Struggling to Understand or Data Does Not Equal Empowerment
Recently upon leaving my doctor’s office I was presented with a print-out of my visit summary. Knowing I worked it the HIT space my doctor proudly stated that this was one the ways that they planned to meet one of the menu objectives of Stage One meaningful use (MU). This is great I thought, until I began looking over that visit summary.
A significant portion of the summary listed the basics such as who I was, why I paid them a visit etc., all pretty boiler plate – nothing new. Then I turned the page to see the lab results of the routine blood-work – YIKES! nothing but acronyms, values and acceptable ranges. I think I was able to decipher about 10% of those lab results and I work in this industry! I can only imagine how difficult and mind-numbing these figures may appear to an “ordinary” patient/consumer.
So seeing some out of range values I began asking my doctor:
What does this acronym stand? Why is this out of range? Is this something I need to worry about?
Being the great doctor that he is, he took the time to explain my results (some of those out of range values are the result of meds) but also expressed a certain level of frustration stating: “I’m not a big fan of passing this information on to a patient for I worry that they won’t understand results such as these and then I need to take time out to walk the patient through their results which can be quite time consuming. Is this another contributor to physician burnout I wondered?
Now I am all for patient/consumer empowerment and do believe that providing patient’s access to their personal health information (PHI) as a critical component of such empowerment. But does providing a patient a visit summary really empower them or does it simply make them confused (as I was) and resigned or worse endanger?
Stage 2 meaningful use rules released last week state that an eligible physician or hospital will be required to:
Use Certified EHR Technology to identify patient-specific education resources and provide those resources to the patient.
But what will that “patient-specific education resource” look like? Will it solve the problem I encountered?
I want more than a generic here is what these type of acronyms and values mean that litter the internet. I want personalization. I want a system that will take my lab results, my problem list, match it up with my meds, allergies etc. and provide me with personalized knowledge of what these results mean to me and my future health. I then want to be provided suggestions as to how to improve those values? This is what I see as true patient/consumer empowerment.
Unfortunately, what I have actually experienced as a result of this grand HITECH effort under Stage One falls far short of empowerment, if anything, it is closer to disempowerment.
Getting a bunch of data in a visit summary without putting it into context is not meaningful, it is meaningless.
My hope is that there are some novel, creative solutions now being developed that will leverage the new concept in Stage Two, the Base EHR, and provide a module that automatically digs into a patient’s PHI and presents the patient with an empowering visit summary. This is one of the ultimate intents of the HITECH Act, I now want to see it happen.
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Reading the Tea Leaves: CMS to Release MU Rules this Month
The healthcare IT (HIT) industry waits with baited breath for the release of preliminary meaningful use (MU) rules, scheduled for later this month. Why the baited breath? Market has basically stalled as physicians & hospital CIOs hold off HIT purchases awaiting what will actually be asked of them to get those ARRA reimbursement checks. Will the pain of adopting a “certified EHR” and demonstrating “meaningful use” be greater than the gain? Will those meaningful use requirements be too onerous to encourage broad adoption, particularly among smaller ambulatory practices?
Looking across the market, following various HIT Policy and Standards Committee meetings, listening to HIT vendor pitches, private conversations with physicians and following various announcements coming out of HHS, be they press releases or Blog postings, Chilmark Research has come to several conclusions as to what one can expect in the near term:
1) HIT vendor pronouncements and promises that they will meet any and all MU criteria are extremely misleading.
Yes, HIT vendors may put in the minimum feature set to become a “certified EHR” (we still do not know what a certified EHR is yet) and they will likely have the capabilities embedded in their solution to meet MU criteria (especially in 2011), but the challenge is not so much the software, but how it is implemented. Implement it poorly and physicians/hospitals will struggle mightily to demonstrate meaningful use of their EHR.
2) CMS will release MU rules with very low barriers to entry in 2011, but 2013 will have much higher barriers/hurdles to jump and same holds true for 2015.
HHS recognizes that the healthcare market is very immature in its adoption of HIT, that ARRA legislation has demanded certain criteria be met (MU) and that it is on a very tight time schedule. A delicate balance is required to drive early adoption while concurrently meeting legislative intent. Thus, for 2011 we can expect simple. basic MU criteria that does not require significant reporting, that is not burdensome to the practice and that HIT vendors can readily deliver upon today. Chilmark Research also foresees 2011 data exchange requirements for care coordination to be extremely simple without a heavy reliance on HIEs.
3) The biggest challenge in 2011 and for that matter the entire HITECH Act is the successful implementation of certified EHRs that have a glide path leading the adopter on a clear upgrade and workflow optimization path for meeting MU criteria in 2013 and 2015.
That almost bears repeating (read it again folks). The successful implementation of certified EHRs is a huge challenge that unfortunately is largely being overlooked with most of the attention being paid to broader policy and standards issues. Granted, HHS is expending a significant amount of energy and resources to address this issue with nearly $600M going to the establishment of regional extension centers, another $80M in grants for training IT professionals in community colleges and today’s announcement on the Beacon Community Cooperative Agreement Program. But again, we are dealing with a very aggressive adoption and reimbursement schedule. Couple that with the rule that there is no partial reimbursement for partially meeting MU criteria and one has the makings of “Day the Earth Stood Still” scenario.
4) The infrastructure for data exchange in support of care coordination is simply not there.
ONC head, Dr. Blumenthal made it quite clear that exchanging data within a private HIE (IDN sponsored) will not meet MU criteria. Problem is, of the 200 or so public HIEs that are now in existence, only 25% are actually moving data of any type (most of that data is very simple labs, med lists, etc. and not what HITECH/MU envision), another 25% are still in PowerPoint and the remaining 50% somewhere in between. Again, HHS is putting significant resources behind this issue, but HIEs just don’t appear out of nowhere. HIEs take time to develop, put in place data use and sharing agreements (DURSAs), define a business model, staff up, implement a vendor’s solution, tie the network together and finally begin moving data. Chilmark still does not see a path on how to get from where we are today to what draft MU guidelines will require for data sharing in support of care coordination. You can’t force a river folks. Major rethink required.
Congress, in its infinite wisdom, gave HHS an albatross in the HITECH Act. That is not to say we need to throw out the entire Act, far from it. What is needed is a relaxation of the aggressive HIT adoption schedule that this legislation has written into law.
As proposed, we are looking at a coming train wreck of major proportions wherein by our estimates, over 35% of the estimated $44B that US taxpayers will be spending on the HITECH Act will be wasted. Before we get any further down the road, it is time for HHS and administration leadership to go back to Congress to modify this Act, extending deadlines to insure adoption of HIT is thoughtful, effective and ultimately successful.
Note: This post was written during a flight delay. Unfortunately, did not have the time to provide links to various supporting points in this post. And thanks to Google for providing free Internet access at Logan airport over the holidays.
Meaningful Use Draft is Tough to Swallow
Today, the Meaningful Use (MU) workgroup of ONC’s HIT Policy Committee presented its recommendations for what physicians and hospitals will need to demonstrate to obtain ARRA funding for “certified EHRs.” Chilmark listened in on the presentation and deliberations of the meeting and also downloaded the slide deck, following is our initial assessment.
The MU workgroup broke down meaningful use into 5 broad categories:
Within each category, the MU workgroup set specific objectives and measures. As proposed, these objectives and measures will ratchet up in two year increments, 2011, 2013 and 2015. In 2011, the broad objective is to capture and share data. For 2013, MU is to advance care processes with decision support. In 2015 MU criteria focus on improving outcomes.
A 7pg MU matrix (PDF) is now up on the HHS site provides a clear picture of what is proposed. This matrix has a significant amount of info, far too much to cover within the context of a post, so please take a look for yourself. Chilmark’s summary assessment:
The MU workgroup was charged with an enormous task and have done an impressive amount of work in a relatively short time-frame defining clear, comprehensive goals and objectives for MU. The five broad categories successfully reflect the prime precepts of the ARRA HITECH legislation, going beyond ARRA’s suggestions of meaningful use to address such critical issues such as consumer rights to Personal Health Information (PHI), public health, privacy and security.
The MU recommendations have a strong focus on creating and exchanging data elements that are already becoming “liquid” (e.g., meds and labs) a logical place to start and one that can be accomplished without undue burden. Also, the strong desire on the part o the workgroup to direct MU recommendations towards outcomes and not just focus on technology is to be commended.
Despite the fine work that has been done the MU recommendations are DOA.
The bar has been set too high and the recommendations put forth will be virtually impossible to implement within the aggressive time schedule of the HITECH Act. Simply put, it appears that not enough attention was paid to the processes/workflow changes that are required as part of a successful HIT roll-out to meet these MU recommendations.
For example, recommendations call for CPOE use in 2011. CPOE is extremely challenging to implement and the technology piece is actually a pretty small component of the overall implentation. The real challenge with CPOE is its direct impact on physician workflow and practices. Thus, CPOE requires significant forethought, process mapping, implementation and training. Getting all that done and to demonstrate meaningful CPOE use by 2011? Don’t bet on it.
An even bigger challenge may simply be the reimbursement schedule’s structure, especially for those smaller practices who may not derive a significant portion of their payments from CMS and thus not heavily impacted with future CMS penalties. (We do not have to worry so much about hospitals and IDNs as the future 5% CMS payment penalty is more than enough incentive). The reimbursement schedule, which was written into the legislation is front-end loaded, i.e., physician reimbursement higher in early years than later ones (see table). Ratcheting up MU criteria from 2011 to 2015 may make compliance to MU criteria so onerous that physicians simply opt-out of reimbursement in 2015, which for one starting in 2011, only represents a loss of $2,000.
There is also the issue of the technology itself. Will the physician’s EHR vendor be able, or willing to keep pace with this schedule of MU recommendations, will they embed the needed technology in their solutions to assist the physician/practice/hospital to readily meet future MU criteria? Will there be enough good, experienced consultants available to assist with implementing new changes? Sure, the larger EMR providers will be able to do it, and large hospitals and IDNs will be able to get the good consultants, but will smaller providers be able to keep pace? Much of this may be answered in the future in how ONC defines “certified EHR” and what may come of extension centers. If ONC keeps the definition of “certified” loose to encapsulate an ability for a physician to readily mix and match any number of apps to meet MU criteria, we may have a chance, but currently, it does not appear that we are heading in that direction for certification.
The MU draft recommendations of this workgroup are just that, DRAFT. Discussions today during the HIT Policy Committee meeting were wide ranging and significant. Chilmark also had an opportunity to participate in an ad hoc call this afternoon sponsored by a mid-western IDN’s CIO. During that call as well, discussion was wide ranging, but in this case the focus was more on whether or not the MU recommendations were even doable. Answer was a universal, No and most on this call plan to provide comments to ONC on what is actually doable/reasonable to accomplish within the tight legislative time-frame of the ARRA.
Looking ahead, core MU recommendations addressing privacy and security will pass through with little change. Details regarding “% values” for reporting of various health data metrics will be a key part of negotiations/deliberations. Significant challenges will arise regarding level of CPOE adoption and by who (hospitals vs practices) as well as patient engagement as it pertains to home monitoring with biometrics and eConsult capabilities (2013) and providing PHR with real-time view of EMR data (2015).
Stay tuned folks, it will be an interesting evolution for MU in the coming months.
Usability & Adoption of EHRs
Policy makers keep wondering why physicians do not readily adopt EMR/EHR software. Under ONC’s first head, David Brailer, it was decided that a big problem was a lack of certification of EMR software to insure that it worked as advertised, which led to the founding of CCHIT. Funny thing though – despite CCHIT’s best efforts to certify EMR software, EMR adoption has not seen any dramatic increase.
I won’t bother with the argument that hey doc, ever hear of caveat emptor? Take the time to actually call a reference customer or two and go see the software in action before you buy it. I mean do you really need someone to do that work for you by way of certification when you are paying for it?
Okay, so if it is not certification, it must be all about the money so let’s pour billions of dollars into the market to encourage clinicians to adopt “certified EHRs”. Oh, and doctor, you are going to have to pay upfront for that software, install it and prove you can use it in a meaningful fashion before we give you one red penny. To which a clinician may reply:
Well it’s nice to see some potential dollars come my way to buy such software, but is it really worth the trouble? I mean after all, it is well-known among the peers I talk to out on the golf course that one takes a huge productivity hit for months after installing this stuff.
To which policy makers and those that echo them reply, well if productivity is an issue, than it must be an issue of usability of the EHR software so let’s set-up a process to certify usability.
Now certifying usability is virtually impossible for a whole host of reasons and worse, traveling down such a path would detrimentally impact innovation, the last thing we need in this market so lacking in such within HIT. And no, such a certification process will have absolutely no effect on adoption of EHRs. Adoption will occur when there is sufficient reason (value) to adopt.
But for those EHR developers out there who are looking to increase the value proposition that they can offer clinicians, certainly making their software easier to use is a good place to start. And to learn more about usability, you may want to take a look at the presentation below that the company User Centric recently presented to the Chicago HIMSS group. Tip: Slide 33 will give you some idea why harried docs hate eCharts and maybe more broadly, EHRs for encounters (something which athenahealth confirmed when I visited their offices today – more on that next week).
The HITECH Challenge: Is $19B Enough to Drive HIT Adoption
With the HITECH Act passed and the Dept. of HHS feverishly working to draft a clear definition of what “meaningful use” and “certified EHR” actually mean for reimbursement purposes, a far bigger question looms: Is the promise of $19B dollars dedicated to reimbursing those hospitals and physicians who adopt and meaningfully use an EHR enough?
Let’s take a quick look at the numbers. (For sake of simplicity, this post will look at physician reimbursement.)
For adopting and meaningfully using a certified EHR a physician may be reimbursed between $44K (Medicare) to $65K (Medicaid). This will not be a lump sum payment, but is parsed out over 5 years as the physician continues to demonstrate meaningful use of an EHR. Important points here, the physician pays up-front costs (sunk capital) and is reimbursed over time if he/she can demonstrate meaningful use and the solution adopted is “certified.”
As the latest Wal-Mart, Dell and eClincalWorks partnership shows, vendors looking to sell into this market opportunity are pricing their solutions at or near reimbursement levels, e.g., $25K year one and $4-6.5K for follow-on years in the Wal-Mart offering.
According to athenahealth CEO, Jonathan Bush, their customer, a physician, grosses $400k/yr.
Virtually every report we have seen and physicians we have spoken to who use an EMR/EHR today, readily admit that the upfont pain of implementation, training and becoming adept at using the solution was significant. The significance is most often felt in an average 30% productivity hit for the first 6 months that is compensated through longer hours or seeing less patients. The proactice does not return to pre-implementation state of operation till a year after go-live.
Combining the above and keeping calculations simple: (Note: we’ll assume productivity returns to previous state within first year and use a sliding scale for productivity hit in year one of, first 6 months 30% hit, second 3 months, 20% and and last 3 months 10%)
Year One Cost: ($25K) for EHR purchase + (0.30($400K/2) + .2($400K/4) + .1($400K/4)) = ($115K)
Year One Reimbursement: $25K (more generous Medicaid)
Total Cost to Physician: ($115K) + $25K = ($90K)
After Year One, the physician is already down $90K. Assuming practice returns to normal operations/productivity in years 2-5 and the physician is successful in getting full reimbursement from Medicaid, at the end of five years, that physician is still down $50K. Depending on how much business the physician derives from Medicaid, it will take many more years of avoiding the “stick,” the sliding decrease of Medicaid payments, before a physician recoups this initial, year one loss.
Bottom-line: Adopting an EHR to tap that $19B dollar Stimulus package does not make economic sense for the average physician.
To drive EHR adoption we will need three things:
1) Low “meaningful use” thresholds to ease the pain that a physician has to go through to demonstrate that indeed they are meaningfully using an EHR. As a starting pointing, let’s target electronic exchange of labs, meds and vitals (including allergies) for care coordination combined with eRx. That should address care coordination, quality and eRx outlined in HITECH Act.
2) Very simple certification process for HIT. Do not burden the system with complex certification processes, ala CCHIT. Don’t get me wrong, CCHIT has done some good things in the past, but to apply CCHIT certification for “certified EHR” will create far too complex and onerous a process for truly new and innovation approaches to provide solutions that assist physicians in meeting meaningful use criteria.
3) Leverage the consumer to create an additional forcing function to drive physician adoption as reimbursement under the HITECH Act is insufficient. Getting the consumer engaged may prove challenging, but engage we must for at the end of the day, the value in a physician adopting and using an EHR must return to the end consumer/taxpayer as they are the one footing the bill.
Over the next few years we, as a nation will be extremely challenged to drive true healthcare reform, healthcare reform as President Obama stated that is “evidence-based.” A common refrain in the manufacturing industry is: “You can not improve what you do not measure.” Today, our healthcare system has absolutely no systematic way of measuring its performance. It truly is a travesty. Healthcare IT can, if effectively deployed and used, can play a critical role in collecting those measurements that we can begin to use to conduct true, evidence-based reform.
We need to articulate to the Joe the Plumbers of this country, what HIT adoption and use means to them. To date, the healthcare industry and government has done an extremely poor job of helping Joe understand that value. Without his/her support, no amount of money thrown at this problem will suffice.