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Technical Doctor's insights and information collated from various sources on EHR selection, EHR implementation, EMR relevance for providers and decision makers
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Who is Adopting EHRs and Why: ONC Turns up Some Surprises

Who is Adopting EHRs and Why: ONC Turns up Some Surprises | EHR and Health IT Consulting | Scoop.it

A high-level view of the direction being taken by electronic health records in the U.S. comes from a recent data brief released by the Office of the National Coordinator. Their survey of physician motivations for adopting EHRs turns up some puzzling and unexpected findings. I’ll look at three issues in this article: the importance of Meaningful Use incentives and penalties, the role of information exchange, and who is or is not adopting EHRs.

Incentives and Penalties
The impact of the Meaningful Use bribes–sorry, I meant incentive payments–in the HITECH act are legendary: they touched off a mad rush to adopt technology that had previously aroused only tepid interest among most physicians, because they found the EHRs outrageously expensive, saw no advantage to their use, or just didn’t want to leave the comfort zone of pen and paper. The dramatic outcome of Stage 1, for instance, can be seen in the first chart of this PDF.

This month’s data brief reconfirms that incentives and penalties played a critical role during the period that Meaningful Use has been in play. In the brief’s Figure 3, incentives and penalties topped the list of reasons for adopting records, with nothing else coming even close (although the list was oddly chosen, leaving out credible reasons such as “EHRs are useful”).

The outsized role payments play is both strange and worrisome. Strange, because the typical $15,000 paid per physician doesn’t even start to cover the costs of converting from paper to an EHR, or even from one EHR to another. Worrisome, because the escalator (a favorite metaphor of former National Coordinator David Blumenthal) on which payments put physicians is leveling off. Funding in the HITECH act ends after Stage 3, and even those payments will be scrutinized by the incoming budget-conscious Congress.

In addition, Stage 2 attestations have been dismally low. Critics throughout the industry, smelling blood, have swooped in to call for scaling back, to suggest that meaningful use provisions be eased or weakened, or just to ask for a more concentrated focus on the key goal of interoperability.

The ONC knows full well that they have to cut back expectations as payments dry up, although penalties from the Center for Medicare & Medicaid Services can still provide some leverage. Already, the recent House budget has level-funded the ONC for next year. Last summer’s reorganization of the ONC was driven by the new reality. Recent initiatives at the ONC show a stronger zeal for creating and urging the adoption of standards, which would be consistent with the need to find a role appropriate to lean times.

Health Information Exchange
I am also puzzled by the emphasis this month’s data brief puts on health information exchange. Rationally speaking, it would make perfect sense for physicians to ramp up and streamline the sharing of patient data–that’s exactly what all the health care reformers are demanding that they do. Why should somebody ask a patient to expose himself to unnecessary radiation because an X-Ray hasn’t been sent over, or try to treat someone after surgery without knowing the discharge plan?

Actually, most physicians would. That’s how they have been operating for decades. Numerous articles find that most physicians don’t see the value of information exchange, and can profit from their ignorance of previous tests and treatments the patient has received.

And that’s probably why, after taking hundreds of millions of dollars from governments, the heavy-weight institutions called Health Information Exchanges have repeatedly thrown in the towel or been left gasping for breath. At least two generations of HIEs have come and gone, and the trade press is still searching for their value.

So I’m left scratching my head and asking: if doctors adopt EHRs for information exchange, are they getting what they paid for? Redemption may have arrived through the Direct project, an ONC-sponsored standard for a low-cost, relatively frictionless form of data exchange. Although the original goal was to make HIE as simple as email, the infrastructure required to protect privacy imposes more of a technical burden. So the ONC envisioned a network of Health Information Service Provider (HISP) organizations to play the role of middleman, and a number are now operating. According to Julie Maas of EMR Direct, nearly half a million people were using Direct in July 2014, and the number is expected to double the next time statistics are collected next February.

So far, although isolated studies have shown that HIEs improve outcomes and reduce costs, we haven’t seen these effects nationwide.

What Hinders Adoption
Some of the most intriguing statistics in the data brief concern who is adopting EHRs and what holds back others from doing so. The main dividing line is simply size: most big organizations have EHRs and most small ones don’t.

I have explored earlier the pressures of health care reform on small providers and the incentives to merge. Health care technology is a factor in the consolidation we’re seeing around the country. And we should probabaly look forward to more.

Americans have trouble feeling good about consolidation in any field. We’re nostalgic for small-town proprietors like the pharmacist in the movie It’s a Wonderful Life. We forget that the pharmacist in that movie nearly killed someone by filling a prescription incorrectly. In real life, large organizations can pursue quality in a host of ways unavailable to individuals.

One interesting finding in the data brief is that rural providers are adopting EHRs at the same rate as urban ones. So we can discard any stereotypes of country hick doctors letting teenagers set up the security on their PCs.

Lack of staff and lack of support are, however, major barriers to adoption. This is the last perplexing question I take from the data brief. Certainly, it can be hard to get support for choosing an EHR in the first place. (The Meaningful Use program set up Regional Extension Centers to partially fill the gap.) But after spending millions to install an EHR, aren’t clinicians getting support from the vendors?

Support apparently is not part of the package. Reports from the field tell me that vendors install the software, provide a few hours of training, and tip their hats good-bye. This is poetic justice toward physicians, who for decades have sent patients out weak and groggy with a prescription and a discharge sheet. Smart organizations set aside a major percentage of their EHR funding to training and support–but not everybody knows how to do this or has grasped the need for ongoing support.

I certainly changed some of my opinions about the adoption of EHRs after reading the ONC data brief. But the statistics don’t quite add up. We could use some more background in order to understand how to continue making progress.



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Stage 2 'flexibility' rings hollow for many | Healthcare IT News

Stage 2 'flexibility' rings hollow for many | Healthcare IT News | EHR and Health IT Consulting | Scoop.it

When the Centers for Medicare & Medicaid Services published its final rule for Stage 2 meaningful use on Aug. 29, it trumpeted the "flexibility" it offered for how providers can use certified electronic health records.

Specifically, the rule allowed providers to use the 2011 Edition certified EHRs, or a combination of 2011 and 2014 Edition technology for the reporting period in 2014. By 2015, all eligible professionals, eligible hospitals, and critical access hospitals are required to use the 2014 Edition certified IT.

“We listened to stakeholder feedback and provided CEHRT flexibility for 2014 to help ensure providers can continue to participate in the EHR Incentive Programs forward,” said CMS Administrator Marilyn Tavenner, in a press statement.

But industry groups did not feel listened-to. And they definitely did not see much in the way of flexibility – at least when it came to reporting periods – a topic on which they'd lobbied particularly hard.

"CHIME is deeply disappointed in the decision made by CMS and ONC to require 365-days of EHR reporting in 2015," said Russell P. Branzell, chief executive officer of the College of Healthcare Information Management Executives, in a press statement responding to the new rule.

"This means that penalties avoided in 2014 will come in 2015, and millions of dollars will be lost due to misguided government timelines," he added. "Now, the very future of meaningful use is in question."

Other stakeholders were similarly wary of CMS' next steps. Even the day before that final rule, MGMA Policy Advisor Robert Tennant (perhaps intuitively sensing what it would contain), told Healthcare IT News that, "We've raised numerous concerns about where meaningful use is going. If significant changes are not coming in the program, I think the program risks a lot. We could see, frankly, failure of the program."

In mid-September, CHIME, MGMA and more than a dozen other stakeholders joined forces to write a pointed letter to HHS Secretary Sylvia Mathews Burwell – Tavenner and National Coordinator for Health IT Karen DeSalvo, MD, were CC'd – to reiterate their serious concern that the success of meaningful use "hinges on addressing the 2015 reporting period requirements.

While the groups – which included HIMSS, the American Medical Association, the American Hospital Association and more – thought their concerns had been heard and would be acknowledged in the Aug. 29 rule, they "were surprised to learn that flexibilities meant to mitigate 2014 challenges did not also address program misalignment in 2015 and beyond."

The numbers speak for themselves, the groups argued. As of September, just 143 hospitals and 3,152 providers have been able to meet Stage 2 with 2014 Edition EHRs.

"This represents less than 4 percent of the hospitals required to be Stage 2-ready within the next 15 days," according to the letter. "And while eligible professionals have more time, they are in comparatively worse shape, with only 1.3 percent of their cohort having met the Stage 2 bar thus far."

While the stakeholders reiterated their commitment to meaningful use, they urged Secretary Burwell to "take immediate action by shortening the 2015 EHR reporting period to 90 days" – and also by adding more wiggle room with regard to Stage 2's notoriously troublesome transitions of care and view/download/transmit measures.

The very next day, a new bi-partisan bill seeking to offer providers meaningful relief was drafter on Capitol Hill. Republican North Carolina Congresswoman Renee Ellmers introduced H.R. 5481, The Flexibility in Health IT Reporting (Flex-IT) Act of 2014, on Sept. 16.

Co-sponsored with Democratic Utah Rep. Jim Matheson, the new legislation is crafted to offer providers more flexibility in showing meaningful use compliance. Specifically, according to Ellmers' office, it would remedy HHS' "short-sighted final rule" requiring 365 days of EHR reporting in 2015.

The Flex-IT Act would allow providers to report their technology upgrades in 2015 through a 90-day reporting period as opposed to a full year. It would be welcome relief for legions of providers, who say the shortened reporting window would help them better manage meaningful use's many onerous mandates.

"The meaningful use program has many important provisions that seek to usher our health care providers into the digital age," said Ellmers in a press statement. "But instead of working with doctors and hospitals, HHS is imposing rigid mandates that will cause unbearable financial burdens on the men and women who provide care to millions of Americans. Dealing with these inflexible mandates is causing doctors, nurses, and their staff to focus more on avoiding financial penalties and less on their patients."

By giving providers the option to choose any three-month quarter for the EHR reporting period in 2015 to qualify for MU, "hundreds of thousands of providers" would have a better shot of meeting Stage 2 requirements safely and effectively, she said.

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