Georgia L. Newman, MD

When I last wrote of the trials and tribulations of Meaningful Use

, I had just failed to attest due to inadequate numbers for "prescription eligibility verification," "electronic summaries of care," and "viewing document images rather than reports."  That was in January 2015, after I had worked and massaged my 2014 information for three months in order to attest successfully.

My EHR vendor maintains a Meaningful Use dashboard, and by July of last year, I could see that in the new Stage 2 measures for 2015, physicians no longer had to include the prescription verification or images.  After that, I then entered the "LOOP OF DEATH," in which multiple attempts to enter the system were met by the same message that my user name and/or password were not correct.  Many password changes later, I was still unsuccessful.  All the while, the system was closed for submission while the new measures were being discussed [by regulators].  I subsequently found by talking to a real person (after 40 minutes on hold), that my difficulties in registration had been due to entering my name as Georgia, rather than georgia.  To enter the CMS Enterprise system, Georgia worked fine, but for Meaningful Use, font case mattered. I will not belabor my difficulties with the enterprise system attempting to view my 2014 Physician Quality Reporting System (PQRS) data, except to say that my office manager and I have EACH spent more than three hours trying to penetrate the obfuscation and obtain my Provider Transaction Access Number (PTAN) number, without which, no data is forthcoming. We are still waiting.

On the positive side, I successfully attested in January 2016 for the last 90 days of 2015.  Only private physicians struggling with this mess can truly appreciate the work involved.  Employed physicians usually have behind the scenes people who are working on it for them.

This year, 2016, the attestation period is the entire year. I 

 do nothing and report on the same measures, just for a longer period.  However, in the interim, I have joined an Accountable Care Organization (ACO). I am still a solo physician, affiliated with the mother organization, but not employed.  We’re now talking about reporting on quality to CMS and rather than using Meaningful Use measures, we have selected several additional, different measures.  We may also be reporting on various Healthcare Effectiveness Data and Information Set (HEDIS) measures, as well as continuing to report on PQRS. I have argued, in vain, that we need to select measures that are THE SAME for all of these entities, but the people in charge, who have obviously not struggled with Meaningful Use at all, haven't listened.  Again, as a solo physician without IT support, I have to figure out how to incorporate all of this, so that the system will report it.

I, for one, cannot WAIT until we have a single payer system, with  per member, per month payment based on acuity, age, etc. and with clearly defined quality metrics, embedded in our EHRs.  The current system is a mess. Of course, if the single payer system is CMS, we are screwed.

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Meaningful Use continues to be a pain in the neck for one doctor, who is struggling to attest as a private practice physician.

More Meaningful Use Misery from One Doc

, an internist and geriatrician, as well as a member of the 

Physician Advisory Board, offers her review of the recent PBS documentary 

As I watched Rx: The Quiet Revolution, an excellent PBS program, I could see several truths emerging. The documentary began with one solo physician in Maine, who was dedicated and trying to spend quality time with patients to encourage them to adopt healthier lifestyles and take better care of themselves. He represented the best of traditional healthcare delivery. Yet the Mississippi delta diabetes telemonitoring project and the developing system of interlocked healthcare in rural Alaska that were also featured in the program were reaching more patients in a much more robust manner than the solo physician.

The documentary took us to Belfast, Maine, where we watched an extremely morbidly obese patient lumber painfully to a chair and sit heavily. The solo physician encouraged her repetitively to "get up and walk" to be healthier, and her husband with neglected diabetes to "eat better." "We're not rabbits," replied the wife.

It's going to take a village to help this couple.

As I watched the doctor also taking house calls on a motorbike, and counseling recovering addicts on suboxone, I could see that in remote Maine, this physician needed to play many roles and was the closest thing to Marcus Welby, MD, imaginable.

Well-meaning physicians are not going to be able to get the job done acting alone. Teamwork is the answer to future care in America. Personalized connection, motivational interviewing, and high-touch care are critically important for engagement, but there aren't enough hours in the day for the physician to "do it all."

The Mississippi experience using in-home telemedicine monitoring, also featured in the documentary, seemed more able to effect change. Responding quickly to blood sugar values enabled a practitioner to adjust regimens on the fly and to show patients at home that someone cared about them.

Instead of the motorbike in Maine, why not an Internet connection? (Unless the motorbike represents protected time for renewal and relaxation.)

In Alaska, the documentary featured a native population that was migrating from being passive recipients of primarily emergency room care to being more active participant-owners in their care using health coordinators and locally-based practitioners.

That experience was also enlightening and is also moving the needle in the right direction. Creating tribal pride and reinvigorating customs and rituals discarded under the  Bureau of Indian Affairs is slowly restoring self-worth and caring, necessary for healthy lifestyle changes.

As an internist/geriatrician, I thought the On Lok home in San Francisco shown in the documentary provided one of the best alternatives to a nursing home I have seen.

We are struggling with increasing numbers of demented elders at Kendal at Oberlin, the retirement community where I am medical director. Currently, we have an open concept, with independent cottage dwellers walking through the nursing home corridors to get to dinner and the main building. With wandering demented residents, this is no longer safe or ideal. We are thinking about a "Green House" concept with a central living room/kitchen/dining room and surrounding bedrooms, so that the residents have privacy but feel that they are living in a home with chores and shared work.

Atul Gawande compellingly writes in his book "Being Mortal," 

 wants to go into a nursing home. We need innovative alternatives so that when you and I are old and frail, 

This fascinating documentary, about improving care while saving money, can teach physicians - and America - a great deal.

'The Quiet Revolution': A Physician's Reaction

As a lifetime holder of an internal medicine certificate  (certified in 1974, recertified in 1980  -before it became mandatory and onerous), I left the path of safety when I decided to take the American Board of Internal Medicine's (ABIM's) offer to certify in geriatrics based on years of experience rather than a fellowship. I passed the exam in 1988, and joined the ranks of those rankled by maintenance of certification (MOC).

Initially, the MOC programs were fairly harmless and consisted of "modules" - self-study programs taken at home. By 2004, the ABIM began adding elements to the "eligibility" to take the exam. The first elements consisted of a practice assessment and a patient survey.

The practice assessment was disease-oriented, consisting of paper chart reviews of 35 patients with a certain disease. I chose diabetes, since I have a fairly large diabetic practice. So I laboriously entered demographic information: A1C, blood pressure, smoking status, lipid levels, foot exams, and eye exams into a data sheet. I quickly discovered that blood pressures weren't ideal, I wasn't performing a foot exam on everyone, and the eye exams were a joke. Patients 

 have had the exams, but the results were languishing in the ophthalmologists' offices, not in mine. I could 

 that the patient have the exam, but that was about all I could do.

The second part of the assessment was to improve something. I picked foot exams and was able to show by another laborious chart review six months later that I was doing better. The benefit of all this was that my numbers were good enough to get me certified by the National Committee for Quality Assurance (NCQA) as a diabetic provider (plus a $1,500 fee paid). Unfortunately, other than having a certificate to frame, the NCQA certificate turned out to be essentially worthless.

The patient surveys were a joke. I got a big box of surveys and passed them out to patients asking them to call the number or go online. After all were passed out, the number returned was less than the minimum required, so lots of time wasted for 

After the 2009 recertification exam, there were ominous rumblings from ABIM that more "elements" were coming and that we had better start right away to get them all done in 10 years. So in 2012, I started a practice assessment, an incredibly time-consuming, completely in-depth look at all facets of my practice. It was so lengthy and involved I have completely blocked it out of my memory. I completed it for 20 points.

 diabetes assessment in 2013 for 40 points; .worked on blood pressure control on that one.

Then the bombshell: ABIM re-invented itself in 2014 and suddenly by 2017 I had to complete a MOC activity, and by 2018, I had to do 

 practice assessment as well as a "patient voice activity," whatever that is. This is despite the 

 from all the above activities plus Medical Knowledge Self-Assessment Programs from the American College of Physicians I have accrued since my last certifying exam in 2009. (Required points to take exam: 100).

Is it any wonder that the MOC program ranks below ISIS in physician's minds?

 when it comes to its MOC program; but it may be too late. Most physicians are disgusted by what they perceive as a huge work burden, often with little connection to daily work, with no understanding of the parallel work required by insurance, hospitals, and medical employers, yet has generated millions of dollars of profit for ABIM.

My motto has always been: "Self-correction is the mark of a true professional." Sure, there are bad apples in every barrel, but the average physician is on the line 

 to make the correct diagnosis and do the right thing in the face of chronic uncertainty. Those who cannot keep up, or take the pressure of practice eventually burn out, retire early, or could wind up being employed by one of these MOC boards.

is an internist and geriatrician at Oberlin Internal Medicine Associates in Oberlin, Ohio. A self-described medicine "junkie," Newman has practiced for 40 years and is also a member of the 

So the ABIM admits they got it wrong when it comes to maintenance of certification. Great, but what about my experiences over the past decade?

Author | Georgia L. Newman, MD

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