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Meaningful Use in the Real World — Is the Additional Administrative Burden Worth the Bonus for Small Practices?

An article in the April 10, 2010 New York Times entitled “Doctors and Patients, Lost in Paperwork,” brought attention to what may be, in the near term, the Achilles heel of the plan to incentivize doctors for the “meaningful use of EHR technology.” The article cited a study published in the Archives of Internal Medicine this past February, which asked a large cohort of physicians in internal medicine training programs about the time they were spending on clerical work, most of which is documentation in patient charts, both paper and electronic. A stunningly large 67.9% of the respondents reported that they were spending “in excess of 4 hours daily” on documentation, while only 38.9% reported spending an equal amount of time in direct patient care.

Now, I am fully aware that practice in the inpatient, hospital setting is not the same as practice in the office, clinic, or ambulatory care environment. Patients tend to be sicker and require more consistent attention while in the hospital, which often means more documentation is necessary. However, the study and the NYT article point to a real world problem that crosses all medical care settings and impacts physicians and other professional providers of all kinds: the enormous burden of documentation, clerical work, and administrative forms completion that impedes real care giving and makes health care less and less efficient even as we add more and more technology.

In both the inpatient and outpatient settings much of the time-consuming and bureaucratic red tape is the product of the fee-for-service health insurance system, in which there are multiple permutations of payment rules, including authorizations and other kinds of forms to be filled out, each health plans forms different from every other health plan. Particularly in the outpatient settings, and for small medical practices, the amount of paper and electronic data collection that must be done to be able to assure payment from a health plan can be staggering. One physician recently compiled this list of activities necessary for a “routine” office visit, CPT coded 99213: verify eligibility; check in; copay determination; get patient to nursing station; see physician; check out; claim to billing person; scrub claim; co-insurance; deductible; send bill to patient; collect remainder; scrutiny; privacy concerns; liability concerns; paperwork_paperwork_telephone calls_paperwork!

Here’s the point. In the real world, most physicians in private practice, and particularly those in primary care, feel that they are deeply under water and drowning in administrative trivia that contributes nothing to, but may often detract from, the quality of care experience that they are able to provide their patients. The administrative documentation is interruptive, mindlessly repetitive, often needlessly duplicative, and costly to the practice in terms of time, money, and nerves. This burden is one, and perhaps the major reason, that so many physicians are selling their practices to hospitals and integrated delivery systems. As one family physician recently put it to me, “I just couldn’t get to sleep at night worrying about all the insurance hassles. At least now that’s someone else’s worry.”

This is the thorny context into which ONC/HHS are launching the ambitious EHR incentive program legislated into existence by ARRA/HITECH, and which will pay physicians up to $44,000 over the next five years for the “meaningful use of certified EHR technology.” While I have expressed on several occasions my basic agreement with this program — in large part because it rewards the outcomes of the use of health IT and not just the purchase of software and hardware, and because I believe that it focuses health IT on quality improvement where it belongs — I have also raised the concerns of my fellow practicing physicians across the country, who must evaluate the incentive payments in terms that reflect their real day-to-day struggles to keep their practices afloat financially. Any additional administrative or bureaucratic burden placed upon the already nearly intolerable levels imposed mostly by the private insurance companies and health plans, is not being taken lightly by these doctors, I can assure you.

To be a “meaningful user” of EHR technology will undoubtedly be an easier task for some doctors, and a more difficult one for others. But let’s not fool ourselves. Meaningful use criteria include a significant number of new data entry/lookup/calculation tasks be taken on by all participating nurses and physicians, often using new and unfamiliar software programs and hardware devices. Meaningful use is at its core the obligation to collect a designated data set about each and every patient, using computers to store those data, and then assuming the obligation to perform a number of operations upon and with those data. The data include demographics, problems, medications, lab results, allergies, smoking history, and so forth. The operations include electronic prescription writing and refilling; sharing or exchange of the data with other providers for care coordination; reporting of quality measurements to Medicare; making available to patients pertinent personal health information and summaries of their visits; the use of clinical decision support tools and reminders for preventive care; and the recording of all orders for labs, referrals, medications, and radiological studies.

I want to be very clear that, in my opinion, were we to re-design health care in this country from the ground up, I would advocate that this set of data and this level of operational workflow using computerized systems would be nearly ideal as a starting point. Meaningful use puts the focus of health IT on some very fundamental information management tasks that are essential to knowing that the right things have been done for patients, at the right time, and with the right level of resources. It provides the basis for Clinical Groupware to flourish, which implies breakthrough improvement in care coordination and continuity. It is a system that could provide doctors with the tools to act smarter, not just harder, and for them to understand where their gaps in performance truly lie, which is the critical element in starting and sustaining an effort at improvement.

But here’s the rub. We’re not starting over. We’re layering these new requirements on top of an already dysfunctional, highly ingrained and overly-complex system that has shown itself remarkably and stubbornly resistant to reform. And in these circumstances, and for most physicians in medical practices today, Meaningful Use does not appear to them to be a way to practice smarter — it appears to be a path to just working harder.

Some might argue that today’s small medical practices represent a cottage industry that is entirely outdated and ought to be replaced by larger, corporate medical enterprises. They would say that it would be a salutary, even if unintended, outcome of ARRA/HITECH were small practices to be driven out of existence and the doctors, nurses, and staff in them integrated into larger and more productive groups. Perhaps there is some truth to this notion, and perhaps it is even part of the Obama administration’s and the ONC/HHS agenda.

However, I would argue that on balance just the reverse is true. Our nation’s small medical practices are the “canaries in the coal mine,” and their suffocation under the burden of bureaucratic complexity that is non-productive and simply cost-additive is a sign of real danger to everyone else in the industry, not just the smallest and most fragile among us. Forcing the small practices out of business doesn’t do anything to relieve the bureaucratic and administrative complexity in the system, it simply moves it to another location, where it will remain a drag on the new and larger units of care. We don’t have the numbers, but anecdotally it is evident that some physicians who sell their primary care practices to hospitals do so as a prelude to early retirement and as the last straw in a chain of events that has ended in failure, at least with respect to their expectations for a career as a physician. We may be actually undergoing an invisible shrinkage in our primary care work force right now.

What I would suggest is this: instead of rushing headlong into a clash that further extinguishes the ability of small medical practices to survive economically, and at worst may significantly diminish the nation’s primary care capacity at the precise time when we need more of it, the current Congress and White House should work together on a rational trade-off between insurance related hassles and the new work associated with adoption of EHR technology. Our national leaders should understand that unless duplicative, wasteful, and completely non-productive documentation is streamlined and significantly reduced, the nation’s small and medium size medical practices will likely sit on the sidelines of ARRA/HITECH — not because the money is too little, or the technical help offered insufficient, but because they simply don’t have the cycles to take on the new paperwork (even if it’s computerwork). If that happens Meaningful Use will be at risk of becoming a failed experiment that merely lined the pockets of the highest utilizing, and therefore highest profit, physician groups and hospitals, along with the legacy EHR vendors who they favor.

My guess is that physicians all across the country would applaud an all-out effort by Congress and the Obama administration to simplify administrative/claims workflow and reduce insurance paperwork, and that they would look at the EHR incentive programs with a much less jaundiced eye if they knew that their overhead costs for billing and claims submission were to be cut in half. It will take bold action to bring this about, but it’s time to do it. Insurance reform is meaningless unless we drive much of the administrative costs out of the system. And unless we do, asking America’s physicians to accept more paperwork isn’t realistic.

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Dan "Beyond Meaningful Use" FellarsVishalTimGeri Verascosachin kumar Recent comment authors
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Dan "Beyond Meaningful Use" Fellars
Guest

I love reading practicing physicians true feelings regarding meaningful use. This is a great meaningful use manifesto, or “MUnifesto” as I like to call them 🙂
I don’t know how this one didn’t get added to my original list. I will be sure to include it at ProfitableUse.com

Vishal
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Vishal

Dear David, I don’t completely agree with you on the point of incentives being futile for small practices. I understand that there is a lot of administrative procedures which are involved in availing these incentives but that I feel is just for the initial phase that too it can be reduced to a greater extent by employing the right tools and services i.e understanding the concept and challenges that posed by specialty of the medical practice. An appropriate specialty EHR takes care of most of these challenges. Looking at the profitability of the EHR investment, I think ROI is very… Read more »

Tim
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Tim

I’m amazed that educated adults still think the government is going to “reduce red tape”. Well, President Obama said it, so we expect it. Really?
It’s like a decades-long session of self-hypnosis. At first, it’s amusing, then you wonder exactly how long the subject will be able to cluck like a chicken.

Geri Verasco
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Geri Verasco

I have to admit I haven’t read all of the responses here but I do believe if meaningful use were more of a sequential implementation rather than ” all or nothing” it would be more successful. Those who cannot affort the cost of the system will throw their hands up and give up. Others may choose to address the processes that meet financial goals getting around the true initiatives of gaining better healthcare for the people. There is much confusion, requirements still being ironed out and lack of vendor product certifications laying open upgrades and other nasty scenarios. Perhaps our… Read more »

sachin kumar
Guest

Electronic total station rts700, rts710 series, absolute encoder GUI and touch screen, dual speed drives, on board professional software, multiple interface options use to surveying and positioning equipments manufacturers suppliers.

J. Stefan Walker
Guest

Great article as always, David; captures the essence of my rural practice challenges to a T. However, we waste time in wishing for the Wizard of Oz to simplify the system whilst we stepwise would adapt to the realities of EMR, PQRI, P4P, and accountable care – a wave that is necessary for medicine’s movement into modernity and sustainability. Our efforts should not be backpedaling but rather busying ourselves as physicians in the work of self-organization, participation in specialty and regional medical societies, helping each other implement and use EHR / HIE. Then – by embracing, not resisting full EHR… Read more »

David C. Kibbe, MD MBA
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David C. Kibbe, MD MBA

Randall: Trying to answer your questions: no, non-participating physicians cannot qualify for Medicare EHR incentive funds. Not quite sure about your other question, but who has paid for the EHR technology used by physicians isn’t a material issue in qualifying for Meaningful Use. So, those doctors who have received subsidies from hospitals under the Safe Harbor rules, would still be able to apply for either Medicare or Medicaid incentives. Hope that is helpful, DCK

Graham Chiu
Guest

If we accept the premise that using electronic medical records will lead to a reduction in health care costs, while improving care, and that the ability to demonstrate meaningful use is an accurate outcome measure for the effective use of such technology, then it seems to me that ONC should be conducting research to identify existing practices who are already capable of meeting such criteria to identify the characteristics of such practices to provide an evidence base for those who wish to pursue this funding.

Graham Chiu
Guest

If we accept the premise that using electronic medical records will lead to a reduction in health care costs, while improving care, and that the ability to demonstrate meaningful use is an accurate outcome measure for the effective use of such technology, then it seems to me that ONC should be conducting research to identify existing practices who are already capable of meeting such criteria to identify the characteristics of such practices to provide an evidence base for those who wish to pursue this funding.
Those practices who lack the necessary qualities

InfoMark
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InfoMark

Reality, To be called a vendor, such a low blow! Actually I’m a care quality specialist, and I’ve seen how difficult it is for primary care practitioners to manage (even small scale) care delivery systems without adequate clinical information structures. Without the measurement opportuniuties that electronic HI systems “could” provide, most docs don’t know how well (or to whom – wothout a patient in fornt of them)they are doing on routine processes like lipid testing and urine albumins for patients with diabetes. Being well meaning and being able to perform well are two different things in a world where the… Read more »

David C. Kibbe, MD MBA
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David C. Kibbe, MD MBA

This just in from the MGMA:
“Nearly 68 percent of 450 physician practices that responded to a questionnaire from the MGMA said that changes in practice operations necessary to meet the federal government’s 25 proposed criteria would slow physicians’ daily work. In addition, 31 percent said productivity would decrease by more than 10 percent.”
source: http://www.mgma.com/press/default.aspx?id=33021
DCK

MD as HELL
Guest
MD as HELL

David,
My worry is once I buy the clunker the fuel will be changed to something I will need an adaptor for.

Margalit Gur-Arie
Guest

The answer to #1 is No. You have to participate with Medicare, and moreover the $44,000 is only the upper limit. The actual incentive cannot exceed 75% of allowables. There is a Medicaid program which is nicer, because it is about $20,000 higher, and you don’t have to show meaningful use for the first year. To qualify, you need to have at least 30% Medicaid patients (20% for Peds). To the best of my knowledge, the answer to #2 is Nobody. If they got a non qualifying EMR from the hospital, they’ll have to replace it, if they want the… Read more »

Randall Oates, M.D.
Guest

I am a little unclear about the status of a couple of related issues:
1. Is the ARRA Meaningful Use Bonus of $44k over 4 years available to physicians whose status is non-participating with Medicare as well as those who are participating?
2. For the physicians who have had their EMR purchases subsidized by hospitals via the safe harbor exemptions to the Stark laws, and who are expecting ARRA bonuses, who will fill the gap if the physicians do not qualify for the bonus payments?

Margalit Gur-Arie
Guest

twa, By and large, physicians want two things, acknowledging the same variations MD as HELL mentions: Take good care of patients and get paid appropriately for their work. One could and should argue with the definition of “appropriately” in this context, but the enormous amount of red tape put in place by government and insurance companies is ridiculous and strangely enough, I believe it is achieving the exact opposite of what it was designed to accomplish. If you are really concerned with patient care, then I am not too terribly convinced that organizing docs in efficient business models will lead… Read more »