If one were to collect a listing of federal programs that have caused tremendous angst among family physicians, CMS' meaningful use (MU) program likely would appear near the top of that list.
Now, a new study(academic.oup.com) titled "Meaningful use's benefits and burdens for U.S. family physicians" quantifies both the usefulness and workload of the program as experienced by FPs who participated in it.
"Since its inception in 2011, the MU program has been criticized more than praised by practicing physicians for increasing non-value-added work during patient encounters," said authors of the study, which was published online in the January issue of the Journal of the American Medical Informatics Association.
"In recent years, increasing negative sentiment has led to a range of commentary comparing physicians to highly paid data entry clerks and mocking the MU Program as 'meaningless abuse,'" they wrote.
- Researchers have published the results of a national survey that asked physicians about certain criteria used in CMS' meaningful use (MU) program.
- Although the MU program ended in 2016, criteria associated with the program were transferred to the Quality Payment Program's Merit-based Incentive Payment System.
- Authors made recommendations aimed at guiding future rulemaking; for instance, they urged stakeholders and policymakers to support criteria that physicians indicated were of high benefit with a low burden.
Steven Waldren, M.D., director of the AAFP's Alliance for eHealth Innovation and one of the study authors, told AAFP News that his team set out to gather data and evidence to show the implications of health policy for health IT.
"Policy needs to be evidence-based, especially when it involves mandates or includes possible financial penalties," said Waldren.
He pointed out that during the MU program implementation, the AAFP cautioned CMS and the Office of the National Coordinator for Health IT of unintended consequences that would hurt practicing physicians.
So, what's the use of exposing the flaws of a program that no longer exists?
Waldren pointed out that MU criteria have been incorporated into the Merit-based Incentive Payment System (MIPS) as a component of the Advancing Care Information criteria. As physicians know, MIPS is one of two pathways for payment under CMS' Quality Payment Program; the other is advanced alternative payment models.
"Policymakers need to have this kind of retrospective data in hand before they implement policies rather than after if they are to avoid the missteps of meaningful use," said Waldren.
"Doing so will increase the likelihood that policy goals are achieved," he added.
In 2015, the AAFP formed a national panel of 13 physicians, industrial and systems engineers, and other primary care experts to develop a survey based on a list of tasks associated with 31 MU criteria.
The project, noted the authors, "was to evaluate the benefits and burdens associated with the MU program from the physician's point of view during patient face-to-face time, arguably the most valuable segment of the patient encounter."
During a four-week period from July to August in 2015, 480 physicians participated in an online survey; 439 of those surveys were deemed useful for analysis.
To facilitate data interpretation, criteria were placed in one of three groups based on how information was most likely used in caring for patients. Those classifications were
- basic/routine care or patient care;
- complex patient care, where continuance of care is required and likely will be coordinated with other health professionals; and
- population care, where data are collected with the intention of managing or surveilling a group of patients.
Researchers found that 18 of the 31 MU criteria were perceived by physicians as useful for more than one-half of patient encounters, and 13 of those criteria were useful for more than two-thirds.
The authors provided a list of high-benefit MU criteria based on their application to more than 66 percent of patients, including
- maintaining an active medication list,
- generating and transmitting electronic prescriptions,
- maintaining an active allergy list,
- incorporating clinical lab test results into an EHR, and
- performing drug allergy checks.
They also designated high-burden MU criteria; items on that list include
- performing drug formulary checks,
- providing a summary care record for each transition of care or referral to the next transition of care,
- using secure electronic messaging to communicate with patients,
- providing a clinical summary for patients after each office visit,
- implementing one trackable clinical decision support rule, and
- providing patients with electronic copies of health information within four days of its availability.
Importantly, four criteria were included on both the "high-benefit" and "high-burden" lists. Those criteria are
- recording electronic notes in patient records,
- maintaining a current problem list with active diagnosis,
- performing medication reconciliation when receiving a patient from another setting or care provider, and
- using computerized physician order entry for new or renewal medication orders.
Authors noted that some 70 percent of physicians perceived MU stage one (related primarily to basic/routine care) as being beneficial to patients; however, stage two criteria (more related to complex and population care) were seen as less beneficial with a higher compliance burden on physicians.
"Thus, most physicians perceive a negative shift in the value of MU moving from stage one to two," wrote the authors.
The researchers noted that to complete the tasks required by MU, physicians need a certified EHR.
"These findings call into question the level of functionality and support EHRs provide to physicians, given the volume of significantly burdensome criteria reported," they said.
Waldren pointed to one of the most relevant findings supported by a grid-diagram that places each of the 31 MU criteria into one of four benefit/burden zones.
"From a policymaker standpoint, zone four is the 'danger zone' -- these are things that have a high burden and have less benefit," said Waldren.
Zone four criteria include items such as generating lists of patients by specific conditions and performing drug formulary checks.
Waldren also cautioned against continuing criteria that create waste in the system and that ultimately add to the administrative burden. For example, asking a physician to urge a technology-averse patient to sign up for a patient portal just to meet a quota is a waste if the patient never uses the portal.
Authors put it this way: "Roughly one-third of MU criteria were perceived as useful in less than 50 percent of patient encounters, which means that time is taken away from typical patients for these non-value-added tasks (i.e. system waste) that must be performed for compliance.
"Hence the policy becomes a burden on the quality of care that physician can provide to their patients. In total, these findings provide insight into CMS' comment that MU has 'lost the hearts and minds of the physicians.'"
Based on the new evidence collected, the researchers made recommendations to guide further rulemaking. For instance, they suggested that stakeholders and policymakers
- support MU criteria with high benefit and low burden,
- recognize that mandating tasks that are not beneficial to the majority of patients diverts attention and effort away from direct patient care,
- minimize burdens associated with beneficial routine tasks through better EHR design to allow for the addition of more complex patient-specific tasks,
- refrain from setting compliance metrics at 100 percent to allow for adaptive patient care, and
- minimize burdens associated with low-benefit tasks by automating them through EHR reporting.
Lastly, the authors suggested that components of tasks that fail to improve efficiency or that do not contribute to the quadruple aim of better patient health, better health care delivery, lower costs and higher physician job satisfaction should be eliminated.
Waldren noted that the AAFP will continue to use its evidence-based findings to push advocacy efforts at the national level and ensure that health IT policies are driven by real data gathered at the medical practice level.