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Stage 3 MU Steadily Loses Favor as EHR Usability Concerns Rise

Can the current plans for Stage 3 meaningful use survive the sustained storm of criticism sweeping through the healthcare industry?

By Jennifer Bresnick

- Support for Stage 3 meaningful use is ebbing to an all-time low as medical societies and prominent stakeholders continue to push back against the program’s ambitious – and some say untenable – implementation timeline and requirements. 

Stage 3 meaningful use and EHR usability

As deep concerns about EHR usability upstage any lingering enthusiasm for the EHR Incentive Programs, it may be time for rule makers to consider whether or not unhappy providers really do have the capability to make the leap to Stage 3 without extreme hardship.

“To Texas physicians, it appears the Centers for Medicare & Medicaid Services (CMS) and other federal agencies never seem to tire in their campaigns to heap more useless requirements onto physicians’ practices,” the Texas Medical Association (TMA) said bluntly in a letter addressed to Senator John Cornyn (R-TX). 

“Meaningful Use started out as a well-intentioned attempt to give physicians incentives to adopt electronic health records. No federal program ever bore a more inaccurate name than ‘Meaningful Use.’ It’s no surprise that physicians around the country have begun calling it ‘Meaningless Abuse,’” the letter continues.

The Texas Medical Association has previously opposed mandates it deems useless or harmful to its 48,000-strong membership, campaigning vehemently against ICD-10 implementation during the run up to the transition, but isn’t entirely opposed to what meaningful use and other healthcare reform efforts are trying to accomplish.  In February, the society formed a partnership with Blue Cross Blue Shield of Texas to bring accountable care skills and health IT tools to local physicians.

READ MORE: ONC Offers $75K for Better EHR Patient Matching Algorithms

The Association has even argued for stronger oversight in the realm of patient safety – which is necessary because of the risks posed by convoluted, inaccessible, and barely usable electronic health records. 

“Until EHR systems truly add value to medical care and can seamlessly interact with other systems, we want Congress to reform the program and eliminate federal mandates that compel physicians to engage in unnecessary activities and reporting.”

TMA isn’t the only physician group grumbling about the upcoming mandate.  The American Academy of Family Physicians (AAFP) has developed an online template that makes it easy for its members to urge Congress to pause Stage 3 meaningful use “before a well-intentioned program drives away the professionals it seeks to help.”

The grassroots campaign follows a number of more formal efforts by the AAFP to hit the brakes on Stage 3.  In September, the organization added its voice to those of forty other professional societies, including the AMA, asking HHS to halt publication of the Stage 3 final rule. 

While the letter did not succeed in preventing the release of the document, the AAFP doubled down on its criticism of federal leadership by shooting off a sharp letter to the ONC saying that family physicians are not to blame for the lack of health data interoperability that makes Stage 3 such an impossible proposition.

READ MORE: New Medical Scribe Exam Keeps an Eye on EHR Data Integrity

“This lack of interoperability and the burden of meaningful use is propelling the health care system down a path that is about to collide with the new MACRA law requirements,” AAFP Board Chair Robert Wergin, MD, FAAFP, pointed out, referencing the Merit-Based Incentive Payment System (MIPS) that will eventually overtake meaningful use.

“Because primary care practices are at capacity, every minute that physicians and their practice staff spend on managing administrative complexity and doing the work health IT should be automating is precious time removed from their focus on patients to deliver better care, better health and lower cost,” Wergin wrote.

The letter followed yet another missive, penned by previous AAFP Board Chair Reid Blackwelder, MD in July, which urged CMS to give healthcare providers the breathing room they need to make the health IT upgrades required for meaningful use success.

“Current health IT does not yet have the interoperability required to support value-based payment nor the functionality to be efficient and effective in this new paradigm. We strongly urge CMS to delay Meaningful Use Stage 3,” Blackwelder said at the time.

EHR usability is one of the biggest obstacles facing physicians who are eager to avoid financial penalties for non-participation in the EHR Incentive Programs, stakeholders have repeatedly said.  Even ONC certified EHR products fail to meet basic usability requirements that would aid providers in real-world care settings, the AMA recently declared.

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A study published in the Journal of the American Medical Association this summer found that few vendors adhered to recommending design testing guidelines. 

Sixty-three percent used fewer than fifteen end-users during the testing process, and seventeen percent did not include physicians who could gauge the efficiency of EHR workflows.  One vendor didn’t even ask any users with clinical experience to test the product, which was still certified for meaningful use by the ONC.

Building off of the study, the AMA and MedStar Health’s National Center for Human Factors in Healthcare have developed an EHR usability framework to compare design and testing processes used by health IT vendors.

“Alignment with best practices for user-centered design and testing is a starting point that regulators and industry should meet and exceed,” said Raj Ratwani, PhD, scientific director of the Human Factors Center and principle developer of the framework. Ratwani was also a lead author on the JAMA study.  “The framework we developed is the first step in bringing greater transparency to the usability processes of EHR vendors.”

When the AMA tested twenty EHR products from major vendors in 2013, they found that only three of the systems exhibited adequate user-centered design elements that enabled providers to document patient care efficiently and safely.

“Physician experiences documented by the AMA demonstrate that most EHR systems fail to support effective and efficient clinical work, and continued issues with usability are a key factor driving low satisfaction with many EHR products,” said AMA President Steven J. Stack, MD.

“Our goal is to shine light on the low-bar of the certification process and how EHRs are designed and user-tested to drive improvements that respond to the urgent physician need for better designed EHR systems.”

Stage 3 meaningful use has a low chance of succeeding without much higher levels of physician buy-in, which may be impossible to secure when the current generation of EHR technology produces such wide-spread disappointment and condemnation. 

In Stage 3, healthcare providers will have more time to upgrade to new CEHRT standards than they have during previous stages of the program – EHRs meeting the 2015 Edition criteria will be optional between 2015 and 2017, and only become mandatory the following year. 

But unless EHR vendors can significantly raise their game in the coming months as they submit these products for the certification process, new EHR options may not be much improved from what is on offer today.  

Asking providers to attest to the robust health data exchange and interoperability capabilities included in the Stage 3 objectives while equipping them with sub-par software will leave even more providers in dire straits, said more than one hundred members of Congress just days before the finalized meaningful use modification rule was published.

"We believe that the Stage 3 rule should be paused as it should rely on proven technology — designed outside the limitations of current federal requirements — that can support a shift to outcomes and interoperability rather than measures and objectives," said the letter addressed to HHS Secretary Sylvia Burwell and OMB Director Shaun Donovan.

"We should incentivize technology that enables interoperability and improves health outcomes rather than incentivizing technology that counts how many times a provider performs an activity," the letter continued.

"The additional time would also give policymakers a chance to understand how the private sector performs relative to modifications for program years 2015 through 2017. Taking the time to get it right now will surely pay dividends in the future."


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