Some fear EHR meaningful use is too much, too soon for doctors

Even before requirements for the second stage of the federal electronic health record incentive programs were finalized, many in the health care industry expressed concern that the promise of a bonus check was pushing some physicians to move too quickly with their transitions from paper.

Their arguments were that by doing too much too quickly, work flow efficiencies and patient safety could decline, because physicians adopting for the first time would be too focused on checking things off a list of meaningful use objectives instead of easing into a new way of practicing medicine.

If rapid adoption is truly a cause for concern, a study in the January/February issue of Annals of Family Medicine shows which states would be playing catch-up the fastest. It found that when the meaningful use incentive program started, some states already had the majority of their family physicians using technology, according to administrative data from the American Board of Family Medicine. Utah had an adoption rate of 94.9%, but Florida, Illinois and Michigan lagged far behind, with less than half using some form of electronic health record system.

Adoption rates climbing rapidly

Because of the introduction of the meaningful use incentive program, which went into effect in 2011, EHR adoption rates are moving more quickly than data collection can keep pace. The Annals report, for example, used the most recent data available — from the ABFM and the National Ambulatory Medical Care Survey of family practices. Both sets were from 2011.

There’s no true comparison to the data in the Annals study, which looked at only family physicians, and other, more recent data sets that look at EHR adoption among physicians overall. However, newer information, which also studies how the meaningful use money has been paid out, gives some indication of the rapid pace at which physicians are adopting in some states.

In Michigan, as of Dec. 31, 2012, 63% of those eligible for the Medicare bonus and 37% of those eligible for the Medicaid bonus had received checks, according to the Dept. of Health and Human Services Office of the National Coordinator for Health Information Technology. While the HHS figures include all physicians, experts believe they show how quickly primary care doctors have adopted EHRs since 2011.

In Ohio, which also was identified as a low adoption state in the Annals study, 58% of the physicians eligible for the Medicare incentive program and 42% of those eligible for the Medicaid program already had received an incentive check as of Dec. 31, 2012.

However, Brian Bachelder, MD, a board member of the Ohio Academy of Family Physicians, said he has concerns about the success of the practices adopting for the first time to receive meaningful use funds. He was an early adopter of EHRs and said it was a time-consuming process because he wanted “to get it right.”

“With this program, it does require a rather rapid adoption,” Dr. Bachelder said. “You think one year is plenty of time and it’s not … especially if you’re talking about starting from square one.”

Organized medicine wants more time

Several medical organizations, including the American Medical Association, have argued that stage 3 of the meaningful use program is asking for too much too soon, and the systems may not even be ready to deliver.

In a Jan. 14 letter to Farzad Mostashari, MD, national coordinator for health information technology, AMA Executive Vice President and CEO James L. Madara, MD, said the Association was worried about physicians moving “full speed ahead” when many barriers had not been addressed. He said many systems still have usability issues. There also are health IT infrastructure flaws that do not yet allow information to flow freely among physicians.

The AMA and others shared concern with proposed stage 3 requirements that nearly double the number of measures a practice must meet for every eligible patient encounter. Failure to meet a measure by just 1% would cause a physician not only to miss out on the incentive pay but also to face the same penalties as a physician who made no effort to adopt an EHR.

Meeting every stage of the program can earn physicians up to $44,000 for the Medicare program or $63,750 from Medicaid. A 1% Medicare penalty takes effect for eligible physicians not adequately using the technology by October 2014; there is no Medicaid penalty. The third and final stage of meaningful use is set to begin in 2016.

Scot Silverstein, MD, an adjunct professor of health informatics at Drexel University in Philadelphia, has argued that physicians are being pushed to use systems that have not been proven to prevent mistakes. Dr. Silverstein, who also writes the Health Care Renewal blog, has published many posts about the dangers of rapid EHR adoption, including one from January 2010 in which he took issue with the use of the term “meaningful use.”

“If we don’t know if [health IT] is beneficial, or have doubts, then such a term presupposes that health IT is inherently beneficial,” he wrote. “A better term would have been ‘good faith use’ — use based on the faith or hope that health IT will have an overall positive effect.”

Staged approach

It has been three years since Fred Van Alstine, MD, a solo family physician in Owosso, Mich., adopted an EHR system. For two years, he focused on learning the new system and figuring out how it fit into the physician-patient dynamic. During that time, he struggled to get back to his pre-EHR productivity until he conceded that he needed to hire a scribe.

Dr. Van Alstine was able to attest to meaningful use last year, but he said he can’t imagine the result had he been going after meaningful use those first two years. He said he would advise any practice going through EHR adoption to “not do it for the money,” but focus on doing what it has to do to make the adoption stick.

Angie Lawrence, on the other hand, has seen many physicians start the adoption process during the past two years as a direct result of the meaningful use program. She is operations manager for the Michigan Center for Effective IT Adoption, the state’s federally sanctioned regional extension center.

Lawrence considers the program a good way for physicians not only to adopt an EHR but also for them to expose — and fix — problems the practice may have had before going electronic. She said the incentive program is a good road map to follow when adopting because of its “staged approach.”

With the right support, Lawrence said, practices can make the necessary changes and meet meaningful use requirements. The federal government had the same opinion when it created the regional extension centers under the Health Information Technology for Economic and Clinical Health Act, the same legislation that created the incentive program. Sixty-two RECs were established across the country to help small practices choose and implement the right EHR.

Lawrence cited a Government Accountability Office report in July 2012 that found practices working with an REC were three times more likely to receive an incentive compared with those that went alone.

Family physician Evan Saulino, MD, president-elect of the Oregon Academy of Family Physicians, said it’s not uncommon for practices to take a year or two after adoption before physicians and staff feel they know what they are doing. Oregon was identified in the Annals report as far ahead of the national average for EHR adoption. Getting back to pre-EHR levels of productivity in less than a year is “really tough to do,” he said.

But meaningful use not only provides the motivation, through the incentives, but also an organized plan for physicians to follow, he said.

“The money associated with it does sort of push the changes along. It doesn’t necessarily make the changes comfortable for folks, but at least it’s not generally a piecemeal effort to do,” he said.

Dan Paoleti, CEO of Ohio Health Information Partnership, agrees the changes that come with meeting meaningful use are “scary.”

“It’s all very doable, but it’s a challenge,” he said. He added that challenging doesn’t mean wrong, or that the practices or the patients they serve are suffering.