Meaningful use’s stage 2: A recipe for failure

The proposed next stage of the EHR incentive program promises to be so burdensome as to discourage embracing the technology it is attempting to promote.

Posted June 11, 2012.

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Winning over skeptics was, no doubt, a big consideration in crafting the first stage of the federal electronic health records incentive program. The requirements were substantial, but for many physicians, they also appeared to be achievable. With stage 2 on its way, the new unrealistic demands of the program now seem better suited to creating cynics.

Tens of thousands of physicians have implemented EHRs and registered them for the Medicare or Medicaid bonuses available to meaningful users of the technology. Many more doctors have determined for a multitude of reasons that they are not able to make the paperless leap just yet. After all, achieving meaningful use during stage 1 requires not just installing and training on a costly new system but also using that system to meet numerous performance measures in a way that satisfies federal minimums.

And even as physicians work hard to comply with all of the stage 1 requirements and anxiously await word as to whether they will obtain any bonuses as a result of all their efforts, the government is moving aggressively ahead with plans for stage 2. That new phase, which for some physicians will start in 2014, is on track to be much more demanding than the first one.

In fact, the proposal in its current form is just too demanding, and physicians can see that clearly. That’s why the American Medical Association and more than 100 state and specialty medical societies sent formal comments to the Centers for Medicare & Medicaid Services calling for significant revisions to the agency’s proposed rule outlining stage 2 before the system can proceed to that advanced level.As the rule stands, the number of core performance measures — functions that a practice must use its EHR to complete a certain number of times or for a certain percentage of patient encounters — is increasing, and the minimum thresholds for those measures are increasing as well. The shift is being done in a way that would leave too little room for error and raise the chances too high that a practice will come up short on one or more key measures, rendering it ineligible for the thousands of dollars of bonus money that it was counting on to help recoup its substantial EHR investment.In many cases, physicians might be unable to hit the minimum thresholds through absolutely no fault of their own. For instance, if a doctor is required to send a certain percentage of laboratory reports electronically but few labs in the area have the health information exchange technology to accept the data directly from physician EHRs, that doctor will have a difficult time meeting the requirement. He or she might be able to have staff enter the data manually, but that cumbersome process will more than erase any efficiency that using an EHR might offer.

Several meaningful use measures also require a certain portion of patients to use paperless technology offered by a practice for the physicians to make their minimums. There’s only so much guidance and encouragement that physicians can give when it comes to patient behavior, and beyond that, matters are out of doctors’ hands. Physicians have enough trouble getting patients to follow their clinical instructions, and it’s not fair to doctors to demand that they enforce patient adherence in this area as well.

For physicians who do encounter such insurmountable barriers to compliance, the proposed stage 2 requirements offer them too few options other than resigning themselves to the fact that meaningful use is going to be unattainable. Part of the problem is that the government has not surveyed physicians who have elected not to participate in stage 1 to see where the real barriers to participation are and adjust the next stage accordingly. If widespread adoption of EHRs truly is the goal of the incentive program, any undue restrictions on doctor participation must be identified and eliminated before physicians should be expected to step up their EHR game.

Organized medicine knows before such a survey is taken that some changes are needed for stage 2 to work. Doctors need to be given more flexibility on meeting minimum measures and more opportunities to be excluded from measures they can’t meet. Possible reasons for these exceptions could include a lack of necessary information exchanges, shortfalls of third parties, or measures that are not relevant to particular doctors’ practices.

Many physicians want to be active participants in the switch to paperless records. That’s why significant good-faith efforts to meet stage 2 requirements should be taken into account when determining compliance, not simply whether practices hit every single minimum under all 20 performance measures. For physicians who truly can’t make the switch by 2014, a sufficient number of exemption categories must be in place so those doctors avoid the Medicare pay penalties that will apply for a failure to meet the meaningful use mandate.

The evolution of the EHR program need not be one that physicians dread, and it can be one that they look forward to being a part of. But if that is the case, then the next stage must be marked not by its burdensome level of rigidity, but by well-founded injections of flexibility and reality.

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