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Curbside Consult with Dr. Jayne 1/21/13

January 22, 2013 Dr. Jayne 6 Comments

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I often make fun of the American Medical Association and some of its initiatives. Despite being a life member (with a lovely crystal paperweight to prove it), I find some of their initiatives extremely whiny and self-serving.

Last week Mr. H mentioned their recent letter to ONC urging review of Meaningful Use Stage 1 and Stage 2 prior to committing to Stage 3. Given some of the murmuring about a potential Stage 4, I’m supportive of this request. The AMA shares key concerns and recommendations from physicians.

First, the requirement for achieving 100 percent on all measures is problematic. Failure to meet one measure by one percent invalidates the physician’s entire effort and opens the door to penalties. I agree, and if Eligible Providers are going to be held to this type of standard, I’d like it to also be applied to federal disability processors, Medicare claims reps, and the people at the Department of Motor Vehicles. I’d also like it applied to my personal insurance carrier. For the four medical claims I had last year, three had processing errors leading to demands that I pay amounts I didn’t actually owe.

In addition to trying to achieve MU perfection, providers are trying to gain Patient-Centered Medical Home recognition, become part of Accountable Care Organizations, submit data for PQRS, and maintain board certification. There are also payer-centric and employer-centric quality initiatives. They all have different rules. I can barely keep up with the CMS FAQs let alone all the other information out there and I have a team to assist. I can’t fathom what it’s like to be a solo physician on this hamster wheel.

Second, one size doesn’t fit all. All specialties are required to meet the same core measures with few exceptions. The document goes on to state that the program is too primary-care focused and asks that specialists be allowed to opt out of any measure that has “little relevance to the physician’s routine scope of practice.” Knowing that my group’s orthopedic surgeons tried to opt out of vital signs (stating that blood pressure wasn’t relevant to their scope of practice), I urge caution here. Personally I think anyone who prescribes medications should be concerned about blood pressures, but quite a few of my colleagues disagree.

Third, the program needs independent evaluation to allow improvement. I agree here as well. Often MU seems like one giant experiment without an Institutional Review Board looking out for the safety of the participants. We’re being used as guinea pigs and the potential outcomes could be disastrous. I’m watching colleagues become increasingly burned out and motivated to leave the profession, which is completely counterproductive.

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The AMA asks for an evaluation between each stage prior to finalizing the requirements for the next stages. I completely agree here. The timeline is too tight and is forcing vendors to abandon true usability enhancements and code changes that support clinical care. Development time and effort is instead focused on making sure their system meets the certification requirements regardless of whether those requirements improve patient care or the user experience. In many ways, it feels like Meaningful Use is stifling innovation.

Fourth, usability needs to be addressed and made part of the certification process. I hope that important issues such as alert fatigue receive attention to better support patient safety and clinical quality. Further down in the usability section, the AMA buries a request that ONC should consider requiring vendors of certified EHRs to commit to supporting subsequent MU stages. They also request protection from “excessive vendor charges” for physicians who switch systems. I’ve never seen a conversion project that didn’t generate excessive charges, so this is a great discussion point.

Fifth, IT infrastructure barriers should be resolved to allow improved data sharing. Working in a major metropolitan market, I experience this every day. The patient who showed up in my emergency department in labor had records at another health system that doesn’t communicate with ours. The suspected drug-seeker next to her admits to filling prescriptions at seven different pharmacies, which means she probably uses far more than that. There was no way to see what she was actually on to determine whether she’d have a risk of drug interaction with my proposed treatment.

The document is 20 pages long and you’ll have to jump to Page 10 to see the additional recommendations, which include streamlining regulatory requirements, aligning MU with other regulatory programs, and allowing three years between states to allow adequate time for rulemaking, product development, and implementation.

Considering the amount of change management that needs to go into any successful workflow redesign project, this may be one of the most important suggestions. Practices are not just coping with technology change but a complete overhaul of how they care for patients. Providers need to learn how to be more transparent with patients and how to better coach patients into a true partnership with their care teams. They need to train staff to operate in a new paradigm. They need to figure out how to juggle the constant demands that having electronic records place on them. They need to combat the burnout that comes with those demands and learn how to regain some kind of work-life balance. And if they fail at an initial stage, providers need time to figure out what went wrong and put measures in place to be successful at their next attempts.

I sincerely hope that ONC is receptive and that Meaningful Use doesn’t continue like the runaway train it seems to be. Have you read the AMA letter, and if so, what do you think? E-mail me.

E-mail Dr. Jayne.

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6 Responses to “Curbside Consult with Dr. Jayne 1/21/13”

  1. 1
    kmhmd Says:

    I am decidedly not an AMA member. Perhaps they could buy me a paper weight with the money they have made over the years marketing information they hold about me as a physician?

  2. 2
    Cindy Wright Says:

    Right on (or write on), Dr. Jayne. All of these requirements and more requirements…what are they doing to improve patient care? Or usability? Information sharing? More penalties and threats doesn’t do much to foster a collaborative or innovative environment. All of which is needed for any type of transformation. In the big scheme of things, that’s what we’re talking about here. Have we lost sight of where we’re going?

  3. 3
    Holly Mathis Says:

    This was brilliant & stop on. I’m the nurse manager of a multi-specialty surgical group that is academic based. MU is very tough for surgeons to meet especially our sub-specialists. While I agree that it is good to be monitoring standards of care so that it is appropriate & beneficial I think that we have gone overboard. We are just picking whatever measure will work & could care less how we got it. As you stated one size does not fit all & MU is clearly geared toward the PCP, not a thoracic surgeon or a plastic surgeon. We now spend a lot of time trying to meet these measures that we would have normally spent with our patients. I love the EHR & never want to see another paper chart (especially the ones that you can’t find because it wasn’t put back) but it is getting out of hand. The rules need to be made (or at the very least have in put) by those that are in the trenches not those at a desk.

  4. 4
    Charles Babbage Says:

    Wonderful commentary. Thank you. But please understand the function of MU1,2 or 3: MU-n exists to promote the sale of health care IT software. The concept of encouraging sales by regulation came from HIMSS and some other advocates. You can read the early documents from Cerner and others. It was not intended to deteriorate the quality of medical care, but that’s an unfortunate consequence. Let us hope the AMA, and many other medical professional groups, will have some influence to redirect this madness. Clinicians should have some say in this process.
    Chuck

  5. 5
    El Jefe Says:

    This makes perfect sense. Best writ so far.

  6. 6
    Sue Thomas MD Says:

    Well said, Dr Jayne. We in physician practices all feel the pain. It is the regulators that we need to convince. What I hear through the grapevine is that they don’t understand at all what we physicians are saying. They are completely convinced that they have created a gravy train of funding and that they made it TOO EASY for physicians and hospitals to reap the rewards. Susan Dentzer, editor of Health Affairs, told me this early on before the first attestations had started. Legislators believe that these rules are “just describing every day practice” and don’t understand that even seasoned EMR users are struggling to meet the letter of the law. I hope against hope that they don’t see this plea from the AMA as “just more whining”. Thank you!

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