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Doctor Survey Can’t Muster Enthusiasm for Electronic Health Records

Posted on September 14, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Medscape’s annual report on electronic health records (EHRs) is out for 2016. With more than 15,000 physicians over 25 specialties responding, there’s little to celebrate in it. The survey confirms what we know about the Meaningful Use program–it succeeded in getting doctors to use EHRs (slide 2) and to convert their paper charts to EHRs (slide 30). What the Meaningful Use program failed at, apparently, is meaningful use of EHRs.

When doctors were asked about the effects of the EHR on their practice, most reported “no change” (page 18). Yes, they say it has helped them with “documentation”–but how is that an achievement? Maybe you can get your thoughts into the record, but that’s of no value if it doesn’t improve patient service or clinical operations. In fact, the EHR has negative value. The survey confirms what we’ve heard anecdotally for years: the EHR is widely reported to slow down workflow (slide 25) and to dramatically degrade almost every aspect of the doctor-patient interaction: face-to-face time, management of treatment plans, etc. (slide 19). The text in slide 19 pallidly argues that, well, the results aren’t as bad as they were in 2014. Certainly, users will learn over time to compensate for bad systems, but that doesn’t turn them into good systems. If they were good systems, doctor satisfaction would have gone up since 2012–instead, it’s plummeting (slide 22). I have to admit that I don’t quite understand what the term “satisfaction” means in this context (as opposed, say, to the Rolling Stones song). I take the specific observations of slides 18 and 19 more seriously.

We can probably count as a success that 30 percent of patients review their data (slide 20). As a proxy for patient engagement, this doesn’t go far (and it happens during the visit, not online), but I bet hardly anyone used to review their data.

E-prescribing remains the most “helpful” aspect of an EHR (slide 17). This probably reflects the dominance of a single service, SureScripts, in that area. With little to worry about in terms of interconnection, the industry can exchange data relatively easily. Other areas of health care continue to struggle and falter when it comes to basic data exchange–for instance, only 35 percent of doctors found EHRs helpful to provide clinical summaries of visits to patients. When we can’t even get to square one on patient engagement, we have a lot left to demand of EHRs.

There’s a huge gap between hospitals and independent practices in their choice of EHRs. This suggests that the major EHR vendors are aimed at lucrative markets–the kind of enormous practices that run in buildings that tower above their urban landscapes. Epic, of course, is far and away the most popular hospital system (page 6). The market for independent practices looks like the Republican presidential polls early in the primaries–totally fragmented (slide 7). eClinicalWorks takes top spot with 12 percent of the market, and all the other services, many of them well-known, trail with single-digit shares of the market.

Strangely, when independent practices were asked to rate their EHRs (slide 11), the order was quite different. It may be that small samples and close margins make the differences between slide 7 and 11 insignificant.

The nice aspect of this finding (satisfying, one might say) is that independent practices really are independent. Doctors apparently do their research and choose what’s best for them. Large systems, by contrast, force their associated outpatient clinics to use the same system the hospital uses, regardless of its suitability or usability.

Ratings show what users truly think of EHRs. On a scale from 1 to 5, you might think that at least one or two might wander into the 4-to-5 range, but none receives that honor. The Veterans Administrations’ VistA interface (see our recent article on it) comes out on top of the pack (slides 8, 9 10, and 12), which is no surprise because it has been rated highest by doctors for decades. This popularity doesn’t help VistA in the fight for institutional dollars. A widely popular, open source, totally customizable, low-cost solution is no match against aggressive salespeople from vendors that cost a cool billion to install.

But to be fair, several major vendors come very close to VistA in popularity, and I don’t know what the margin of error is (for the survey as a whole, it’s +/-0.8 percent). Epic may well make just as many people happy as VistA. Furthermore, VistA’s rating fell a tiny bit over the past two years (slide 9) and it doesn’t show up at all among independent practices (slides 7 and 11). Vendors are also shuffled around a bit when doctors rate them for particular features, such as ease of use, vendor support, or connectivity. (Connectivity is an odd thing to rate, because it takes two to tango. If doctors rate a vendor well just for exchanging records with other providers using the same vendor, the whole point is lost).

There’s little age difference in doctors’ comfort using EHRs (slide 23). The reported revolt by older physicians doesn’t seem to be real. However, it may be that a truly transformative use of EHRs, with data and clinical decision support intensely integrated into the practice, would appeal more to newer members of the field. Perhaps slide 23 reveals that EHRs aren’t having much effect.

With all the dissatisfaction, 81 percent plan to keep their current EHRs. Perhaps that’s a resigned acceptance of how bad the field is; no alternatives exist. By the way, only 32 percent of the doctors have attested for Stage 2 of Meaningful Use (slide 29). How they’ll meet the requirements of the new MACRA law is beyond me. And unless real EHR competition picks up (in an industry that already has too many vendors), I don’t expect a radical improvement in vendor ratings in the 2017 survey.

Study: Health IT Costs $32K Per Doctor Each Year

Posted on September 9, 2016 I Written By

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

A new study by the Medical Group Management Association has concluded that that physician-owned multispecialty practices spent roughly $32,500 on health IT last year for each full-time doctor. This number has climbed dramatically over the past seven years, the group’s research finds.

To conduct the study, the MGMA surveyed more than 3,100 physician practices across the U.S. The expense number they generated includes equipment, staff, maintenance and other related costs, according to a press release issued by the group.

The cost of supporting physicians with IT services has climbed, in part, due to rising IT staffing expenses, which shot up 47% between 2009 and 2015. The current cost per physician for health IT support went up 40% during the same interval. The biggest jump in HIT costs for supporting physicians took place between 2010 and 2011, the period during which the HITECH Act was implemented.

Practices are also seeing lower levels of financial incentives to adopt EHRs as Meaningful Use is phased out. While changes under MACRA/MIPS could benefit practices, they aren’t likely to reward physicians directly for investments in health IT.

As MGMA sees it, this is bad news, particularly given that practices still have to keep investing in such infrastructure: “We remain concerned that far too much of a practice’s IT investment is tied directly to complying with the ever-increasing number of federal requirements, rather than to providing patient care,” the group said in a prepared statement. “Unless we see significant changes in the final rule, practice IT costs will continue to rise without a corresponding improvement in the care delivery process.”

But the MGMA’s own analysis offers at least a glimmer of hope that these investments weren’t in vain. For example, while it argues that growing investments in technologies haven’t resulted in greater administrative efficiencies (or better care) for practices, it also notes that more than 50% of responders to a recent MGMA Stat poll reported that their patients could request or make appointments via their practice’s patient portal.

While there doesn’t seem to be any hard and fast evidence that portals improve patient care across the board, studies have emerged to suggest that portals support better outcomes, in areas such as medication adherence. (A Kaiser Permanente study from a couple of years ago, comparing statin adherence for those who chose online refills as their only method of getting the med with those who didn’t, found that those getting refills online saw nonadherence drop 6%.)

Just as importantly – in my view at least – I frequently hear accounts of individual practices which saw the volume of incoming calls drop dramatically. While that may not correlate directly to better patient care, it can’t hurt when patients are engaged enough to manage the petty details of their care on their own. Also, if the volume of phone requests for administrative support falls enough, a practice may be able to cut back on clerical staff and put the money towards say, a nurse case manager for coordination.

I’m not suggesting that every health IT investment practices have made will turn to fulfill its promise. EHRs, in particular, are difficult to look at as a whole and classify as a success across the board. I am, however, arguing that the MGMA has more reason for optimism than its leaders would publicly admit.

Three Words That Health Care Should Stop Using: Insurance, Market, and Quality (Part 2 of 2)

Posted on August 23, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The previous part of this article ripped apart the use of the words “insurance” and “market” to characterize healthcare. Not let’s turn to another concept even more fundamental to our thinking about care.

Quality

The final element of this three-card Monte is the slippery notion of quality. Health care is often compared to the airlines (when we’re not being compared to the Cheesecake Factory), an exercise guaranteed to make health care look bad. Airlines and restaurants offer relatively homogeneous experiences to all their clients and can easily determine whether their service succeeded or failed. Even at a mechanical level, the airlines have been able to quantify safety.

Endless organizations such as the National Association for Healthcare Quality (NAHQ) and the Agency for Healthcare Research and Quality (AHRQ) collect quality measures, and CMS has tried strenuously to include quality measures in Meaningful Use and the new MACRA program. We actually have not a dearth of quality measures, but a surfeit. Doctors feel overwhelmed with these measures. They are difficult to collect, and we don’t know how to combine them to create easy reports that patients can act on. There is a difference between completing a successful surgery, caring for things such as pain and infection prevention after surgery, and creating a follow-up plan that minimizes the chance of readmission. All those things (and many more) are elements of quality.

Worst of all, despite efforts to rank patients by their conditions and risk, hospitals repeatedly warn that quality measures underestimate risky patients and therefore penalize the hospitals that do the most difficult and important work–caring for the sickest. Many hospitals are throwing away donor organs instead of doing transplants, because the organs are slightly inferior and therefore might contribute to lower quality ratings–even if the patients are desperate to give them a try.

The concept of quality in health care thus needs a fresh look, and probably a different term. The first, simple thing we can do is remove patient ratings from assessments of quality. The patient knows whether the nurse smiled at her or whether she was discharged promptly, but can’t tell how good the actual treatment was after the event. One nurse has suggested that staff turnover is a better indication of hospital quality than patient satisfaction surveys. Given our fascination with airline quality, it’s worth noting that the airline industry separates safety ratings from passenger experience. The health care industry can similarly leverage patient ratings to denote clients’ satisfaction, but that’s separate from quality.

As for the safety and effectiveness of treatment, we could try a fairer rating system, such as one that explicitly balances risk and reward. Agencies would have to take the effort to understand all the elements of differences in patients that contribute to risk, and make sure they are tallied. Perhaps we could learn how to assess the success of each treatment in relation to the condition in which the patient entered the office. Even better, we could try to assess longitudinal results instead evaluating each office visit or hospital admission in isolation.

These are complex activities, but we have lots of data and powerful tools to analyze it. Together with a focus on changing behavior and environments, we should be able to make a real difference in quality–and I mean quality of life. Is there anything an ordinary member of the health professions can do till then? Well, try issuing Bronx cheers and catcalls at any meeting or conference presentation where someone uses one of the three misleading terms.

Three Words That Health Care Should Stop Using: Insurance, Market, and Quality (Part 1 of 2)

Posted on August 22, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Reading the daily papers, I have gotten increasingly frustrated at the misunderstandings that journalists and the public bring to the debates of over health expansion, costs, and reform. But you can’t blame them–our own industry has created the confusion by misusing terms and concepts that work in other places but not in health. Worse still, the health care industry has let policy-makers embed the incorrect impressions into laws and regulations.

So in this article I’ll promote the long process of correcting the public’s impressions of health care–by purging three dangerous words from health care vocabulary.

Insurance

The health care insurance industry looks like no other insurance industry in the world. When we think of insurance, we think of paying semi-annually into a fund we hope we never need to use. But perhaps every twenty years or so, we suffer damage to our car, our house, or our business, and the insurance kicks in. That may have been true for health care 70 years ago, when you wouldn’t see the doctor unless you fell into a pit or came down with some illness they likely couldn’t cure anyway. The insurance model is totally unsuited for health care today.

The Affordable Care Act made some symbolic gestures toward a recognition that modern health care should embrace prevention and wellness. For instance, it eliminated copays for preventative visits. The insurance companies took that wording very literally: if you dare to bring up an actual medical problem during your preventative visit, they charge you a copay. Yet the “preventative” part of the visit usually consists of a lecture to stop smoking and go on the Mediterranean diet.

Effective wellness programs jettison the notion of insurance (although patients need separate insurance for catastrophic problems). They keep in regular contact with clients, provide coaching, and sometimes use intelligent digital interventions such as described by Dr. Joseph Kvedar in The Internet of Healthy Things (which I reviewed shortly after its release). There are scattered indications that these programs do their job. As they spread, the system set up to deal with catastrophic health events will have to adapt and take a modest role within a behavioral health model.

The term “insurance” is so widely applied to our healh funding model that we can’t make it go away. Perhaps we should put the word in quotation marks wherever it must be used.

Market

This term is less ubiquitous than “insurance” but may be even more harmful. Numerous commenters have pointed out the difference between health care and actual markets:

  • In a market, you can walk away and refuse to pay for a good that is too expensive. If the price of beef goes through the roof, you can switch to beans (and probably should, for your own health). So the best time to argue with someone who promotes a health care market may be right after he’s fallen from a ladder and is clutching at his leg in agony. Ask him, “Do you feel you can walk away from an offer of health care?” Cruel, but a lesson he won’t forget.

  • A market serves people who can afford it. It’s hard to find a stylish hair dresser in a poor neighborhood because no one can pay $200 for a cut. But here’s the rub: the people who need health care the most can’t afford it. Someone with serious mental or physical problems is less likely to find work or be able to attend a college with health insurance. Parents of seriously ill children have to take time off from work to care for them. And so on. It’s what economists–who have trouble discarding the market way of thinking–call a market failure.

  • In a market, you know what you’re going to pay for a service and what your options are. Enough said.

  • In a market, you can evaluate the quality of a service and judge (at least in retrospect) whether it was worth the cost. I’ll deal with quality in the next section.

The misconception of health care as a market came to a head in the implementation of the Affordable Care Act. Presumably, millions of “young invincibles” were avoiding health insurance because of the cost. The individual mandate, combined with affordable plans on health care exchanges, would bring them flooding into the insurance system, lowering costs for everyone and balancing the burden created by the many sick people who we knew would join. And yet now we have stubbornly rising health care rates, deductibles, and caps, along with new costs in the states where Medicaid expanded Where did this all fall apart?

Part of the problem is certainly the recession, which caused incomes to decline or stagnate and exacerbated people’s health care needs. Also, there was a pent-up need for treatment among people who had lacked health insurance and avoided treatment for some time. This comes through in a study of prescription medication use. Furthermore, people don’t change habits overnight: many continue to over-rely on the emergency room (perhaps because of a shortage of primary care providers).

But there’s another unanticipated factor: the “young invincibles” actually start using health care once they get access to it. An analysis showed that mental health needs among the young are much higher than expected. In particular, they suffer widely from depression and anxiety, which is entirely reasonable given the state of our world. (I know that these conditions are connected to genetics and biology, but environment must also play a role.)

Ultimately, until we get behavioral health in place for everybody, health care costs will continue to rise and we won’t realize the promise of near-universal coverage. Many health care activists–especially during the recent political primary season–call for a single-payer system, which certainly would introduce many efficiencies. But it doesn’t solve the problems of chronic conditions and unhealthy lifestyles–that will require policy action on levels ranging from improvements in air cleanliness to new opportunities for isolated individuals to socialize. Meanwhile, we still have to look at the notion of quality in tomorrow’s post.

If MACRA Fails, It Will Be a Failure of IT, Not Doctors or Regulators

Posted on August 8, 2016 I Written By

The following is a guest blog by Steve Daniels, president of Able Health.

There has been a whole lot of mudslinging over the last month between regulators and healthcare providers over MACRA, which shifts Medicare payments further toward pay-for-performance starting January 1. On the one hand, CMS Acting Administrator Andy Slavitt is clear that CMS is ready for change. “We need to get out of the mode of paying physicians just to run tests and prescribe medicines,” he told a Senate Finance Committee hearing. Meanwhile, Dr. Thomas Eppes of the American Medical Association has called MACRA a “quantum shift” and pushed for a delay.

Yes, the Medicare Quality Payment Program instituted by MACRA should—and will—evolve based on comments made on the proposed rule. But the reality is the program provides enormous opportunity for providers to increase bonus payments, while streamlining reporting requirements across a patchwork of outdated and duplicative programs. And it’s worth noting that the potential penalties under the Merit-Based Incentive Payment System (MIPS) over the next four years are actually lower than the sum of the penalties of the programs it is replacing.

To meet MACRA goals, it will take a well-prepared team of providers and administrators—empowered by data and well-designed tools. Doctors can’t be solely responsible for achieving patient outcomes, reducing costs and documenting it all for CMS as they go. Unfortunately, the history of health IT has not been kind—or affordable—to doctors. And today, the health IT stack has a new challenge—keeping pace with the proliferation of value-based programs, from accessing data all the way through enabling new clinical practice.

We must move from a mindset of meeting Meaningful Use checkboxes toward supporting a more effective way of operating. And in the modern world of software-as-as-service, there’s no good reason left that IT needs to cost providers millions of dollars. We can do better. As things stand, if MACRA fails, it will be a failure of IT, not doctors or regulators.

Gathering all the data

For value-based care to work, patient data needs to be made available for providers to coordinate with each other, as well as to payers, to properly evaluate performance based on all known information. Those still blocking or jacking up prices for data access are complicit in obstructing the vision of a learning value-based system.

It is time to remove technical barriers through modern and open data standards like FHIR, as well as rules and unreasonable fees that prevent parties from accessing data when they need it. Thankfully, the Advancing Care Information performance category will reflect the emphasis on information exchange set forth in Meaningful Use Stage 3.

Calculating performance flexibly

The new era of performance-based pay requires continuous monitoring of quality and cost, with the ability to track progress across multiple programs on an ongoing basis. To measure quality today, we often use static algorithms hard-coded by EHRs vendors and health system IT departments, conforming to standards set by NCQA or CMS.

But providers need tools that are tailored not just to one or two programs like Meaningful Use and PQRS, but across the organization’s full range of value-based programs as these program continue to expand, evolve, and proliferate. With efforts to standardize IT for quality measures stalling, vendors need to focus less on one-size-fits-all quality measure calculations and more on flexible systems that enable measures to be rapidly constructed and customized to move with the trends. Expect change to be the norm.

Informing new behaviors

With so many health IT professionals focused on gathering and reporting data, it is not surprising that design has taken a back seat so far. But this year, not a single population health vendor earned an “A” rating from Chilmark, due to poor user engagement and clinical workflow. This is no longer acceptable. The challenge of enabling the new clinical and administrative behaviors associated with value-based care is too vast. User experience must be top of mind for any IT implementation, with representative users involved from the start. We have seen the impact of poor user experience in the fee-for-service system, from frustrated clinicians to alarming patient safety issues.

Design is even more important when the challenge is not just documenting billing codes but also achieving health outcomes for patients across a care team. Don’t bombard clinicians with notifications and force clumsy form-filling. Instead, employ best practices from cognitive psychology to inform professionals with lightweight and intelligent touchpoints. Automate documentation and interpretation of data wherever possible.

A new era of health IT

Whether or not it’s delayed, the Quality Payment Program is coming. And the healthcare industry is moving inexorably toward value-based care. Will health IT step up to the challenge of building toward a value-based future that is accessible to all providers? Or will we sit back and wait for the next list of requirements?

About Steve Daniels
Steve Daniels is the President of Able Health, which helps providers succeed under MACRA and value-based programs. Formerly the design lead for IBM Watson for healthcare and a lifelong patient advocate, he is passionate about the role of open data exchange and intuitive experience design in fostering a continuously improving healthcare system. Find him on Twitter and LinkedIn.

ONC Offers Two Interoperability Measures

Posted on July 14, 2016 I Written By

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

For a while now, it’s been unclear how federal regulators would measure whether the U.S. healthcare system was moving toward the “widespread interoperability” MACRA requires. But the wait is over, and after reviewing a bunch of comments, ONC has come through with some proposals that seem fairly reasonable at first glance.

According to a new blog entry from ONC, the agency has gotten almost 100 comments on how to address interoperability. These recommendations, the agency concluded, fell into four broad categories:

  • Don’t create any significant new reporting burdens for providers
  • Broaden the scope of interoperability measurements to include providers and individuals that are not eligible for Medicare and Medicaid EHR incentives
  • Create measures that examine usage and usefulness of exchanged information, as well as the impact on health outcomes, in addition to measuring the exchange itself
  • Recognize that given the complexity of measuring interoperability, it will take multiple data sources, and that more discussions will be necessary to create an effective model for such measurements

In response, ONC has come up with two core measures which address not only the comments, but also its own analysis and MACRA’s specific definitions of “widespread interoperability.”

  • Measure #1: Proportion of healthcare providers electronically engaging in the following core domains of interoperable exchange of health information: sending; receiving; finding (querying); and integrating information received outside sources.
  • Measure #2: Proportion of healthcare providers who report using information electronically received through outside providers and sources for clinical decision-making.

To measure these activities, ONC expects to be able to draw on existing national surveys of hospitals and office-based physicians. These include the American Hospital Association’s AHA Information Technology Supplement Survey and the CDC National Center for Health Statistics’ annual National Electronic Health Record Survey of office-based physicians.

The reasons ONC would like to use these data sources include that they are not limited to Medicare and Medicaid EHR incentive program participants, and that both surveys have relatively high response rates.

I don’t know about you, but I was afraid things would be much worse. Measuring interoperability is quite difficult, given that just about everyone in the healthcare industry seems to have a slightly different take on what true interoperability actually is.

For example, there’s a fairly big gulf between those who feel interoperability only happens when all data flows from provider to provider, and those who feel that sharing a well-defined subset (such as that found in the Continuity of Care Document) would do the trick just fine. There is no way to address both of these models at the same time, much less the thousand shades of gray between the two extremes.

While its measures may not provide the final word on the subject, ONC has done a good job with the problem it was given, creating a model which is likely to be palatable to most of the parties involved. And that’s pretty unusual in the contentious world of health data interoperability. I hope the rollout goes equally well.

2 Major Problems with MACRA

Posted on May 4, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Everyone’s started to dive into the 10 million page MACRA (that might be an exaggeration, but it feels about that long) and over the next months we’ll be sure to talk about the details a lot more. However, I know that many healthcare organizations are tired of going through incredibly lengthy regulations before they’re final. Makes sense that people don’t want to go through all the details just for them to change.

As I look at MACRA from a very high level, I see at least two major problems with how MACRA will impact healthcare.

Loss of EHR Innovation
First, much like meaningful use and EHR certification, MACRA is going to suck the life out of EHR development teams. For 2-3 years, EHR roadmaps have been nothing but basically conforming to meaningful use and EHR certification. Throw in ICD-10 development for good measure and EHR development teams have basically had to be coding their application to a government standard instead of customer requests and unique innovations.

Just today I heard the Founder of SOAPware, Randall Oates, MD, say “I’m grieving MACRA to a great degree.” He’s grieving because he knows that for many months his company won’t be able to focus on innovation, but will instead focus on meeting government requirements. In fact, he said as much when he said, “We don’t have the liberty to be innovative and creative.” And no, meeting government regulations in an innovative way doesn’t meet that desire.

I remember going to lunch with a very small EHR vendor a year or so ago. I first met him pre-meaningful use and he loved being able to develop a unique EHR platform that made a doctor more efficient. He kept his customer base small so that he could focus on the needs of a small group of doctors. Fast forward to our lunch a year or so ago. He’d chosen to become a certified EHR and make it so his customers could attest to meaningful use. Meaningful use made it so he hated his EHR development process and he had lost all the fire he’d had to really create something beautiful for doctors.

The MACRA requirements will continue to suck the innovation out of EHR vendors.

New Layers of Work With No Relief
When you look at MACRA, we have all of these new regulations and requirements, but don’t see any real relief from the old models. It’s great to speak hypothetically about the move to value based reimbursement, but we’re only dipping our toe in those waters and so we can’t replace all of the old reimbursement requirements. In some ways it makes sense why CMS would take a cautious approach to entering the value based world. However, MACRA does very little to reduce the burden on the backs of physicians and healthcare organizations. In fact, in many ways it adds to their reporting burden.

Yes, there was some relief offered when it comes to meaningful use moving from the all or nothing approach and a small reduction in the number of measures. However, when it comes to value based reimbursement, MACRA seems to just be adding more reporting burdens on doctors without removing any of the old fashioned fee for service requirements.

MACRA is not like ICD-10. Once ICD-10 was implemented you could see how ICD-9 and the skills required for that coding set will eventually be fully replaced and you won’t need that skill or capability anymore. The same doesn’t seem to be true with value based care. There’s no sign that value based care will be a full replacement of anything. Instead, it just adds another layer of complexity, regulation, and reporting to an already highly regulated healthcare economic system.

This is why it’s no surprise that many are saying that MACRA will be the end of small practices. At scale, they’re onerous. Without scale, these regulations can be the death of a practice. It’s not like you can stop doing something else and learn the new MACRA regulations. No, MACRA is mostly additive without removing a healthcare organization’s previous burdens. Watch for more practices to leave Medicare. Although, even that may not be a long term solution since most commercial payers seem to follow Medicare’s lead.

While I think that CMS and the people that work there have their hearts in the right place, these two problems have me really afraid for what’s to come in health IT. EHR vendors the past few months were finally feeling some freedom to listen to their customers and develop something new and unique. I was excited to see how EHR vendors would make their software more efficient and provide better care. MACRA will likely hijack those efforts.

On the other side of the fence, doctors are getting more and more burnt out. These new MACRA regulations just add one more burden to their backs without removing any of the ones that bothered them before. Both of these problems don’t paint a pretty picture for the future of healthcare.

The great part is that MACRA is currently just a proposed rule. CMS has the opportunity to fix these problems. However, it will require them to take a big picture look at the regulation as opposed to just looking at the impact of an individual piece. If they’re willing to focus MACRA on the big wins and cut out the parts with questionable or limited benefits, then we could get somewhere. I’m just not sure if Andy Slavitt and company are ready to say “Scalpel!” and start cutting.

Has MU Been Useful? A Review of MU and Merit-Based Incentives – Breakaway Thinking

Posted on March 16, 2016 I Written By

The following is a guest blog post by Lori Balstad, Learning and Development Specialist at The Breakaway Group (A Xerox Company). Check out all of the blog posts in the Breakaway Thinking series.
Lori Balstad
Is it really the end of Meaningful Use? According to Andy Slavitt, Acting Administrator for the Centers for Medicare and Medicaid Services (CMS), it’s time for a change in incentive programs and 2016 may be the year for it. Alternative Payment Models and Merit-based Incentive Payments (MIPS) as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) may be replacing the complicated layers of requirements in Stage 1, 2, and 3 of Meaningful Use.

While CMS works on rolling out a new set of regulations, you may be wondering if this will ease the lingering pain of the past years. Will the program be easier to understand, navigate, and comply with?

First, let’s do a quick review:

CMS’s Meaningful Use Incentive program was rolled out in 2011 to incentivize eligible professionals and hospitals to adopt electronic health records (EHRs).

The goal was three-fold:

  • Improve quality, safety, efficiency, and reduce health disparities
  • Increase patient engagement and satisfaction
  • Improve care coordination, and population and public health

Stage 1 dealt with data capture and sharing, Stage 2 focused on advance clinical processes, and Stage 3 was to bring us to improving healthcare outcomes.

Achieving these goals is not an easy or quick process, but there have been many noteworthy accomplishments. As of 2015, 95 percent of all eligible and critical access hospitals have demonstrated meaningful use of certified health IT through participation in the CMS EHR Incentive Programs. Ninety-eight percent of all hospitals have demonstrated meaningful use and/or adopted, implemented or upgraded any EHR. As of January 2016, more than 484,000 health care providers received payment for participating in the Medicare and Medicaid EHR Incentive Programs, according to the CMS.

There have also been bumps along the way. Clinical quality reporting is controversial due to unrefined standards and a lack of a comprehensive strategy around the measures. Providers struggle to balance healthcare reform efforts with patient engagement and education under Stage 2. Eligibility determination issues in the CMS website threatened some physicians and other eligible professionals with Medicare payment penalties in 2015. Physicians are at the point where the regulations are so difficult that they feel like they are unable to focus on patient care.

So what’s next?

CMS has been working closely with physicians and healthcare organizations to address their needs and concerns, and plans to share the new regulations this spring under MACRA. They will work towards keeping the original ideologies while establishing new critical principles. The most important improvement will be moving away from incentivizing providers for the mere use of the technology towards the actual outcomes achieved with their patients. Other goals include allowing for flexibility to customize health IT to ensure physicians are supported instead of distracted.

Meaningful Use is not going away, just the way it’s measured and incentivized. Moving toward quality outcomes instead of measuring technology adoption levels will hopefully move us closer to the original goals of Meaningful Use. It all comes back to what physicians and healthcare organizations do on a daily basis – strive to provide the best possible care for patients.

Xerox is a sponsor of the Breakaway Thinking series of blog posts. The Breakaway Group is a leader in EHR and Health IT training.

#HIMSS16 Mix Tape

Posted on February 5, 2016 I Written By

Colin Hung is the co-founder of the #hcldr (healthcare leadership) tweetchat one of the most popular and active healthcare social media communities on Twitter. Colin is a true believer in #HealthIT, social media and empowered patients. Colin speaks, tweets and blogs regularly about healthcare, technology, marketing and leadership. He currently leads the marketing efforts for @PatientPrompt, a Stericycle product. Colin’s Twitter handle is: @Colin_Hung

On February 29th the #HealthIT community will descend on Las Vegas for the annual HIMSS conference and exhibition.

One of the best parts about attending HIMSS is getting the chance to meet people in real life who I interact with through social media. There is nothing quite like meeting someone face to face for the first time yet feeling like you already know them. I think hugging and fist bumps are the official greetings at HIMSS. It’s an absolute blast to be able to share stories and laughs with likes of Mandi Bishop, John Lynn , Rasu Shrestha and Wen Dombrowski.

With an expected attendance of 45,000 this year, I’m hoping to meet even more people than ever before at the various HIMSS gatherings.

Last year, ahead of HIMSS15, I decided to do a fun blog post. I asked some friends to send me a song they thought reflected what was happening in #HealthIT at the time. I compiled everyone’s selections along with the reasons behind their choice. I called it the HIMSS15 Mix Tape. The response was amazing. I had so many people DM me and stop me at the conference to give me their song choice. Even John Lynn blogged about it.

This year, I asked an even larger number of friends to contribute a song. So without further rambling, here is the #HIMSS16 Mix Tape. Enjoy!

HIMSS16 Mix Tape

Night on Bald Mountain – Disney’s Fantasia. Chosen by Regina Holliday @ReginaHolliday. “Disney. Because although morning will come, we now walk among the terrors.”

Confident – Demi Levato. Chosen by Mandi Bishop @MandiBPro. “For a couple reasons: 1) it’s beyond time #HealthITChicks / #WomenInHIT got equal recognition and pay for their contributions to the field, and I’m seeing an increasing strength of voice supporting those efforts, 2) patients have had enough of their attempts to engage being discounted by clinicians and other caregivers, and we are all demanding respect and inclusion at the table of our healthcare decisions.”

Stronger – Kelly Clarkson. Chosen by John Lynn @techguy. “This should be the anthem of those of us in healthcare IT.  First, do no harm, but don’t be afraid to take some risks and make mistakes.  Not taking some risks is killing more people than doing something and sometimes making mistakes.  Healthcare will be stronger for the mistakes we make.”

Runnin’ Down A Dream –  Tom Petty & the Heartbreakers. Chosen by Melody Smith Jones @melsmithjones. “I got into this industry because my grandmother died of cancer in rural USA in 2003. I’ve been running down the dream of care everywhere ever since. I believe 2016 will bring us the most growth in Connected Health that we have seen to date.”

Talk to Me – Stevie Nicks. Chosen by David Harlow @healthblawg. “The chorus includes the line: “You can talk to me/You can set your secrets free, baby” which can be read as a coded message to legacy systems … One of the verses goes: “Our voices stray from the common ground where they/Could meet/The walls run high/ … / Oh, let the walls burn down, set your secrets free” — a prescient call to interoperability, to communication, to enabling broader collaboration across provider, payor and health care information technology silos. We’re almost there, Stevie.”

Heroes – David Bowie. Chosen by Nick van Terheyden @drnic1. “Because I love that track and was sad to see David Bowie leave this universe. But also: We need to be heroes for Healthcare and I hope Healthcare Technology can beat the madness of our system and Ch-ch-ch-ch-change the world:

A million dead-end streets / And every time I thought I’d got it made / It seemed the taste was not so sweet…… / We can be Heroes, just for one day / We can beat them, for ever and ever … ICYMI – I blended the lyrics from David Bowie’s Changes with Heroes”

Another Brick in the Wall – Pink Floyd. Chosen by Rasu Shrestha @RasuShrestha. “In memory of Meaningful Use ‘All in all it was just a brick in the wall…’ “

Numb – Linkin Park. Chosen by me @Colin_Hung. I think many physicians, nurses, administrators and patients are numb from all the competing priorities this past year and from the years of chasing Meaningful User dollars. I think this verse sums it up:

I’m tired of being what you want me to be / Feeling so faithless, lost under the surface / Don’t know what you’re expecting of me / Put under the pressure of walking in your shoes / (Caught in the undertow, just caught in the undertow) / Every step that I take is another mistake to you

Fire – Jimi Hendrix. Chosen by Chad Johnson @OchoTex. “The reason is simple: HL7 FHIR continues to dominate the headlines and discussions around health data interoperability, and rightfully so. FHIR will bring exciting changes to interoperability.”

Taking Care of Business – Bachman-Turner Overdrive. Chosen by Charles Webster @wareFLO. “Taking care of business in healthcare means getting sh*%$t done. Effectively and efficiently accomplishing goals is only possible with great…wait for it…WORKFLOW”

I Want It All – Queen. Chosen by Joe Lavelle @Resultant. “Because we want it all – Interoperability, “our damn data”, #mhealth, Patient Engagement, Population Health, Telemedicine. etc.”

Robot Rock – Daft Punk. Chosen by AJ Montpetit @ajmontpetit. “We’re heading to the integration of AI into healthcare to create a streamlined experience, and assist in comprehension of all the multiple factors that each patient has individually.”

Upgrade U – Beyoncé. Chosen by Cari McLean @carimclean. “I’ll go with a song that not only always makes me dance but one that reflects a growing happening in healthcare. I chose this song because the EHR replacement market is growing as the rip and replace trend continues and health information exchange is prioritized.”

Give Me Novacaine – Green Day. Chosen by Linda Stotsky @EMRAnswers. “LOL- because providers are in PAIN!!! They need something to soften the blows”

Changes – David Bowie. Chosen by Brad Justus @BradJustus. “A classic from a classic and something that is a constant in #HealthIT”

Fight Song – Rachel Platten. Chosen by Jennifer Dennard @JennDennard. “I think it encapsulates the #healthITchicks ethos – not to mention patient advocates’ – quite well :)”

 What Do You Mean – Justin Bieber. Chosen by Sarah Bennight @sarahbennight. “For SO many reasons. What do you mean MU is going away? What do you mean you need me to fill out ANOTHER demographic profile, what do you mean you don’t have my allergies? What do you mean by interoperable? I could go on all day, but we all have real jobs to do….like to figure out this healthcare IT thing :) Plus in the Justin B song…you hear a clock…do you ever feel like Health IT is running out of time? I don’t agree with JB on ANYTHING, but I agree we are running out of time.”

Shape of Things – David Bowie. Chosen by Pat Rich @pat_health. “In my mind this song evokes the futuristic world of health IT in a steampunk/sci-fi sort of way”

Hello – Adele. Chosen by Bill Bunting @WTBunting. “Because there is an emerging side of healthcare that’s trying to break free and be heard (i.e. adoption), and no one is answering the call to do so”

Under Pressure – Queen & David Bowie. Chosen by Joy Rios @askjoyrios. “There is so much pressure to get through these health IT initiatives unscathed and there’s so much at risk if they get it wrong.  I see providers across the country dealing with so much change, when they mostly just want to focus on their practice. Unfortunately, the changes are not letting up. I feel like the healthcare system is right in the middle of its metamorphosis… not a caterpillar anymore, but by no means a butterfly!”

Please Please Me – The Beatles. Chosen by Jim Tate @jimtate. “Providers want better EHRs”

New New Minglewood Blues – The Grateful Dead. Chosen by Brian Ahier @ahier. “Because I was inspired by this @healthblawg post ‘The New New Meaningful Use’ “

EHR State of Mind – ZDoggMDChosen by Andy DeLaO @CancerGeek. “Does it really need an explanation? J”

Dha Tete – Pandit Shyamal Bose. Chosen by Wen Dombrowski @HealthcareWen. “Some reasons I like this song:

  • Focus, Mindfulness
  • Flow states
  • Collaboration, Staying in Sync with each other (it is actually 2 people duet)
  • Speed, Moving fast
  • Precision, deciveness
  • Artistry, Beauty”

You Can Get It If You Really Want – Jimmy Cliff. Chosen by Steve Sisko @ShimCode. “I believe true, widespread interoperability is not that far away. The technology, standards (FHIR, OpenNotes), and group consensus (outfits like CommonWell, The Sequoia Project) are finally coming together.

You can get it if you really want / But you must try, try and try, try and try / You’ll succeed at last

Do you have a song you think reflects #HealthIT or healthcare at the moment? Add it to the comments below!

[Update: Here is a link to a Spotify playlist of the entire #HIMSS16 Mix Tape https://open.spotify.com/user/12163763158/playlist/7mO6DlpVa4MoJ7roW0bqiG or if you like videos, here is a YouTube playlist https://www.youtube.com/playlist?list=PLOxadHqniaPTYUUY5cMSmW14VZQpngUOU]

Meaningful Use Is Going to Be Replaced – #JPM16

Posted on January 12, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Big news came out today during the JP Morgan annual healthcare conference in San Francisco. Andy Slavitt, acting administrator of CMS, live tweeted his own talk at the event including this bombshell:


Technically meaningful use is not quite over, but it’s heading that way. We always read about lame duck head coaches in sports. I guess this is the version of a lame duck government program? Of course, this is just coming from the acting administrator of CMS. It’s not yet law. So, all those working on meaningful use reports, keep working.

The end of meaningful use as we know it will be generally welcome news to most in healthcare. Although, I’m sure that most will also take it with a grain of salt. Many in healthcare likely worry that the “something better” that replaces meaningful use and MACRA will actually be something worse. The cynics might argue that nothing could be worse, but I’ve never seen the government back down from that challenge.

What interests me is what levers they have available to them to be able to make changes. Can they do it without congressional action? Are doctors angry enough that congress will take action? What will happen to the remaining $10-20 billion allocated to meaningful use? What will hospitals and doctors that were counting on the meaningful use money do? Will they not get it anymore or will it be available in a new program? Obviously, there are more questions than answers at this point.

All in all, I’m glad to hear that Andy Slavitt is open to change. I suggested they blow up meaningful use a couple years ago.

Andy also did a tweetstorm to outline the 4 themes for reforming the MACRA and post-MU tech program:

These all seem surprisingly reasonable and mirror many of the comments I hear from doctors. However, the challenge is always in the implementation of these ideas. Some of them are very hard to track and reward. I can’t argue with the principles though. They highlight some of the major challenges associated with healthcare tech. It’s going to take some time to infuse entrepreneurship instead of regulation back into the EHR world, but these guidelines are a good step towards that effort.

UPDATE: Here’s the full text of Andy Slavitt’s talk at the JP Morgan Healthcare Conference.