, etc. etc.) the faster we’ll get there and the better off we’ll all be. We’re not working together yet. We’re still in our separate corners. We’re still mostly focused on What’s In It For Me.

  • In the Washington, DC area where I live, it’s already started. Medicaid patients can’t find PCP providers, and if they do, it’s to be seen by a nurse practitioner or physician assistant, usually in a free clinic setting. Medicare patients are increasingly finding it difficult to find a physician too. I have yet to go the non-par route yet, but will by next year… I’ve been swamped by new Medicare patients.

    There are many rumors, and the one that would really piss me off is if my state of Virginia goes the route of West Virginia and Massachusetts, both of who are contemplating forcing physicians to see these Medicare/Medicaid (M/M) patients as part of the licensure process. In 1985 the MA Med Society and the AMA lost a decision concerning balanced billing. It went all the way up to the Supreme Court, which refused to hear it. Now “anti-social acts” which in 1985 was specifically about balanced billing to what is being added on now- refusing to see the elderly or the poor, even if it puts physician offices out of business, is synonymous with “unfitness,” and can be added as a prerequisite to being licensed. The Massachusetts bill, which failed to be enacted, is about forcing participation and actually seeing a certain amount of M/M patients, s.a. 15% of one’s practice. This type of forced-servitude bill means that the physicians’ license to practice medicine is held in servitude to state-perceived medical needs. If it eventually does pass, these M/M patients would invariably be given exact 5-10 minute slots and be seen universally by PAs and NPs. They would be forced to wait for hours. It wouldn’t be a pretty sight. Slavery supposedly died 150 years ago- I’m surprised that it’s being resurrected again.

    >>> it’s time ALL healthcare clinicians “get over it” and start using tools that benefit patient care.

    The scientific method still is pertinent- show me a randomized, prospective study pitting the EHR vs a “basic EMR” and/or paper with the end point being not just “benefit patient care” but actually decreased errors, increased quality, decreased costs, and most importantly, an increased survival benefit and I’ll be the first to go on-board with the EHR concept. Many of the studies that I’ve read show either no statistical difference or a worsening of all of these parameters with the use of EHR.

    RustBeltFan, we don’t need to “get there” just because vendors will benefit economically from physician usage of their products. We don’t need to have heavily lobbied politicians trying to force one industry (physicians) to capitulate to another (vendors) just because of a perceived future windfall for the latter. That’s not right and it’ll never work- docs will see right through it and not buy-in.

    The fact remains that healthcare in the USA is the best in the world. Stop trying to fix something that’s not broken.

    AL

  • The fact remains that healthcare in the USA is the best in the world. Stop trying to fix something that’s not broken.

    Al, I don’t think the statistics bear that out.
    The U.S. health system spends a higher portion of its gross domestic product than any other country but ranks 37 out of 191 countries according to its performance, the [WHO]report finds.

    I’m not trying to get into a “pissing” match, just pointing out that when a larger purchaser of any product (cars, healthcare, etc.) wants deliverables a certain way, that’s what they’ll likely get. Look what happened in the auto industry. Suppliers who wanted to stay in the game, had to march to the Autos tune. You are a supplier. Medicare is a buyer of your services. That means they have a right to ask their suppliers to use certain tools, meet certain threshholds, etc. etc. You always have the right to provide or withhold the services you produce, but it may limit those who will buy from you. Just the facts.

  • >>> You always have the right to provide or withhold the services you produce, but it may limit those who will buy from you. Just the facts.

    Medicare is not an auto dealer- it represents big government which unfortunately doesn’t play by the simple rules of supply and demand. We’ll agree on the above issue, which is why this year when my older partner retired, I’ve decided to stay solo, so as to pare down to the best paying patients and decrease my overall exposure to the socialized medicine plans that are coming down the road. This is the reason why I’m telling my son and those that I care about to NOT go into medicine.

    When an entity (CMS/Medicare) cuts what it pays its providers and demands increased bureaucracy without paying for that effort, then this will restrict the capability of the system of providers from providing the needed services. In 10 years there will be a shortfall of some 150000 providers. Where is that going to come from? If things continue to progress in this manner, I feel that the shortage will be larger, and as seen in Massachusetts, the waiting lines will reach some 60 days or so just to see a PCP.

    Al

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