Meaningful use: A program in transition

Medicare meaningful use (MU) requirements were first introduced to physicians in 2011 to promote the adoption of electronic health record (EHR) systems. MU policies were a product of the Health Information Technology for Economic and Clinical Health (HITECH) Act, a key component of the American Recovery and Reinvestment Act of 2009. The HITECH Act charged the U.S. Department of Health and Human Services (HHS) Office of the National Coordinator for Health Information Technology (ONC) with the responsibility of developing a universal infrastructure that would facilitate the secure exchange of digital information. It also authorized the Centers for Medicare & Medicaid Services (CMS) to create the Medicare and Medicaid EHR Incentive Programs, which established financial incentives for physicians who demonstrate MU of an EHR system.

Program structure

The Medicare EHR Incentive Program is divided into three stages, each intended to prepare a provider to successfully achieve MU of an EHR system (see Figure 1, below). Stage 1 established the foundation for the program by instituting requirements for the electronic capture of clinical data and by providing patients with electronic access to their health information.1 Providers who began participating in the program in 2011 or 2012 were eligible to achieve incentive payments totaling up to $44,000 over five years. Providers who started reporting in 2013 or 2014 could achieve up to $39,000 over four years, or $24,000 over three years, respectively. No new incentive payments were provided after 2014.

Figure 1. The three stages of meaningful use

The Three Stages of Meaningful Use

Once an eligible provider (EP) has completed two years of MU under the Stage 1 criteria, the EP must move on to Stage 2. This second stage encourages the use of health information technology (HIT) for continuous quality improvement at the point of care and the exchange of information in a structured format. Stage 2 retains the core structure of Stage 1, though some objectives were reorganized, combined, or eliminated. For many of the objectives, the thresholds were raised to show improvement and demonstrate MU for a larger proportion of patients.2

To align the first two stages with the planned introduction of Stage 3, CMS released a modified version of Stage 2 requirements in 2015.3 The changes aimed to reduce the complexity of the program and created a single set of objectives and measures. Providers who started the MU program in 2015 used the modified Stage 2 requirements instead of the original Stage 1 criteria.4

The third and final stage of MU is planned for implementation in 2018. Stage 3 will contain a single set of criteria focused on the advanced use of EHR systems. CMS recently decided to abandon the staged approach, however, and will instead require all providers (including first-time participants) to satisfy the objectives and measures of Stage 3 by 2018.

Beginning in 2019, the MU program will transition into the new Merit-based Incentive Payment System (MIPS) program established by the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act enacted last year.5 The Stage 3 requirements and objectives will be maintained.

Cost

Much has been written about the perils and virtues of the MU program, but less attention has been paid to the associated costs that frontline health care providers and their support staff are likely to incur in implementing it. In an environment of increasing demands on physician time and decreasing reimbursement, fulfillment of MU requirements has posed a challenge for physicians. Implementation costs are estimated at $250,000 per facility, and projections show that only 27 percent of practices will achieve a return on this investment.6-8 Once the initial capital purchases and training to support the EHR systems have been completed, practices experience significant recurring costs with respect to provider time required to fulfill MU criteria. Because much of the data entry for MU involves historical information, these requirements are especially burdensome to surgical and subspecialty practices where most encounters are for new patients or those who present infrequently.

To understand these costs, the two surgeon authors of this article developed a study of the time and costs for fulfilling MU requirements in a pediatric plastic and oral surgery practice at a large children’s hospital.9 Using a time-driven, activity-based, micro-costing analysis, the average total time to complete MU criteria for both Stages 1 and 2 for a single patient encounter was found to be 39.75 minutes with a cost of $184.67; 20.5 minutes/$74.26 for Stage 1; and 19.25 minutes/$110.41 for Stage 2 (see Table 1, below). For a provider who sees 20 patients a day, the total costs of meeting current MU criteria are $3,693.40 per day. Assuming the costs for Stage 3 will increase by the same percentage as from Stage 1 to Stage 2 (48.7 percent), this additional stage is projected to add 20 minutes and cost an additional $164.18 per patient encounter. This would bring the total time and cost of MU to 59.75 minutes and $348.85 per encounter, or $6,977 per day.

Table 1. Average time and cost for completing Stage 1 and 2 MU criteria

Stage Meaningful use criteria (clinical staff member) Average time (minutes)

1

Log into system (OSA and OMS) 0.25
Record patient demographic measures (receptionist) 1.5
Maintain up-to-date problem list of diagnoses (OMS) 1
Use CPOE for medication orders (OMS) 2
Incorporate laboratory test results into EHR (OMS) 0.5
Generate and transmit prescriptions electronically (OMS) 2
Reconcile home medication list (OMS) 2.5
Provide clinical summary for patients for each visit (OMS) 1
Record vital signs (OSA) 9
Maintain active medication list (OSA) 0.5
Maintain active allergy list (OSA) 0.25
Record smoking status for patients ≥13 years (OSA) 0.25
Total Stage 1 time 20.5
Total Stage 1 cost $74.26

2

Use secure electronic messaging to communicate with patients on relevant health information (OMS)*
Send reminders to patients regarding preventative and follow-up care (receptionist) 1.5
Electronically transmit summary of care (receptionist) 3
Use CPOE for lab orders (OMS) 0.5
Use CPOE for radiology orders (OMS) 0.5
Use electronic notes during the EHR reporting period (OMS) 10
Use EHR to identify patient-specific education resources and provide those resources to the patient (OMS) 0.5
Provide online access (within 4 business days) to patient health information with the ability to view, download, and transmit to a third party (OMS)*
Patients view, download, or transmit to a third party their health information (OMS)*
Imaging results made accessible through EHR (OMS)*
Record patient family health history as structured data (OMS) 0.5
Provide a summary of care record for each transition of care (OMS) 2.5
Total Stage 2 time 19.25
Total Stage 2 cost $110.41
Stage 1 and 2 total time 39.75
Stage 1 and 2 total cost $184.67

Abbreviations:

OSA = Oral surgery assistant, OMS= Oral and maxillofacial surgeon,
EHR = Electronic health record, CPOE = Computerized physician order entry

*Time estimates were not obtained for processes that were either automated or uncommon to the daily activities of oral and maxillofacial surgery practices.

Implications and additional challenges

To comply with Stage 3 and maintain the same caseload, many practices will need to hire additional administrative staff and mid-level health care practitioners. Other practices may decide to ignore the requirements and accept the financial penalties. Some primary care physicians, solo and small group physician practices, and surgeons in resource-poor environments will find these recurring costs untenable and may choose to join or merge with larger group practices to develop shared resources. Some providers may retire from clinical care earlier than planned. These decisions could exacerbate current access to care challenges. For physicians and hospitals that do successfully navigate these requirements, ever-increasing administrative burdens will further limit their ability to spend adequate time with patients, create disincentives to add more patients, and adversely affect job satisfaction.

Many providers anticipated that EHR would enhance the availability of clinical data, support clinical registries, and streamline daily workflow. However, early products have largely failed to provide these benefits. Paper systems have been replaced with a costly digital infrastructure that lacks ease of use in the collection, analysis, and return of useful information at the point of care. For many clinicians, the EHR is simply an expensive and inefficient means of recording data previously stored in a paper record.

Several impediments must be overcome on the path to true meaningful use of digital clinical information. Because of limited information exchange, a lack of data standards and interoperability, and inadequate real-time clinical analytics, time spent entering data into current EHR is a poor use of resources. Establishing methods for data standardization and analysis will be critical in developing a universally accepted EHR system. Improving interoperability and regulating data blocking, the process by which vendors charge providers large sums for hosting data, will be additional challenges.

HIT leads to safer, better care

Despite concerns with existing EHR systems, universal adoption of HIT holds the promise of facilitating safer and more efficient delivery of medical care. The spirit of health care policy that incentivizes providers to reach this goal is sound, even though the engine for this change may seem misguided. Earlier studies have suggested that the simple adoption of EHR technology will not necessarily lead to improved patient outcomes.10,11 A more productive approach would be to create a digital infrastructure for universal secure data sharing between providers and practices, as proposed in the latest report from the ONC.11 This design could leverage current EHR systems to serve as entry points for a robust cloud-based and interactive record that would follow a patient from provider to provider.

It is conceivable that, in the future, every patient will be associated with a primary care provider, and primary care networks will be financially supported, allowing them to act as portals of entry for clinical patient data stored in a universal cloud. At every visit to a specialty provider, current patient data will be available to inform decision making, cross-check potential medication interactions, and avoid exposures to known allergens. Subsequent providers will add additional information relevant to their findings and treatment to the universal record; thus, any treating physician will be able to access a complete clinical picture of their patient. In this scenario, MU could be measured based on improvement in patient outcomes and health care systems rather than on data input criteria.

ACS advocacy

The American College of Surgeons (ACS) dedicated significant time in 2015 to educating members of Congress about MU’s shortcomings and the challenges it presents for surgeons. More specifically, the College has called for a delay in the introduction of Stage 3 of MU in light of the fact that, as of the time of this publication, only 19 percent of health care professionals and 48 percent of hospitals have successfully met Stage 2 requirements. For example, the College provided testimony outlining its priorities for the meaningful use of HIT at one of six hearings convened by the Senate Committee on Health, Education, Labor, and Pensions (HELP). Lawmakers have been receptive to the ACS’ concerns and have taken responsive steps.

On the House side, Rep. Renee Ellmers (R-NC) introduced The Further Flexibility in HIT Reporting and Advancing Interoperability Act (Flex-IT 2 Act, H.R. 3309) on July 29, 2015. This legislation would delay Stage 3 implementation until 2017 or when the final MIPS regulations have been issued. The act also would expand the MU program’s current hardship exceptions, including allowing eligible professionals who are at or near retirement age to be exempt from MU reporting and would adjust the reporting requirements to allow providers to choose any three-month measurement period. The ACS sent a letter of support for this legislation on September 8, 2015, and is actively seeking cosponsors.

In addition, Reps. Ellmers; Tom Price, MD, FACS (R-GA); and David Scott (D-GA) circulated a congressional sign-on letter asking HHS Secretary Sylvia Burwell to delay the final rule on Stage 3 MU requirements. Partly as a result of ACS grassroots efforts to encourage members of Congress to sign on, this letter received an impressive 116 bipartisan signatories. The Ellmers/Price/Scott letter was sent to Secretary Burwell on September 28, 2015.

Senate HELP Committee Chairman Lamar Alexander (R-TN) and Sen. John Thune (R-SD) sent similar correspondence to Secretary Burwell, asking that MU Stage 3 requirements be delayed. The final rule for Stage 3 was released October 16, 2015, and includes an optional 2017 implementation and a required 2018 implementation deadline.

Since the release of the final rule for Stage 3, the ACS has shifted its advocacy focus to improving MU requirements and implementation. CMS has solicited public comments on the program, and the College submitted its comments on December 15, 2015.

In a related move, Sens. Bill Cassidy (R-LA) and Sheldon Whitehouse (D-RI) introduced the Transparent Ratings on Usability and Security to Transform Information Technology (TRUST IT) Act of 2015, S. 2141, on October 6, 2015. This bill encourages fairness and transparency in the process of choosing vendors for EHR systems. Under this legislation, HIT vendors must attest that they abstain from information blocking activities and face a fine if they do engage in these practices. Furthermore, the legislation calls for the establishment of an HIT rating program; fines would be collected from noncompliant vendors and used to provide financial assistance for providers who use a system that loses certification. The ACS sent a letter of support for this legislation on November 11, 2015, and is actively seeking cosponsorship.

Most recently, CMS has compelled providers to attest that they met Stage 2 requirements for a period of 90 consecutive days in 2015 to avoid a penalty. CMS did not publish the modified rule for Stage 2, which altered and added requirements, until after October 1, 2015. As a result, by the time providers were informed of these modified requirements, fewer than the 90 required days remained in the calendar year. Before adjourning in December, Congress passed ACS-backed legislation—H.R. 3940, the Meaningful Use Hardship Relief Act of 2015, introduced by Rep. Price—requiring CMS to grant blanket exceptions to providers who apply for one.

A way forward

Health care must keep pace with the changing landscape of the digital age by embracing EHR technology. Achievement of this goal requires a partnership between policymakers and providers, with buy-in from both parties. The essence of MU is ultimately to allow a free flow of clinical data to inform physician workflows and improve quality at the point of care. The EHR Incentive Program has done much to expand the use of EHR but little to attain these goals. However, in the creation of a secure and universal digital clinical data warehouse, an opportunity exists for a mutually beneficial arrangement that could also significantly improve safety and the patient experience.

Streamlining CMS quality programs, including the Medicare EHR Incentive Program, into the single MIPS program provides an opportunity to re-examine our priorities and broaden our understanding of what constitutes MU. MU should be viewed in terms of facilitating efficient and effective use of the data to improve patient outcomes and patient experience, rather than use of the EHR technology itself. This type of MU may exist in many forms, likely extending beyond the limits of the EHRs themselves.

Adoption of EHR systems and other forms of HIT have been critical steps toward this future. To take advantage of a shared cloud-based highway of secure clinical data, we must first fully live in a digital arena. Although most large medical centers have managed to make this switch, the task of converting to an EHR system may be daunting for smaller physician groups and community hospitals. Organizations like the ACS and the American Medical Association have an opportunity to support this transition by acting as conduits for information about the collective experiences of those hospital systems that have successfully overcome these hurdles. Furthermore, better, more flexible, universal standards for health data elements will be needed to improve HIT and attain true interoperability.

As providers dedicate resources to adopting EHR systems, the federal government must do its part. This starts with conception of a shared digital environment and continues with creation of health policy that allows for the unencumbered sharing of data in a secure way. Finding the balance between safeguarding privacy and facilitating the free exchange of information will be a struggle down the road.

This task is complex, and many challenges to its fruition will arise. However, surgeons and other health care professionals must prudently and tirelessly work toward a solution for the good of our patients and our profession. Universal real-time access by treating physicians to relevant patient data that is collectively updated with minimal burden to individual providers would constitute true meaningful use.


References

  1. Centers for Medicare & Medicaid Services. Medicare electronic health record incentive payments for eligible professionals. Available at: www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/MLN_MedicareEHRProgram_TipSheet_EP.pdf. Accessed December 2, 2015.
  2. Centers for Medicare & Medicaid Services. Stage 2 overview tipsheet. Available at: www.cms.gov/regulations-and-guidance/legislation/ehrincentiveprograms/downloads/stage2overview_tipsheet.pdf. Accessed December 2, 2015.
  3. Centers for Medicare & Medicaid Services. Medicare and Medicaid programs; Electronic Health Record Incentive Program—Stage 3 and modifications to meaningful use in 2015 through 2017. Federal Register. Available at: www.federalregister.gov/articles/2015/10/16/2015-25595/medicare-and-medicaid-programs-electronic-health-record-incentive-program-stage-3-and-modifications. Accessed December 10, 2015.
  4. Centers for Medicare & Medicaid Services. EHR Incentive Programs: 2015 through 2017 (Modified Stage 2) overview. Available at: www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/2015_EHR2015_2017.pdf. Accessed December 2, 2015.
  5. Centers for Medicare & Medicaid Services. Request For information regarding implementation of the Merit-based Incentive Payment System. Federal Register. Available at: www.federalregister.gov/articles/2015/10/01/2015-24906/request-for-information-regarding-implementation-of-the-merit-based-incentive-payment-system. Accessed January 13, 2016.
  6. Adler-Milstein J, DesRoches CM, Furukawa MF, et al. More than half of U.S. hospitals have at least a basic EHR, but Stage 2 criteria remain challenging for most. Health Aff (Millwood). 2014;33(9):1664-1671.
  7. Adler-Milstein J, Green CE, Bates DW. A survey analysis suggests that electronic health records will yield revenue gains for some practices and losses for many. Health Aff (Millwood). 2013;32(3):562-570.
  8. Fleming NS, Culler SD, McCorkle R, Becker ER, Ballard DJ. The financial and nonfinancial costs of implementing electronic health records in primary care practices. Health Aff (Millwood). 2011;30(3):481-489.
  9. Inverso G, Flath-Sporn SJ, Monoxelos L, et al. What is the cost of meaningful use? J Oral Maxillofac Surg. October 16, 2015. [Epub ahead of print].
  10. Linder JA, Ma J, Bates DW, Middleton B, Stafford RS. Electronic health record use and the quality of ambulatory care in the United States. Arch Intern Med. 2007;167(13):1400-1405.
  11. The Office of the National Coordinator for Health Information Technology. Connecting health and care for the nation: A shared nationwide interoperability roadmap version 1.0. Available at: www.healthit.gov/sites/default/files/hie-interoperability/nationwide-interoperability-roadmap-final-version-1.0.pdf. Accessed January 15, 2016.

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