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The MU Hearings: DrLyle Goes to Washington 1/18/11

January 18, 2011 News 9 Comments


You may have read some stories about the Meaningful Use Hearings this past week. It’s always interesting to read what the regular press picks up on, but I’d thought I’d give you my "on the ground" report as well.

Background: ONCHIT created the Health IT Standards Committee, which is Federal Advisory Committee "charged with making recommendations to the National Coordinator for Health IT on standards, implementation specifications, and certification criteria for the electronic exchange and use of health information." This committee then has five sub-committees or workgroups: Clinical Operations, Clinical Quality, Privacy & Security, Implementation and the Vocabulary Task Force.

Each of these committees is staffed by volunteers from healthcare organizations and various vendors. I give them a lot of credit for spending the time to do this.

The Implementation Committee held a hearing last week on "Early Adoption of Meaningful Use", meaning they wanted to hear from Eligible Providers (EPs) and Hospitals about their early experience in preparing to meet MU requirements for this year. This makes sense. The government is going to potentially spend tens of billions of dollars on MU. It is smart to get a leg up to see if things are going smoothly from the start. And if not, figure out how they can start fine-tuning.

I was asked a few weeks ago to provide some input at this meeting (as an EP). I figured, hey, this is on my bucket list ("give testimony to a federal advisory committee"), so I’ll do it!

My first responsibility was to send in written testimony answering some questions they provided (e.g. tell us about your successes, your challenges, etc.) Next step was to fly to DC to talk to them in person. We would be given five minutes to provide oral testimony, and then there would be Q&A with the committee.

The first day and the start of the second had various HIEs and RECs commenting. Then came the active EMR users who were planning on applying for MU in 2011 (ten representing EPs, another ten representing hospitals). Most were physicians, along with a few CIOs.

While I was hoping to be in some hallowed marble halls, they did have us in a nice large conference room at a local Marriott. The Committee was in a U-shaped formation. Below that was a table where up to five presenters could sit and behind that was general seating for the public.

The following is my summary of the testimony given by these end users, with a slight bias towards the EP testimony. The following were relatively consistent themes, with my comments intermixed:

The good news is that this bill has indeed "stimulated" many organizations to move forward with various upgrades and focus on how to produce quality reports from the data in their EMRs.

But mostly we heard about the challenges.

  • This is hard. It’s not impossible, but it’s a higher bar than many had anticipated because the requirements are not simple, nor are they fully explained. Everyone had at least some questions about interpretation. The worrisome thing is that if it gets to the point where users start thinking this is too hard, they won’t even try. I made it clear that I was thankful to be part of a hospital organization which is helping us with this process, but I feel sorry for those EPs who are trying to do it on their own. If you are one of those, make sure you ask your hospital if they can support you in any way and find out if there is a REC in your neighborhood who can help as well.
  • There are lots of questions. For example, many wondered whether we could only use the EMR functions the vendor created or whether we could create our own (e.g. do we have to use a vendor’s "Smoking Status" form if we think we can build a better one). One big question I brought up was getting clarity on whether can we use scribes in the exam rooms to help with documentation and orders, as well as use other intermediaries later on to help with data collection (e.g. clerks or nurses to transfer free text into standardized forms).
  • Time crunch. There is a very tight timeframe between the release of the requirements, embedding them into EMRs, the "rollout" of the new EMRs, and the updating of workflows and reports to ensure users are actually meeting the MU requirements. The government does not seem to fully appreciate all the steps involved, especially with large vendors who often need 18 months of lead time for making updates and for larger health organizations who then need a lot of time to do system upgrades. Many felt they really need to consider extending the timeframes for future stages, as rushing these upgrades can have some serious risks.
  • Resource crunch. This is often a zero-sum game with resources. I was quoted by some media as saying that working on MU meant that our people could not work on other IT projects. That wasn’t exactly what I said, but rather that spending time on MU meant staff had less time to work on ANY other projects. And this can be an issue since the same people who are on MU committees are often also the ones dealing with operations and quality improvement in general.
  • We need more flexibility. Not every practice is the same, and requiring 100% mandate of every requirement is not reasonable. My suggestion is that for Stages 2 and 3, they should create a variety of options like the Menu concept in Stage 1. The result should be that every practice could show they are using an EMR meaningfully, but they don’t all have to show they are doing it the same exact way.
  • Functionality is not the same as usability. In other words, there is often a large gap between whether something can be done and whether it can be done in a usable manner. A function might meet the requirement’s definition while being very hard to use. An EMR vendor can get MU certification for their functionality whether their usability is great, good, or poor. Fortunately, the government is starting to look into usability requirements for the certification process, so let’s hope they follow through on that sentiment.
  • Data sharing alone is never enough. Dr. Reid Coleman from Lifespan had the quote of the day when he said, "Data is like salt water… you need a filter to drink it". I’d also add that it helps to have good plumbing to connect it to the right facilities, and then also to have plenty of glasses available to make it easy for people to get it to the "final foot."
  • Standards. There were lots of people saying they would like the government to make standards for a national MPI and for data in general. I loved the line that many people reiterated, saying "We’d rather have one bad standard we can work with than three good ones without a clear winner." On the other hand, we should make it clear we do NOT want the government to make standards about actual functionality – we can and should be creative in that domain.
  • The cost of implementing MU may often be more than the actual monies themselves, when you factor in costs for various software upgrades, consultants, and change management. It also sounded like there were vendors charging significant amounts of money for MU upgrades, that consultants were increasing their fees due to demand, and that some RECs are charging doctors even though they are also receiving money from the government to help. One doctor pointed out that the government needs to either make the requirements easier or pay more (and we know they are not going to pay more).
  • Certification requirements don’t always exactly match MU process requirements. Someone has to keep a better eye on this.
  • Communication with CMS and ONCHIT has not been easy. The Committee pointed out the five different blogs and websites to get information. I’d suggest they consolidate down to one and create a content management system that can expand on the FAQ concept they currently have in place.
  • The result of most of the above is that the biggest and the best are struggling with MU… so you have to wonder, how much harder will it be for others? This is an interesting contrast to the recent reports that "many" hospitals and EPs plan to apply for MU dollars based on a recent survey. My hunch is that most hospitals and doctors like to think they will apply for this, but that is altogether different than actually doing it. Considering that less than 25% of EPs even have basic EMRs in place, it will be interesting to see what happens. And in the end, some limited testimony and lightweight surveys will be long forgotten… the proof will be in the pudding.

Finally, it was concerning was that ONCHIT did not even send a representative to the meetings (one of them called in for the morning only). I do believe that the committee will represent us well, so let’s hope ONCHIT is listening to what they say and take serious the fact that there is increasing concern about the scope and timing of these requirements. If their goal is to make it so just 10-20% of the EPs can meet the MU criteria, then the folks from this meeting would say they appear to be doing well. But if their goal is to get over 50%, then they may need to rethink some of the complexity of the requirements and the timing involved in meeting them.

Full details and testimonies of this Committee Meeting are available online.

Lyle Berkowitz, MD is a practicing internal medicine physician, a healthcare IT consultant (www.DrLyle.com) and founder of the Szollosi Healthcare Innovation Program (www.TheSHIPHome.org). He blogs regularly at The Change Doctor (http://drlyle.blogspot.com/).

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Currently there are "9 comments" on this Article:

  1. DrLyle – What a great wrap up and wonderful set of insights!!

    Thanks, not only for your efforts in sharing the word from the EPs’ perspective to the feds, but also for letting us in on the process.

    (I gotta add: You have a curious bucket list.)

  2. The result of most of the above is that the biggest and the best are struggling with MU… so you have to wonder, how much harder will it be for others?

    A good observation from Mr. Histalk. I would extend that to say that the biggest and best ate struggling with creating useful and effective HIT (cf: National Research Council report of 2009), so you have to wonder how much harder it will be for others.

    On a somewhat humorous although ironic note:

    Full details and testimonies of this Committee Meeting are available online.

    Did they get their links straightened out yet?

  3. I came upon this transcript of testimony pertinent to what Dr. Lyle reported: http://hcrenewal.blogspot.com/2011/01/dr-monteith-hit-testimony-to-hhs.html

    However, it is much worse than what Dr. Lyle reported.

    The defects in the care are so pervasive when that care is controlled by CPOE and EHR that it requires tedious searches for the errors. If you do not trust these devices, and try to reconcile orders with the results, you will be shocked at the deficits in care.

    These are are errors that are not being reported, because the blind trust in the systems blind would be observers and users from finding the errors, and the hospitals and their vendor financial partners blow off the complaints, when reported. I have stopped reporting them, but the care is sick.

    Meaningful Use is another patient needing care. Meaningful use ignores safety and efficacy and will make front line care more dangerous.

    HITECH should be repealed. You read it here first.

  4. I met with our Heme/Onc Division Director yesterday, and she said she hates writing inpatient chemotherapy orders because if the patient’s body surface area is > 2 square meters, she gets an alert on every order, “are you sure you want this dose”?

    This situation highlights 3 problems:
    1. The computer is too stupid, and unnecessarily so, to know that the dose is appropriate for the patient.
    2. The computer should not alert on every order, and throw up a modal dialog box for each! It should instead show one screen with warnings on each order that it has concerns with.
    3. There is a workaround she tries to use as much as possible which is to write the orders when the patient is in a “pre-admit” status, because then the alerts don’t fire.

    Meaningful use, I submit, is impossible, when this is the best the HIT industry has to offer.

  5. Dr. Berkowitz: Excellent summary of the problems with MU! Thank you.

    Not Tired of Suzy- hopefully the Republicans will reconsider HITECH, but since it’s a mandate that many politicians see as forcing doctors (not taxpayers) into paying for a good portion of healthcare (HIT), I doubt that will happen. Some powerful Republicans, including the likes of Gingrich, Romney, and Pawlenty are all pro-EHR/HITECH. Gingrich has even been the speaker at numerous HIMSS events. It’ll be up to the physician masses to just not show up at the party and stay on the sidelines while HITECH dies-on-the-vine. When it comes to the EHR, nobody will be looking out for us.

    Dr. Zeddemore- HITECH will destroy oncology as I see it. All oncologists will need to cow-tow to MU else expect up to a 7% cut in reimbursements (ie the maximum of eRx, 2% plus the maximum for HITECH, 5%) which will impact reimbursements for chemotherapy purchases. If you have a 50% overhead, this translates then to a 14% hit; many if not most oncologists have overheads as high as 70%. Oncologists, which have heavy Medicare/Medicaid practices will truly be in a bind. Oncology EHRs cost as much as $100000.00 per license. With all of these factors, I just don’t see how many oncology small offices will survive. I closed mine 2 years ago so as to prepare for the upcoming changes- by going into straight internal medicine not only do I have more time to enjoy life, but I don’t see Medicaid, and I’ve limited my Medicare. Soon I’ll be a non-par provider for Medicare. No HITECH for me…


  6. Thanks for the comments – and I’m now taking new requests for my bucket list. In response to a few things
    – The link above worked when I tried it today
    – The link to Dr. Montheit’s testimony was noted as a “worse” view of the hearings… My comment on that is that I tried to provide a general overview of the hearings, and that link was simply Dr. M’s personal testimony. For some reason, he seemed on a vendetta to say that MU was “impossible”… which immediately gave him very low credibility since there are already people getting money for MU and there will be more this year- but I believe it will be along the lines of 10-20%, not close to 50%.

    And I think he missed the point of the hearings. If they had asked me whether I thought that MU was the best way to spend $44 billion to stimulate EMRs – I would have said that I would have spent it differently, perhaps on creating more underlying standards or a platform upon which EMRs could differentiate by usability and cost (eg why should all EMRs create their own data models). I’d also pay for showing creation of quality reports in whatever manner a medical group wanted – since that data will then inspire innovative manners of improvement. And of course I’d put as much money as possible to changing general reimbursement from volume based to value based.

    However, these hearings were meant to help the government evolve a program already in place, and I think the majority of us stayed focused on that – we were not there to simply complain, but to present challenges and potential solutions as well.

  7. If by “possible”, Dr. Lyle, you mean “I can get the money”, then yes, MU is possible. I don’t want to speak too much for others, but like you, they doubt the MU for which it is now possible to get reimbursed is truly MU, or perhaps much less M than U can be.

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