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Members of two professional medical societies griped about what they view as the Obama administration's inept attempts to regulate electronic health records (EHRs) and shared their visions for the ideal online platform at a second "town hall" meeting here Tuesday.
The discussion was sponsored by Break the Red Tape, a lobbying arm of the American Medical Association (AMA) and co-hosted by the Massachusetts Medical Society. An earlier town hall meeting took place in Atlanta in July.
"How many of you have taken pass-fail tests where 100% was pass and 99.9% was fail, ever?" asked Steven Stack, MD, president of the AMA and an emergency physician practicing in Lexington, Ky. "That's the meaningful use program," he said.
"Meaningful Use" is the term adopted for a set of policies established by the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, that reward clinicians and hospitals for using EHRs in substantive way -- and penalize those that fail to meet certain benchmarks.
While the first two stages of the program focus on the capturing and sharing of information, the third stage targets improvements in clinical outcomes.
In mid-September, 42 physician groups including the AMA lobbied the Department of Health and Human Services for a delay of the proposed Stage 3 provisions of the Meaningful Use program. Many of these groups have been making similar requests since at least 2013. A delay to 2017 in rulemaking would push the effective date of implementation to 2019 or 2020.
At the town hall on Tuesday, Stack noted that while elements of the program have succeeded -- roughly 80% of practices have adopted EHRs -- instead of encouraging innovation, these regulations appear to be stifling it. Less than 10% of physicians "successfully participated" in Stage 2 of Meaningful Use. In December, CMS announced that it would cut Medicare reimbursement by 1% for nearly 300,000 physicians who did not meet Meaningful Use requirements.
Stack noted that instead of making physicians more efficient, it appears to reducing productivity.
Struggling to advance
Kate Atkinson, MD, of Amherst, Mass, said that three of the physicians who left her practice in the last year did so because of frustration with the Meaningful Use requirements. She said the practice underwent an expensive audit associated with the program that lasted more than a year, which had the ironic effect of delaying other programs aimed at improving patients' health.
If Stage 3 goes into effect, Atkinson said, she will be obliged to stop accepting Medicare patients, leaving 1,500 elderly and disabled patients without a primary care doctor. "I couldn't take care of my patients and take care of myself," she said.
Another physician mocked the requirement for a certain percentage of patients to use online patient portals to communicate with doctors. He said he has his secretary log in his patients, most of whom are geriatric, so that they can send "a note of clinical relevance... which says 'hi'."
Several physicians decried the program's one-size-fits all metrics. Lauren Henderson, MD,a pediatric rheumatologist from Boston, said that the requirement to develop a summary and care plan immediately after seeing a patient was unrealistic. She sometimes waits days for lab tests to be returned and also gains more context for a case by discussing it with colleagues.
Fernando Catalina, MD, PhD, a pediatrician from Leominster, Mass., agreed that certain metrics were inappropriate for certain specialties. "I think of this every time I check the blood pressure on a screaming 3-year-old who has an ear infection."
And a number of physicians, including Stack, commented on the futility of punishing providers for the failures of technology vendors. Stack said he has the knowledge and expertise to take a patient whose liver has ruptured through numerous protocols and into the operating room in just enough time to keep the patient from bleeding to death internally. " I shoudn't have to write the software code for the electronic health record at the same time."
Hope for change
In addition to lobbing complaints, members also described their ideal EHR platform.
Kenneth Mandl, MD, MPH, a professor at Harvard University and a researcher for the Children's Hospital Informatics Program at Boston Children's Hospital, said EHRs should be as adaptable as the apps on an iPhone.
"If the makers of Angry Birds want to add a new bird they don't have to fly to Cupertino... to figure out how to do that."
EHRs should have the capacity to update apps, substituting one for another, said Mandl. To make such a system functional, all EHRs would have to include an Application Programming Interface (API), he explained. "That's how all modern computers talk to each other and that's what you need in an EHR."
Mandl said the five top vendors including Athena have begun to implement EHR systems with such adaptability. One example is Argonaut, which has the capacity to run apps.
Other physicians and some vendors suggested the following changes to either EHRs or their regulations:
- Separating billing from EHRs
- Revising meaningful use metrics so they are specialty specific
- Having patients control their own data and carry it with them from site to site
- Placing the responsibility of interoperability on vendors instead of punishing physicians
- Enabling patients to have surrogates who can access their data, this could include physicians
The popularity of these suggestions with the audience was unclear, but there was clear agreement that physicians shouldn't bear the burden of ensuring interoperability.