Physicians sound an urgent call to retool stage 2 EHR program

Usability of electronic health records remains a top concern for physicians as other goals of interoperability and information sharing appear to be far off.

By Charles Fiegl amednews staff — Posted May 27, 2013

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Physicians may not be able to meet rigid electronic health record requirements unless the Centers for Medicare & Medicaid Services revisits stage 2 criteria for demonstrating meaningful use, the American Medical Association stated in a letter to six senators.

Specialty and state medical societies also expressed similar concerns as thousands of physicians prepare to meet much tougher EHR standards in 2014. New requirements mean that physicians must meet 100% of the measures to earn EHR payments and stop future penalties. Achieving high thresholds is unnecessarily burdensome when using an EHR in a meaningful way, the AMA stated in the May 17 letter. Interoperability and information-sharing gaps also present challenges to practices that will need to manually enter data, such as lab test results, so they can fulfill mandates.

“The AMA firmly believes that the most prudent course of action is to comprehensively evaluate what worked well in stage 1 and assess where implementation challenges remain,” wrote AMA Executive Vice President and CEO James L. Madara, MD.

The AMA letter and responses from other organized medicine groups were in reply to an April white paper by six Republican senators. The report reviewed how the Obama administration has spent billions of dollars to spur EHR adoption and facilitate exchange of health information. The white paper was critical of current policy addressing interoperability, costs and other technology issues.

The program may be moving too quickly to prevent a negative impact on health care, organized medicine groups said. The federal government requires physicians to do more than just adopt EHRs. CMS sets about two dozen objectives defining how physicians can demonstrate meaningful use. Feedback on stage 1 provides evidence that some measures were almost impossible to meet or were not relevant to practices, the AMA said. At the same time, the usability of systems, which often require multiple tedious steps to perform simple functions, is not a factor considered during the federal review and certification process of EHRs.

“The AMA firmly believes that the [meaningful use] certification process must be retooled in order to address a variety of problems many physicians are experiencing with their use of certified EHRs,” Dr. Madara wrote. “Physicians are complaining that the certified EHRs available in the market are not matching their clinical needs.”

The AMA is recommending that federal officials stop adding measures to the meaningful use program and allow vendors to work on usability concerns. Regulations establishing stage 2 should be changed to allow more flexibility and exclude physicians from requirements when they are inappropriate for their work flow or patient population, the AMA stated.

Physicians began attesting to meeting initial meaningful use standards in 2011. Strengthened meaningful use criteria under stage 2 of the program will be required beginning Jan. 1, 2014, for some physicians who began receiving EHR payments in 2011 or 2012. CMS already has halted work on developing stage 3 criteria, which the AMA recommended should not be implemented before 2017.

Clearing a path for interoperability

The push on meaningful use stage 2 is occurring while there appears to be no clear path to interoperability, the Senate Republicans' report stated. Dept. of Health and Human Services officials have said they are focusing on electronic exchange of information across health settings, but they also note rapid progress in EHR use in an environment that had relied on paper records for generations.

For many physicians, interoperability and sharing health information electronically is a goal far from achievable. Physicians, hospitals and other health professionals have pursued their own goals during the transition to electronic from paper, said Joseph H. Schneider, MD, chair of the Texas Medical Assn. ad hoc committee on health information technology. Systems may send and receive patient information, but it's often in an unworkable or inefficient format.

For instance, a patient with six health problems may see five doctors, Dr. Schneider said. Each physician documents a problem list in his or her own terms. In the end, a physician downloads the patient's history on the EHR and finds unreconciled information with the same set of problems listed 22 ways. The problem list may be sorted, but that takes time, and there may be no way to save the work in a health information exchange.

The average cost of adopting, implementing and upgrading a certified EHR is $54,000 per physician.

“We have light-years to go,” he said.

The American Osteopathic Assn. recommended that federal health agencies survey physicians, patients and vendors about experiences with EHR implementation before proceeding with new meaningful use and certification requirements.

“We understand the need to increase requirements for the exchange of health information in future stages of meaningful use,” wrote AOA President Ray E. Stowers, DO, in a May 16 letter. “However, the success of EHR adoption and its meaningful implementation hinge on a sound infrastructure and on interoperability with clinical information systems outside of the physician's practice.”

Examples of successful interoperable systems can be found and will be more visible going forward, said Leigh Burchell, an executive with the vendor Allscripts and vice chair of the EHR Assn. EHRs have developed interoperable functions for sharing information within health systems. Exchanging information is required in stage 2 and will be critical in new payment models, such as accountable care organizations and patient-centered medical homes, she said.

Sequestration hits EHR pay

The average cost per physician to adopt, implement and upgrade a certified EHR is $54,000, plus $10,000 in annual maintenance costs, the AMA stated, citing numbers from CMS. But these costs do not account for all the functionalities required by CMS, such as purchasing lab interfaces so test results can be reviewed electronically. Interfaces can cost physicians thousands of dollars. That means meaningful use incentives don't cover costs. Incentive amounts from Medicare are up to $44,000 per doctor over five years or $63,750 over six years if doctors attest under Medicaid.

The Medicare bonus total is actually 2% less than what had been authorized in the 2009 legislation creating the bonus program because of mandatory budget cuts through sequestration, which also cut physician Medicare payments by 2% beginning April 1. The Medicaid bonus program was not affected by sequestration.

As in other Medicare initiatives, physicians soon will be penalized for not using EHRs. A 1% cut will be assessed in 2015 for eligible professionals who do not begin demonstrating meaningful use by July 2014. The penalty will grow to 2% in 2016 and 3% in 2017.

The costs of meeting meaningful use will go on once EHR payments run out. Physicians switching to better EHRs will pay for the systems and the large expense to send patient data. For example, a physician importing months of patient data received a bill for $12,000, Dr. Schneider said. He recommended requiring vendors to use universal tags for key elements of patient data so migrating and storing data can be done more easily. Tagging also might solve interoperability issues, he added.

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Physicians receiving EHR payments

CMS projects that 65% of primary care physicians in large groups, 45% in small groups and 44% of specialists could earn meaningful use payments by 2015. The agency expects these percentages to climb to 80%, 65% and 66% for the three groups in 2019, respectively. These figures show the numbers of doctors achieving meaningful EHR use through 2012.

Specialty Physicians Payment total
Family practice 34,331 $566.4 million
Internal medicine 32,607 $546.5 million
Cardiology 12,948 $220.0 million
Orthopedic surgery 9,036 $155.7 million
Gastroenterology 7,547 $127.9 million
General surgery 6,782 $115.8 million
Ophthalmology 5,395 $93.4 million
Urology 5,269 $89.5 million
Neurology 5,262 $88.5 million
Obstetrics-gynecology 4,848 $63.1 million
Pulmonary disease 4,371 $74.2 million
Otolaryngology 4,340 $73.0 million
Nephrology 3,890 $66.8 million
Dermatology 3,560 $60.8 million
Hematology/oncology 3,368 $58.0 million
Other 29,058 $490.4 million
Total 172,612 $2.9 billion

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

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Physicians moving to stage 2 meaningful use

CMS requires physicians to spend at least two years achieving stage 1 meaningful use criteria before moving on to tougher standards. Stage 2 requirements may apply to more than 150,000 physicians who began participating in the electronic health record program by 2012. First-time users in 2013 would not need to achieve stage 2 until 2015. The number of physicians who reached stage 1 by the end of 2011 and 2012:

Program 2011 2012
Medicare 51,459 121,153
Medicaid 37,718 31,323

Source: “Active Registrations,” EHR incentive program, Centers for Medicare & Medicaid Services, March (link)

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External links

“Forecasting the Use of Electronic Health Records: An Expert Opinion Approach,” Medicare & Medicaid Research Review, second quarter 2013 (link)

“Active Registrations,” EHR incentive program, Centers for Medicare & Medicaid Services, March (link)

“Medicare Incentive Payments,” EHR incentive program, Centers for Medicare & Medicaid Services, March (link)

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