When it comes to the meaningful use program, Tenet Healthcare's Liz Johnson is a happy camper-about $320 million happy. That's the amount that Tenet's 49 member hospitals (which last fall expanded to 77 after a merger with Vanguard Health) stand to receive from the EHR incentive program through 2017, estimates Johnson, vice president, applied clinical informatics.

In 2014, Tenet's legacy hospitals are in line for about $75 million-a number sure to rise, as the health system is still calculating the total payout once it has consolidated management of its newly acquired facilities. Tenet spans 23 states, but widespread geography has not gotten in the way of a technology deployment that demands standardization of workflows. "Sixty-six of our hospitals have attested for at least one stage of meaningful use," Johnson says, adding that more than 35 of the facilities will begin attesting for stage two in 2014.

Not only has Tenet qualified for a hefty payout, it has accomplished an EHR rollout that is nothing short of remarkable for its speed-at least in comparison to historic industry norms, Johnson says. And the technology has resulted in improved patient safety, enhanced quality, and reduced costs associated with maintaining paper records, she says.

By April of this year, Tenet's original hospitals will complete a major EHR overhaul that began in 2010, converting 48 of its facilities (one remains on Epic) from a hodgepodge of best-of-breed and paper documentation systems to a common Cerner platform. Now standardized physician documentation, order entry and pharmacy systems are in place across Tenet's pre-acquisition hospitals. "We have always wanted to improve care," Johnson says. "Long before meaningful use, we embarked on providing advanced clinical I.T. for clinicians. But the meaningful use program accelerated our program. People do not normally move at this pace, but meaningful use gave us an opportunity to receive very generous incentive dollars along the way."

More work

Johnson's praise for the multi-staged, increasingly difficult meaningful use program, however, is not unqualified. "Stage 1 requirements were fairly easy and you could meet them by doing a thorough job of implementing," she says. "But as the program deepens into more complex measures, it will become more difficult to comply. We have to add more work for clinicians."

EHR adoption by itself is only the starting point. The program's more meaningful outcomes-namely, improved clinical performance, reduced health care expenditures and enhanced patient engagement-are far from a given at this point. The same I.T. champions who praise the meaningful use program for spurring adoption are quick to point out that the incentive program's long-term success is, at best, uncertain and its overall impact on the industry is unclear. Even the staunchest EHR advocate points to the many wild cards in the deck being stacked by the Obama Administration. These include bureaucratic complexity, EHR vendor distraction and, in the long-term, provider willingness to stay the course with the program (despite its penalties of reduced Medicare reimbursement for non-compliance, beginning in 2015).

Johnson's assessment of the meaningful use program-which launched in 2009 as part of the Obama Administration's stimulus spending package aimed at energizing a sputtering economy-is widely shared. Whether meaningful use sparked any broader economic recovery is debatable. But few contest that the program-which gives financial incentives to hospitals and physicians for adopting clinical I.T., provided by government-certified vendors, to uphold various performance and process measurements-has succeeded in its initial goal of promoting health I.T. deployments in an industry long laden with paper charts.

According to CMS data released early this year, eligible providers and hospitals have shared some $17.7 billion in incentive payments as of November 2013, with 86 percent of hospitals and 76 percent of eligible professionals participating. The uptake of EHR technology in the ambulatory sector may stand as one of meaningful use's most pronounced impacts. As late as 2010, not even half of physician practices had adopted EHR technology, and only a small fraction had fully functioning systems-enabling such basic functions as visit summaries, lab results and electronic prescribing (all mandated under meaningful use), according to the Medical Group Management Association.

"Health I.T. has remarkable promise, particularly when the EHR is interfaced with clinical decision support," says Nicolas Terry, director of the Hall Center for Law and Health at the Indiana University School of Law, Indianapolis. "But the benefit of the meaningful use program is extremely difficult to assess. It's easy to point out the flaws and there are many of them, including the lack of interoperable technology.

The strongest criticism you could make is that the program has been successful in moving the industry from paper silos to electronic silos. It is not that bad yet, but that is the fatal bullet the industry has to miss."

Useful links: 7 New Objectives Recommended for Meaningful Use Stage 3; 8 Notes About Changes to EHR Stage 2/Stage 3; Too Many Deadlines for eHealth Incentive Programs? Here’s Help

That's a bullet that the South Carolina Heart Center is trying to dodge. Based in Columbia, the 19-physician cardiology practice has struggled to find usable EHR technology since its first deployment ... 20 years ago. "We're on our third vendor," sighs Sherry Shults, CIO. "Our first two went out of business, and each time, we would go back to dictation." In 2007, the group tried again, with NextGen, and to date, the results have been positive, Shults says. The group has participated in the meaningful use program since its inception, and began attesting for Stage 1 in 2011. In the first two years, the practice received about $700,000 in incentive money (CMS doles the money out incrementally, and physicians can receive up to $44,000 each over a five-year period). "The money helps, but participating in meaningful use was more a quality initiative for us," Shults says. "We have an EHR and have all this data, so the program is a way to recoup some of our expense."

Although Shults describes the meaningful use program as "cumbersome and hard to understand," she credits it with helping the practice improve documentation practices.

And technology requirements, such as a lab interface, have also boosted efficiency-as all results now flow directly back into the EHR, Shults says. The meaningful use program-which mandates such practices as smoking cessation counseling-helped the practice become more conscious of quality outcomes. As a result, physicians more readily embrace NextGen's clinical decision support features, she adds. "We are hoping this is our last implementation."

Improved performance

Ochsner Health System, a New Orleans-based delivery system spanning eight hospitals and 900-plus employed physicians, has also seen marked improvement in standardization around clinical documentation and adoption of best practices-performance improvements that have been driven by the meaningful use program, says Lynn Witherspoon, M.D., system vice president and chief medical information officer. Witherspoon monitors the health system's compliance with the program and keeps constant tabs on its physicians.

"Physicians don't like to be told what to accomplish, but the objective activities defined in Stage 1 and Stage 2 are now inculcated into our practices," he says. "The program forced us to think about standard workflows and processes in the ambulatory setting to a good end. Nobody would argue that the patient should be seen without capturing blood pressure, counseling on smoking cessation and doing medication reconciliation. These objectives are things we should be doing anyway."

Ochsner has about 700 physicians who qualify for the program, of whom 600 are participating in the Medicare meaningful use program with the other 100 in the state's counterpart Medicaid meaningful use effort. All have attested and thus far the physicians have received about two-thirds of the available money, Witherspoon estimates. Ochsner's hospitals got a later start in the program and have received about one-third of the available funds, but Witherspoon is optimistic that both the physicians and the hospitals will collect their incentive payments in their entirety.

Uncertainty prevails

But when it comes to the long-term industry-wide utility of the meaningful use program, Witherspoon-and many others-are less certain. These experts say that the broader impact of the incentive program falls in the "TBD" category. Spend much time talking with health I.T. proponents about meaningful use and common issues that could derail the effort over time emerge. Once the conversation shifts from the incentive money to a deeper consideration of true "meaningful use," any number of caveats and outright warning signs appear. In combination, these issues threaten industry progress toward interconnected health I.T. more than uphold it, many fear. The program's complexity, its effect on EHR vendors and their system designs, and even concerns about long-term willingness of providers to continue their participation loom as ominous signs.

For many observers, the single biggest drawback of the meaningful use program rests in the sheer complexity of the regulatory details surrounding it (the Stage 1 final rule comprised 276 pages; Stage 2 weighs in at 196). Although participation is voluntary, providers must use certified technology and meet given metrics. But figuring out such underlying details as which patient to count in a given physician's mix is anything but easy, they say. "We have spent a lot of time preparing and understanding the details," says Witherspoon, who figures he devotes about half his time to managing compliance. "The program is way too complicated. The doc in the street hasn't got a chance and can't do it by themselves."

For Johnson, at Tenet, the timing of meaningful use attestation reports-those electronic submissions of data providers submit to CMS-has become very complicated. The start and stop dates for data collection can vary widely within a health system spanning multiple hospitals, and if physicians attest individually (they can attest as a group if they choose, but most do not), the same principle applies. Like Witherspoon, Johnson monitors compliance and reporting activities on behalf of member hospitals.

Rules, rules, more rules

And the rules of the game are prone to changing mid-stream, as new regulations emerge with qualifications and revised deadlines. Terry, at Hall Center for Law and Health, describes the underlying regulatory process of meaningful use as a major wrench in the gears. "What should have been a regulation has turned out to be a rather painful negotiation between providers, vendors and the federal government," he says. "The program had a framework at the beginning, but that has proven to be indeterminate. Markets like certainty."

For example, CMS recently extended the timeframe for Stage 2 reporting while it delayed the launch of Stage 3. "The extension of Stage 2 reporting did not change your beginning date, but depending on when you start, you may have an extra year," Johnson says, launching into a detailed account of how the federal fiscal year that underlies the program and the hospital calendar year do, or do not, match up. "It is very confusing."

Just how confusing? Here is how I.T. consultant Michelle Holmes describes the revised timelines for Stages 2 and 3 of meaningful use, a late 2013 switch that many say caused widespread industry confusion: "CMS added an additional year for Stage 2 reporting before Stage 3 starts. Stage 2 starts at the same time. If you start this year, you can report Stage 2 for three years--2014, 2015 and 2016. Stage 3 is delayed to 2017. So instead of describing the regulatory change as an extension to Stage 2, describe it as a delay of Stage 3. Using Stage 2 in the description of the change is what threw people. Stage 2 reporting begins depending when you started Stage 1. You must be in each stage for at least two years. You may be in Stage 1 and 2 for a full three years. The earliest for Stage 2 is this year, if you have been in Stage 1 for three years."

Avoiding the thicket

Holmes, a principal at ECG Management Consultants, has worked with multiple group practices trying to implement EHRs and participate in meaningful use at the same time. She avoids burying practices in regulatory minutiae, and instead focuses on the intent of the program. "Providers need to step back and think about that, and why CMS came up with the measures it did," she says. "It is more important to look at workflows and how you are interacting with patients to get to that value, as opposed to merely working through numerators and denominators."

Nonetheless, practices must "hit their numbers" to qualify for incentives, she acknowledges, and
that fact has shifted much of the discussion around meaningful use to technical matters as opposed to overall practice improvement. "We do a really good job of making meaningful use complicated and CMS doesn't dissuade that," she says. "Look at the FAQs on the CMS Web site. They are very technical. What can I do and can't I do to meet a given exclusion? There are only a few questions that take a step back and look at meaningful use criteria from a workflow perspective. We need to take a measure and offer clear guidelines around how to adjust workflows to meet it, not just for the math to work, but to derive benefit from the measure."

Holmes says many of her clients have struggled to comply with the requirement to provide a clinical summary of the visit within three days for at least half the patients. "It requires having a portion of the documentation done if you are giving the summary to the patient before leaving the office," she says, a step that many are taking because: a) they don't have a patient portal to disseminate the summary electronically or b) they want to avoid the added cost of mailing the summary. Thus, to meet the requirement (which is one of almost 20 measures), many practices are providing a bare-bones clinical summary that includes only required elements, Holmes says.

"There is no explanation of the treatment plan, or such information as trended lab data, or reminders of upcoming tests, items that would make the summary more meaningful to patients and inspire a conversation with providers about how best to use it," she says. "Providers 'game' this requirement the most. Some practices have put a confidential recycling box at the front door, so if patients want to chuck the summary, they can do it securely."

Shults at South Carolina Heart Center says the clinical summary requirement has helped patients, who now receive the summary in paper before they leave. But complying with the measurement required a major overhaul of long-time practice patterns. "It meant the physicians had to finish their office note before the patient left. And the medical assistants had to step up and make sure they document allergies and demographics at the start of the visit, and that the summaries were printed after the visit. It tacked on extra time to the visit. A visit that used to take 15 minutes now takes 20."

Shults adds that over time, the practice absorbed the change and that overall patient volume did not go down. The practice has applied for exclusions from some of the metrics-such as those relating to immunizations-but the CIO says the rules caused confusion among the physicians. "They don't understand why it was required in the first place. CMS is trying to fit everybody into the same bucket, but everybody doesn't fit in."

That's an issue not lost on Witherspoon, who points to the one-size-fits-all design of meaningful use to be a major flaw in the program-particularly when it comes to specialist participation. "The definition of eligibility is based on site of service for billing-and we have 99 defined sites of services, with 97 counting as ambulatory facing. The only two that don't count are ED and hospital inpatient. If I put any of those 97 on the bill, Medicare counts the visit toward my number. The radiologists, pathologists and anesthesiologists are swept up, which really means they are in harm's way (of later non-compliance penalties-which apply to all eligible providers). My role is to protect physicians from the penalties to the extent we can. But the program doesn't allow customization of workflows to reflect what radiologists and other specialists really do."

Witherspoon says that Ochsner, by virtue of the fact that it's a large group practice, can overcome some of the complexity via a common EHR. Specialists, in essence, can piggyback on the work of referring physicians when it comes to documenting smoking cessation and other required elements. But independent community physicians-Ochsner is affiliated with some 2,500 of them-would have to make sure all the relevant documentation is in the patient's chart. "CMS needs to rethink its approach," he says.

Normalizing the abnormal

Some observers take the program's complexity in stride. "I would love to see meaningful use more simplified and include more realistic requirements," says Russ Branzell, a long-time health system I.T. leader who became CEO of member association CHIME last year. "But we are trying to automate the most complex industry in the history of mankind and that is a major undertaking. You are trying to normalize an industry that is very fragmented."

For Branzell, the Achilles' heel of meaningful use is not so much the program's burgeoning requirements as its timing. "The program is logical in terms of technology," he says. "What is not logical is how it converges with multiple other programs. We have the right direction, but the wrong sequence."

For Branzell, the biggest looming land-mine is ICD-10, the new coding and classification system at the heart of the health care revenue cycle slated to launch in October of this year. Although not directly related to meaningful use, ICD-10 requires major systems remediation. "Many providers will not be able to do ICD-10 and meaningful use at the same time," he says. "If you have to choose between your billing system, which keeps you financially sound, or the meaningful use program, you will pick the revenue cycle."

CHIME has lobbied for revised timeframes around the two programs, and Branzell thinks that if the government can demonstrate flexibility in its requirements, the industry can accommodate. "We won't get to meaningful outcomes until the later stages" of meaningful use, he says. "The program has worked to spur laggards to adopt and has been very successful to date. But the next six months could make or break it. If we sequence Stage 2 correctly and Stage 3 is appropriately timed, we can get to outcomes-oriented wellness models."

Vendor distraction

Regardless of how various regulatory timelines play out, the meaningful use program has irrevocably changed the health I.T. vendor landscape-and not altogether for the good. The vendor certification program-intended to be a kind of Good Housekeeping Seal of Approval-is supposed to assure EHR purchasers that their systems can perform basic functions.

Observers like Holmes contend that the program has accomplished that-but at a price. EHR vendors, she says, have had to focus on making sure their systems can provide metrics required under meaningful use, rather than on making them fit health care workflows.

"Meaningful use is distracting vendors away from usability," says Holmes, who has worked with a multitude of ambulatory software packages. "For most providers, there is still not a good system out there that mirrors their workflow and doesn't make them feel clerical. The systems are hard to train, implement and use from the physician perspective. I don't know if that was avoidable, but it is the major negative outcome when you focus on creating reports versus making systems more effective for the clinical user."

Witherspoon at Ochsner doesn't mince words when it comes to the usability issue. Certification requirements were too low, he says. "You have to put your foot on the vendors' necks," he says. "For Stage 1, the bar was very low, and the requirements were not as rigorous as they need to be. A lot of physicians have had trouble with their certified platforms. We now have less than usable EHR platforms widely deployed across the county. We have computers with physicians but are not where we need to be to take better care of patients. Usability is the big looming problem."

To work effectively, EHRs require a great deal of customization-and I.T. expertise often beyond the reach of smaller providers, experts say. For Terry, the health lawyer, the checklist orientation of EHR vendors is no surprise. "The idea of a subsidy program is flawed," he explains. "Meaningful use creates a 'synthetic market,' not a real market in which people will spend to buy things. It's a market in which someone says, 'We will pay you to go and buy something.' If EHRs had done what hospitals and doctors wanted, they would have gone out and bought them anyway. So instead of vendors doing R&D to make their applications more usable, they had to move to a checklist approach and make sure their systems do what meaningful use requires. To get the subsidy, providers had to use products not ready for prime time."

Even providers with well-worn EHRs look at the future with a cautious eye as the meaningful use program unfolds. "We had no issues with Stage 1," says Shults, the cardiology practice CIO. "But Stage 2 presents major financial issues for us." In question are forthcoming requirements around data sharing with other facilities, electronic communications with patients and integration of radiology images into the EHR. Shults says the practice faces "significant expenditures"-well beyond any forthcoming incentive payments-to stay in compliance and avoid Medicare penalties.

Searching for value

For example, the practice will join a statewide HIE in order to meet data sharing requirements. But it must pay a subscription fee to the HIE as well as upgrade its EHR with a $16,000 module plus additional ongoing support fees. The practice is also implementing a portal, an additional software and maintenance cost. And integrating its PACs, from Siemens, into its EHR will cost an as-yet indeterminate sum. Shults sees plenty of value in the patient portal, but questions the merits of a PACs interface and an HIE. Right now physicians toggle back and forth between the systems, rather than accessing the PACs through the EHR.

"I don't see much value with viewing images, since we can do that side by side already," says Shults. "The meaningful use regulations are getting to the point of being very costly. I am having a harder time explaining the value and ROI to the physicians. Their biggest frustration is that it is a government mandate and we have no other option. We are 65 percent Medicare, so the program is advantageous. But if you are only 20 percent Medicare, you might be better off taking the penalty and not participating."

Holmes, the consultant, says the forthcoming ICD-10 deadline may knock some practices off the meaningful use escalator. "Once you start, you need to stay in the program to avoid the penalties, regardless of what stage you are in. You can miss a year and still get back in. But if a physician doesn't have a big Medicare population, they are not as likely to stay in."

 

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