Stage 2 of EMR bonus program seen as too onerous

Organized medicine says the proposed rules for demonstrating meaningful use starting in 2013 are unrealistic for physician practices.

By Charles Fiegl — Posted March 21, 2011

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Medical associations are warning that overly strict meaningful use criteria proposed by the Dept. of Health and Human Services for the next phase of the Medicare and Medicaid electronic medical records incentive program could dissuade physicians from participating.

The American Medical Association and 38 other members of organized medicine sent a letter outlining their concerns to the Office of the National Coordinator for Health Information Technology, which is developing the objectives for the program.

Physicians can obtain bonuses -- up to $44,000 from the Medicare program, or up to $63,750 from Medicaid -- for installing and using an eligible EMR system.

The organizations urged the HHS technology office to revise future meaningful use measures so that they are more attainable for physician practices.

"Physicians are working hard to adopt [EMRs] into their practices, and inflexible incentive program requirements will only hinder the health IT transitions under way today," said AMA Secretary Steven J. Stack, MD. "Unrealistic stage 2 requirements will overly burden physicians and hamper adoption -- especially for those physicians in small or solo practice."

Thousands of physicians are trying to meet stage 1 requirements during the first year of the EMR program, which launched in January. Eligible EMRs must be able to meet 15 core measures of functionality and the physician's choice of five out of 10 elective measures.

Stage 2, which is scheduled to begin in 2013, will place higher expectations on physicians using EMRs.

For instance, while stage 1 requires that 40% of all permissible prescriptions be transmitted electronically, stage 2 would increase the threshold to 50%. New measures, such as secure online messaging, also would be added. The administration plans to finalize the requirements in a final rule this year.

McDuffie Medical Associates in Thomson, Ga., recently spent $75,000 upgrading the practice's EMR to meet meaningful use stage 1 requirements after investing $200,000 to launch the system five years ago, said Jacqueline Fincher, MD, one of four physicians at the primary care practice. The upgrades include new capabilities, such as a secure online patient portal, but she said she doesn't know how many of her elderly and poor patients in the rural area will be able to take advantage of it.

Fulfilling stage 2 requirements to continue qualifying for bonuses probably would require the practice to make more upgrades, Dr. Fincher said. "The incentives are just going to go right through us and straight to the vendor."

In its Feb. 25 letter, the AMA and the other organizations recommended five actions the HHS technology office must take to maximize participation in the EMR program after 2012:

  • Survey physicians who decided to participate during stage 1 and those who didn't, and identify barriers to and solutions for physician participation before moving to stage 2.
  • Factor in appropriate use when determining meaningful use measures. Allow a physician to opt out of a measure if it has little relevance to his or her practice.
  • Thoroughly assess and publicly vet measures before moving them from the stage 1 elective menu set to the core set for stage 2. Initially place any new proposed measure in the elective menu set.
  • Avoid high thresholds for any objectives that cannot be met due to the lack of available, well-tested tools or health information exchanges.
  • Remove measures that require adherence by another party. For instance, performance measures relying on patient access to a practice's patient portal should be eliminated.

Upgrades "too aggressive"

The Certification Commission for Health Information Technology recently surveyed 468 physicians and vendors to gauge their readiness for the next phases of meaningful use.

Nine proposed upgrades to stage 1 measures were thought to be problematic by 30% to 50% of those surveyed.

These measures included the ability of an EMR to send syndromic surveillance data to public health agencies, run drug formulary checks and conduct medication reconciliation. The upgrades were considered too aggressive, said Karen Bell, MD, the commission's chair.

She also noted that certain measures present potential problems because they rely on compliance by parties outside the physician office. For instance, syndromic surveillance requires electronic communications with public health departments.

This would be a core requirement in stage 2. However, not all health agencies have the technology to accept the data. "The incentive payments should be focused on those actions the physician can truly be held accountable for," Dr. Bell said.

More than 21,000 health care professionals registered for meaningful use incentives in Medicare and Medicaid in January, according to CMS. Dr. Bell said most physicians who haven't adopted EMRs yet will find implementing systems and meeting meaningful use requirements during stage 2 of the program very difficult.

Moreover, Dr. Bell said she does not believe any vendor's system can meet stage 2 requirements yet. Developing EMR technology is expensive, and vendors don't want to build complete systems when the standards probably will change in the future.

"The bottom line is it will be different, and vendors are looking at a muddy crystal ball here," she said.

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Getting ready for stage 2

Starting in 2013, physician electronic medical records will need to have added capabilities to be eligible for meaningful use bonuses from Medicare and Medicaid. Under proposed revisions, several functionality measures will require meeting higher thresholds, several elective measures will become mandatory and several new measures will be added:

Higher thresholds (in % of eligible patients, visits or orders)

  • Use computerized physician order entry (from 30% to 60%: CPOE will expand from drug orders to lab and radiology orders)
  • Use e-prescribing (from 40% to 50%)
  • Record demographics (from 50% to 80%)
  • Record vital signs (from 50% to 80%)
  • Record smoking status (from 50%to 80%)
  • Use medication reconciliation (from 50% to 80%)

Elective to mandatory

  • Implement drug formulary checks
  • Record existence of advance directives
  • Incorporate lab results as structured data
  • Generate patient lists for specific conditions
  • Send patient reminders
  • Provide summaries of care record
  • Submit immunization data
  • Submit syndromic surveillance data

New measures

  • Use electronic physician notes
  • Offer clinical encounter information for download
  • Offer health record information for download
  • Ensure patient use of online portal
  • Ensure patient use of secure messaging
  • Record patient preferences for communication medium
  • Provide lists of care team members
  • Record longitudinal care plans

Source: "Meaningful Use Workgroup Request for Comments Regarding Meaningful Use Stage 2," Office of the National Coordinator for Health Information Technology (link)

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