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Tuesday Jul 07, 2015

Moving from Meaningless to Meaningful Use

A decade ago, President George W. Bush created the Office of the National Coordinator of Health Information Technology (ONC) and called for the "widespread adoption of electronic health records in 10 years." This directive set our nation on a path towards the establishment and implementation of a national health IT system.

In 2009, Congress moved us further down this path when it enacted the Health Information Technology for Economic and Clinical Health (HITECH) Act. This law established an implementation framework through the meaningful use program and created an expectation that physicians and hospitals participating in the Medicare and Medicaid programs would use certified electronic health records (EHRs) by 2017. 

This is where our story departs from script. To date, federal and state governments collectively have paid more than $28 billion in incentive payments to hospitals, physicians and other health care providers. By surface measures, one could argue that this investment and the meaningful use program have been successful. A 2014 HHS press release(www.hhs.gov) touted "significant increases in the use of electronic health records (EHRs) among the nation’s physicians and hospitals."

Although we should not overlook progress, there are some epic challenges (pun intended) that must be overcome if we are to realize the full potential of electronic medical records. 

Despite a massive investment by federal and state governments, the quality and functionality of EHRs has not improved, and physician enthusiasm for EHRs have plummeted. Many family physicians, regardless of practice setting, complain about EHRs. The complaints fall in four major themes:

  • "My EHR is clunky and disrupts workflow in our office."
  • "My EHR cannot communicate with other physician offices or my local hospital."
  • "I cannot access data in my EHR without paying a fee or hiring a consultant."
  • "I can't afford all the upgrades, and I can't afford to change vendors."

These same themes were captured in a 2014 Medical Economics physician survey(medicaleconomics.modernmedicine.com) regarding EHRs. This survey found that nearly half of physicians think that EHRs are making patient care worse, more than 60 percent think that EHRs are hurting care coordination, and an astonishing 70 percent of physicians said that the implementation of their EHR was not worth the time, resources and cost. Adding insult to injury, a 2013 RAND study(www.rand.org) showed that EHRs are a leading driver of negative job satisfaction among physicians.

The AAFP has been a leader for more than a decade in assisting ONC, CMS, HHS and Congress on policies aimed at improving the nation's fledgling health IT system. We have conducted dozens of meetings and written numerous letters on this subject. In March, AAFP President Robert Wergin, M.D., testified(www.help.senate.gov) before the Senate Health, Education, Labor and Pensions Committee (HELP) where he laid out a series of recommendations from  the AAFP on how to improve both EHRs and the health information system.

Not only have we failed to meet the directive set forth by President Bush or capitalize on the investments made in the HITECH Act, but we may actually be further from reaching the 2017 goal today than we were five years ago. For the first time, member feedback suggests that a growing percentage of family physicians are simply giving up on meaningful use. Put another way, some physicians would rather pay a penalty than participate in meaningful use.

The decreasing levels of participation in meaningful use is concerning to the AAFP on its own, but with the passage of the Medicare Access and CHIP Reauthorization Act (MACRA), our sense of urgency around failing HIT policies is increasing rapidly. The ability of family physicians to achieve success in advanced delivery and payment models will depend on the availability of data and the ability to transmit and receive medical information in real-time. We cannot call the emailing of an 80-page discharge summary "interoperability." We need a system that can transmit clinically relevant health information in real-time and contributes to true care coordination, and we need EHR vendors to design products that actually fit into the workflow of a physician's office.

The reasons are complex, but one thing is clear -- current meaningful use criteria are not moving us closer to widespread adoption, and it is time for a change in direction. The AAFP advocated for changes in meaningful use stage 2, and we are pleased that ONC and CMS responded positively to reduce the required percentage of interactions through a patient portal and reduced the reporting period from 365 to 90 days. Additionally, we have called for a delay in meaningful use stage 3 to align these requirements with those contained in MACRA.

However, we are convinced that these changes are not sufficient to salvage the meaningful use program and facilitate an interoperable health information system. We need dramatic improvements in the program if we are to achieve the goals contained in the HITECH Act, and the AAFP is prepared to work with Congress and ONC to achieve these improvements. But, in order to accomplish these improvements it is clear that we should operate in a space that is free of financial penalties. This is why, in the coming weeks, the AAFP will be launching an advocacy campaign aimed at delaying the meaningful use stage 2 and 3 penalties.

Wonk Hard: Supreme Court Edition
On June 25, the U.S Supreme Court handed down a 6-3 decision in King v. Burwell in which they upheld that individuals who purchase health insurance though a federally facilitated health insurance marketplace are eligible for subsidies. The majority opinion was written by Chief Justice John Roberts, marking the second occasion that he has written the majority opinion in a case involving the Patient Protection and Affordable Care Act. The dissenting opinion, written by Associate Justice Antonin Scalia, offered a scathing rebuke of what the dissenting judges viewed as judicial activism going so far as suggesting the law be referred to as "SCOTUScare."

The King lawsuit is the last of the major challenges to the law or its provisions.  Certainly additional cases will be filed, but the pathway for additional legal challenges to the ACA will be extremely challenging following this decision.

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Stephanie Quinn, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.