- “Hate” may seem like a strong word to use for describing a series of regulations intended to improve the quality and delivery of patient care, but it barely scratches the surface for many providers responding to the public comment period associated with Stage 3 of the EHR Incentive Programs.
Stage 3 of meaningful use urges providers along an ambitious quick-march towards more advanced use of EHRs for care coordination, population health management, and big data analytics.
Envisioning an interconnected, “learning” health system that leverages health information exchange and seamless interoperability for smooth transitions of care and data-driven clinical decision-making, Stage 3 hopes to bring healthcare organizations into a uniform ecosystem of mature health IT adoption.
Almost immediately upon its conception, however, the measures and objectives started to attract skepticism, frustration, and vitriol from Congressional leaders and industry stakeholders concerned about the financial and organizational burdens imposed by the framework.
No group has complained more loudly than physicians and the professional societies that represent them. Even those providers who recognize that CMS has the healthcare industry’s best interests at heart cannot endorse the manner in which they are forcing healthcare organizations to pour time, money, and effort into what they view as a flawed program.
A few major themes have emerged from more than 170 comments contributed by providers from across the care continuum. What are the top five reasons why providers are taking a dim view of the future of the EHR Incentive Programs?
The all-or-nothing approach to attestation
Meaningful use doesn’t give out points for trying. Nor does it reward providers for making significant improvements in certain areas but not in others. Healthcare organizations have been calling for increased flexibility since the start of Stage 1, but CMS has only responded with exemptions and hardship exceptions in a relatively limited number of circumstances.
“I would like CMS to remove the pass-fail approach from meaningful use,” said Micha Rojany from California. “We should be allowed more flexibility in the program as vendors of software are going to be consumed making changes for MU3 instead of allowing us to improve our clinical work flow and practice caring for patients.”
“Make MU reimbursement in stages based on successful staged completion of requirements instead of an all or none approach,” urged Robert Margolis of Ohio.
Removing the pass/fail approach was a top priority for a number of other commenters, including Jeffrey Muir, a private practice physical medicine and rehabilitation physician with a pain management sub-specialty.
“The all or nothing or pass-fail approach to the program is ridiculous,” he said. “I estimate my staff and I spend around 300 hours per year to try to become compliant with meaningful use but if there is a single measure we fall short on, then we are penalized and all the work is in vain. How can you have such strict rules for a program like this? It is frustrating to the physicians and their staff to spend such long hours trying to comply with your program and not see any benefit if even one single measure is missed.”
The patient engagement and health information exchange portions of Stage 2 meaningful use have always presented a challenge to providers, and are likely to continue to do so even after a drastic reduction in expected patient portal and secure messaging use.
“We have 100% on all our all core measures except for direct messaging,” said Andrea Sall from Virginia. “We have sent our referring physicians a fax with our direct messaging number and have asked them to insert their direct messaging number on our form and fax it back. Almost without exception, we have received messages that state: ‘We do not have a direct messaging number,’ or ‘we are not going to get a direct messaging number.’
“We have saved all of these faxes as proof that we have tried to get the information but it is totally out of our hands. We should not fail Meaningful Use because someone else is not doing their part. We have done a lot of work to complete Meaningful Use and it will all be for naught because of these issues.
“How do I appeal these issues?” she asked. “In all fairness, if there was a mechanism in the EMR that we could check off for lack of compliance by others then we wouldn't have to appeal. It could come right from the EMR to CMS's lips!”
Inadequate and unusable EHR technology
EHR usability has been a hot-button topic since the very start of meaningful use. Cumbersome interfaces, time-sucking point-and-click features, confusing documentation fields, convoluted methods to access historical data, and a “walled garden” approach to health information exchange have put providers in the pressure cooker for more than half a decade.
“We are not data entry personnel,” said one anonymous respondent. “If you want data entry personnel, then hire a million of them and send them out to our offices. It will be much more efficient and safer and easier to take the penalties until you give up on this ridiculous regulatory nonsense.”
Researchers have certainly suggested the use of medical scribes and EHR transcriptionists as a temporary antidote to EHR frustrations, but many providers either cannot afford or cannot spare the time to train and integrate these assistants into their practices.
“I am a solo practicing internist. I have been using an EHR over the past 3 years and went through the meaningful use. However, I decided to quit after finishing my first 3 months of stage 2,” stated Mo-Ping Chow of Maryland.
“It is hard for me to work until midnight every day to complete the required documentation (which is going to be more and more). I am more distracted to complete the computer items. Rather, I would like to focus on my patient's whole picture. I don't need to worry [about] the hardship in case I make [an] unintentional mistake, and then [get] audited by CMS as my colleague experienced.”
Despite the efforts of EHR vendors to improve their offerings, the EHR Incentive Programs still require too much documentation that detract from the compassionate practice of meaningful care, other respondents stated.
“The notes are cookie-cutter algorithms and do not do justice to what a physician is trying elucidate from a well performed history and physical,” said Aruna Ramayya, a private practice internist in Southern California. “It does not even come close to a well-written narrative report from a good clinician who can convey the complete essence of HPI, ROS, assessment and treatment plan to anyone that reads the report. This is impossible with EHR.
“With all the physician uproar, reluctance to adapt, and willingness to not only give up the so called incentives but also get penalized, CMS should get the message loud and clear that nobody wants these MUs, PQRS, and whatever else is in the pipeline, let alone advance to the next stage of reporting.”
Lack of control over infrastructure development
Not only are meaningful use measures difficult for individual providers to meet, they also require cooperation from across the care continuum. Well-meaning healthcare organizations that do their best to comply with CMS’ system of check boxes and measure sets cannot be responsible for what their independent business partners may or may not do – yet a successful attestation requires health IT maturity from all parties.
“I am completely computer savvy and has an excellent support staff and IT personnel and still cannot get my electronic medical record to interact with large health organizations or radiology practices or adjacent local smaller offices and therefore has no way of satisfying meaningful use 3 requirements,” said Andre Barkhuizen of Oregon. “It is extremely unfair to penalize physicians for a clearly flawed system and will adversely affect our ability to continue caring for patients with chronic illness. There is absolutely nothing meaningful about the current use criteria.”
Frustration with EHR vendors also sparked complaints. While Stage 3 is supposed to encourage interoperability across care settings, providers simply do not have the infrastructure required to exchange data and perform advanced population health management.
They are not likely to be able to retool their practices and health IT systems quickly and comprehensively enough to meet Stage 3 requirements without some significant action of the part of the developer community, commenters added.
“I feel that EHR systems really need to be accountable for the lack of interoperability which exists,” John Matulis said. “Addressing this is critical to actually making meaningful use meaningful. You cannot ask healthcare providers and patients to make such incredible sacrifices and go through so many disruptive transitions only to have a number of fragmented, disconnected systems which are not able to communicate with each other. Please, please, please put pressure on vendors to work towards this difficult but worthy goal.”
Bruce Gordon, an otolaryngologist from Massachusetts, summed up his frustrations with a lack of interoperability in similar terms.
“Online test ordering has not been very successful, due to the inability of linking up with our hospital (although we can with one outside lab),” he wrote. “P2P messaging would also be great, but, we can only do it with other docs who share the same EHR. We cannot even easily review discharge information, labs, radiology, and medications from our hospital, without signing in to their system, locating the info, printing it on paper, and manually scanning it into our EHR.
“It is an insane waste of time to even document that lab results have been reviewed. Good functional systems interoperability and electronic communications would be far more useful, in my view, then these MU attempts are. Finally, we still depend on old-fashioned, poor quality, faxing to exchange records with most of our colleagues, when it ought to be simple to send records from one office or hospital to another, anywhere in the country.”
Leaving specialists out of the loop
Specialists like Gordon have long complained that the EHR Incentive Programs are geared almost entirely towards a very narrow definition of the primary care setting, leaving out thousands of providers who might want to participate, but find the requirements irrelevant to their daily practice.
“Meaningful use requires even more time away from direct patient interaction, and achieves very little, especially in otolaryngology, where we already know the lessons the computer is trying to teach, and the excessive repetition is neither instructive, nor a good use of scarce time,” Gordon said. “Few of the options we have to achieve MU are really important to Otolaryngology, and of those that are, these are things we already know and do.”
Jamie Brant, a medical director for a home-based palliative care and geriatric practice in Utah, agreed that meaningful use is simply not a fit for many specialists. “We have a very unique practice (most are end of life) and our patients would benefit so much from more meaningful measures based on their needs not the cookie cutter needs/measures that would apply to most primary care practices.”
For providers working closely with non-eligible organizations, like rehabilitation and long-term care facilities, the challenges only increase.
“I am part of an organization that is responsible for several small surgical hospitals,” said Bobbie Britt of Oklahoma. “We are having a hard time meeting Objective 5 specifically because we do not transfer to facilities with Secure Messaging. Ninety-nine percent of our patients transfer to rehab after surgery. These rehabs do not have secure mailboxes. Our vendor suggest we send the C-CDAs to another hospital within our organization just to prove we can do it, but this does not meet the true intent of the measure. This concerns me and I don't think it would pass an audit.”
Even providers who do delivery primary care can’t always meet the one-size-fits-all framework that doesn’t take unusual circumstances into account.
“I practice in a rural area doing house calls,” said Alabama provider Regina Harrell. “I don't have cell phone reception at many of the houses I visit, so I can't use an electronic health record and have never met meaningful use. If there was adequate internet access in my area, I still wouldn't meet meaningful use.
“Most of my patients have dementia or are bedbound. None of them will ever send me an email through a patient portal,” she continued. “None of them will ever schedule an appointment online or check their own lab work results on a portal. I don't have a way to weigh bedbound patients. If I had an EHR, I could either leave it blank to miss meaningful use or make up a number for the patient's weight, which to me amounts to Medicare fraud.”
“This is not a good choice, especially for data that serves no useful purpose in my patient population. I keep frail elderly people out of the hospital providing significant Medicare savings, and for it I will get paid less.”
Taking time away from patient care
All of these complaints add up to one overarching problem: EHRs and meaningful use take time, effort, and attention away from the basics of patient care.
“Meaningful use is causing significant decrease in my patient interaction,” stated Jusrin Miller of New York. “So much so I am going to have to sacrifice important face to face time with patients to try to be compliant. The patients are not happy with the fact physicians are spending less time concentrating on their needs due to the continued mandates and demands on physicians.”
“These demands are effectually causing a physician shortage due to the more time required to manage the patient and the additional MU requirements. It causes me to see fewer patients and causes patients to wait longer for their appointments in the office and to get into the office. We have passed the saturation level.”
Sam Horton from Indiana agrees. “I want to practice medicine! Not try to sign 90-year-old demented patients up for email and help them remember their password, so that I can pass along a medication list electronically. High healthcare cost should be the priority, not trying to meet silly measures! Let's please refocus on issues important to patient care, with the goal of maintaining humanity in the patient encounter.”
The EHR Incentive Programs are contributing to provider dissatisfaction and physician burnout without adding anything to the quality or delivery of patient care, the majority of the commenters implied.
Without significant reductions in reporting burdens, a more sedate pace towards increased regulations, and better technology to support the time-consuming and expensive process of attestation, providers are convinced meaningful use will continue to illicit condemnation from front-line clinicians doing their best to juggle mandates with a human approach to patient care.
“Meaningful use should be renamed ‘meaningless use,’” said Dr. Craig Brewer, echoing sentiments expressed by many of his peers. “It, by design can only measure certain objective items which may or may not be pertinent to a patient's management and when not pertinent it is a frustrating waste of time and money to document an unnecessary expense to the system.”
“Medicine is an art as well as a science. It cannot be assessed meaningfully with a ‘cookbook’ approach. If there is a concern about doctors’ burn-out and dissatisfaction…look first at meaningful use as the culprit.”