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Meaningful use: Is it time for the program to end?


The incentive program for electronic health records is in limbo as physicians and their advocates dig in their heels.

Dubbing it a ”widespread failure,” a broad coalition of physician organizations wants Congress to call a halt to onerous rules under the meaningful use program-or lose physician buy-in altogether.
A letter authored by the American Medical Association (AMA) and backed by 111 medical societies sent in early November to key members of the U.S. House of Representatives and Senate voices frustration that the Centers for Medicare & Medicaid Services (CMS) is moving forward with stage 3 of the program despite the fact that stage 2 “can be qualified as a widespread failure.”
“Stage 1 and 2 have been overly rigid and restrictive and proscriptive, and have compelled doctors and hospitals to do a number of things that don’t necessarily improve patient care,” Steven Stack, MD, president of the AMA told Medical Economics.
CMS notes that nearly 80% of physicians and hospitals now use some form of electronic health record (EHR) an increase of approximately 60% since the meaningful use program’s inception. Yet despite a barrage of criticisms from physician groups about 11th-hour amendments to stage 2 in October, and frustrations with the time burden the program places on physicians, CMS is moving ahead with stage 3, which is scheduled to begin as optional in 2017 and mandatory by 2018.
Of major concern to the societies who co-signed the letter is the “all or nothing methodology” of stage 2, Stack says, where failure to complete just 1% of the requirements  equals total program failure, resulting in financial penalties and delayed payments to practices.  


If CMS doesn’t make changes to the stage 3 rules, the AMA will be forced to seek further legislative pressure to bring about the necessary changes, Stack says.
Kenneth Kubitschek, MD, FACP, a North Carolina-based internal medicine physician and member of the Medical Economics editorial advisory board, is frustrated by the sudden rule changes. “We’ve done the second stage of phase 2, but [CMS] didn’t let us attest because they changed the rules in the middle of the game,” he says.
Even though his practice has met the requirement of having 5% of its members using the EHR portal, he says, “We had to create artificial circumstances to get them to engage, which is poorly thought out.” He says his practice is still unable to attest for 2015 because the new rules for stage 2 came with changed requirements his practice is scrambling to meet.
Wanda D. Filer, MD, FAAFP, a family practitioner and president of the American Academy of Family Physicians, is concerned that meaningful use’s unnecessarily tough requirements not only cost physicians time and effort they cannot spare, but drives them to new levels of burnout. “I had a phone call with a woman ready to leave her practice after 15 years. She loves her patients but she is burned out by meaningful use,” Filer says.
According to the AMA, only 12% of physicians have successfully attested to stage 2 of meaningful use, and some are getting frustrated to the point that Filer says “they are washing their hands of it.” She adds, “I don’t hear any interest from my members of pursuing meaningful use stage 3.”
Filer points out that the percentage of physicians who have attested to stage 2 has actually dropped compared with stage 1. “The biggest barrier is that the EHRs don’t do what they’re supposed to do. CMS is penalizing people for EHRs that have not been able to keep up or get the results that are needed,” she says.
Stack echoes these frustrations on behalf of AMA members. “Several thousands of doctors are being penalized for not moving on from stage 1 to 2,” he says. “They’re using the tool, but are being punished for an overdesigned, misguided program.”


Indeed, stage 3 requirements will not decrease the amount of time physicians must engage in digital paperwork, Stack says. “If we are spending our time in a nursing station typing on a computer for more than half our hours, patients lose out. We get frustrated and burned out.”
In response to a request for comment on the physician unrest, CMS said in an e-mailed statement to Medical Economics that it extended the comment period on stage 3 from 30 to 60 days, until December 15. CMS says in the statement that it is transitioning to a “new and more responsive regulatory framework” based on the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which will move Medicare from a fee-for-service to a value-based payment system.
While most physicians agree that this shift toward value-based payments has positive implications for patient care, almost all medical organizations recommend a pause to stage 3 of meaningful use, so that the software vendors can catch up with the changes.
Stack says, “The open comment period suggests they have heard that there is a great deal of frustration, concern, and angst that this next phase is not going to help achieve what [CMS] wants.” However, he’s not encouraged by CMS’s lack of effort on streamlining stage 3. “We feel it is interfering with our ability to do what we need to do,” he says.
Robert Rowley, MD, a family physician and health IT consultant who developed an EHR, feels that the burden of meaningful use falls on the vendors to make products that are not just “bolted-on” to existing technology. “Health data is still pretty siloed in the institutions that create them,” Rowley says. “Stage 2 of meaningful use required a certain amount of interoperability so that different systems could import and export information in a somewhat standard way.”


While that is starting to happen, Rowley says, it’s not sufficiently widespread and it’s not necessarily the best approach in an evolving technology landscape. “I advocate that the next stage of health IT is that data gets decoupled from the EHRs, becomes patient centered into longitudinal records that patients have the ability to own and manage.” He envisions small apps that “open up the possibility of competition,” similar to a smartphone. “I don’t think stage 3 meaningful use will cause vendors to make that leap,” he adds.
He, too, recommends a pause to stage 3. “Health IT will evolve faster than the 10-year road map that CMS talks about in stage 3,” Rowley says.

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