Meaningful Use – Lost in Translation

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By Michael Burger, Senior Consultant

Back in the beginning of the Meaningful Use Incentive Program for Electronic Health Records (EHRs), I was a product manager working at an ambulatory EHR vendor. One of my jobs was to understand Meaningful Use (MU) so that we could get our EHR ready for certification.  Another was to evangelize MU to our staff and our clients – explain the program, how it works, and the reasons to participate – both as a vendor and as a provider.

It wasn’t easy to pore over the hundreds of pages of regulations and requirements. But I did it, and came away at the end of the process with a firm understanding of the program and what needed to be done.

I stepped away from product management a few years ago and began a new career as a consultant. The relief I felt from not having to take another EHR through another MU certification was palpable. In the ensuing few years as a consultant, I’ve watched from the sidelines as the tug o’war raged – should MU be cancelled, should it be deferred, when will the new rules be published.

And then early this year, in almost an offhand comment, the Centers for Medicare and Medicaid Services (CMS) mentioned that MU is going away.  Or at least that’s the way the industry press reported it.  As it turns out, this isn’t exactly true, as the essence of MU is being blended into the new Merit-Based Incentive Payment System (MIPS), coming in 2017.

CMS’ statement has pulled me pulled back into the MU fray.  I heard from a number of clients, who ask, “Now that MU is dead, how should our strategy shift?”  In order to answer that question, it was necessary to delve into the requirements of MU Stage 3 and into the details of MIPS.

To say that my head is spinning is an understatement. The MU program has been “bureaucratized” to the point where it’s really challenging to understand (as if that weren’t impossible before). The stages have been rebranded as editions. The time periods have gone from a year to 90 days, the reporting periods have gone to a calendar year. Core and menu measures are no more, replaced by objectives with multiple associated measures.  Measures are retired. New measures are added.

And then there’s MIPS.  It’s a points-based incentive program with multiplier bonuses—not to mention a mandate to use certified EHR software.  MIPS also has bonuses calculated in 2019 using 2017 performance data–even though the specific bonus requirements may not be available in time for 2017.

Now this highly confusing program is even more confusing and convoluted—so much so that even we techies and policy wonks are challenged to figure it out. Physicians are among the most highly educated professionals, trained to make life or death decisions. The program has become so confusing that it’s little wonder than physicians are confused and apathetic (or combatant) about MU and have been abandoning the program in droves, according to the latest statistics.

Government programs by definition are bureaucratic.  And it is true that despite the complexity, Meaningful Use has been effective in its goal of installing the infrastructure for the digitalization of healthcare. For sure, simplification is needed. I don’t claim to have the full answer, but If we’re struggling with providers abandoning the original MU program, its replacement CAN’T be even more complicated.

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Medicare Creates Experimental Pilot Incentive Program to Boost Medication Adherence

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By Bill Hein, Payer/Provider Executive Lead

As a strong believer in harnessing the power of pharmacists as part of the patient care team, I’m pleased to see some critical national action being taken to further evaluate the impact they can have.  Medicare—the Nation’s biggest payer—is taking steps to close the medication adherence gap among beneficiaries.  The Centers for Medicare and Medicaid Services (CMS), the agency that oversees the program, is launching an experimental five-year pilot program to increase medication adherence for Medicare beneficiaries in Part D plans in five parts of the country.  

The new CMS initiative, known as the Enhanced Medication Therapy Management (MTM) model, will offer incentives to stand-alone Part D plans in five areas, through experimental pilots, to boost adherence. The areas are:  Arizona, Florida, Louisiana and Virginia, and a larger region that includes Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming.  The plans can design their own pilots and tailor them to their unique patient populations and geographic needs.

There are several drivers behind this initiative. Among elderly beneficiaries with four or more chronic conditions, medication non-adherence increased from 14.4% in 2009 to 17% in 2011, according to a 2014 Health Affairs analysis. The prevalence (among the sickest elderly) of forgoing basic needs to purchase medicines went from 6.8% in 2009 to 10.2% in 2011. The cost of nonadherence has been estimated at $100 billion to $300 billion annually, including expenditures for avoidable hospitalizations, nursing home admissions, and premature deaths. Chronic diseases are also on the rise, and older Americans are particularly vulnerable. Today, some 70 million Americans aged 50 and up suffer from 4-5 chronic conditions. Treating the chronically ill accounts for $3 out of every $4 spent on medical care, so reducing outlays for chronic disease management through improving medication adherence can result in significant savings to the U.S. healthcare system and improve quality of care.

CMS will accept applications for the Enhanced MTM model via a Request for Applications (RFA), to be released shortly.  Once released, application materials will be available at: http://innovation.cms.gov/initiatives/enhancedmtm/.  As experts in MTM and pilot management, Point-of-Care Partners offers subject matter expertise and a variety of technical assistance in proposal development and project management.  E-mail or call me if we can help.

More information about the Enhanced MTM model test can be found in the model announcement, available at http://innovation.cms.gov/initiatives/enhancedmtm/.  A webinar on the initiative will be held on October 21, 2015. Registration information will be available on the same site.

 

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EHR Blamed for Ebola Death. REALLY?

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By Michael Burger, Senior Consultant

Last week, a headline caught my eye:  “Report Finds EHR Contributed to Dallas Hospital’s 2014 Ebola Issues.”  The report is written by an independent panel convened by Texas Health Resources, which operates Texas Health Presbyterian Hospital Dallas. This is the hospital where patient Thomas Duncan received care, was not diagnosed with Ebola and subsequently passed away at his residence. 

The report illustrates the issues involving electronic health record (EHR) usability, including accusations that some EHR vendors have attested in the Meaningful Use certification process to use “user-centered design” or UCD. The events in Texas illuminate the challenge faced by EHR vendors regarding usability.

The report draws several interesting conclusions about what happened. It finds that the care team failed to monitor the patient’s clinical information as documented in the EHR and that the hospital seemed more concerned with patient satisfaction and less about outcomes. Moreover, the report concludes that the hospital was ill prepared to address Ebola by failing to get Ebola treatment information into the right hands quickly.

The comments related to electronic health records (EHRs) are particularly fascinating. The report concludes that there is “over reliance on the EHR to convey critical information,” that the “EHR configuration did not provide for automatic alerts related to travel history” and that “[the EHR had] no systems in place that would trigger a review or re-asking of critical travel information.” 

The report further notes that the sharing of travel history was not easily accessible to the physician, as viewing it “required extra and non-intuitive steps to be taken by the physician to access information highly relevant to clinical decision-making.” In the end, the hospital “[did not] optimally utilize the full capability of the EHR.”

It’s not surprising that Mr. Duncan’s death and the specter of Ebola elicited a post-mortem evaluation.  But is it right to blame EHRs for what happened in Texas?

We all agree that, used to their potential, EHRs can be a tremendous diagnostic tool, capable of detailed analysis of vast amounts of data in seconds. The challenge is how to make the analytical results useful in a life-or-death situation. EHR designers observe clinical workflows and build software to accommodate them. Smooth and efficient clinical workflow does not allow for “automatic alerts related to travel history” and certainly not “a review or re-asking of critical travel information.” Having observed clinical workflow more times than I can count, I can say for sure that nothing irks a doctor more than being interrupted by alerts.   Alert fatigue is a well-known phenomenon and barrier to EHR user satisfaction. I can only imagine a physician’s reaction if the EHR began prompting to re-ask questions! 

And what is the definition of smooth workflow? We have an expression in EHR product management: ask a group of 5 doctors for their opinion, and you’ll get 6 opinions. Consensus is difficult among physicians, particularly when it comes to EHR workflow.   It’s not a surprise then that the report concludes that the EHR “required extra and non-intuitive steps” to access relevant clinical information.  What is relevant to one physician is irrelevant and non-intuitive to another.  Plus, it varies across specialties and work environments, such as this particular hospital.  This means that EHR vendors must seek the middle of the road when it comes to workflow – to provide what is most relevant to most physicians. They also must trust that the physicians are relying on their medical training, not the EHR, to make their clinical decisions. Physicians wouldn’t have it any other way; they want to use EHRs as a resource, not a replacement for their training and medical judgment.

In a nod to our legal team’s advice at my former employer, we had a disclaimer that would display as users logged into the EHR. It contained a paragraph of “legalese,” which I’m sure that everyone clicked through without ever reading. Buried in it were important words: “This software contains logic including warnings and reminders meant to be used as reference material.  It is not designed and cannot be a substitute for the clinical decision making of a licensed healthcare professional.” While it’s tempting to blame the EHR for lapses in care quality, in the end it comes down to the caregivers. The best caregivers refer to the EHR as a reference, but rely on their diagnostic skills. Sometimes obscure diagnoses will be missed – to err is human.

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