Is health information technology (IT) being set up to fail? Might we be facing a lost generation of health IT investment? Will Kaiser Permanente and Mayo Clinic get windfall profits while small practices receive nothing but hassles? It's beginning to seem that way.
I'm sure you already know the broad outlines of the government's plan to pay physicians roughly $44,000 each (a national investment of $20 billion or more), over a five-year period starting next year, for “meaningful use of certified electronic health record technologies.” (If not, see “‘Will the Feds Really Buy Me an EHR?’ and Other Commonly Asked Questions About the HITECH Act,” FPM, July/August 2009.) While we now have the U.S. Department of Health and Human Services (HHS) proposed rule for defining meaningful use and the “interim final rule” for EHR certification criteria, we won't know until later this year precisely what meaningful use means, how doctors can apply for the payments, what technologies will be certified, or when the payments will start. But it's not too early to begin asking some hard questions.
How can we decide whether to buy an EHR when the future is so uncertain? Federal Reserve Chairman Ben Bernanke is said to have made this comment more than 30 years ago: “If you as a business were considering buying a new boiler, and if you knew the price of energy was going to be high, you would buy one kind of boiler. If you knew the price of energy was going to be low, you'd buy another kind of boiler. If you didn't know what the price of energy was going to be, but you thought you would know a year from now, you wouldn't buy any boiler at all.”
Similarly, physicians will not be able to judge the costs of EHR technology easily for at least the next year given that a certification process yet to be implemented may force vendors to modify their products in as-yet unforeseeable but potentially costly ways, and given that we don't know what it will cost physicians to use the technology “meaningfully.”
More, physicians face uncertainty regarding their future revenues – the revenues that will determine how much they can spend on EHRs. While the health care reform bill passed by the U.S. House of Representatives includes a modest increase in Medicare fees for primary care physicians, the fate of that bill and of health care reform in general is more uncertain than ever now that the Republicans have 41 seats in the Senate. And while the threatened 21-percent cut in Medicare rates seems unlikely now, it's not completely out of the picture. If the massive cut is averted, who knows what will replace it – a short-term preservation of the status quo, perhaps, to be followed by … what?
One hopeful but still unsettling prospect: With HHS's replacement of criteria for certification developed by the Certification Commission for Health Information Technology (CCHIT) and what may be the replacement of CCHIT as certifying body, the current crop of EHR vendors may have diminished influence over market offerings in the future. This could open the door to innovative and affordable web-based EHR technologies.
Also, content in the new regulations suggests that the Office of the National Coordinator for Health Information Technology (ONC) and HHS are now favorably disposed to EHR technologies that are modular and able to be assembled from components – what I and others have called “clinical groupware.” These changes suggest that HHS-certified EHRs could be less expensive to own and operate than the monolithic, single-vendor products that CCHIT certified through mid-2009. (To learn more about the advantages of a modular approach to EHR technology, see “Toward a Modular EHR,” FPM, July/August 2009.) If this is the case, then physicians who don't yet have EHRs might be wise to wait until at least late this year to make any decision about a purchase.
Physicians who already own EHRs are in their own limbo. Even regularly upgraded systems will still need to go through the new HHS certification process before they can be considered platforms for meaningful use – and the upgrades or patches needed to enable existing software to meet the new standards could be expensive.
About the only physicians who have certainty in this environment are those working for large provider organizations. These salaried physicians can expect their administrations to upgrade their EHRs for certification, regardless of cost, with the incentive payments flowing to the enterprises.
Can we trust the government to run this program any better than the Physician Quality Reporting Initiative (PQRI)? Physician confidence in the government is at an all-time low. Many I speak with openly challenge the ability of the Centers for Medicare & Medicaid Services (CMS) to pay physicians who fulfill the meaningful-use requirements. They cite the administrative nightmare of PQRI, which David Brailer, MD, PhD, the first national health information technology coordinator and predecessor to David Blumenthal, MD, MPP, recently called a “mangled set of incentives” that “turned into a massively complex bureaucracy of forms and applications,” and “failed to do what it promised physicians it would do.”
To many physicians, meaningful-use qualification looks like more of the same: a maze of bureaucracy, attestation forms and applications, and new outlays for software, hardware and consulting services, with a very uncertain chance of receiving a check from Medicare or Medicaid when all is said and done. It is a lot of risk, so far without a lot of assurance of return. Small- and medium-size medical practices may feel the risk much more profoundly than larger groups, because they lack the administrative apparatus to smooth the transition and assure that payment is received.
What if CMS isn't able to handle the data? The proposed rule defining meaningful use includes a core mandate for physicians to use certified EHR technology to submit quality and performance data to CMS. What confidence can we have that the government will be technologically competent to handle this massive amount of raw data?
This is a question that physicians understand almost instinctively. Quality and performance data reporting is highly specific to practice context and fraught with technical problems. Now, along comes a requirement to use an untested set of EHR technologies, possibly involving hundreds of different vendors' products, most rarely if ever used for the submission of these clinical data, paired with a so-far nonexistent infrastructure intended to collect, aggregate and analyze these data. And this is supposed to work? It's hard to believe that ONC/HHS/CMS can put all of these pieces together in a matter of 12 to 18 months, let alone ask physicians to accept the risk that this will eventually validate their claim of meaningful use. And what happens if the Republicans take back the White House in 2012 and scuttle the whole program?
Will Congress really penalize doctors who don't comply? Meaningful-use implementation could prove onerous and overly complicated for doctors in small- and medium-size practices, costing them much more in dollars and productivity than they would gain in incentive payments. Given that, will Congress have the will to punish physicians who chose to forego the program, paying them at a lower Medicare fee schedule starting in 2016 as the plan calls for? What would such a penalty accomplish, other than to drive even more primary care physicians into retirement or large groups, where they are generally the lowest paid and least respected members of the organization? What would be the political backlash from physician organizations and patient advocacy groups?
The Congressional Budget Office has opined that physicians are unlikely to respond to financial incentives in large numbers and that it will take a penalty to get them to comply with mandates for EHR use, but physicians know that Congress has never been willing to punish them for any behavior. The threat of a penalty may be empty, or at least worth risking.
I'm not yet at the point where I would recommend that doctors reject the incentive program. But it's hard for me to recommend participating, given the degree of uncertainty and risk. I'd like to see evidence that the feds understand the complexity of community-based medical practices and can refine and simplify their meaningful-use criteria. And I worry a great deal that big organizations will get windfall profits out of this deal, while most family medicine practices will only get new hassles and unfunded mandates.