ONC’s Perspective through Consumer Group Remains Rigidly Myopic
The Office of the National Coordinator for Health Information Technology (ONC) has been encouraging consumers to voice their opinions on the HIT incentive program, and recently the Consumer Partnership for eHealth (CPeH) published its perspective on providers’ concerns regarding the appropriateness of the meaningful use standard. CPeH seems to be marching in lock step with ONC; the group’s perspective largely mirrors the sound bites we’ve heard from Dr. David Blumenthal and other ONC staff during HIT Policy Committee meetings and in their public comments and blog postings.
I have no quarrel with CPeH, but am unwilling to cede the mantle of “the public” to any organization that happens to claim it. We are all consumers of healthcare, and we should all be held accountable for discussing these issues from the premise that the incentive program should be designed to maximize the quality and cost effectiveness of healthcare.
In reading through CPeH’s responses to provider criticisms of the proposed rule, what strikes me most is that CPeH provides absolutely no factual support for its positions. More troubling, the CPeH perspective misrepresents information in support of policies that have the potential to undermine our common goals for the program.
1. The Meaningful Use Definition’s Appropriateness for 2011
On the issue of the meaningful use definition being too aggressive for 2011, CPeH makes the following claims: (1) the proposed meaningful use criteria for 2011 don’t ask for capabilities beyond those of today’s certified vendors, (2) the incentives are voluntary; they are not an entitlement and there is no requirement to participate, and (3) we must ensure the investment pays off in better care.
Certified Vendors Already Have the Proposed Capabilities
The first point is clearly false. The 2011 criteria do ask for capabilities beyond those of today’s certified vendors. Addressing this from the hospital side, there are about 10 currently CCHIT certified inpatient vendors, and most of those will have significant work to do to meet the current 2011 proposed standards. Areas of development will include (1) electronic medication reconciliation, (2) generation of children’s growth charts, and (3) electronic summary care record for transitions of care.
Perhaps CPeH meant that if the hospital were using Epic (whose CEO sits on the HIT Policy Committee) then the certified vendor currently meets the 2011 requirements. But Epic is the most advanced hospital EHR on the market, and does not even sell to small rural hospitals or practices, who couldn’t afford it even if they did. Important to note that EHR vendors that service small providers will have more work to do than others. Not necessarily because they are maliciously deficient, but because their model is to provide less functionality for a lower costs, which is how small providers are able to afford EHRs in the first place.
It makes sense to require vendors to develop this functionality, but to pretend that it already exists in defense of a flawed strategy is irresponsible.
The Voluntary Nature of the Incentive Program
The second point is severely misleading. If the incentive program didn’t include significant penalties for providers not implementing by 2015, one could make the argument that this is a voluntary program. The penalties make this position untenable. For those providers (mostly small and rural) that don’t have the upfront capital or staff to make a successful transition to EHRs, the “voluntary” incentive program is a lifeline to avoid penalties that could have devastating effects. To call the incentives voluntary without mentioning the penalties misrepresents the true nature of the program.
Ensuring the Investment Pays Off in Better Care
I of course agree that we must ensure the investment pays off in better care. What is false is the assumption that unattainable standards will somehow improve care. Rushing implementation will ensure that the investment pays off with failed implementations and lower quality.
In summary, the totality of CPeH’s argument that the meaningful use definition is appropriate for 2011 consists of two false statements, and one truism not relevant to the truth of the conclusion.
2. Small Practices Being at a Disadvantage
On the issue of whether small practices are at a disadvantage, CPeH makes the following misleading claims: (1) the incentive funds will cover the cost of the IT systems; (2) Regional Extension Centers will support small practices; and (3) the Medicaid program will help since it provides funds one year before meaningful use is required.
First of all, this topic misrepresents the provider argument. The argument is not just that small practices are at a disadvantage, but also that small hospitals are at a disadvantage. It’s important for us to consider each of these categories of providers, both of which are starting at significantly lower levels of HIT adoption than other providers.
The Incentive Funds Will Cover System Costs
Even if we concede that the amount of the capital investment will be covered (which is not true for hospitals), it will only be covered for those who can attain meaningful use in the timeframes established. For those working toward EHRs, but unable to meet the deadlines because they are starting at early stages, it will be a race to avoid penalties with the capital costs not covered. Additionally, the costs of operating EHRs, which for small hospitals will be significant (since they will have to double or triple their IT FTE levels to appropriately support EHRs), will in no case be covered.
Regional Extension Centers Will Help
Regional Extension Center will not help small (or any) hospitals, unless they own physician clinics. The original ARRA language categorized critical access hospitals (CAHs) as prioritized providers, but ONC subverted the definition of prioritized provider to “prioritized primary care providers with prescriptive privileges,” which effectively excluded RECs from getting funds to help small hospitals with their inpatient meaningful use efforts.
It is true, however, to say that small physician practices (with 10 physicians or less) will qualify to get assistance from RECs.
The Medicaid Program Provides Flexibility
The Medicaid Program does provide a level of flexibility for qualifying providers by allowing the first payment year to be for implementation without the need to attain meaningful use. This would have been a great model for the rest of the program. The problem is that most small practice professionals don’t qualify for the program’s 30% needy utilization threshold, and all critical access hospitals (the smallest of our nation’s hospitals, and those with the lowest average EHR adoption levels) have been excluded by CMS from receiving any Medicaid incentives.
Given the above, and the many other small provider challenges that I have discussed in other blogs, I think the CPeH position that small providers are being treated fairly is indefensible.
3. Should CPOE Be Included as Part of Stage 1 Meaningful Use?
On the issue of including CPOE as part of Stage 1 meaningful use, CPeH claims: (1) CPOE is a foundational tool to provide the most effective care for patients, and (2) only 10% of CPOE orders are required for hospitals as part of Stage 1.
CPOE is Foundational Tool for Effective Care
If CPeH is claiming that CPOE is a foundation of an EHR (i.e. an early component upon which other aspects of the EHR are built), then they are absolutely incorrect, as is supported by nearly every CPOE implementation case study in existence. If they are claiming that the system is an important way to improve patient safety as a capstone EHR application, then I would agree. The issue is how long it takes a provider from beginning the EHR building process to be ready to even start a CPOE implementation. Case studies tell us the answer (at least in the hospital setting) is many years. I can only conclude that those who want providers to slam in CPOE because they believe it will reduce errors have not read the literature and/or have never participated in a hospital CPOE implementation.
John Glaser, who is a senior advisor to David Blumenthal, has been quoted as saying “CPOE is the most difficult technology implementation I can think of in the acute care setting.” How is it possible that people who actually understand the challenges (especially for those at early stages of EHR adoption) are not standing up to clearly state the obvious fact that CPOE does not belong in Stage 1? See my blog on CPOE for more detail: http://www.worh.org/hit/2010/02/hit-policy-committee-recommendation-one-small-cpoe-step-from-flexibility/
Only 10% of Orders Are Required in Stage One
I realize that those who created the 10% rule felt it was a compromise, but it really only helps providers that are positioned to start a CPOE implementation. Hospitals at early stages of EHR adoption have so much work to do in preparation for CPOE that 10% may as well be 100%.
4. Implementing HIT Too Quickly Can Ultimately Harm Patients
On the issue of whether implementing HIT too quickly can harm patients, CPeH claims: (1) again that the program is voluntary, and (2) patients are currently harmed by lack of HIT/data.
Other Comments on the Program Being “Voluntary”
To design an incentive program for EHR adoption that only providers that have already implemented EHRs can realistically qualify for, to add penalties for all, thereby to ensure that the existing digital and financial divide between large and small providers will be increased, and then to call it voluntary? My guess is that CPeH and ONC (which has also made this point) are using the term “voluntary” to prepare for mitigating their responsibility when it becomes clear how bad the effects of their slash and burn strategy truly are.
Patient Already Harmed By Current State of Affairs
This is perhaps the most extraordinary claim in the CPeH plastic arsenal. There are too many studies that demonstrate that quickly and poorly implemented HIT systems can lead to harm for anyone not to take this issue seriously. Yes, patients are harmed by lack of data, but poorly implemented HIT systems will make things worst and not better.
In a situation where an intervention will be effective only under certain circumstances, it is wrong to claim that the current state of affairs will be improved by performing the intervention under essentially any circumstances.
Conclusion
The only logical course of action is to use data from actual case studies to determine what timeframes and activities are reasonably achievable for providers (who are starting at different stages of EHR adoption) to safely meet our common goals. The AHA and other provider groups have begun to do this analysis. As far as I can tell, CPeH and ONC have done nothing to assist.
This rural consumer of healthcare expects more from my “consumer” representatives.
