Meaningful Use — Doctors Have No Choice

By James O'Connor, MD | November 12, 2010

EHR vendors, consultants, regulators, and even some CIOs have giddily promoted the EHR incentive program (“meaningful use”) for nearly a year. Countless businesses and blogs have been born to fulfill the need to ingest and digest compliance information. In-your-face marketing has been a powerful current sweeping doctors towards choosing an EHR system or meaningful use consultant.

Physicians’ responses are all over the map. A surprising number of our colleagues still don’t know about meaningful use. Some doctors plan to ignore it altogether. (It appears that the fewer the number of years to retirement, the greater the apathy towards meaningful use.) Some practices are optimistically and enthusiastically making plans. Others are revealing their ambivalence, wrestling with the question “should we or shouldn’t we?”

I whole-heartedly support the adoption of electronic health records. I was an early adopter in my own practice and have spent a good deal of time in the industry. I am aware that the majority of my colleagues remain resistant to EHRs. Government incentives are a positive way to initiate widespread adoption. Meaningful use has its flaws, but the stimulus will fuel innovation in healthcare IT, potentially creating a powerful engine for economic recovery.

On the other hand, meaningful use places a burden on doctors with little direct return on investment. In most cases, the incentive will not cover the real cost of adoption, which includes more than just hardware and software. There is a well-documented productivity loss in the first 12 to 18 months after adoption of an EHR. It is widely reported that compliance with meaningful use will require medical practices to hire additional staff. Experts predict a shortage of staff with requisite skills. Meaningful use coincides with the planned elimination of the consult code and looming 21 percent cut in Medicare reimbursement.

Nonetheless, the pros and cons of meaningful use are not really the problem. The problem is that, once again, we physicians are subject to a mandate over which we have little control and no choice whether to comply. Is this surprising to you? Consider these facts:

1. CMS penalties begin in 2015.
2. What if you won’t or don’t accept Medicare/Medicaid patients (13 percent of practices in 2009, up from 6 percent in 2004? In August, four major insurers (Aetna, Highmark, United Health Group, and Wellpoint) announced that, at a minimum, they will link their pay-for-performance programs to federal meaningful use criteria. Other insurers are likely to follow.
3. Do you run one of the increasing number of “boutique” or VIP practices that work on a cash-only basis? The American Board of Medical Specialties (ABMS) released a statement in August saying that they intend to link meaningful use of health information technology into the ABMS Maintenance of Certification© program.
4. You don’t care about being board certified? (Sound of crickets chirping.) The Final Rule gives states the authority to impose additional requirements that promote compliance with meaningful use. As reported in Physicians Practice, the state of Massachusetts may take away your license to practice medicine in 2015 unless you demonstrate meaningful use of an EHR system. In Maryland, private insurers will be required to build incentives for acquisition of EHRs and penalties for not adopting them into their payment structure.

OK, so technically, we do have a choice. We could stop taking Medicare and Medicaid patients, accept cash only, give up our board certification (and thus usually hospital privileges), and move to a state (or country) that doesn’t impose EHR requirements. But is that really a choice? No. Our only real choice is action. Here are a few suggestions:

1. Submit comments to the Office of the National Coordinator (ONC). Although meaningful use is not likely to be repealed (even with the recent change of guard in the House), the 276-page Final Rule shows that ONC is at least considering and responding to comments. Some comments actually yielded changes in the Final Rule.
2. Contact your specialty organization and initiate a grassroots movement to push back against the ABMS mandates. Larger specialty organizations, such as those for family practice and cardiology, may be able to influence ABMS to repeal the requirement or at least gain reprieve.
3. Get your state medical association involved. Those in Idaho, Wyoming, and Texas may even be powerful enough to prevent state involvement in meaningful use.
4. Call your state legislators and let them know you expect them to protect doctors’ interests.

The final choice — watchful waiting — may seem like capitulation. But there are two reasons this may be the wisest course. First, there are many who doubt CMS’ ability to deliver on the incentives. Small practices can probably wait until early- to mid-Spring 2011 to see what develops and still have enough time left in the year to choose an EHR and qualify for the 2011 incentive. Second, EHR vendors have a huge stake in this market. Vendors will have to introduce innovation into their offerings in order to distinguish themselves and win your business. The right innovation could make this pill easier to swallow.

James O'Connor is an OB/GYN, founder of MDcohort LLC, and co-chair of CCHIT's Clinical Research Group.

Do you agree with Dr. O'Connor?

by Alfred Harding | December 01, 2010 11:17 AM EST

One of the ways to tie lab system together is by using the LOINC standard. This way, lab results may be received from many different lab companies, but the resultant data will be uniform in the providers EHR.

These values can then be trended and displayed on flow sheets so that the provider can look across time. Since all the data is in the system is uniform, it does not matter where the data originated.

It could have come from an number of different lab companies, you HIE, another practice, etc.

Other standards such as SNOWMED and Medicin are also being used for other areas of the EHR so that other types of data in the EHR can also be uniform.

Alfred Harding
CEO
CL Medical Consulting
Lubbock, TX

by Robert Coli, MD | November 26, 2010 1:15 PM EST

Normal 0

Dr. O'Connor,

I completely agree that if a buyer's market for ambulatory and hospital EHRs does develop in the U.S., vendor survival and prosperity will require them to overcome two main challenges---achieving and maintaining federal certification and introducing usability and workflow-enhancing innovations into their offerings. From a physician-user perspective, one of the first innovations EHR and HIE platform vendors should develop is a solution for a clinical application software defect that has created significant problems in patient care processes since clinical computing was first introduced into hospitals in the 1960s.

The problem, familiar to every practicing physician who orders diagnostic tests, is that existing EHR and HIE platforms still use infinitely variable formats to report cumulative test results as fragmented data that is incomplete and hard to read. This is a serious systemic "unsafe condition" that increases the probability of producing all three types of adverse EHR "events" recently described by the iHealth Alliance and its EHRevent.org Safety Event Reporting Service. This flawed and anachronistic test results reporting process endangers patient safety by disrupting physician thought flow, workflow and care flow, wastes time by making it difficult to find individual test results and follow trends and wastes money by contributing to duplicative, redundant and non-contributory testing.

Fortunately, as Ronald Reagan famously noted, "There are simple solutions, just no easy solutions." The simple, vendor and platform-neutral solution is to use a standard reporting format that enables clinically integrated, easily read test results information to be displayed on up to 80 percent fewer screens. Independent, privately funded efforts to develop this physician and patient-friendly functionality in leading EHR and HIE platforms have been underway since Dr. David Brailer was appointed as the first ONC Director in 2004. Predictably, they have encountered all of the usual barriers to disruptive technology innovation so well described by Clayton Christensen in "The Innovator's Prescription."

The efforts will continue for two compelling reasons. First, because standardizing and clinically integrating cumulative test results reporting to facilitate efficient viewing and sharing of this key clinical patient information will help all physicians improve patient safety, deliver higher quality care and reduce its cost. Second, this is one practical IT innovation that could make the MU pill easier to swallow for physicians and help win business for the vendors who offer it.

Bob Coli, MD

by Doug Mitchell | November 20, 2010 5:14 PM EST

Though PCs were available and affordable, I went without while an engineering student in the early 90s. I worked by hand, on graph paper, and only when required used the school's computer lab. Meanwhile, my brother in high school had a PC. It was a glorified typewriter. Today, computers are essential to both my brother and me. And the ones from the early 90s wouldn't cut it now. Like many people, we made ill-informed technology choices. He should have "waited watchfully," and I should have invested. And like others, we learned in time what technology we needed -- and the market answered. The software industry in general has been rapidly, innovatively responsive. I trust EHR vendors can be, too -- in a *rational* market. Many should act now. But others shouldn't fear a rational decision to wait and watch (except, maybe, in MA). By 2015, the MU requirements will seem quaint.

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