A significant portion of the physician market has still not adopted an EHR, despite the lure of government incentives and the fear of the penalties looming on the horizon. The stock prices of most publicly traded ambulatory EHR companies are down sharply, as sales are lower and earnings projections have not been met throughout the industry. How can this be, when the EHR incentive program has successfully increased EHR adoption and was expected to be such a boon to EHR vendors?
I know why, and it is not—as commonly thought—because the initial EHR-adoption rush fostered by the incentives has ended. Rather, it is because of rampant physician dissatisfaction that has reached a more-than-palpable level. I have noticed a dramatic change in the tenor of conversations with physicians, most recently at professional society conferences, where physicians who have not yet purchased an EHR are frozen in their tracks. They are worried by the horror stories they hear from colleagues—even from those who have succeeded at meaningful use—because many of those physicians continue to experience major workflow disruptions and significant productivity losses from which they see no potential to rebound. Recent surveys point to the number of physicians looking to replace their EHRs, and based on my company’s experience in the replacement market, that number is growing. A recent article summarized the findings of a large study on EHR satisfaction and presented an insightful analysis of the potential reasons for these disappointing results.
This heightened level of frustration has resulted from frantic, insufficiently researched EHR purchase decisions by physicians and rushed, inadequate implementations conducted by resource-strapped vendors. Massive EHR failures are exactly what I predicted in an EMR Straight Talk post on the unintended consequences of the EHR incentive program in February 2010:
After an initial peak in implementations, long-term EHR adoption will slow—particularly among high-performance specialists—and the current failure rate will escalate. Many factors will contribute to this: (1) Some physicians will rush into EHR purchases without conducting proper due diligence. (2) Products that were overly complex and did not work in busy specialists’ practices in the past will surely not succeed now, particularly since these same products must now be used in an even more structured and demanding way. (3) Sorely needed implementation and training will be provided by inexperienced and rushed implementation teams, further reducing the likelihood of success with providers, many of whom are less technologically savvy than the early adopters. (4) Where there was never a convincing economic justification in the past, the addition of data-collection requirements will further lessen the economic feasibility of traditional, point-and-click EHRs. . . . The result? The high failure rate will leave physicians “holding the bag” after investing large sums of money, failing to earn the anticipated incentives, and owning a system that doesn’t meet their needs.
So, what can physicians do to avoid falling victim to EHR failure, and to instead reap the benefits of successful EHR adoption—government incentives and practice productivity? I have written extensively about the importance of physicians doing thorough and objective reference checking—that advice is as valid now as when I first wrote about it, and perhaps is even more critical today. For guidance on how to conduct a thorough and fair evaluation of an EHR, read EMR Selection: How to Uncover the Truth or 100% EHR Success – A Clinical Approach.
This week, six senators released a white paper, Reboot: Re-examining the Strategies Needed to Successfully Adopt Health IT, that argues that there is no evidence that the $32 billion in taxpayers’ money being spent on meaningful use is returning the results it was designed to deliver. Although it would be naïve to discount the political motivation of the authors—all six being Republicans—they raise some of the same criticisms and concerns that I have written about in the past. They also make some claims that I feel compelled to dispute.
The senators have it right on these issues:
I vociferously disagree, however, with the senators’ criticism regarding interoperability. Of course, we are not there yet—and clearly they are frustrated by that fact—but progress is underway toward that universally supported goal. Contrary to their claim that there are no meaningful use measures that require interoperability, there are in fact several in Stage 2, including the requirement that physicians electronically send a patient care summary for 10% of patients transitioned to the care of another physician or provider. This exchange is facilitated by the fact that all certified EHRs must communicate using the same formats.
Not only does interoperability relate to provider-to-provider communication, but it also allows for easy integration between products of different vendors, without requiring additional programming. I was recently speaking with another HIT vendor about a potential partnership arrangement, and we both talked the same language—XDR Direct for transport protocol and CCDA or HL7 in terms of content. This conversation would neither have been possible, nor would we be able to create a tight, simple interface between our products, were it not for the standards promulgated by the EHR incentive program. This kind of interoperability will ultimately be better for physicians and for their patients. The EHRA (EHR vendor association of HIMSS) hit the nail on the head: the appropriate role for government is to set the standards, but then the vendors should be free to innovate and let the market take over from there.
I have frequently said that meaningful use is a primary-care program, and I still maintain that it was designed with primary-care physicians and their patients in mind. But I believe that specialists will be the greatest beneficiaries of Stage 2’s shift in focus to interoperability. If EHR vendors expand upon the groundwork laid by meaningful use, they will provide physicians with not only a reliable way to get information about their patients’ clinical history, but also an efficient way to reconcile that information and incorporate it into their charts.
As increasing amounts of discrete clinical data is shared between physicians—Stage 2 adds new elements to the Stage 1 required data set—many physicians will find themselves subject to significant workflow disruptions as they struggle to incorporate all of this data into their patient charts. The workflow impact is clearly greatest when the physician sees a new patient, so specialists—for whom new patients typically constitute 25–35% of their office visits—will feel the impact more intensely than primary-care physicians, who may see only a few new patients a week.
How does the physician get this data into the patients’ chart, and where should the data come from? While patients are a good source of demographic data, the primary-care physician is the best source of an authoritative and vetted record of the patient’s health history. Stage 2 of meaningful use creates standards that facilitate the transport of this clinical data from the primary-care physician to the specialist via the “Direct” messaging protocol—a secure e-mail-like exchange process. The data is sent in a standard format called the CCDA (Consolidated Clinical Document Architecture). But this is where meaningful use ends, leaving it up to the recipient of the data to incorporate it into the patient’s digital chart, and this can be time-consuming and disruptive to workflow if the process is not automated.
For physicians, having the tools to accomplish these tasks in an efficient, productivity-focused manner will be a veritable game changer. It will not be sufficient for an EHR to merely display the data from the primary-care physician. Rather, it will be critical for vendors to provide physicians with an efficient means of reconciling this data and automating the process of entering the approved discrete clinical data elements into the patients’ charts. The key for EHR vendors will be to go above and beyond the requirements specified by meaningful use.
CMS just released the December 2012 attestation data, and one thing is abundantly clear—many EHR vendors will not be around to see Stage 2.
Of the 472 EHR vendors offering certified “Complete EHRs” in early 2012, many lacked even a single physician who had attested to meaningful use by the end of the year. And while it is not surprising that large vendors dominate the EHR market, they do so to a far greater extent than the 80/20 rule would predict. The top 24 EHR companies (just 6% of the 392 ambulatory EHRs with attestations) account for 80% of the total attestations to date—only 19 companies have delivered over 1,000 attestations and only 32 have exceeded 500. At the other end of the spectrum, 112 of the vendors produced only 1 to 5 attestations and a full 252 report 50 or fewer.
So what does this mean for the future? Consider why so many vendors have so few attestations. It could be that they are small companies, new to the market, with limited revenue, resources, and staffing—which suggests they likely lack the significant development resources required to meet the increasingly complex certification requirements of Stages 2 and/or 3. Or it could be that their software is challenging to use and their physicians were unsuccessful at demonstrating meaningful use. In either case, these vendors will not survive in the long run—if lucky, they will be acquired by one of the large vendors. The survivors will most likely be those who have already established themselves in the top tier, and whose physicians experience only minimal disruption in the process of satisfying the government’s requirements. Was it the intention of CMS and ONC to force market consolidation? Or is the demise of small, innovative EHR companies an unintended consequence of the complexity of the EHR incentive program?
I woke up Tuesday morning excited to see a lead story about EHRs in the New York Times. I had expected to read about the impact that meaningful use is having on the EHR industry and the practice of medicine, because that was the subject of the 45-minute interview I had with the author 3 weeks ago. Instead, I was rather surprised to see the article’s title: “A Digital Shift on Health Data Swells Profits in an Industry.”
The article focused on the politics behind the funding of the EHR Incentives Program— aka “meaningful use”—which is a very important story but one that was already covered in 2009 in a Washington Post expose titled “The Machinery Behind Health-Care Reform: How an Industry Lobby Scored a Swift, Unexpected Victory by Channeling Billions to Electronic Records.” (For more information, see my EMR Straight Talk post on that article.)
The New York Times article went on to castigate EHRs with the following statement, backed up by a quote from a physician:
. . .these systems also have many critics, who contend that they can be difficult to use, cannot share patient information with other systems and are sometimes adding hours to the time physicians spend documenting patient care.
“On a really good day, you might be able to call the system mediocre, but most of the time, it’s lousy.”
The online version of the article had 495 highly charged negative comments, which are worth perusing to understand the current sentiment among physicians.
I have not been shy about expressing my concerns about the effect of the typical point-and-click EHR on physician productivity, and about the sapping of innovation brought about by the complexities of the meaningful use regulations. However, I do see a silver lining in the meaningful use cloud, and that is the establishment of standards that are already having profound and positive effects on interoperability. In my interview with the author, we talked at length about the problems of EHR-siloed information and the benefits that certification will bring to the sharing of clinical data among providers, HIEs, and patients. Painful and costly as the certification process has been for EHR vendors, this standardization is advancing the industry and addressing many of the concerns expressed in the comments.
I hope that the New York Times will consider future stories about the progress being made towards EHR interoperability and about the differences among EHRs that distinguish the physicians who are reaping the benefits of their EHRs from those who are suffering from the negative impact of theirs.
Physicians, professional societies, and EHR vendors are now aligned against the complexity and pace of the meaningful use program. In my last two EMR Straight Talk posts, I shared my concerns about the future of the meaningful use program. My letter to Farzad Mostashari relayed the rampant dissatisfaction expressed by physicians about the program’s complexity, the government’s unrealistic expectations, and the impact on physician productivity. In my last post, Physicians Are Crying “Uncle!”, I discussed how physicians and the professional societies that represent them are demanding that the runaway meaningful use train be slowed. Of paramount concern to physicians is the fact that the EHR usability they crave is being sacrificed in the pursuit of certification.
EHR vendors collectively expressed their concerns in a comment letter from the HIMSS EHRA (Electronic Health Record Association) to the HIT Policy Committee about the initial proposal for Stage 3, and their message was in synch with that of the physicians and their societies. The vendors focused on the government’s interference with their ability to innovate, and they expressed their frustration over being unable to creatively address the needs and demands of physicians for new capabilities:
The needs of such experienced and often sophisticated [physician] users will best be met by market innovation, while extensive and detailed standardized requirements dictated by the federal government are not only unnecessary but may actually interfere with the pace and direction of needed innovations.
Vendors advocate, as I do, for the government to limit its focus to overarching issues like ensuring interoperability, and they argue against the government simply piling on more new measures. The opportunity to innovate is being thwarted by government programs that force vendors to devote all available resources to an ongoing chase after continually changing certification requirements.
Rarely do we see such close alignment between physicians and vendors on any matter. If CMS and ONC continue plowing ahead, ignoring the pleas of these major stakeholders, history will deem them to have been woefully negligent stewards of a program that started out with such laudable goals.
The increasingly unrealistic demands of meaningful use are leading to a groundswell of resistance. While 96,000 physicians have demonstrated meaningful use and earned EHR incentives, the majority did so while complaining about the negative impact that the Stage 1 “minimal” set of requirements had on their practice workflows. (See the results of a physician survey and read physicians’ comments in my last EMR Straight Talk post.) As Stage 2 approaches, those who have previewed the increasingly complex and demanding requirements are consumed by trepidation. Many are already considering abandoning meaningful use after they collect their $30,000 for Stage 1. Despite the fact that no one has yet had experience with the Stage 2 requirements, the Stage 3 proposal from the HIT Policy Committee is already out for public comment. Physicians and the professional organizations that represent them—already close to the breaking point—are crying “Uncle!”
The following is only a partial list of organizations that have commented: the American Medical Association, American Academy of Family Practice, College of Healthcare Information Management Executives, American College of Physicians, and the American Hospital Association. You can read their comments by googling the organization name and “Stage 3 comments” or “Letter to Mostashari.”
Although they phrase it in slightly different ways, all of these organizations are pleading with the powers that be to slow down what is perceived as a runaway train. Their comments center around several problems: lack of EHR usability, unrealistic and excessively complex requirements, the undue speed with which they are being imposed, and a lack of evidence of the program’s success. Physicians see the program as a massive data collection and reporting project with no proven quality improvement outcomes attached to it. Unless the government pays heed to the concerns and recommendations being voiced, the EHR incentive program is doomed to failure. Physicians will simply toss in the towel.
The following is a description of the most common sentiments expressed in the letters and formal comments:
Don’t sit back and wait for the Stage 3 rules to be finalized. Express your opinions either by writing to your professional organization or directly to Dr. Farzad Mostashari. It is critical to keep up the pressure on the decision makers.
A call went out on SOAPM last week looking for personalized patient recall letters. I've looked at hundreds over the years, so I asked for volunteers. I immediately heard from the wonderful folks at the Child and Adolescent Clinic in Longview, WA, who allowed me to rifle through their hard word and share it here.
Sure enough, CAC (as we know them) has dozens of condition-specific letters that they send to patients. In addition to the usual well visit suspects, they have very specific letters for:
[Updated with the new Excel version.]
Welcome to the free 2013 RBRVS Calculator.
[01/03/13 Update: with the release of our latest episode, we have the Google Community page running nicely and the podcast is available both directly and in itunes (search for "pediatric practice management" or click there). Please subscribe as we expect to deliver a new episode every two weeks.]
Brandon Betancourt and I have had hours of conversations over the years, both in person and over the phone, in which we undoubtably solved all of the world's problems. At least the pediatric practice ones.
However, we never wrote any of it down. All that amazing information is lost to the wind.
A good friend remarked that my blog is a little "stale" these days, and she was right. I am so caught up in putting out fires these days - ARRA, PCMH, portal design, etc. - that I forget to come back here.
Two important resources from my SOAPM friends.
Part one, from Jose Lopez @ AAP:
SOAPM partnered with the AAP's Childhood Immunization Support Program to
produce the attached poster for AAP members at no charge. Please feel
free to print (11x17 paper) and display it in your practice, we hope
that you like it! Feel free to distribute- we will be posting online
soon. And don't forget to have your practice staff get their flu shots
if they haven't already!
Short of riding the mechanical bulls on Bourbon Street, I think we fulfilled our social requirements at the AAP NCE this week. I starting making a list of people I got to greet, but gave up after 50. And it always remains a treat to meet people I've only known virtually - thanks for introducing yourselves.