Stage 2 meaningful use rules sharply criticized by physicians

The American Medical Association and state and specialty societies call for less aggressive criteria in the Medicare and Medicaid electronic health record incentive program.

By Charles Fiegl amednews staff — Posted May 14, 2012

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Physicians are objecting to proposed Medicare and Medicaid guidelines for demonstrating the next stage of electronic health record meaningful use, saying the new standards would be too burdensome and may discourage practices from adopting the technology.

The American Medical Association and other organized medicine groups want federal officials to survey physicians on EHR stage 1 requirements and identify issues preventing physician participation before the agency finalizes rules for stage 2, according to a May 7 letter submitted to the Centers for Medicare & Medicaid Services. Measures defining meaningful use also should have exclusions that allow physicians to opt out of requirements that don’t apply to their routine scopes of practice. Also, requirements should be limited to actions within a physician’s control — and not rely on patients or another third party’s use of technology, the organizations said.

The AMA and others also argued against proposals to backdate EHR penalties that are authorized to start in 2015.

The proposed stage 2 requirements need more flexibility to foster adoption of EHR systems, said Steven J. Stack, MD, chair-elect of the AMA Board of Trustees. More than 185,000 physicians have registered for the program, but hundreds of thousands had yet to apply for the incentives as of March. Nearly 62,000 physicians who registered have earned incentives from either Medicare or Medicaid.

“Physicians are at varying stages of implementing health IT into their practices and should get credit for making a good-faith effort to meet the meaningful use requirements,” Dr. Stack said.

CMS is offering up to $44,000 over five years from Medicare, or $63,750 over six years from Medicaid, to eligible health professionals who adopt EHRs and use them in a meaningful way. The agency has developed performance measures to define meaningful use criteria. Stage 1 rules were implemented in 2011, and stage 2 objectives would be required for early EHR adopters starting in 2014.

In stage 1, physicians were required to meet 15 core measures and five optional measures. Physicians would be required to meet 17 core objectives and three of five optional objectives under stage 2.

CMS issued proposed rules outlining stage 2 in February. Dozens of organizations representing physicians, hospitals and health administrators responded by submitting comments by a May 7 deadline.

“The AMA is supportive of widespread adoption and meaningful use of EHRs by physicians, but the cumbersome proposed criteria will make successful physician participation extremely difficult,” Dr. Stack said.

Many of the proposed requirements are too aggressive, according to the organized medicine letter, which was co-signed by the AMA and 98 state and specialty societies.

For instance, CMS proposed that physicians incorporate more than 55% of all clinical lab test results into EHR technology as structured data. The physicians suggested that not all laboratories have the technology to send results to practices’ EHR systems, so the organizations recommended that the threshold be lowered to 40%.

“Due to physicians’ limited ability to exchange data with other health care partners, many of the proposed stage 2 measures will require extensive manual data entry, which is not an efficient way of practicing medicine or improving quality care outcomes for patients,” Dr. Stack said.

Broadened measures would include more doctors

Other societies representing specialists also have specific concerns with proposed core EHR measures. The American Psychiatric Assn. found that several of the required measures for all doctors appear to be geared largely toward primary care practices, said Robert Plovnick, MD, director of the association’s Dept. of Quality Improvement and Psychiatric Services. For instance, meaningful use criteria would require physicians to record vital signs ­— blood pressure, height and weight — during more than 80% of unique patient encounters.

The measure contains an exclusion clause for physicians who believe the requirement is not relevant to their practices. Taking vital signs is relevant to a psychiatrist’s scope of practice, but it is not routine, and achieving the 80% threshold would be problematic, Dr. Plovnick said. The association recommended a modification to the exemption language that would exclude physicians who believe it is not a routine part of their practice, not just those for whom it is not relevant.

Overall, the association praised CMS for making the incentive program more applicable to specialists. The agency has created exclusions for other core and optional measures that are broad enough to include psychiatrists.

“In our comments, we focused on the challenges to psychiatrists, but we also tried to remain positive about the impacts to the practice — care coordination and improving quality,” Dr. Plovnick said. “It’s not all negative.”

Opposition to penalty timing

Several groups support a proposal that extends stage 1 criteria for early EHR adopters through 2013. The AMA and other advocacy groups strongly oppose CMS plans to cut rates by 1% in 2015 and 2% in 2016 for failing to meet meaningful use standards by October 2014. Physicians argue that timing was not the intent of the law.

Penalties could begin in 2016 based on failing to meet meaningful use requirements in 2015, wrote Susan Turney, MD, Medical Group Management Assn. president and CEO. That would bring the penalty assessment in line with the way bonuses are handled, she wrote.

CMS has proposed exemptions from the penalties for physician practices with insufficient Internet access, for newly practicing doctors and for other relatively unusual circumstances. However, the exemptions should not stop there, said Rep. Renee Ellmers (R, N.C.), chair of the House Small Business Committee’s panel on health care and technology.

“I urge you to allow hardship exemptions for very small practices (those with five or fewer physicians) and those physicians who are nearing retirement (those who are over 60 years of age),” Ellmers wrote in a May 1 letter.

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Medicare physician EHR bonuses total $711 million

Nearly 62,000 physicians have earned electronic health record bonuses from Medicare and Medicaid since May 2011, with nearly 40,000 getting bonuses from Medicare. Primary care physicians have received the most from Medicare, with about 17,000 doctors sharing more than $300 million.

Specialty Physicians Bonus total
Family medicine 8,614 $155.1 million
Internal medicine 8,418 $151.5 million
Cardiology 3,214 $57.9 million
Gastroenterology 1,907 $34.3 million
Orthopedic surgery 1,721 $31.0 million
General surgery 1,501 $27.0 million
Urology 1,267 $22.8 million
Neurology 1,190 $21.4 million
Otolaryngology 1,085 $19.5 million
Pulmonary disease 1,027 $18.5 million
Nephrology 953 $17.2 million
Ophthalmology 902 $16.2 million
Obstetrics/gynecology 771 $13.9 million
Dermatology 747 $13.4 million
Endocrinology 594 $10.7 million
Other 5,628 $101.3 million
Total 39,539 $711.7 million

Source: “EHR Incentive Program,” Centers for Medicare & Medicaid Services, March (link)

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