As both congressional chambers debate reopening of the goverment, budgets and whether to defund all or pieces of the Affordable Care Act (ACA), healthcare reform continues to be implemented in various areas, such as electronic health records (EHRs) and the meaningful use program. Over the last several weeks, various healthcare stakeholders and groups have expressed their concerns over the implementation deadlines of the Meaningful Use stages as well as other aspects of the program that may be burdensome to physicians and their staff.
As a brief refresher: Under the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act (part of the Recovery Act), hospitals and healthcare providers must be able to demonstrate by 2015 that their EHR systems are capable of certain tasks that constitute "meaningful use."
Currently, to receive a payment, providers must meet 19 of 24 "meaningful use" objectives that include electronically tracking patients' medications and allergies, sending reminders, sharing lab test results and producing summaries of a patient's office visit. The Centers for Medicare& Medicaid Services (CMS) oversees the incentive program.
More than 3,750 hospitals have received a total of $8.8 billion in "meaningful use" incentive payments as of July, according to the CMS website.
Concerns About Meaningful Use
For example, FierceEMR reported that the American College of Physicians recently sent a letter addressed to federal health officials saying that the "very aggressive" timeline and "overly ambitious" objectives of Meaningful Use Stage 2 threaten to limit the success of the overall program.
In the letter—sent to U.S. Department of Health & Human Services (HHS) Secretary Kathleen Sebelius, Centers for Medicare& Medicaid Services (CM) Administrator Marilyn Tavenner and National Coordinator for Health IT Farzad Mostashari—ACP Medical Informatics Committee Chair Peter Basch added that relying on "evolving and draft standards" and untested technology could create "unintended consequences" and "additional costs" for physicians.
"As Meaningful Use has become more prescriptive of certain workflows, it has become less relevant to internal medicine subspecialists," Basch writes. "We are concerned that subspecialists may not adopt and fully realize the potential of certified [electronic health record] products if the requirements of the program do not allow for the unique workflows required by some subspecialists." The letter outlines five areas of concern for ACP members, including:
- The Stage 2 timeline: ACP recommends an extension of at least one year or "perhaps even longer" for Meaningful Use Stage 2. "The implementation of software by a practice does not mean that the practice is prepared to use it appropriately or to make the care process changes needed to accomplish the objectives," Basch says.
- Clinical quality measures: ACP believes that the clinical quality measures reporting process won't be ready in time for Stage 2. According to Basch, there hasn't been "sufficient time either for the new e-measures to be tested and validated, or for a determination if the output of the EHR systems is an accurate representation of the performance of the [eligible providers]."
- ICD-10 and physician quality reporting systems: The implementation of the former means that physicians will need new or updated EHR systems on Jan. 1, 2014, to comply with data collection requirements for the latter.
- Scoring Meaningful Use measures: ACP calls the "pass-fail" requirements "counter-productive." Basch says that a "partial scoring" or "tiered" system would be more fair and representative of what providers can realistically accomplish. "Not every measure is absolutely appropriate and of equal value to every practice situation," he adds.
Planning for Stage 3: ACP believes that "deeming" should be the "preferred pathway" for most providers in achieving Stage 3 of Meaningful Use. "There are better ways for EPs to prepare for and to deliver better outcomes than logging activities that may or may not have direct impact on the quality, safety or value of care," Basch says.
In addition to the ACP's latter, the Medical Group Management Association (MGMA) asked HHS last month to extend reporting for Stage 2 by at least one year and delay the penalties to be imposed on providers who are not meeting the Meaningful Use requirements, as reported by FierceEMR. The CEO of MGMA, Susan Turney, told Secretary Sebelius that while there are more than 2,200 products and almost 1,400 "complete EHRs certified under the 2011 criteria for ambulatory eligible providers, there are only 75 products and 21 complete EHRs for Stage 2 criteria."
"This lack of vendor readiness has significant implications for EPs," and "without the appropriate software upgrades and timely vendor support, EPs will be unable to meet the Stage 2 requirements and thus will be unfairly penalized starting in 2015," Turney wrote. MGMA also called for an extension for providers on the reporting period for Stage 2 incentives from 90 days to one year, as well as an extended reporting period for Stage 1 incentives for providers whose EHR has not been re-certified by January 2015 for the Stage 2 criteria.
The American Academy of Family Physicians (AAFP), also asked federal health officials for a one-year extension to the time frame for compliance with Meaningful Use Stage 2, saying that the current time frame "will outstrip the capacity" of both vendors and family doctors. AAFP Board Chair Glen Stream, M.D., said that such an extension would create "three distinct cohorts:"
- Cohort 1, which would include eligible professionals attesting to Meaningful Use in 2014 as their first payment year;
- Cohort 2, which would include EPs attesting to Meaningful Use in 2014 as their second payment year, and;
- Cohort 3, which would comprise EPs attesting to Meaningful Use as their third or fourth payment year
As reported by FierceEMR, EPs in each of the cohorts under AAFP's proposal would be required to follow specific but distinct timelines for Meaningful Use reporting to receive their bonus payments.
"This modified timeline would allow exemplar practices to implement Meaningful Use Stage 2 requirements early in 2014 and for their experience and learnings to be leveraged by vendors, implementers and other providers to optimize subsequent transitions," Stream said. "Pressure would be kept on vendors to be ready for Meaningful Use Stage 2 by Jan. 1, 2014, while distributing the strain of conversion of vendor product and physician workflow over a 21-month period rather than a nine-month period."
In addition to these letters, Seventeen Republican senators urged HHS to extend the deadline Stage 2 of the Meaningful Use Incentive Program.
The senators—led by John Thune (S.D.), chair of the Senate Republican Conference, and Lamar Alexander (Tenn.), ranking member of the Health, Education, Labor and Pensions Committee--sent a letter Sept. 24, to Secretary Sebelius, asking for a one-year extension "for providers who need extra time to meet the new requirements." The senators expressed three key concerns with the current timeline:
- Significant timeline pressure
- A widening of the "digital divide" for small and rural providers
- Serious unintended consequences of the rush, such as stifling innovation and increasing medical errors
The senators asked Sebelius to respond by October 8th.
Back in July 2013, Sen. Orrin Hatch (R-Utah) in called for HHS to pause and reassess the program. Hatch's statement came during a Senate Finance Committee hearing, which focused on health IT. National Coordinator for Health IT Farzad Mostashari, who attended the hearing, defended the program, testifying that the Meaningful Use objectives are "strongly aligned with other policy drivers to help" the healthcare system to become safer and more efficient. When asked by Hatch if a break from the program would be a good idea, Mostashari responded that doing so would interrupt momentum being built, reported FierceEMR.
Patrick Conway, chief medical officer at CMS, agreed with Mostashari, testifying that increased EHR adoption will improve the quality of care for CMS beneficiaries. "EHR data can be used to display information in ways that are beneficial for providers and their patients. … By providing tools and incentives for EHR adoption, quality reporting, e-prescribing and patient engagement in their healthcare, CMS is encouraging clinicians, hospitals and beneficiaries to use HIT as a platform for improved healthcare quality and better health outcomes at lower cost."
In addition to this testimony, four hospital Chief Information Officers (CIOs) representing the College of Healthcare Information Management Executives (CHIME) expressed their concern, about increasingly rigorous demands and shorter deadlines in Meaningful Use Stage 2. The CIOs called for a one year extension for Meaningful Use Stage 2.
FierceEMR noted that a majority of hospital CIOs recently polled by healthsystemCIO.com in late May called the Meaningful Use program flawed, agreeing with CHIME's request for a one-year extension. CHIME's proposal came in response to a call in April from six GOP senators to reboot the Meaningful Use incentive program.
"The biggest issue … is that we just don't have enough time to implement and exercise the 2014 certified software," said Pamela McNutt, CIO of Dallas-based Methodist Health System. "All of the objectives listed as challenges require significant work to implement after upgrading … For example, after delivery of the patient portal we will have to map data elements from the patient record and clinical staff will need to ensure that the data is representing accurately."
Others expressed concern about funding, noting that small and rural hospitals already make ends meet on "razor-thin margins." In fact, Reuters reported on a recent study, which found that small and rural U.S. hospitals are most at risk of not satisfying certain federal requirements for using electronic health record systems.
In this new study, lead author Catherine DesRoches, from Mathematica Policy Research, collaborated with the American Hospital Association (AHA) and analyzed Medicare data to see which types of hospitals were receiving incentive payments indicating progress toward the meaningful use goals.
Between 2011 and 2012, the researchers found, the percentage of hospitals nationwide receiving incentive payments more than doubled from about 17 percent to about 37 percent.
But considerable disparities among hospital types and regions have emerged, the researchers report in the journal Health Affairs. Hospitals in the Northeast were most likely to receive incentive payments, compared to those in other parts of the country, with the West trailing. In 2012, 47 percent of Northeast hospitals got the payments, followed by 41 percent of hospitals in the South, 32 percent in the Midwest and just under 29 percent in the West.
Teaching hospitals were more likely to receive federal incentive payments than nonteaching hospitals, and for-profit hospitals more likely to receive the payments than not-for-profits. Less than 30 percent of government-owned hospitals got the incentives in 2012.
In all categories, as the number of beds at facilities got smaller, the percentage of hospitals receiving payments dropped.
More than half of the hospitals with 200 or more beds received incentive payments, compared to just about 27 percent of hospitals with fewer than 100 beds. And just 10 percent of critical-access hospitals received the incentives in 2012.
These smaller hospitals may have difficulty coming up with the financial resources to implement an EHR system meeting the requirements, they may have trouble attracting the proper support staff to manage the EHRs and they may also have trouble competing with larger clinics for the systems, the study authors point out.
There have been "infrastructure issues" when it comes to smaller and critical-access hospitals, according to Kimberly Lynch, director of the Regional Extension Center (REC) Programs at the Office of the National Coordinator for Health IT in Washington, DC.