Last summer, the Commonwealth of Massachusetts enacted legislation that will fundamentally alter the physician-patient relationship by giving politicians the right to specify the processes that must occur during an office visit. The relevant law is Section 108 of Chapter 224 of the Acts of 2012, which reads as follows:

The first paragraph of section 2 of chapter 112 of the General Laws … is hereby amended by inserting (the following)… The board (of Registration in Medicine) shall require, as a standard of eligibility for (medical) licensure, that applicants demonstrate proficiency in the use of computerized physician order entry, e- prescribing, electronic health records and other forms of health information technology, as determined by the board. As used in this section, proficiency, at a minimum shall mean that applicants demonstrate the skills to comply with the “meaningful use” requirements (1).

Thus, any Massachusetts physician who does not use a Federally certified EMR AND meet the contemporary Meaningful Use requirements will be denied a license to practice medicine effective 2015. Most unfortunately, the Meaningful Use mandates will continue to become every more onerous in Stages 2, 3, 4, 5, 6 and 7.

As we all know, the practice of medicine has become increasingly difficult as a result of external mandates. These mandates specify which medicines we may prescribe, which radiology tests we can order, how many days our patients are allowed to remain in the hospital, which CME classes we must take, etc. And now, the politicians intend to tell physicians which software they must use in their office and which EMR options must be utilized during the office visit.

The Government’s decision to foist “certified” EMRs on the medical profession is predicated on the hypothesis that the widespread adoption of EMRs will eventually reduce the cost of healthcare. Unfortunately, data published to-date does not support this hypothesis (2). Thus, the continued imposition of the EMR mandates will only delay the implementation of a truly effective solution that could reduce the cost of healthcare.

As the developer of an EMR, I sincerely believe that a well designed EMR is a useful tool for many practices. However, the Federal and State Government’s misguided obsession to stipulate which features must be in the EMRs, and how the physician should use the EMRs in the exam room places the politicians in the middle of the exam room between the patient and the physician, and seriously disrupts the physician-patient relationship.It is past time that physicians reclaim control of their offices, if not the practice of medicine.

It is past time that physicians reclaim control of their offices, if not the practice of medicine. I strongly encourage all Massachusetts physicians you to contact Governor Deval Patrick, Secretary of Health and Human Services John Polanowicz, your Massachusetts state Senator and Representative and ask them to rescind Section 108 of Chapter 224 of the Acts of 2012. Also tell the politicians to desist from interfering in the physician-patient relationship, which is a prerequisite for high quality healthcare.Please feel free to forward this letter to your colleagues. I also encouraged you to plagiarize this letter, as needed, for your communication to your state representative.

Hayward K. Zwerling, M.D., FACP, FACE is an a board-certified internal medicine physician who specializes in endocrinology. He practices at the Lowell Diabetes & Endocrine Center in North Chelmsford, MA. Zwerling is also the president of ComChart Medical Software, LLC.

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41 Responses for “The EMR Use Rule: An Open Letter to Massachusetts Physicians”

  1. Linda Stanch says:

    Learn to use a computer, doctors.

    • MD as HELL says:

      Turn in your licenses, Docs. It is either that or slavery. That hand up your back is not up your shirt.

  2. Linda, doctors already know how to use computers.

  3. legacyflyer says:

    I think Linda’s response is very revealing of what many people think. “It’s just a bunch of old fogey docs being dragged kicking and screaming into the computer age”

    I hope someday Linda is forced to use badly designed software that slows her down, provides no benefit to her customer, but does make sure that billing and legal issues are taken care of.

    Or perhaps she has already been forced to do that and wants others to share her suffering!

  4. Wow. Really? Unable to be licensed? This rule might just take the form of some meaningless on-line “education” module you can flip through in 5 minutes, or it might be something much more onerous. Do people know the amount of time and money we all invest in licensing every couple of years? Do they know we don’t all have secretaries to full all this repetitive paperwork together? And it can’t just be an EMR you choose and like? It has to be one the federal government has certified and paid for (which comes with the meaningful use restrictions)? Lord. I’m glad I’m getting out of the field.

  5. Joe Heyman says:

    This law is ludicrous for several reasons. The first is that only about 10,000 out 40,000 will be MU certified in Massachusetfs in 2015. What is the Board of Registration in Medicine going to do about the 30,000 who are left? Second, even if they fix up some silly educational requiremnt instead, it adds another useless burden to licensing. Third, doctors are always the first to use new valuable technology (cell phones, robots, ipads, are only a few) when there is a clear benefit. Physcians see a clear benefit in using e-technology but not necessarily MU. True connectivity is not available with current EMRs and there is inconsistency in usability and workarounds for Meaningful Use.

    I have been using this technology since 2001 when I went paperless and I am MU certified in 2012, but I decided it was too much of a hassle to do it again 2013. I am a happy user of of EMRs and I think they make my practice meainingful withourt the general nuisance outweighing the benfits of MU requirements. MU was meant as incentive payment to get physcians to use the technology, never as a requirement for licensure.

  6. platon20 says:

    Just wait kids, it gets worse.

    Massachusetts is also considering a bill that would force all doctors to treat Medicaid patients AS A CONDITION OF LICENSURE.

    Thats right folks! If you want a medical license in the state of Massachusetts, you MUST accept Medicaid patients!

    • MD as HELL says:

      See above

    • Bill Ryder says:

      Massachusetts does not have a proposal to require Medicaid participation by all physicians and has not considered such a proposal for many years. MassHealth works through the Primary Care Clinician Plan and through contracts with Managed Care Organizations. They are moving towards integrated care organizations for dual eligible recipients. There is no mandatory participation nor is there an any willing provider provision either. It is more likely that physicians would be denied participation in such organizations than that it would be mandated.

  7. Richard Mindess, M.D. says:

    EMR’s have enormous potential….potential to improve quality in many ways and potential to lower cost. However, I hope the same politicians and policy people who are cramming this legislation through with presumably good intentions are also willing to take the blame when the wait to see a doctor increases (it takes time to enter information accurately into an electronic medical record), when patients notice that doctors are spending more time with their computers and less time with them, and when all the time spent on complying with meaningful use makes it increasingly difficult to focus on patient’s chief complaint, diagnostic dilemmas, caring and thorough communication with patients, and the careful attention to detail that in many circumstances is required to provide high quality, cost effective care.

  8. Mark says:

    I am not in the healthcare field but have watched the discussion around EMR’s with interest as I have extensive experience with the implementation of web-based information systems in large organizations. Effectiveness of implementation depends on how well the system meets the customer’s needs. But first you need to figure out who is the customer.

    As I follow these discussions it has become increasing clear that In healthcare the customer is not the medical professional or patient. The customer is your new boss – government administrators. These systems are designed for their convenience. In that context, the actions of the Massachusetts legislature makes perfect sense. This is not about you – it’s about them. Your obligation is to provide the information they need in a timely and efficient manner. Perhaps there are ways they may improve quality for health professionals and patients but those are byproducts of their primary purpose.

    I find this to be an odd way of approaching healthcare quality and cost issues but it looks like the obvious conclusion based upon what I keep seeing in the discussions on this blog.

    • I believe your comments are correct to some extent, however I think there are other “players” who are also driving the user of EMRs and the structure of EMRs. The large EMR vendors have a tremendous amount to gain from capturing huge quantities of health data and then using it to advanced her own interests. In addition, the information technology community is also clearly a vested interest.

      Although everybody (patients, businesses, government, physicians) agree that we need to improve the quality and reduce the cost of health care in the United States, it is my belief that the solution to these problems does not lie in the HIT world. If I am correct, then attempts to solve the problem via the promotion of health IT will only succeeded in delaying the implementation of an effective solution to the health care problem.

      • Mark’s point that physicians and patients are not the customer, is key and Hayward echoes that when he implies that we’re being farmed as valuable feedstock to all sorts of corporations.

        The solution to the HIT dilema lies in hundreds of years of medical tradition where medicine is practiced and taught openly. The overwhelming majority of today’s EHRs are proprietary and their code is secret. Not only does this prevent peer review and incremental improvement as in the rest of healthcare but it forces physicians and patients to suffer the effect of the same bugs and flaws as each vendor and institution repeats the same mistakes rather than fixing and sharing.

        The EHR system is perfectly designed to give us the results we’re getting. It’s time to shift to a more patient and physician-centered view of how we manage valuable private health information.

  9. BobbyG says:

    “The Government’s decision to foist “certified” EMRs on the medical profession is predicated on the hypothesis that the widespread adoption of EMRs will eventually reduce the cost of healthcare. Unfortunately, data published to-date does not support this hypothesis (2). Thus, the continued imposition of the EMR mandates will only delay the implementation of a truly effective solution that could reduce the cost of healthcare.”

    While I don’t support this law — or the very idea of it, — it is wholly premature at this point to expect rigorous empirical evidence of the effects of Health IT on cost (and/or outcomes quality). Moreover, citing that weak Anthelio “Healthcare Innovations Council” letter doesn’t buttress the argument. Their letter is pretty much comprised of 8 pages of platitudes and vague anecdotes and otherwise muddledness.

    See my REC blog.

  10. The entire premise of HIT is based on the hope/expectation that the widespread adoption of HIT will solve the healthcare crisis.

    As all physicians are aware, healthcare is far more complicated (as a result of an imperfect understanding of the biology of medicine) than other “industries” and it is very common that new treatments, which theoretically should “work,” fail to “work” when they tested in clinical trials. There is a long list of treatment failures.

    I believe that the practice of medicine needs to be “evidence based.” The widespread institution of HIT is not evidence based.

    The Federal government should have setup demonstration projects in several states to test the validity of the assumption that HIT will solve the healthcare crises before forcing the solution on physicians. To do otherwise is foolish, expensive and potentially dangerous.

  11. Scott Knutson, MD says:

    This is the result of the third party payer ‘elephant’ inserted in the patient/provider relationship. As said above, that is the customer, ergo micro-management in certification requirements to publicly prove competency, because real quality standards beyond death and readmission are elusive, and in many cases, subjective.

    Specific to the question of verifying the proficiency in EHR use has such a wide and varied standard potential that said bar from a state level will have to be exceedingly low, which by itself does nothing to guarantee improved patient care. Each EHR and the workflow which surrounds it, is unique to the institution in which it is implemented.

    It seems what they’re after is a generation of physicians willing to modify and adapt their practice patterns. Not so hard to suggest, but difficult to prove proficiency for licensure, and it seems state licensure is a poor place for that requirement. This would better fall under privileging in the individual institution where a failure to correctly use that system may cause patient harm. Pass/fail on local privileges based on demonstrated competency after education/orientation and a ‘willingness’ to learn and not to be a jackass about it (editorial-this requirement alone would address a host of other concerns about med staff as well). What we need is a generation of physicians willing to flex practice patterns to enable better communication, clarification of orders and documentation and the desire/demand for evidence in justifying process change. Ironically, that means standing up as a group and questioning the benefits to date in EHR mandates. The idea is good, the products, implementation, and personal data extraction usable at the individual provider level, leaves much to be desired. Right now it’s all about meeting federal mandates, which does little to motivate the individual physician to comply or to engage the process for meaningful change.

  12. Dr. Zwerling correctly points out that there has been too much “micromanaging” by the federal MU legislation about what features are needed in an EHR and how a physician uses the EHR. Even more appalling is taking this to a punitive level by punishing physicians who choose to (or, especially independent practitioners…unable to) comply with these MU requirements, epecially in the purchase of these high-cost EHRs that have not proven themselves to improve workflow (too much variability with user friendliness…most of them poor or difficult to use) and reduce health care costs (the cost of EHR’s are drowning hospital budgets and utlimately ratchet up costs across the board). Mark’s point is exactly the kind of question that I have been asking and decided that health care providers need to take action. I’ve written about this exact issue (who is the customer for EHRs…or who gets to have control of the data, more specifically) in my blog here –

    • Adrian Gropper MD says:

      Thank you Michael. Open source EHRs like yours are the only long term solution to physician frustration with clinical information technology. The medical profession has always controlled and taken responsibility for our own tools and clinical IT should be no exception.

  13. BobbyG says:

    Notwithstanding that I am a veteran Health IT advocate, this Section 108 law is a serious overreach. What if I’m a demonstrably competent (heretofore duly licensed as such) and successful cash-only “concierge” clinician (they exist) who has no need of an MU certified EHR system?

  14. Rob says:

    So, will this stand up to legal challenge? Can we as physicians be required to have something that is not proven to be necessary for our profession? This, and the specter of a requirement of accepting Medicare/Medicaid to have a license is terrifying to me (and was even before I opened a direct care practice). It seems like it really crosses the line, standing in the way of a person’s ability to work in their profession (no license means no job). It just seems illegal. I hope it is.

  15. anon says:

    I am sorry to say that people contemptuous of physicians’ and nurses’ time deserve clinicians equally as contemptuous of their well being.

  16. Len Lewis says:

    Most know how to use the EMR the only ones complaining are those who cannot provide documentation of the visit and yet bill Medicare. This gets harder…especially when the Health Information Exchange happens …everyone who is taking care of the patient will see how you managed the patient and the patient themselves will be able to see their own records.

    • Hayward Zwerling says:

      With all due respect, I do not believe you’re correct. I know many physicians who have used an EMR for well over a decade, (and are very adept at using them,) and these physician believe that EMRs are problematic in many different ways.

      Of course, it is ludicrous to blame the physician user for the fact that many EMRs are difficult to use. Like all good software, EMRs should be designed so that it is intuitively obvious how to use the EMR. Unfortunately, many EMR companies think it is perfectly appropriate to expect physicians to join “user groups” in order to learn how to use their EMR. This is totally backwards. The EMR companies should spend their time learning how how to design an EMR so that a “user group” is totally unnecessary. Clearly, the physician’s time is better spent taking care of patients, rather than learning how to use a piece of software.

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  32. Hayward Zwerling M.D. says:

    In response to the comments made by many interested individuals and organizations, the Commonwealth of Massachusetts has created an implementation of the aforementioned legal issue which is reasonable and will interfere with a physician’s efforts to ensure that their patients get the best possible medical care.

    I want to thank everybody who I has taken the time to voice an opinion on the subject.

    Hayward Zwerling, M.D.

    From the Massachusetts Medical Society:

    Proposed EHR/Meaningful Use Regulations
    November 12, 2014

    The Board of Registration in Medicine on Nov. 5 adopted final changes to regulations that implement a state law requiring physicians to demonstrate proficiency in the use of electronic medical records, as well as the skills to achieve the federal Meaningful Use standard.

    Final promulgation will occur after the Patrick administration reviews the regulations.

    The regulations establish multiple ways in which physicians would be in compliance with the requirement.

    There are also a broad set of exemptions for certain license categories, where electronic health record use is intrinsic or not relevant.

    Demonstrating Proficiency

    Under the regulations, physicians are considered to have demonstrated proficiency if they meet any one of the following conditions:

    Participating in the Meaningful Use program as an Eligible Professional
    Having a relationship with a hospital that has been certified as a Meaningful Use participant. This relationship would be satisfied by any one of the following conditions:
    Employed by the hospital
    Credentialed by the hospital to provide patient care
    Having a “contractual agreement” with the hospital
    Completing at least three hours of accredited CME program on electronic health records. Such a program must, at a minimum, discuss the core and menu set objectives, as well as the clinical quality measures for Meaningful Use.
    Participating or being an authorized user in the Massachusetts Health Information Highway (the state’s official health information exchange)
    Proposed Exemptions

    Applicants for a Limited License, such as interns and residents
    Applicants for a Volunteer License
    Applicants for an Administrative License
    License applicants not engaged in the practice of medicine
    Applicants on active duty in the National Guard, or in military service who are called into service during a national emergency or crisis
    Applicants for an Emergency Restricted License
    Other Provisions

    Physicians may ask the Board of Registration in Medicine for a 90-day waiver to delay implementation of the requirements due to “undue hardship.” Except for “exceptional circumstances,” this request must be made at least 30 days before the license renewal date.
    The demonstration of proficiency is a one-time requirement.
    The MMS is grateful to the Board’s chair, Candace Sloane, MD, and its members, who voted to implement the regulations in a responsible manner that will help move physicians towards adoption of electronic records without denying access to care for patients with physicians without access to meaningful use certified systems.

    The MMS is also grateful to those many physicians, specialty societies, the Conference of Boston Teaching Hospitals and Massachusetts Hospital Association who provided supportive, constructive testimony on the regulations.

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