Meaningful use 2? Just say no

“I’m as mad as hell and I’m not going to take this anymore!”
-Howard Beale, in Network (1976)

No matter where you turn these days you are reminded that you need to attest to your meaningful use Stage 2 requirements in order to continue to receive payments from the Centers for Medicare and Medicaid Services (CMS) Medicare and Medicaid Electronic Health Records (EHR) Incentive Program. In this article I would like to discuss “real world” meaningful EHR use. Pediatricians who have already received incentive payments should consider whether it’s worthwhile to continue to participate in the program.

Incentive payments by the numbers

Healthcare reform began 5 years ago with the implementation of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, (passed in conjunction with the American Recovery and Reinvestment Act), developed by Congress to incentivize physicians to adopt approved EHRs.

The CMS provides payments to providers and hospitals via the EHR Incentive Program over a period of years if they demonstrate meaningful use of certified EHRs. Those participating in the program are eligible to receive up to $63,750 for Medicaid providers over 6 years or $44,000 over 5 years for Medicare providers. Additionally, Medicare providers would be penalized by a gradual reduction of up to 5% of their Medicare payments if they were not in compliance beginning in 2015.

To qualify for full incentive payments, pediatricians must have at least 30% of their visit encounter volume within a 90-day period provided to patients enrolled in Medicaid, whereas those with at least 20% will qualify for partial incentive payments. Pediatricians who meet the 30% Medicaid threshold will qualify for an incentive payment of $21,250 for the first year and $8500 per year for the next 5 years. Those who meet the 20% Medicaid rate would qualify for an incentive payment of $14,167 for the first year and $5567 per year for the next 5 years. Incentive payments to eligible hospitals are based on a number of factors, beginning with a $2 million base payment.

According to the CMS, “The concept of meaningful use is strongly supported by consumers and purchasers because it supports critical goals,” which include:

• Increasing care coordination and fostering better doctor-patient communication;

• Reducing medical errors and improving patient safety;

• Supporting delivery of evidence-based care;

• Reducing disparities by recording demographic information;

• Improving quality of care, while fostering more cost-effective delivery;

• Advancing payment reform (by supplying needed data on provider performance);

• Providing patients with their own portable health information.

In order to continue to receive incentive payments (or avoid reduction of payments in the case of Medicare providers), users would transition the way they use their EHRs; ie, in 3 sequential stages over the course of the program.

STAGE 1: Adopting EHR certified technology and using the technology in a meaningful manner, including electronic prescribing (e-prescribing).

STAGE 2: Demonstrating the capability of exchanging electronic health information to improve quality.

STAGE 3: Submitting information on clinical quality measures.

As you are likely aware, in order to receive incentive monies, practices must “attest” to meaningful use, and report to CMS that “objectives” are being met. Stage 1 requires reporting on 13 core objective and 5 of 10 menu objectives, while Stage 2 (Table) requires reporting on 17 core objectives and 3 of 6 menu objectives. Both Stage 1 and Stage 2 meaningful use also require that practices and hospitals report on a number of quality measures. (See “Renovating your medical home,” Contemporary Pediatrics, July 2014.)

By the way, in case you were wondering, meaningful use measures were developed by the National Quality Forum (NQF) at the request of the Office of the National Coordinator for Health Information Technology. The full final report can be found on the NQF website.

The fly in the ointment

In previous Peds v2.0 articles, I’ve discussed how to best comply with government requirements and how to improve office efficiencies while maximizing revenue. In my view, the population view of healthcare is misdirected as well as mismanaged. I have suggested that pediatricians should embrace what I call the “Golden Rule of Pediatric Practice”-simply treat the patient as you would like to be treated yourself. In practice, this means that we treat one patient at a time to achieve the best outcome for that patient and family. It means listening thoughtfully; providing diagnostic and treatment options; using technology to improve care; educating the patient; and assisting patients in navigating what has become an extremely complicated healthcare system.

This is not to say that there is not a role for population health in identifying trends and making suggestions for reform. However, no one would want a “population doctor” as his or her personal physician. Challenging physicians to comply with meaningful use (in addition to numerous other healthcare mandates) while we strive to provide quality care just makes our job that much more difficult.

Problems with EHRs and meaningful use

I believe that EHRs, when used correctly and efficiently, can improve the healthcare we provide patients. Just the acquisition of an EHR is itself quite “meaningful” in regard to increasing the quality of care provided to patients. However, EHRs are very expensive, and very few are expertly designed to expedite documentation. There are just too many buttons to click and data fields requiring input to complete in a simple office visit. So, over time we learn to be nimble with our EHRs, using templates and voice dictation to speed documentation and macros to populate fields quickly.

Realistically, it will take several years for all EHRs to mature to the point where they improve rather than hinder productivity and help us achieve all those noble “meaningful” goals outlined above. Just by producing readable notes (versus handwritten notes in paper charts), EHRs improve care and can reduce (but not eliminate) medical errors. Facilitating an updated medication list and problem list improves the quality. On the other hand, e-prescribing is a mixed bag. When it works correctly it’s wonderful, but it has its own set of problems and annoyances. For example, there is no way to retrieve a prescription sent electronically when a patient wants the prescription sent to a different pharmacy than the one he or she approved a moment ago. Few EHRs have correct insurance formularies and many don’t caution you regarding harmful drug interactions. Another enormous benefit of EHRs is that it provides practices the ability to benchmark operations to see how they are performing compared with national averages (see “Renovating your medical home,” Contemporary Pediatrics, July 2014) so that problems can be identified.

In an era of growing EHR use, physicians need to streamline their notes. We must document correctly to justify the level of service, but excessive documentation wastes time. I long for the time when we establish a new, shorter standard of medical documentation and our EHRs have the ability to extract information from our notes to populate discrete data fields that can be used for benchmarking purposes.

Consequences of meaningful use

Healthcare reform, including meeting meaningful use requirements, has had a profound effect on physicians. A recent survey of more than 20,000 physicians performed by the Physicians Foundation revealed some chilling information:

• 81% of physicians consider themselves either overextended or at full capacity (compared with 75% in 2012);

• 44% of physicians are considering retiring, changing jobs, or cutting back on patient access;

• 35% of physicians are in private practice (down from 49% in 2012);

• 85% of those surveyed have adopted EHRs (an increase from 69% in 2012), however, 45% indicate the EHR has detracted from their efficiency;

• 26% of surveyed physicians participate in an Accountable Care Organization (ACO), but only 13% believe that ACOs will improve quality and reduce cost.

Meaningful use requires data entry and button pushing that are not always relevant to a patient visit. This requirement often complicates workflow and adds to the office overhead expenses because more staff is needed to enter data. As a consequence, visits take longer, productivity decreases, and overhead increases. Keep in mind we don’t get credit for putting family history or comments regarding smoking cessation in our notes. These must be entered in their own discrete EHR fields to be counted toward meaningful use.

What is a pediatrician to do?

Sometimes it does help to get just a little bit “angry.” A better alternative to shouting out the window is to carefully consider one’s options.

For many independent pediatricians, the simplest option is not to participate in Stage 2 of the CMS EHR Incentive Program. Initially, many pediatricians thought the compliance monies could help them invest in an EHR. The initial incentive may have helped practices afford an EHR, which often can cost upward of $100,000. Following the first year payments, the per-provider incentive is no more than $8500. Many pediatricians have discovered that losses in productivity and the real cost of compliance is not worth one’s continued participation. Pediatricians do not participate in Medicare and therefore are not subject to payment reductions as are our colleagues in family and internal medicine. Also, Medicaid payments have increased because of the Affordable Care Act, so practices should not be wanting financially if they choose not to participate.

If you are an employed physician, you have little choice in the matter if your organization continues to participate in the CMS EHR Incentive Program. However, you can adopt efficiencies to help your organization comply. This means that you and your staff need to enter required information in such a manner as to minimize the impact on your workflow and productivity.

The ship may sink anyway

There are well-publicized problems unique to meaningful use Stage 2. It requires patients to enroll in a patient portal and communicate electronically with providers, so compliance depends on the whim of patients, a situation over which physicians have little or no influence. It also requires that EHRs communicate electronically with immunization and cancer registries as well as transmit data securely via statewide information “exchanges.” Integrating lab services, imaging services, and clinical decision support into EHRs has proved to be a challenge for many EHR vendors. As of this writing, only a little more than 200 EHRs of the 1400 available are certified for Stage 2 meaningful use. If yours is not among them, you may need to switch your EHR if you want to continue to participate in the program!

So, bide your time

More than 490,000 eligible professionals, eligible hospitals, and critical access hospitals are actively registered in the Medicare and Medicaid EHR Incentive Program as of August 2014. However, only 1203 providers have attested to Stage 2 meaningful use in contrast to several hundred thousand providers who have attested to Stage 1 meaningful use.

I would recommend that pediatricians continue to use their EHRs to improve patient care; help EHR vendors improve their products; and not continue to participate in Stage 2 of the EHR Incentive Program. As time passes, if few providers are able to attest to Stage 2 meaningful use, the EHR Incentive Program will need to be modified or perhaps even abandoned altogether.

Just the acquisition and use of a reasonable EHR should be “meaningful” enough for everyone.

 Stage 2 Meaningful Use: Core and Menu objectives

17 Core Objectives

1. Use computerized provider order entry (CPOE) for medication, laboratory, and radiology orders.

2. Generate and transmit permissible prescriptions electronically (eRx).

3. Record demographic information.

4. Record and chart changes in vital signs.

5. Record smoking status for patients 13 years old or older.

6. Use clinical decision support to improve performance on high-priority health conditions.

7. Provide patients the ability to view online, download, and transmit their health information.

8. Provide clinical summaries for patients for reach office visit.

9. Protect electronic health information created or maintained by the Certified EHR Technology.

10. Incorporate clinical lab-test results into Certified EHR Technology.

11. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach.

12. Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care.

13. Use certified EHR technology to identify patient-specific education resources.

14. Perform medication reconciliation.

15. Provide summary of care record for each transition of care or referral.

16. Submit electronic data to immunization registries.

17. Use secure electronic messaging to communicate with patients on relevant health information.

6 Menu Objectives

1. Submit electronic syndromic surveillance data to public health agencies.

2. Record electronic notes in patient records.

3. Imaging results accessible through CEHRT.

4. Record patient family health history.

5. Identify and report cancer cases to a state cancer registry.

6. Identify and report specific cases to a specialized registry (other than a cancer registry).

Abbreviations: CEHRT, certified electronic health record technology; EHR, electronic health record.

Centers for Medicare and Medicaid Services. Stage 2 Overview Tipsheet. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Stage_2.html. Updated August 2012. Accessed October 20, 2014.   

Dr Schuman, section editor for Peds v2.0, is clinical assistant professor of pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, and editorial advisory board member of Contemporary Pediatrics. He has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.