Meaningful Use Stage 2

Physicians are lining up against Meaningful Use.Dale Sanders

In a detailed letter sent this week to CMS Administrator Marilyn Tavenner and National Coordinator Karen DeSalvo, MD, the American Medical Association presented a long list of ideas to make Meaningful Use better for doctors.

The AMA warned that “unless significant changes are made to the current program and future stages,” doctors will drop out of the meaningful use program, patients will suffer as existing EHRs fail to migrate data for coordinated care, thousands of doctors will incur financial penalties, and new delivery models requiring data will be jeopardized.”

All of which is true. But the AMA didn’t go far enough.

Meaningful use is well intentioned, but like a teacher who “teaches to the test,” the program has created a byzantine system that might pass the test of meaningful use stages, but is not producing meaningful results for patients and clinicians.

A formal study published in the April 2014 issue of JAMA Internal Medicine reveals there’s no correlation between quality of care and meaningful use adherence. This study validates what common sense has told many of us for the last few years.

Meaningful Use Stage 1 was a jump-start for EMR adoption in the industry. That’s a good thing, I suppose, although meaningful use also created a false economic demand for mediocre products. It’s time to put an end to the federal meaningful use program, eliminate the costly administrative overhead of meaningful use, remove the government subsidies that also create perverse incentives, and let “survival of the fittest” play a bigger part in the process.

Let the fruits of EMR utilization go to the organizations that commit, on their own and without government incentives, to maximizing the value of their EMR investments toward quality improvement, cost reduction, and clinical efficiency.

Continue reading “The Case for Dropping MU Stages 2 and 3″

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flying cadeuciiWhy politics, parity and performance requirements mean behavioral health hospitals should adopt now.

Imagine you go to work one day and your boss says all employees will be evaluated based on the performance of a new set of job skills that require additional training and, perhaps, new computer hardware and software. The boss also announces that some employees will be reimbursed for the cost of acquiring these skills and tools. You aren’t among this privileged group.

In government, this is called an unfunded mandate. The unlucky employee in this case is psychiatric hospitals, who aren’t eligible for Meaningful Use incentives even while Congress and the Obama administration have legislated greater accountability:

A precursor to the 2010 Affordable Care Act (ACA), the Mental Health Parity and Addiction Equity Act of 2008 mandated that insurers must make the financial cost of benefits—co-pays, deductibles, out-of-pocket maximums—equal for psychiatric and physical care.

By making behavioral health an Essential Health Benefit, the ACA requires health plans to cover mental health on par with other types of care.

On October 1, 2012, CMS launched the Inpatient Psychiatric Facility Quality Reporting Program (IPFQR), a pay-for-reporting program in which facilities could lose federal dollars by not providing data on Hospital Based Inpatient Psychiatric Services (HBIPS):

  •  Screening for violence risk, psycho trauma Hx, patient strengths
  •  Hours of physical restraint use
  • Hours of seclusion use
  • Patients discharged on multiple antipsychotic medications
  • Patients discharged on multiple antipsychotic medications with appropriate justification
  • Post discharge continuing care plan created
  • Post discharge continuing care plan transmitted to next level of care provider upon discharge

Whether explicit or implicit, these programs amount to unfunded EHR mandates. How so?

Organizations still on paper records will find it expensive and inefficient to capture events and collect results for both reporting to government and submitting claims to insurance companies. Hospitals will need to train clinicians to document post-discharge continuity of care plans.

They will have to train staff to send plans by snail mail or fax to the provider at the next level. Then they will also need to do chart reviews to assure that all these steps took place and the data is recorded in a spreadsheet or database. Any quality improvement process that requires benchmarking and scoreboarding of performance based on these measures will be a tremendous challenge using paper records.

Continue reading “An Unfunded Mandate For Behavioral Health”

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At HIMSS 2014, the health information technology’s (HIT) largest annual confab, the bestest-best news we heard from a policy perspective, and maybe even an industry perspective, was the Centers for Medicare & Medicaid Services’ (CMS) dual announcement that there will be no further delays for either Meaningful Use Stage 2 (MU-2) or ICD-10.

Perhaps we should have immediately directed our gaze skyward in search of the second shoe preparing to drop.

As it turns out, CMS de facto back-doored an MU-2 delay by issuing broad “hardship” exemptions from scheduled MU-2 penalties. To wit: any provider whose health IT vendor is unprepared to meet MU-2 deadlines, established lo these many months ago, is eligible for a “hardship” exemption.

Few would disagree with the notion that it’s unproductive to criticize policy without offering constructive ideas to fix the underlying problems.

Here,  the underlying problem is easy to define: it is in point of irrefutable fact fundamentally unfair to penalize care providers for their vendors’ failings—especially when the very government proposing to penalize them put its seal of approval on the vendors’ foreheads to begin with.

CMS’s move to exempt providers from those penalties is correctly motivated, but it seeks to ease the provider pain without addressing its cause.

Instead of issuing a blanket exemption for use of unprepared vendors, CMS should:

  1. Waive penalties only for those providers who take steps to replace their inferior technologies with systems that can meet the demands of the 21st century’s information economy;
  2. Publish lists of health IT vendors whose systems are the basis for a hardship exemption, along with an accounting of how many of those 21 billion dollars have been paid to subsidize those vendors’ products; and
  3. Immediately initiate a reevaluation of the MU certification of any vendor whose products form the basis for a hardship exemption.

This proposal might seem bold, but if we’re truly looking to advance health care through the application and use of EHR, then what I’ve outlined above simply represents necessary and sound public policy. Current practice rewards vendors whose products are falling short by perpetuating subsidies for those products.

The federal government should stop paying doctors to implement health IT that cannot meet the standards of the program under which the payments are issued. That’s just a no-brainer.

An EHR should not be a federally-subsidized “hardship.”

Continue reading “Congratulations, Doctor, On Your Federally-Subsidized “Hardship””

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The photo says it all.

The green notebook and pen represent the latest and greatest health IT innovations used by the hospital nurse to record my wife’s health information in the hours before her surgery to re-attach a fully torn Achilles tendon.

(Apologies for the cheeky intro and to my wife and anyone else for any HIPAA violations I may have committed in the capturing of this image).

It’s not that the hospital does not have an electronic health record.

They do – from a vendor widely considered a leader in the industry: Meditech. Same goes with the physician practice where she receives all her care and where her surgeon and primary care doctor are based.

They too have an EHR from another leading vendor: NextGen.

The problem? These systems are not connected. Thus, confirming the not so surprising news that health data interoperability has yet to make its debut in our corner of the NYC burbs.

Fortunately for my wife, she is well on her way to recovery (a bit more reluctant to juggle a soccer ball with her son in airport passenger lounges, but nevertheless feeling much better…and mobile). By everyone’s estimation – hers, mine, friends who suffered the same injury and friends who happen to be doctors – she received high quality care.

What’s more, we feel the overall patient experience at our physician practice and the hospital was quite good. That said, I cannot help but ask myself a series of ‘what ifs?’

What if…we forgot to mention a medication she was taking and there was a bad reaction with medication they administered as part of the surgery or afterwards?

What if… the anesthesiologist or surgeon couldn’t read the nurse’s handwriting?

What if the next time we go to the hospital, it is a visit to the emergency room and the attending clinicians have no ability to pull any of my family’s health records and we are not exactly thinking clearly enough to recall details related to medical history?

Continue reading “What A Green Three Ring Binder Says About the State of Meaningful Use and Health Information Exchange”

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SMART C-CDA infographic -- click to enlarge2014 will see wide-scale production and exchange of Consolidated CDA documents among healthcare providers. Indeed, live production of C-CDAs is already underway for anyone using a Meaningful Use 2014 certified EHR.

C-CDA documents fuel several aspects of meaningful use, including transitions of care and patient-facing download and transmission.

This impending deluge of documents represents a huge potential for interoperability, but it also presents substantial technical challenges.

We forecast these challenges with unusual confidence because of what we learned during the SMART C-CDA Collaborative, an eight-month project conducted with 22 EHR and HIT vendors.

Our effort included analyzing vendor C-CDA documents, scoring them with a C-CDA scorecard tool we developed, and reviewing our results through customized one-on-one sessions with 11 of the vendors.

The problems we uncovered arose for a number of reasons, including:

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As Meaningful Use 2014 EHRs come online this winter, clinicians across the country gain access the host of new features included in the MU 2014 Certification Requirements.

In this post, we’ll dig into one of these features: EHR-based secure e-mail capabilities that operate using the “Direct Project” specification. (If you’re new to this world: when you hear “Direct Project,” you should think “secure e-mail for healthcare.”)

It’s a party!

In theory, giving every clinician in the country a secure e-mail inbox ought to enable something amazing (and amazingly familiar, for anyone who has used e-mail outside of healthcare): the ability to converse electronically, back-and-forth, in one-on-one or one-to-many discussions with… well… whomever you choose.

… but not everybody’s invited

Unfortunately, the practice hasn’t caught up to the theory. EHRs provide restricted inboxes that allow messaging to some recipients but not others. Why? It comes down to “trust,” which is a broad topic that we’ll treat only glancingly, where it intersects with the technology.

One of the requirements for Direct Project messaging is security, which means (among other things) that messages must be encrypted as they travel. To properly handle encryption, the sender’s EHR software (or Health Information Service Provider) needs to reliably discover the recipient’s cryptographic certificate, extract a public key from that certificate, and use that public key to encrypt each message before sending it out over the wire.

So far so good.

Continue reading “Teach Your EMR to Do Email? Impossible!!?! Unthinkable??? Maybe Not”

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Let me concede from the outset that, in this blog post, I lean toward the negative—dire predictions, worst-case scenarios, a bit of doom and gloom, etc.

But I ask you, oh gentle, patient reader, how could I not?

Let’s go to the satellite. You can see warm air from a low-pressure system (Meaningful Use Stage 2, not changed dramatically by the one-year extension) collide with cool, dry air from a high-pressure area (the turmoil of Obamacare) and tropical hurricane moisture (ICD-10). Tell me you don’t see the Perfect Storm yourself.

And here we sit in our little fishing boat, waiting for the mighty ocean to consume us.

Overly dramatic? Certainly, but still not wholly inappropriate, I will argue.

Consider a recent report on the HIMSS/WEDI ICD-10 National Pilot Program collaborative that was created to, “…minimize the guess work related to ICD-10 testing and to learn best practices from early adopter organizations.”

Designed to ascertain the realities of the entire healthcare system adopting and using ICD-10, this pilot included an education and adoption program for all participants, followed by a set of “waves” in which diagnoses for the 100-200 most common medical conditions were actually coded and submitted using ICD-10.

The end-to-end testing approach …

…would encompass a number of medical test cases that mirror actual processing, including situations with multiple “hops” or “steps” between providers, clearinghouses, and health plans; the identification of high-risk medical test cases to help prioritize testing; the identification of available testing partners; and key reporting and sharing of test results. The test environment must mirror production.

And how did this pilot testing go? (Cue dark, foreboding music here …)

The average accuracy was in the 60 percent range with low scores around 30 percent.  Yes, some medical scenarios had nearly 100 percent accuracy, which is great. But very low accuracy accompanied a number of very common conditions. Not so great.

Continue reading “Does ICD-10 Pilot Forecast a Perfect Storm for Healthcare?”

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The Massachusetts Medical Society may be the first to notice that Meaningful Use EHR mandates favor large providers and technology vendors. Control over the Nationwide Health Information Network sets the stage for how physicians refer, receive decision support, report quality, and interact with patients. State health information exchanges and policy makers are caught in the cross-fire over health records interoperability. Are the federal regulations over Stage 2 being manipulated to put physicians and the public at a disadvantage?

On Dec. 7, the Massachusetts Medical Society took what might be the first formal action in the nation. A resolution stating:

“That the Massachusetts Medical Society advocate for a more open, affordable process to meet technology mandates imposed by regulations and mandates; e.g., that all Direct secure email systems, mandated by Meaningful Use stage 2, including health information exchanges and electronic health record systems, allow a licensed physician to designate any specified Direct recipient or sender without interference from any institution, electronic health record vendor, or intermediary transport agent.”

Scott Mace’s column Direct Protocol May Favor Large Providers and Vendors is the first to report on this unusual move by a professional society. Full disclosure: I’m a member of the MMS and the initiator of what became this resolution.

Meaningful Use is intended to support health reform by promoting interoperability and innovation in health service delivery. The Affordable Care Act, Obamacare, is fundamentally a free-enterprise model without single payer or even a public option. Obamacare depends on the market for eventual cost controls and sustainability. Meaningful Use is regulation designed to enable market-driven health reform by reducing interoperability barriers.

Although Meaningful Use regulations have already handed out $17 Billion to drive “voluntary” adoption of interoperable electronic health records, meaningful interoperability is still elusive. Meanwhile, the doctors are chafing about Meaningful Use intrusions and policymakers worry that the regulations will actually increase costs.

Continue reading “It’s Doctors versus Hospitals Over Meaningful Use”

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I want to update you on ComChart EMR’s “Meaningful Use Certification” status.

ComChart EMR will continued to be certified as a Complete EMR for Stage I Meaningful Use. Unfortunately, we will not be able to meet the Stage 2 (or greater) Meaningful Use certification requirements as these requirements are technically extremely difficult to implement.

In addition to the Meaningful Use mandates, there continues to be a never ending stream of new mandates such as ICD-10, PQRI, Meaningful Use 2, Meaningful Use 3, SNOMED, ePrescribing, LOINC, Direct Project, health information exchanges etc.  As a result of the mountain of mandates, ComChart EMR  and the other small EMR companies will have to choose to implement the mandates or use their resources to add “innovative” features to their EMR. Unfortunately, the small EMR companies do not have the resources to do both.

(I suspect this is also true, to some extent, for all EMR companies.)

While the individual people involved in promulgating these EMR mandates (mostly) have the best of intentions, they clearly do not understand what transpires in the exam room, as many of the mandated features confer little or no benefit to either the patient or the healthcare provider.

In addition to a lack of understanding of what is important during the process of providing healthcare, it has also become apparent to me that the Federal and State health information technology agenda is now largely driven by the strongest HIT companies and health institutions; the individual physician is only an afterthought in the entire process.

Continue reading “Open Letter From a Small EMR Vendor To Our Customers and Our Friends In Washington”

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I’ve recently written about healthcare.gov and the lesson that going live too soon creates a very unpleasant memory.

As I work with healthcare leaders in Boston, in New England, and throughout the country, I’m seeing signs that well resourced medical centers will struggle with Meaningful Use stage 2 attestation, ICD-10 go live, HIPAA Omnibus Rule readiness, and Accountable Care Act implementation, all of which have 2013-2014 deadlines.

People are working hard. Priority setting is appropriate. Funding is available.

The problem is that the scope is too big and the timeline is too short.

What are the risks? 

Continue reading “Fine Tuning the National Health IT Timeline”

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