The Challenges Keep Changing: Meaningful Use Roundtable

As the federal government looks toward more detailed and stringent requirements for Stage 3 of the Meaningful Use program, most healthcare organizations still struggle to meet the objectives of Stage 2. A panel of experts in the field share their thoughts, frustrations and hopes for the EHR incentive program.

What are the biggest challenges facing healthcare organizations related to Meaningful Use (MU) at this point?

Kevin McEnery, MD: The biggest things are the messaging to patients and the continuity of documents. Institutions are struggling to collaborate with other institutions. The rules are changing a little bit but in what I’ve seen in current requests for comments on proposed rules, we need more time.  I don’t think anybody’s saying the program itself is incorrect or not of value.

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From left: Sameer Badlani, MD, CMIO University of Chicago Medicine and Secretary, AMDIS Board, Robert Budman, MD, MBA, CMIO Yuma Regional Medical Center, John Halamka, MD, CIO Beth Israel Deaconess and Kevin McEnery, MD, Director, Innovation in Imaging Informatics M.D. Anderson Medical Center

John Halamka, MD: We all have MU Stage 2 software installed. The problem is that the ecosystem is not ready for some of the MU Stage 2 workflows. We’ve tried our best—installed the software, trained the docs. But if you have the only fax in town, you’re not going to be sending a lot of faxes. How many doctors in your neighborhood have a qualified Direct address that you could use for transitions of care summary for MU Stage 2 certification and reporting rules? None. We need more time to get that ecosystem ready.

Although noble in direction and scope, Stage 2 is a little too much too fast. Some of it is out of our control. An ecosystem built on everyone having a Direct address is going to take more time than July through September 2014.

ONC is highly prescriptive about how you accomplish a policy goal. Give us a goal such as reducing readmissions by 5 percent in 30 days or something and how we choose to use technology is up to us locally.

KM: Using a Direct message is not meaningful if it doesn’t change the readmission rate. The goal is not to increase the number of Direct messages and care summaries. It’s to fundamentally improve transitions of care and the downstream outcomes of the patient. That’s not necessarily being measured.

Robert Budman, MD, MBA: The American Medical Association said to the ONC ‘give us a wild card. Let us leave out something from the list that’s too difficult but if we do all of the other ones we’re still doing a good, meaningful job.’

KM: What’s more frustrating than anything is how they sequence things. They’ve made assumptions about sequencing projects, people prioritize and then the rules change. Vendors are frustrated as well. The system requirements keep changing and the time keeps changing. At some point, you have to take a deep breath and say is this the best we can do. I don’t think anybody is saying we don’t want these systems to improve care to get the value-added outcomes we’re expecting of them. But it may not be accomplishable to move everybody at the same pace.

JH: We have what I call regulatory and compliance enforcement du jour. Can you get through a 24-hour period without some state or federal regulatory agency sending you something about a violation or breach or another problem?  This tyranny of the urgent distracts from more longitudinal efforts like Stage 2 and ICD-10.

Sameer Badlani, MD: While I understand and support the fundamentals behind the MU program, the way the rules are set in their current form for Stage 2, they take away the ‘meaning’ in MU. We are all trying to re-do our clinical workflows just to meet the summary of care measure with no focus on how it will help patient care or whether the information in the summary of care is even useful or correct/updated. Every clinical informatics leader in the country is trying to figure out what this means for his or her organization and has put every other informatics project on hold. Vendors are more focused on meeting the MU rules rather than responding to much-needed upgrades to existing functionalities. There is significant frustration in the CMIO community.

There has been a significant emphasis on patient safety related to health IT. What impact do you think health IT is having?

JH: Poor software implemented badly will not have a good outcome. The vendors are working overtime to produce software that meets these highly prescriptive requirements. Did they have time for extensive usability testing? Did they have time for a pilot and revision cycle? No, so they’re ending up gluing on functions. It’s really hard to use.

RB: Patient safety has been in the media but what metric are you using to measure patient safety? Is it one single case that had a bad result or is it really a metric you followed before and after implementation of the software and you really saw significant change? Even in the paper world there were patient safety issues and we didn’t know about them. They tend to be glaringly obvious in the IT world because you’re tracking so many things. It’s a two-way street. Is it really patient safety because of IT or are there other processes before and after IT implementation that are impacting patient safety? It’s not just IT that impacts patient safety, it’s a lot of people processes as well.

KM: I wholeheartedly agree. Patient safety is not necessarily just the responsibility of the EMR or IT. The EMR can enable and help measure and identify some patient safety issues but patient safety is well beyond just what can be measured by IT. It has to be part of the culture of an institution. If an institution only relies on the EMR for patient safety then assuredly they’re going to have patient safety incidents.

SB: Automating a bad paper process will always lead to worse outcomes in scale and size. The difference now is we keep uncovering the gaps and do not have time to create thoughtful and user-friendly workflows. Usability is the last thing on any vendor’s plate since it does not show up in any federal alphabet soup such as MU, PQRS, ACA, ACO, etc.

What has been your experience with MU audits?

JH: We’ve gone through the audit process which is fascinating. They said ‘prove that in a 90-day attestation period you didn’t turn off your drug-drug rules or allergy-checking rules.’ How do you prove a negative?

RB: We went through a standard audit and had additional requests for further evidence. We did OK but they’ve been very keen to say that just because you passed one it doesn’t mean you won’t get another one.

Our audit came a week before our Stage 1 year 2 reporting period was about to wrap up. Audits are a completely separate process. The auditors follow a strict set of engagement rules, but you can establish relationships and get more information on what they’re actually trying to find out in terms of the audit by picking up the phone and talking to the auditor.

JH: Keeping everybody honest is absolutely fine. We don’t want fraud and abuse. We don’t want someone creating a revenue stream when they don’t even have an EMR. But debating whether the transition of care denominator of care should include SNFs on a Tuesday? That’s probably a little beyond where auditors should go.

SB: We have had an audit for our [eligible hospital] and a few post- and pre-payment audits for [eligible professionals]. The experience was more nerve wracking for the colleagues (EPs) who were audited than for the informatics team as they felt they had done something personally wrong to be audited. Hopefully, I was able to reassure them adequately. We keep detailed documentation and passed our audits without any major issues. It would be nice if there was guidance from ONC especially for Stage 2 measures on patient engagement and sharing patient information on what documentation is needed for potential audits.

Do you think the ONC is doing enough to help providers achieve Meaningful Use?

JH: We have to be so very careful as we go into Stage 3. We can easily create docs and hospitals opting out of the program. If there are too many demands too fast with too much complexity they’re just going to give up.

RB: When you consider individual physicians, my guess is half or more are not going to attest. It’s just too difficult and a diversion from patient care.

JH: ONC is trying really hard. I hope Stage 3 won’t have 19 criteria with a lot of these esoteric, highly prescriptive standards and procedures. Give us five outcome goals and then evaluate us based on the success achieved. Just give us something.

SB: Are they trying? Yes. Enough? I don’t think so. Many of us on the panel come from large organizations with a lot of resources. I can only imagine what small practices and hospitals are going through. There was hope with the new leadership at ONC we would get a one-year break between Stages 1 and 2 and that did not happen. So far, only eight hospitals have attested for Stage 2 and having to worry about Stage 3 is just not right.

Looking ahead to Stage 3, what are your thoughts?

JH: We love some of the general ideas in Stage 3 but there are some provisions that are so burdensome. They presuppose technology exists that doesn’t. I just don’t think they’re practical. For example, we love clinical decision support. But, the Stage 3 proposal says that at every single point in the entire EHR decision support is presented, there must be a full audit trail including the nature of the alert fired, the action of the provider, if the alert was ignored, what were the consequences, and determine the quality outcome deficit based on the provider not following the alert. In a software system of this complexity, good luck implementing that.

RB: There’s a long time before the final rule and I’m interested in the comments. I like the order tracking part proposed. It’s important that if you order tests or procedures there’s actually a way to follow up that the tests have been reviewed. My pet peeve is sending patients out for specialty consults and then never getting a letter back or a couple weeks later and finding out that another doctor changed the medications. The proposed rule requires that referrals and consultations get returned to the chart. That’s a pretty useful function.

JH: Closed loop ordering is no problem but a referral process across disparate organizations that are not necessarily in the same geographic region or part of the same ACO, with different EHRs. We have mapped out this process. It requires 11 unique interfaces and we probably don’t even control half of them.

KM: I’m a radiologist and the sustainable growth rate by statute said that clinicians need to have procedures approved by clinical decision support for appropriateness. So it’s not only MU criteria that’s driving decision support but also other legislative actions. Physicians are going to be legislatively required to have every single procedure approved by these systems. Initially, they don’t need to adhere to the rules but they will be judged by whether they do.

RB: Back in the ‘80s I wanted to do something simple like find out if a patient received a tetanus shot. There wasn’t a single database for that. Here we are in 2014 struggling behind countries like Taiwan and Australia in terms of EHR deployment at massively higher cost. We’re spending a ton of money but in the recent report on standards of healthcare, the U.S. is still way back in 14th position. Where did we miss the boat?

JH: That’s a complex societal political question. I’ve worked on health IT in other countries and in many cases, they have a population of 5 to 7 million people for which there is a single centralized infrastructure for which top-down command and controlled deployment actually work. I asked in Scotland how they deal with image exchange throughout the country. They have one PACS for everyone. Problem solved. That doesn’t work so well for 330 million people with different rules and requirements.

KM: If there’s a silver lining in all this, ONC is starting to embrace standards that every other IT industry is based upon with the FIHR proposal, HL7 and standards that are common on Amazon and Google. The concept that EMR vendors should have an API to get that information out of their system to potentially be viewed in other systems is a very positive, forward-looking thing. We’re still tied to these monolithic systems and can only get data out if we can find the back door. We need to get to a different place. Innovation is entirely focused on meeting MU requirements not necessarily on moving healthcare forward. Hopefully that will change in the coming years.

SB: There are lots of interesting and useful measures like image exchange, consult letters, clinical decision support for procedures, but, as always, the devil is in the details. There has to be a way to engage more operational leaders to make sure the measures do not lose their objective in the process of being implemented. I would also like to see a hiatus before Stage 3 to assess the impact of Stages 1 and 2 from the perspective of whether the outcome was achieved vs. how much money was distributed and how many institutions attested successfully.

Any final thoughts on the state of health IT?

JH: Regulations can be a catalyst for change. Here in Massachusetts, we found that economic incentives are an even more powerful catalyst for change. In 1997, when payers and providers recognized HIPAA simplification activities, people talked about the burden of the regulations but we said, if we take the existing fee-for-service processes and take out the waste we will take the cost of a transaction from $5 to 25 cents. Within one year, we had 100 million transactions flying across Massachusetts. We let the market move us and maybe move faster than through regulations.

KM: In radiology, there isn’t a requirement that institutions be filmless or totally digital but the marketplace created the technology that was achievable. If you weren’t filmless you weren’t in the mainstream. The transition in radiology was not legislated. That happened because the marketplace effectively mandated it. 

RB: Mobile health and remote patient monitoring is a burning issue. We’ve toyed with a few of those things particularly with trying to lower readmissions for congestive heart failure with some limited success. The promise of an app or device—that’s going to turn the tide and save a lot of costs.

JH: It’s such an important trend. Social, mobile, analytics and cloud computing in the rest of industry is just creeping into healthcare now. Eighty percent of all the Beth Israel Deaconess publicly available websites are accessed via mobile devices. The desktop is dead.

RB: The interesting thing from the patient’s perspective is that apps don’t last long. People get tired of them. But if you have a way to send that information to their physician and physicians can review it, it raises the value of that app. It may have more stick-to-itiveness. None of that is covered in any current regulation or current goals for health. Let’s look at those things that drive lifestyle changes. We’ve all had patients bring us their spreadsheets but there’s not electronic point-to-point transmission yet. It’s getting there.

SB: For all its problems and issues, health IT is the only tool at our disposal to drive down cost, increase value to the patient and change the way we practice to a more outcomes-based model. It is up to us as leaders in the field and our organizations to continuously push for greater efficiency and leverage technology for patient care. Innovation and optimization should not become a permanent victim of the arms race to meet regulatory deadlines. The ONC plays a central role in this journey and I hope they do so in a more meaningful manner, all pun intended.