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Annual Evaluation of Health IT: Are We Stuck in a Holding Pattern? (Part 1 of 3)

Posted on April 13, 2015 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site ( and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

I don’t think anyone has complained of excessive long-term thinking among health care providers. But an urgent lack of planning has worsened in the past few months as key drivers of the health IT field search for new directions. Given today’s issues with Meaningful Use Stage 3, the FHIR data exchange standard, Accountable Care Organizations, medical device regulation, and health IT staffing, I expect the next several months to be a time of waiting.

This article will look over what has happened during the past year and try to summarize large-scale trends. I used to report annually from the HIMSS conference, the largest health IT gathering in the US, but stopped going because my articles were always cynical, cantankerous, and depressed. So I figure I just write up a cynical, cantankerous, and depressed summary of what’s happening in health IT from home.

Meaningful Use Stage 3: Shoot the Moon?

There are clear indications that the Meaningful Use program has gone off the tracks. I don’t consort with those who disparaged Meaningful Use from the start and claimed that it held back progress in the IT field. What little progress has occurred can be credited to Meaningful Use, because frankly, the health care industry was totally mired before. Choose your favorite metaphor: deer in the headlights (of oncoming disruptive competitors), ostrich in the sand, even possum in the road.

And no one can challenge that Stage 1 met its (very limited) goals. Centers for Medicare & Medicaid Services (CMS) just reported that the vast majority of hospitals have attested to Stage 1 (with rural and children’s hospitals lagging significantly). In fact, while defining Stage 3, CMS could remove some of its requirements because they have “topped out,” meaning that almost everybody already does them.

All the sharper is the contrast between Stage 1 and Stage 2, which was supposed to be incremental but apparently broke the camel’s back for many EHR vendors as well as providers, a lot of whom have thrown in the towel.

Interoperability was certainly a big stumbling block. Two different EHRs can claim to support a standard (such as the C-CDA) while not actually being able to exchange data in a useful manner, for reasons ranging from outright errors to differing interpretations of a fuzzy standard.

But the most whining from providers in Stage 2 arose over a requirement that patients view, transmit, or download (VDT) data from a patient portal. Even though providers needed only 5% of their patients to take a look at the site, they complained bitterly that they were being judged for something that relied on somebody else’s behavior (their patients).

The VDT measure is indeed a responsibility that depends on the behavior of outsiders (as are the interoperability requirements). But health providers seem slow to grasp the whole idea of “pay-for-value,” which means they won’t be rewarded in the future for doing stuff–they’ll be rewarded for results. Not that patients will get healthier just by viewing or transmitting data. But we need something measurable to mark progress, and since everybody issues paeons to patient engagement, the VDT measure is a natural one.

Calls have come from around the industry to water down or otherwise “simplify” Meaningful Use for Stage 3. A common request is to eliminate clinical quality measures (such as how many patients smoke) and focus on interoperability, which I oppose.

To muddy the Meaningful Use landscape further, Congress has started weighing in with complaints that the Office of the National Coordinator (ONC) hasn’t done enough to achieve its goals. One proposed bill overrides ONC and CMS to mandate changes in health care policy. There are rumors that Congress (who of course created the Meaningful Use provision in the first place) will take it back and do some serious micromanagement, perhaps as part of a bill on a totally different topic, the “doc fix” that is supposed to regularize Medicare payments.

In the midst of this turmoil, the ONC and CMS recently released Stage 3 recommendations, and it looks like they haven’t pulled their punches on a single thing. Interoperability is central, but the clinical quality measures still appear in full force. The requirement that patients engage with the technology has been softened, but still requires patients to take some action such as using a portal or uploading their own data.

Perhaps the boldest stake that CMS put in the ground was to force all providers onto a single schedule in Stage 3, a tremendous departure from the gentle steps offered by the first two stages. This has touched off a provider frenzy. They’ve been lobbying for years to slow Meaningful Use down, and notoriously ran to Congress to delay adoption of ICD-10 disease coding. But putting everyone on the same track makes eminent sense, particularly at this stage. If you’re really serious about data exchange and coordinated care, everybody has to equally capable. Otherwise we’re back to finger-pointing and claims that technology lapses have prevented compliance.

So what are ONC and CMS up to? Are they shooting the moon–hoping to make the big leap to their maximal goals in one bold play? Are they floating an audacious wish list that they know will be cut back in the course of negotiation? Are they even taunting resistant industries to go to Congress, knowing that Congress recently has been making even more radical noise than the Administration about the drawbacks of health IT? Something along these lines seems to be in the works.

To return to the theme of this article, I’m afraid that health care providers, insurers, EHR vendors, and all their business associates will freeze up while waiting for Congress and the various branches of Health and Human Services to determine which behaviors to prescribe and which to punish. So that’s my take on meaningful use–more on other developments in health IT in the next installments.

If Meaningful Use Were Gone – Perspective from EHR Executive at Modernizing Medicine

Posted on February 3, 2014 I Written By

The following is a guest blog post by Michael Sherling, MD, in response to the question I posed in my “State of the Meaningful Use” call to action.

If MU were gone (ie. no more EHR incentive money or penalties), which parts of MU would you remove from your EHR immediately and which parts would you keep?

Michael Sherling
Michael Sherling, MD, MBA
Chief Medical Officer and Co-Founder, Modernizing Medicine

What a great question! As both the co-founder of Modernizing Medicine, and a practicing dermatologist that uses EMA, I can appreciate the amount of time and effort it goes into developing MU feature sets, as well as inputting the data in to be a “meaningful user.”

The Top 3 Measures I would remove

  1. Clinical Summaries Provided to Patient
  2. Vital Signs
  3. Clinical Quality Measures

I understand the intent for patients to receive clinical summaries of each visit- but this places an incredible burden on the end user (physicians and office staff) to make sure that each patient has access to their clinical summaries.  For instance, even though we live in the digital age, several of my older patients don’t own a computer or have access to one.  Additionally, these summaries lead to more questions by the patients after the visit has been concluded often times regarding details of the summary that are relatively innocuous.

I have a serious beef with government mandating of Vital Signs.  Health care providers know when it is medically necessary to take vital signs and when it is not.  Those who never take vital signs, because it is unrelated to their scope of practice can claim exceptions, but those who take a few are often stuck between their medical responsibilities and getting an incentive.  In the end, these dermatologists and ophthalmologists wind up taking more blood pressures or measuring the height and weight of their patients unnecessarily to achieve the incentive.  This paradoxically is medically meaningless since dermatologists don’t treat blood pressure, and ophthalmologists don’t often dose weight-based drugs (they like eye drops).

Clinical Quality Measures needs to be renamed to Cost Effective Measures.   Clearly, the goal of CQM is to change physician behavior so that physician decisions are more cost effective.  This is needed in our health care system.  What today is an incentive based on pay for reporting, will be transformed to pay for performance tomorrow.  My concern as a physician is how do we know these are the right questions to ask?  If physicians comply with these CQM guidelines, will that result in not just lower costs, but more effective care?  I’d much rather see benchmarking around actual patient clinical outcomes themselves, using tools like static global assessments of disease rather than a questionnaire about whether or not I followed a recipe for how a committee thinks I should treat every patient with condition Y.

The Top 5 Measures I would Keep

  1. Electronic Prescribing
  2. Medication List
  3. Allergy List
  4. Drug-Drug, Drug-Allergy Interaction Checks
  5. Patient Search

All of these measures are critical to patient care and have obvious benefits.  With electronic prescribing, prescription orders are standardized and LEGIBLE! No need for the pharmacist to discern my own poor doctor handwriting anymore.   Keeping the medication and allergy lists updated and the drug-drug and drug-allergy checks enabled makes for great patient care.  No physician wants to prescribe a medication that interacts with another in a negative way, nor do we want to prescribe a medication that could potentially cross-react with a known allergy. Finally, patient search is a really cool feature that allows all of us to search for patients with specific diseases and medications. This is an important first step in getting records to behave more like research databases for clinical studies and less like word-processors for just note taking.