As the 60-day open comment period for the Meaningful Use NPRM has come to a close, numerous physician organizations have voiced loud concern about this process. The $34 billion subsidy earmarked for Electronic Health Record (EHR) adoption incentives, contained in the HITECH portion of the American Recovery and Reinvestment Act of 2009 (ARRA), was hoped to be enough to incentivize physicians to begin moving their documentation away from paper and toward electronic systems.
However, in order to qualify for the incentives (which can total up to $44,000 per physician, paid out over a 5-year period), physicians need to jump through a series of hoops in order to demonstrate that they are “meaningfully using” certified EHR technology.
These hoops have been criticized as being too “aggressive,” according to a letter to the Centers for Medicare and Medicaid Services (CMS) signed by the AMA and 95 state and specialty medical societies. The concern was that some of the 25-or-so Meaningful Use criteria categories were too onerous, and that physicians would be likely to throw their hands in the air and walk away from stimulus moneys – hindering, rather than helping, the desired result of increasing EHR adoption. The societies urged CMS to abandon its “all-or-nothing” approach for determining candidacy for HITECH/ARRA stimulus moneys.
Another objection came from the Medical Group Management Association (MGMA), who said that physicians were being required to perform functions that might not be possible due to factors beyond their control – electronic prescribing, or immunization registry interface, or lab connectivity all depend on those external systems being able to interface with the physician’s EHR. Such capability by these outside systems is quite variable (as we have seen in our own experience), and holding physicians accountable in instances where there is no such capability is not right.
On the other hand, numerous other stakeholders – such as AARP, the National Partnership for Women and Families, and the Pacific Business Group on Health (PBGH) – argued at a press conference that the underlying intent of Meaningful Use is extraordinarily important, in order to move healthcare delivery forward. Doctors and hospitals have traditionally invested and quickly adopted other technologies, particularly when these technologies add to the bottom line. But health IT has not been seen as a revenue-generator, and instead is seen as a cost burden (monetarily as well as time) – and government stimulus money is a questionable offset to that burden.
Our sense is that much of the resistance by physicians in adopting health IT has to do with bad software. A recent review in Forbes magazine speaks to this issue. Adopting EHR technology sounds like a great idea on the surface, but when installed and being utilized, many of the shortcomings of a system become evident – the result is that productivity slowdowns can occur, and can sometimes take up to 12 months before productivity levels return to pre-implementation levels. For primary care physicians (PCPs), who operate at extraordinarily narrow margins and need to keep office throughput high (“keep the hamster wheel spinning”) – which is the consequence of a fee-for-service environment that favors procedures over cognitive services – such an anticipated slowdown is often the biggest obstacle to making the move to an e-platform.
So how do we move forward here? How do we get physicians to adopt EHRs as a core tool in their day-to-day work, which is the intent of all of this in the first place?
We need better software
Traditional, legacy EHR systems have been part of the problem. Frequently, training around a new health IT install – whether in a hospital or a clinic – involves adapting workflows around how the EHR is built. We believe this is backwards.
EHR software needs to be built around how physicians actually work, and the workflows encountered are quite variable. That means that an EHR system needs to have a different “face” and a different behavior depending on a user’s role and physician specialty. This is quite difficult in a traditional client/server approach, and we believe it can best be achieved through a web-based, software-as-a-service (SaaS) approach, as we commented previously.
Further, EHR software needs to adapt to user suggestions for improvements. A user feedback button (or some easy mechanism that can be launched when the user is “in the moment”) should allow for a good development pathway. At Practice Fusion, we note that over 80% of user feedback items work their way into product enhancements. This kind of approach dovetails with the interest around testing EHR Safety, as we have commented previously.
CMS needs to abandon the all-or-nothing approach to Meaningful Use
A step-wise approach to Meaningful Use is more likely to foster EHR adoption, and reduce the “fear factor” of “not getting it all right” and therefore missing out on incentives despite investment of time and money into EHR technology. If there are, for example, 26 categories for Meaningful Use, and a given physician meets the requirements for, say, 17 of these categories, then the HITECH incentive moneys should be a proration of 17/26 of the total amount available. This would encourage progressive adoption.
EHR software needs to be able to capture Meaningful Use in a way that does not burden the physician. The software needs to be a fast, indispensable tool that physicians can’t imagine living without – and in the process of moving through an ordinary workday, all the Meaningful Use requirements are tallied in the background. This falls on the shoulders of EHR vendors, and may well be part of certification. When these kinds of systems are readily available to rank-and-file physicians, then the kinds of objections heard from physician and hospital organizations will become answered.
As EHR developers and vendors, our challenges are in front of us – and we remain committed to creating the kinds of tools that truly do help move healthcare forward into a new, transformed system that has been at the heart of the whole ONC vision.
Robert Rowley, MD
Chief Medical Officer, Practice Fusion, Inc.
