November 24, 2015 Owen Carey

Thanksgiving Argument Cheatsheet: EHR, Meaningful Use & Accountable Care

There are a few universal truths about the great American Thanksgiving holiday.  The turkey is never cooked just right, the TV is on too loud, there’s that one family member that will show up late to the party – and someone, somewhere is going to spark a disagreement that quickly devolves into sniping, name calling, or the furtive Googling of facts under the tablecloth.

If there’s more than one healthcare professional at your table this Thursday, chances are that spat is going to revolve around some of the industry’s most controversial topics.

Whether you’re clashing over the course of Stage 3 meaningful use, the real impact of value-based reimbursement, or the extent to which EHRs have torpedoed the healthcare industry, it’s important to have some data on hand to provide backup for your position.

No matter which side of the EHR and health IT debate you’re on, has your back.

Use this quick primer to fire off some well-crafted arguments and devastating statistics at your opponents while your relatives roll their eyes and continue to pass the cranberry sauce.

Is Stage 3 of the EHR Incentive Programs destined to fail?

Few initiatives have produced quite as much vitriol and instant condemnation as Stage 3 meaningful use, an ambitious and anxiety-inducting framework for improving care coordination, fostering population health management, encouraging more advanced EHR use, and doing a better job at measuring systematic improvement.

Arguments in favor of implementing Stage 3 in 2017 and 2018 point to the desperate need for standardization and interoperability across the healthcare system, while those who oppose the current requirements for technology upgrades and stringent reporting measures believe that the industry is simply not ready to make the leap.

The basic facts are these:

• Stage 3 will be optional in 2017, but required for all providers, no matter what their previous attestation level, in 2018.  Attesters in 2018 will be required to use updated 2015 CEHRT systems.  This will bring all participating providers up to the same level of technology capability over the next three years.

• Eligible professionals and eligible hospitals will have fewer measures and objectives for reporting.  Rule makers have stated that the remaining measures will be more focused on outcomes than on checking boxes for processes.  In Stage 3, more than 60 percent of these measures will require EHR interoperability.

• Stage 3 works to align complementary reporting programs, such as the Physician Quality Reporting System (PQRS) and Hospital Inpatient Quality Reporting (IQR) program to reduce administrative complexity and prepare the industry for the eventual transition to the Merit-Based Incentive Payment System (MIPS) slated to take over from meaningful use.

• The patient engagement and secure messaging requirements, cut down to just one user per reporting period in Stage 2, will likely not greatly challenge providers in Stage 3.  The provisions have been viewed as some of the most burdensome features of the program.

Naysayers point to low Stage 2 attestation numbers and significant difficulty with EHR usability and interoperability.  Only 19 percent of providers had met Stage 2 requirements as of July of 2015, saidRepresentative Renee Ellmers (R-NC) at the time.

Professional societies like the American Medical Association and the Texas Medical Association have accused rule makers of piling pointless mandates onto the weary shoulders of cash-strapped physicians.

“Meaningful Use started out as a well-intentioned attempt to give physicians incentives to adopt electronic health records,” said the Texas Medical Association in a recent letter to CMS. “No federal program ever bore a more inaccurate name than ‘Meaningful Use.’ It’s no surprise that physicians around the country have begun calling it ‘Meaningless Abuse.’”

Some of the biggest objections to going ahead with Stage 3 include the all-or-nothing attestation structure, lackluster attention to the needs of specialists and non-traditional primary care providers, inadequate EHR usability, and extreme difficulty of balancing meaningful patient care with the demands of the complicated regulatory framework.

In contrast, those in favor of Stage 3 stress the importance of aligning the staggered efforts of the healthcare system under a single, codified program.  Bringing all providers into the same fold will destroy data siloes, reduce barriers to health information exchange, ensure a smooth journey for patients across the care continuum, and help providers manage populations on a broad scale.

Stage 3 will encourage the adoption of standardized big data technologies like APIs that will help providers overcome their EHR usability frustrations and deliver more robust clinical decision support tools to usher in an era of personalized medicine and precision care.

Getting over the hump is a difficult process, but without the threat of penalties and consequences for failure, the industry will not be able to develop the learning health system that will take full advantage of the technologies at hand.

Advanced EHR use has been identified as a key driver for a 27 percent decline in patient safety errors and a promising avenue for saving a whopping $78 billion in unnecessary costs over the next four to five years.  Stage 3 meaningful use may be the only way to drag providers over the wall that is preventing the industry from achieving these results.

Why can’t the health IT vendor community deliver on its promises?

Unusable software and competitive vendor squabbling may be part of the reason why providers don’t feel as if they have the tools to meet Stage 3 standards.  Congress has repeatedly called for developers to up their interoperability game and deliver products that are safe, intuitive, and productive.  But the vendor community has been achingly slow to respond to the pleas of physicians.

EHR vendors often protest that the tight deadlines and slow certification processes for Stage 2 meaningful use forced them to grind out less-than-optimal products so providers could attest on time, and there’s no shortage of snippy comments being passed between business rivals, who accuse each other of information blocking, extorting exorbitant fees, and being just plain rotten to their customers.

Are vendors to blame for the dismal and fragmented state of health IT adoption? If you’re a physician, you’re likely to say yes.  After all, EHRs are rotten to the core.  Just 37 percent of certified EHR vendors surveyed by researchers adhered to recommended usability testing guidelines, a recent JAMA study found.  Companies like Epic Systems have been known to charge significant fees for data exchange outside their own networks, and research has repeatedly shown that providers lose hours each week – up to 48 minutes per day – to navigating convoluted workflows and frustrating EHR interfaces.

The AMA branded EHRs one of the primary “sources of stress” for physicians in 2014, calling the health IT systems a “barrier” to providing high quality patient care.  Many of the most well-known EHR vendors have received dismal scores on usability in recent assessments, including Epic, eClinicalWorks, and Greenway.

Shady business practices like gag clauses and information blocking keep customers suffering at the hands of rapacious vendors with money on their minds, and put patients at risk, some stakeholders say, though proof of these actions is often hard to find.

That may be because vendors aren’t the ones at fault for slipshod adoption and poor EHR optimization, those on the other side of the fence will argue.  Vendors themselves have urged the industry to provide hard evidence of their guilt before slamming them for information blocking that may or may not exist.

And healthcare providers first need to fess up to their own shortcomings and hyper-competitive natures if they are going to complain about the dismal state of health IT interoperability.

“In my opinion, the responsibility for assuring secure interoperable exchange resides primarily with the healthcare provider organizations, not the EHR vendors, and not the government,” said DirectTrust President and CEO Dr. David Kibbe in recent testimony before Congress.

“Health care provider organizations must come to realize that acting in the best interest of patients is to assure that health information follows the patient and consumer to whatever setting will provide treatment, even if that means in a competitor’s hospital or medical practice,” he continued.  “And they must demand collaborative and interoperable health IT tools from their EHR vendors to make this routine and ubiquitous as a practice in every community in the United States.”

After all, one could argue that the EHR vendor community is the one leading the way into a new cooperative era with interoperability collaboratives like the CommonWell Health Alliance and Carequality.  Providers are more likely to take a reactive stance, waiting for mandates and regulations to force them into upgrading their capabilities to avoid financial penalties.

Is that because the newest generation of EHR products aren’t worth installing if they are just going to reproduce the same old usability concerns?  Have mandates and technology requirements forced providers into this defensive posture in order to preserve their professional lives?

Or are providers not giving EHR vendors enough credit for the progress they have made in recent years?  Should they be less wary of viewing vendors as true partners in the struggle to navigate a tide that will raise all ships?

Are value-based reimbursement and accountable care reforms really worth it?

If there’s one thing that everyone can agree on, it’s that you have to follow the money if you want to understand why and how all these changes are taking place.

Value-based reimbursement is at the root of the healthcare reform movement.  EHRs, population health management technologies, big data analytics, and interoperability are all just supporting players for this fundamental financial transition.

Accountable care organizations, the patient-centered medical home (PCMH), bundled payments, and outcomes-based reimbursement are gaining steam as Medicare and private payers try new tactics to stop the hemorrhaging of healthcare spending on chronic diseases and an increasingly elderly population.

But how effective are these strategies?  Evidence from initiatives like the Medicare Shared Shavings Programs (MSSP) is often mixed, and stakeholders are divided on the real costs and benefits of care improvement paths like the PCMH.

The patient-centered medical home is costly and time consuming, but can be very effective.  One recent study showed that PCMH maintenance can cost providers an average of $8000 per month.  Even partial implementation of PCMH features can drain more than $100,000 per full-time clinical each year from organizational coffers.

Becoming a patient-centered medical home can take an extraordinarily long time, and maintaining the certification can siphon precious minutes away from patient consults, stress administrative staff, and may not be an appropriate path for many low-resource providers already struggling to make ends meet.

On the other hand, success can be very sweet.  The PCMH can produce significant savings – between five and eleven percent, one review found – as well as help to reduce improper ED use, raise quality, and raise patient satisfaction.

In the Department of Veterans Affairs’ Patient Aligned Care Team (PACT) initiative, similar to the PCMH, continuity of care visits lowered emergency department usage rates by a whopping 46 percent.  Chronic disease patients at New York-Presbyterian Regional Health Collaborative were 36 percent less likely to experience a 30-day readmission when cared for under the PCMH model.

The PCMH is one way to make an impact, but the accountable care organizations brings financial risk into the mix.  Medicare’s Pioneer and MSSP ACOs brought in $411 million in savings in 2014.  Ninety-seven out of the 353 ACOs qualified for shared savings last year, a statistic that has been used to justify the success of the accountable care framework and illuminate its shortcomings.

The Pioneer program has been picked apart since its inception, with many observers pointing to the high dropout rate as proof that high-performing ACOs are too few and far between.

While many of the organizations fleeing the Pioneer mold have instead turned to less risky value-based programs, including the new Next Generation ACO option, the level of difficulty involved in shouldering downside risk has left many providers wary of diving in.

Ninety-nine percent of MSSP ACOs do not engage in two-way financial risk sharing.  Only three ACOs have chosen to expose themselves to losses if they fail to meet stringent quality requirements.

Opponents of the current CMS ACO options point to badly tuned benchmarks, insufficient metrics, and additional reporting requirements as reasons why a thorough overhaul is required, but successful ACOs do exist.

They are most likely to be smaller, to adhere to care improvement programs like the PCMH, and to use health IT tools to aid population health management and advanced data analytics, industry data shows.

Success also comes to those who invest whole-heartedly in financial accountability.  Those with longer experience in an ACO framework are more likely to accrue shared savings, and “putting all your eggs in one basket,” as Vice President of Population Health at Atrius Health Emily Brower puts it, can actually make the transition much easier than straddling the line between value-based care and fee-for-service payment.

As for effectiveness, CMS stated in July that accountable care strategies were integral in extending Medicare’s hospital payment fund until 2030, which has to count as a meaningful result.

CMS is so convinced that accountable care and value-based reimbursement are the way to save the foundering healthcare industry that rule makers are actively shifting away from traditional reimbursements.

By 2016, HHS Secretary Sylvia Burwell plans to see 30 percent of the current traditional payment volume issued by accountable care organizations instead.  By 2018, ninety percent of all Medicare payments will be tied to some sort of value-based program, Burwell has pledged, making accountable care less of an argument and more of an inevitability.

Only time will tell if CMS can meet its goals.  To do so will require EHR vendors, providers, and rule makers to put aside their differences, work collaboratively towards process and technology improvements, and embrace the notion that all parts of the healthcare industry must work together for the good of the patient and the delivery of safe, high-quality, effective care.

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