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Thursday, June 27, 2013

Bad news for the Meaningful Use initiative

Well, let's see how Farzad et al spin this.
Here’s an alarming fact: the meaningful use dropout rate is already 17%.

A recently published assessment of the government’s April EHR attestation data revealed that 17% of the providers who earned an $18,000 EHR incentive in 2011 did not earn the $12,000 second incentive in 2012. Although the analysis was performed by the venerable Wells Fargo, my immediate response was, “That’s impossible! They must have miscalculated the data.”

So I crunched the numbers for myself, and to my astonishment, the conclusion is absolutely correct. A staggering 17% of the providers who succeeded at demonstrating meaningful use for 90 days were unable to sustain that performance for a full year—the second required reporting period—despite the fact that the program’s requirements remained exactly the same and the providers already had the necessary workflows in place to support those requirements. What makes this fact even more troubling is that the 2011 attesters were typically the early EHR adopters and therefore most experienced in the use of the technology.

A 17% loss rate in any business is wholly unacceptable, and this failure does not portend well for the future of the EHR Incentive Program. If $12,000 proved to be insufficient motivation for physicians with meaningful use experience to meet the relatively low requirements of Stage 1 on an ongoing basis, it would be foolish to expect physicians to muster the wherewithal to meet the increasingly demanding requirements of Stage 2. The incentive for a year’s performance at that point will be a mere $4,000.
Compounding this finding is the fact that 14% of physicians who attested to Stage 1 have already stated that they have no intention of attesting to Stage 2...
- Evan Steele
RECs, recall, were commissioned for "One and Done" -- Our HITECH mandate was to help get providers through Year One, Stage One (and Adopt/Upgrade/Implement on the Medicaid side).

The upshot of this news should be interesting.

But wait! There's more!

At the end of December 2012, federal records showed that 96,000 eligible physicians had received an incentive payment for the early implementation and attestation of an EHR system, out of a total 505,000 eligible doctors. Mytych (pictured) said those systems must be in place and the providers must meet meaningful use rules by 2015, or face potential federal Medicare penalties. (That deadline, he added, is subject to change.)

The current deadline for implementation of Stage 2, requiring practices to have implemented 90 days of consecutive meaningful use, is now set for next year. Mytych, however, predicts that the deadlines and penalties may be pushed back as well after the Department of Health & Human Services reviews the comments on proposed rules. “It would be good to see them push the deadline back but keep in mind that the federal government will make money off this, since they’re making more in penalties than paying in incentives,” he said...


Commentary: Concerns about quality improvement organizations actions around meaningful use
June 25, 2013 | James M. Hofert, Partner, Hinshaw & Culbertson LLP and Roy M. Bossen, Partner, Hinshaw & Culbertson LLP and Linnea L Schramm, Associate, Hinshaw & Culbertson LLP and Michael A. Dowell, Partner, Hinshaw & Culbertson LLP

The federal government is pressuring the medical community to reduce patient care costs while improving the quality of patient care to all patients, including Medicare beneficiaries. Congress, recognizing that hospital readmissions are too common and are costly and often avoidable, passed the Hospital Readmission Reduction Program (HRRP), which ties-in readmission metrics to monetary penalties to encourage hospitals to reduce readmission rates. Federal lawmakers also passed the Health Information Technology for Economic and Clinical Health Act (HITECH), which is intended to stimulate the rapid evolution and adoption of information technology in the healthcare industry, promote the development and use of clinical decision support (CDS) treatment algorithms, encourage active provider participation in discharge planning and care to decrease recidivism, and enhance care coordination through provider-patient communication.

Consistent with these legislative strategies, the Center for Medicare and Medicaid Services (CMS) appears to be encouraging contracted quality improvement organizations (QIOs) to adopt quality care principles (meaningful use criteria), created pursuant to HITECH, as additional criteria to be applied in the evaluation of the adequacy of care provided to Medicare beneficiaries under their jurisdiction...

QIOs such as Telligen have essentially associated the principle of “professionally recognized standards of care” under Section 1156 with “meaningful use criteria” enunciated under HITECH along with other historically applied principles of care. The term “professionally recognized standard of care” is not specifically defined by regulators (the Quality Improvement Organization Manual suggests that the term may be equated to evidence-based practices and/or documented consensus statements, best practices and/or identified norms).
The failure of a physician, hospital or other covered institution to implement acceptable corrective action plans can lead to financial penalties or exclusion from reimbursement for services rendered to Medicare patients. This remedy goes beyond HITECH provisions, which simply provide that institutions not presently in compliance are not entitled to incentive payments...

QIOs should be circumspect in sanctioning physicians and covered institutions for violation of “meaningful use” criteria that has yet to be implemented or fully evaluated by CMS. QIOs may need to consider application of a “sliding scale” assessment, at least initially, as it relates to application of “meaningful use” criteria during care reviews, to allow nonuniversity based hospitals as well as safety-net institutions, the necessary time to bring themselves into compliance with evolving EHR, CDS and discharge planning and care requirements incorporated into recently passed healthcare legislation.
I have worked for HealthInsight -- a "QIO" -- three times spanning a 20-year period, and am quite familiar with the ongoing "conflict of interest" beefs that have dogged them. There have long been concerns regarding "voluntary" provider participation in non-judgmental, collaborative "quality improvement" initiatives under the ongoing three year CMS QIO "Scope of Work" contracts with entities also possessing the statutory sanctions hammer (case reviews and bene complaints). A large number of RECs are also QIOs, and this concern has extended to the Meaningful Use program. This (above) takes that issue to an even higher level.

HealthInsight is (a) a three-state QIO (UT, NV, and NM), (b) a bi-state REC (UT and NV), and now (c) the first Nevada HIE (Health Information Exchange). Doesn't take much imagination to see the myriad questions of conflict that arise in such a circumstance.

Tangentially related to this QIO/Meaningful Use dustup is the recent flap over the new Massachusetts law requiring Meaningful Use competency as a condition of physician licensure.

But, in the wake of all this Luddite and otherwise partisan carping cometh ONC...

June 2013

The Office of the National Coordinator for Health Information Technology (ONC) Department of Health and Human Services 200 Independence Avenue SW Washington, DC 20201

Information is widely recognized as “the lifeblood of modern medicine.” Health information technology (health IT) has the potential to improve the flow of information across the health care system and serve as the infrastructure to enable care transformation. Health IT comprises technologies — from electronic health records (EHRs) and personal health records (PHRs) to remote monitoring devices and mobile health applications — that can collect, store, and transmit health information. By enabling health information to be used more effectively and efficiently throughout our health system, health IT has the potential to empower providers and patients; make health care and the health system more transparent; enhance the study of care delivery and payment systems; and drive substantial improvements in care, efficiency, and population health.

ONC collaborates with policymakers and stakeholders to address critical issues related to health IT. Working directly with the health IT community, ONC develops consensus-based standards and technologies that facilitate interoperability and health information exchange (HIE). ONC aims to protect the privacy and security of health information and ensure the safe use of health IT in every phase of its development and implementation. The ultimate goal of these efforts is to inspire confidence and trust in health IT. ONC provides expertise, guidance, and resources to ensure that health IT is widely and effectively implemented. ONC also administers a reliable Health IT Certification Program and works closely with CMS to establish the certification criteria for certified EHR technology (CEHRT) that eligible providers must adopt and meaningfully use in order to qualify for incentive payments under the Medicare and Medicaid EHR Incentive Programs.


Data show steady increases in the adoption of EHRs and key computerized functionalities related to EHR Incentive Programs’ Meaningful Use criteria among office-based physicians and non-federal acute care hospitals.

  • In 2012, nearly three-quarters of office-based physicians (72 percent) had adopted any EHR system. Forty percent of physicians have adopted a “basic” EHR with certain advanced capabilities, more than double the adoption rate in 2009.5 Physicians achieved at least fifty percent adoption rates for 12 of the 15 EHR Incentive Programs’ Stage 1 Meaningful Use core objectives.
  • As of 2012, 44 percent of non-federal acute care hospitals had adopted a “basic” EHR, more than triple the adoption rate of 2009.7 The percent of hospitals with certified EHR technology increased by 18 percent between 2011 and 2012, rising from 72 percent to 85 percent. 8 Hospital adoption rates for Meaningful Use Stage 1  requirements for the EHR Incentive Programs’ ranged from 72 percent to 94 percent.
  • The percent of physicians e-prescribing using an EHR on one of the nation’s largest e-prescribing network (Surescripts) increased almost eight-fold from 7 percent in December 2008 to over half of physicians (54 percent) in December 2012.10 In the same period, the percent of community pharmacies active on the Surescripts network grew from 69 percent to 95 percent. The percent of new and renewal prescriptions sent electronically between 2008 and 2012 has increased ten-fold to approximately 47 percent.

The CMS Medicare and Medicaid EHR Incentive Programs provide financial incentives for the adoption and Meaningful Use of certified EHR technology to improve patient care. CMS established the EHR Incentive Programs through notice and comment rulemaking and created the necessary infrastructure to implement the program in accordance with existing payment policies and program eligibility criteria. CMS regulations spell out the objectives for the Meaningful Use requirements that eligible professionals, eligible hospitals, and CAHs must meet in order to receive an incentive payment.11 In addition to the incentives, eligible professionals, eligible hospitals, and CAHs that fail to demonstrate Meaningful Use of certified EHR technology will be subject to payment adjustments under Medicare beginning in 2015.

As of April 2013, more than 291,000 professionals, representing more than half of the nation’s eligible professionals, have received incentive payments through the EHR Incentive Programs. Over 3,800 hospitals, representing about 80 percent of eligible hospitals, and including Critical Access Hospitals, have received incentive payments through this program as well. ..

The Office of the National Coordinator for Health IT:

Health IT Regional Extension Centers Program (REC): RECs have played a pivotal role in providing technical assistance to providers. The 62 RECs are actively working with over 133,000 primary care providers, surpassing the 2012 HHS High Priority Goal of providing assistance to 100,000 primary care providers...
 "Pivotal." Yeah. And "dispensable."

Really not much new. Full PDF report here.

Data show steady increases in the adoption of EHRs and key computerized functionalities related to EHR Incentive Programs’ Meaningful Use criteria among office-based physicians and non-federal acute care hospitals.

One of the ONC report graphs:

This has become a staple visual representation of Health IT and MU "progress." (At least they wrote "data show" rather than the gauche "data shows".) A "doubling" of ME capacity.

Any problems here?

"...with computerized capabilities to meet Meaningful Use core objectives"?

Not that they met the criteria, just that they had EHRs "capable" of doing so. Well, for one thing, since the deployment of ARRA/HITECH, "Certified" EHRs have really become the Only Game In Town, no? Are any mainstream vendors going to write products that don't meet ONC CHPL criteria?

Moreover, let me call your attention to the ever-astute Margalit Gur-Arie:
Spinning EHR Adoption Numbers

On May 22nd, the Secretary of Health and Human Services (HHS) published a momentous press release announcing that “Doctors and hospitals’ use of health IT more than doubles since 2012”. The release was accompanied by two beautiful graphs, one for physicians and one for hospitals, titled “Adoption of Electronic Health Records by Physicians and Other Providers” and “Adoption of Electronic Health Records by Eligible Hospitals”, respectively. Both graphs, shown below, start at zero (0) adoption in January 2011 and climb rapidly to “[m]ore than 291,000 eligible professionals and over 3,800 eligible hospitals” by April 2013.

Of course, the graph titles are incorrect, since there were plenty of electronic medical records in use well before 2011, and the actual text of the press release does make some references to the world prior to 2011...

[T]he compulsive need to spin everything prompted HHS to declare that “use of health IT more than doubles since 2012”, which is ridiculous, and to put forward questionable historical numbers. A more cautious White House, while sticking with HHS provided numbers and crediting the President with this miracle, declares for no apparent mathematical reason that “adoption of electronic health records doubled among office based physicians from 2008 to 2012 and quadrupled in hospitals”. Of course every industry publication and health policy pundit (not to mention Twitter) is repeating these things, including the New York Times, where Mr. Thomas Friedman in a customary fact-free infomercial for his investor buddies is stating: “According to the Obama administration, thanks to incentives in the recovery act there has been nearly a tripling since 2008 of electronic records installed by office-based physicians, and a quadrupling by hospitals”. So which one is it folks? Doubled? Tripled? Quadrupled? Something bigger? Does it matter?
Read the whole post. Kudos to Ms. Gur-Arie.


The 82 page ONC report is amply festooned with the obligatory words "interoperable" and "interoperability" -- 59 hits in all. (avg ~0.72 times per page)

I have commented at some length regarding my dubiety over this totemic incantation before. e.g., from my April 25th, 2013 post:

One. Then stand back and watch the Market Work Its Magic in terms of features, functionality, and usability. Let a Thousand RDBMS Schema and Workflow Logic Paths Bloom. Let a Thousand Certified Health IT Systems compete to survive. You need not specify by federal regulation any additional substantive "regulation" of the "means" for achieving the ends that we all agree are desirable and necessary. There are, after all, only three fundamental data types at issue: text (structured, e.g., ICD9, and unstructured, e,g., open-ended SOAP note narrative), numbers (integer and floating-point decimal), and images. All things above that are mere "representations" of the basic data (e.g., text lengths, datetime formats, logical, .tiffs, .jpegs etc). You can't tell me that a world that can live with, e.g., 10,000 ICD-9 codes (going up soon by a factor of 5 or so with the migration to ICD-10) would melt into a puddle on the floor at the prospect of a standard data dictionary comprised of perhaps a similar number of metadata-standardized data elements spanning the gamut of administrative and clinical data definitions cutting across ambulatory and inpatient settings and the numerous medical specialties. We're probably already a good bit of the way there given the certain overlap across systems, just not in any organized fashion.

Think about it.


What’s behind the 17% EHR Incentive Program dropout rate?
Jennifer Bresnick

The pace at which eligible providers are leaving the EHR Incentive Program is higher than most high school dropout rates, according to the latest data from CMS. Seventeen percent of providers who collected a 90-day incentive payment in 2011 either decided not to pursue the program for the following full year or were unable to sustain their efforts for that long. Despite the continued increase of new providers joining the program, the rate of failure is astonishing and somewhat troubling. If meaningful use can’t hold on to participants by offering big incentives, what will happen when that money goes away – and what does that say about the deeper issues underlying EHR adoption in the United States?

Some EHR implementations simply detonate on impact, falling prey to poor planning or the dreaded EHR backlash from unhappy physicians and clinical staff. Other providers find that their first EHR system doesn’t meet their needs, and hunt for a replacement that better suits their practice’s style, which might delay their participation in meaningful use by a few months. But after investing in a certified EHR, adapting their workflow to successfully meet the EHR Incentive Program’s requirements for three months, and collecting their money from CMS, why would a provider decide that continuing on that path just isn’t worth it?...

It’s no secret that physicians just want to practice medicine. They want to spend time with their patients and have the freedom to decide how to run their own businesses and take their own notes. Not everyone sees the EHR Incentive Program as an effective way to make medicine smarter and reduce costs. Not everyone agrees with the ONC’s methods of fostering interoperability of health IT systems, or the way CMS is threatening non-compliant providers.

But left to its own devices, it’s unlikely that healthcare would make the necessary sacrifices to bring it into the digital age and realize the benefits of health IT. It’s clear from the haphazard and reluctant ICD-10 transition that people will put off anything that isn’t mandated as long as humanly possible, no matter how inadequate their current state of affairs.

Meaningful use may be painful, and it may be difficult. It may not be perfect.  However, providers who drop out of a program that’s paying them to participate are setting themselves up for an uncertain future, and need to think carefully about frying pans and fires before choosing to leave meaningful use behind for good.

More to come...

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