opinion

Fast could lead to furious over EHR meaningful use

CMS' schedule for physicians to show electronic health record proficiency is too ambitious given system limitations and issues that haven't been addressed from stage 1.

Posted Feb. 18, 2013.

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The first stage of the federal meaningful use program, covering physician adoption of electronic health records, has not been completed. Yet already the Centers for Medicare & Medicaid Services not only is rolling out proposals for the second stage but also is talking about what is going to be in the third and final stage of the program.

While meaningful use certainly has encouraged physicians to adopt EHRs, to some extent stage 2 and most definitely stage 3 demand physicians to reach standards that are nearly impossible to meet in full. And yet, at stage 3, doctors will have to be at 100% compliance in some measures to meet the standards. The program requires doctors to buy potentially expensive technology that they then must configure and adapt to meaningful use requirements. This is even though those systems might not be right for their practice and aren't capable of doing the things that CMS requires of doctors. On top of that, all of this must be done in the next three years.

That is an ambitious schedule not required by law but by regulators at CMS. The agency would do well to take a breather. Outside help should be enlisted to review how the meaningful use program has gone so far. Then, substantive change can be made to requirements so meaningful use of EHRs really does mean better and more efficient care, and not just lots of meaningless data entry and technological frustration.

The meaningful use program, borne out of the Health Information Technology for Economic and Clinical Health Act in 2009, pays physicians and other eligible professionals up to $44,000 over four years in Medicare bonuses or $63,750 in six years in Medicaid bonuses for attesting, or proving, to CMS that they are meeting certain requirements using EHRs. If Medicare physicians don't participate by Oct. 1, 2014, they get 1% knocked off their payments. There is no Medicaid penalty.

The first stage, which has the least stringent requirements, has succeeded in pushing doctors to adopt EHRs. By some counts, 75% of practicing physicians now have access to an EHR. CMS says that as of December 2012, about 175,000 physicians and eligible professionals had received $3.3 billion in meaningful use payments, and another 175,000 have registered for the program. Many more are expected to register.

Despite that success, some flaws in the system have emerged. For example, the 2009 federal stimulus package required the development of interoperability standards for health information exchange in a secure, private manner. That has not happened. A survey by the Bipartisan Policy Center found that 70% of clinicians identify a lack of interoperability, lack of an information exchange infrastructure, and the cost of setting up and maintaining interfaces and exchanges (to overcome the lack of interoperability) as major barriers to EHR use. Still, stages 2 and 3 accelerate the requirements for physicians to share information, even though, technically, in many cases it isn't possible without the doctor taking time to manually re-enter and send information.

Another flaw is that the program is very primary care-centric, with specialities having to collect information that is of little use to them to meet requirements under the later stages. Also, usability of technology has become a major concern, with physicians reporting that EHRs certified by the Health and Human Services Office of the National Coordinator for Health Information Technology fail to match their clinical needs and can contribute to coding and patient safety issues.

Before CMS talks further about stage 3, whose requirements are in a preliminary phase, it should address these concerns to make sure that physicians have access to systems that truly are meaningful to improving care. Physicians shouldn't be required to meet mandates on exchanging information when systems aren't capable of doing it. Doctors should be able to opt out of meaningful use measures that don't apply to what they do. Additional measures for meaningful use should be held off so vendors can fix the problems current systems have.

Before implementing stage 2 (which starts in 2014) and stage 3, CMS should have an independent evaluation conducted of stage 1 and share those results with the public so everyone can learn what went wrong, what went right and what is the best course going forward.

That all takes time, but the meaningful use schedule would be better for it. It would help to ensure that EHRs reach their best potential, not become one more rightfully resented bureaucratic hassle.

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External links

AMA resources on health information technology (link)

AMA on meaningful use stage 3 EHR program, including Jan. 14 comment letter (link)

December 2012 EHR incentive program report, Centers for Medicare & Medicaid Services (link)

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