Medicare incentives seen as crucial to coordinated EHRs

The AMA and other organized medicine groups encouraged federal agencies to align Medicare pay so it supports interoperability of paperless systems.

By Charles Fiegl amednews staff — Posted May 6, 2013

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Improving health information exchanges and interoperability in the nation's network of electronic health records will push the U.S. toward achieving goals of an efficient and high-quality health system, organized medicine groups stated in recent comments to federal health officials.

But significant gaps in adoption of health information technology and separate silos of electronic information remain as the nation prepares to move beyond the initial stage of a movement to abandon paper records and spur the use of EHRs. Critics of the Obama administration's implementation of the EHR adoption program said they have seen little progress after billions of dollars have been spent since federal incentives first were offered to physicians and hospitals in 2011.

The Dept. of Health and Human Services Office of the National Coordinator for Health Information Technology recently sought comments on advancing interoperability and overcoming challenges to health information exchanges. More than 200 organized medicine groups, including the American Medical Association, and other key stakeholders responded with ideas to improve the current EHR environment.

The AMA urged ONC and the Centers for Medicare & Medicaid Services to focus on providing physicians incentives that encourage greater care coordination across the health care system. Care coordination depends on communication, but Medicare, for example, does not pay for email consultations, consults with other physicians or support for patient self-management.

“Providing Medicare payments for these services would provide an enormous incentive for physicians to devote more time and resources to care coordination, and to redesigning the delivery of care to support better coordination,” the AMA letter stated.

Currently, CMS sets objectives and thresholds for EHR users to demonstrate meaningful use of paperless systems, while ONC coordinates efforts to use new health technologies. Many physicians have felt that the meaningful use effort could benefit from more flexibility. Requirements to earn bonuses and prevent future penalties do not always fit a physician's practice.

For instance, specialists such as pathologists and radiologists, who typically do not see patients face to face, have difficulty meeting measures for meaningful use that can be associated with a typical office visit. Anesthesiologists also treat Medicare patients but do not provide follow-up care, while others treating beneficiaries in their homes might lack access to broadband Internet and thus are unable to achieve certain thresholds. Requirements will get only tougher for physicians once early adopters move to stage 2 of the program in 2014.

Exchanging health information electronically with professionals throughout the health system has been challenging. There are noticeable gaps, as long-term care and home health professionals are excluded from the meaningful use program and continue to use paper records, the AMA letter stated.

Many EHR systems can't communicate with others because most originally were designed to be stand-alone systems, the American Academy of Dermatology stated in an April 17 letter. Physicians must bear the cost of building electronic interfaces to share information with other professionals who use different EHR systems. The task is difficult, given that physicians are responsible for protecting patient information and could face large fines if there were data breaches.

“While new technology is coming out every day, the current incentive and certification programs, however, heavily favor the older technology, which further impedes EHR adoption,” the academy's letter said. “We urge CMS/ONC to move ahead thoughtfully to maximize utility of newer, more innovative technology and minimize redesign and retrofitting of myriad middleware layers between disparate systems.”

EHR certification requirements for stage 2 of meaningful use should improve functionality, the American Academy of Family Physicians stated in an April 18 letter. New standards will allow family physicians to share clinically relevant data sets.

40% of doctors used EHRs to write clinical notes in 2012, up from 17% in 2008.

“Achieving quality improvement across a variety of care settings is a difficult but worthwhile task,” the AAFP letter stated. “Physicians must be held accountable for care provided to their patients and thus should be expected to continuously improve the delivery of care. However, the AAFP is concerned that physicians could be held accountable for the actions or inactions of organizations and individuals beyond the physician's scope of control or even influence.”

Interoperability pressure from the GOP

The EHR program has yet to achieve key health information technology goals, including increased interoperability and the creation of widespread health information exchanges, despite $12.7 billion in federal dollars being spent, a group of six Republican senators stated in a report. The senators, led by Sen. John Thune (R, S.D.), published an April 16 white paper outlining their criticisms of the Obama administration's role overseeing the EHR program that eventually will pay out a projected $35 billion in bonuses and grants.

“We have significant concerns with the implementation of the [Health Information Technology for Economic and Clinical Health] Act to date, including the lack of data to support the administration's assertions that this taxpayer investment is being appropriately spent and actually achieving the goal of interoperable health IT,” the report said.

In 2009, President Obama signed legislation authorizing the EHR incentive program. The program has achieved notable successes since then and is working to improve further adoption of EHRs and to encourage the sharing of information electronically, said ONC spokesman Peter Ashkenaz.

More than 388,000 physicians and health professionals, or 73% of those eligible for the program, have registered for incentives from Medicare or Medicaid. More than 230,000 had received incentive payments as of March 1.

The interoperability will improve under the next stage of meaningful use, Ashkenaz said. Stage 2 will place a greater emphasis on exchanging information with other physicians and communicating with patients electronically, he said.

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GOP criticizes meaningful use effort

Senate Republicans warn that the federal program to encourage adoption of electronic health records is going astray. A GOP white paper outlined five areas in which the lawmakers see implementation deficiencies:

  • No clear path to interoperability, as meaningful use of an EHR has proceeded without a plan to ensure information sharing.
  • Reports of increased costs associated with EHR adoption.
  • Lack of oversight to prevent waste and fraud in health IT programs.
  • Potential patient privacy risk, as identified by federal auditors.
  • Doubts about sustainability of EHRs for physicians once program funding runs out and Medicare penalties start being assessed for those who don't adopt paperless records.

Source: “REBOOT: Re-examining the Strategies Needed to Successfully Adopt Health IT,” Sens. John Thune (R, S.D.), Lamar Alexander (R, Tenn.), Pat Roberts (R, Kan.), Richard Burr (R, N.C.), Tom Coburn, MD (R, Okla.), and Mike Enzi (R, Wyo.), April 16 (link)

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Early EHR successes

The Centers for Medicare & Medicaid Services has refuted criticisms of the Obama administration's electronic health records incentive program by pointing to important meaningful use milestones. CMS outlined progress on EHR adoption and interoperability after spending $12.6 billion on incentives for physicians and hospitals since 2011. These achievements include:

  • 85% of eligible hospitals and 73% of eligible physicians and health professionals participated in EHR incentive programs.
  • 40% of physicians used EHRs to write clinical notes and view paperless imaging results in 2012, compared with 17% in 2008.
  • 50,000 jobs added to the health information technology sector since 2009.

Source: “A Record of Progress on Health Information Technology,” Centers for Medicare & Medicaid Services, April 23 (link)

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External links

“REBOOT: Re-examining the Strategies Needed to Successfully Adopt Health IT,” Sens. John Thune (R, S.D.), Lamar Alexander (R, Tenn.), Pat Roberts (R, Kan.), Richard Burr (R, N.C.), Tom Coburn, MD (R, Okla.), and Mike Enzi (R, Wyo.), April 16 (link)

“A Record of Progress on Health Information Technology,” Centers for Medicare & Medicaid Services, April 23 (link)

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