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Return on Investment Remains a Problem for Meaningful Use

Whatever direction the EHR Incentive Programs and meaningful use requirements take, they are already responsible for compelling providers into making costly health IT purchases.

The Hubert H. Humphrey Building is home to HHS headquarters

Source: HHS

A mixture of surprise and relief likely met the recent revelation by the head of the Centers for Medicare & Medicaid Services (CMS) regarding serious changes to meaningful use requirements that will bring the EHR Incentive Programs more in line with the federal agency's transition to value-based care.

Joined by the head of the Office of the National Coordinator for Health Information Technology, CMS Acting Administrator Andy Slavitt expanded on recent comments indicating the imminent end of meaningful use as it once was. The motivation behind the revelation was the need to place greater emphasis on patient outcomes rather than the means of achieving those ends (i.e., EHR technology).

"The EHR Incentive Programs were designed in the initial years to encourage the adoption of new technology and measure the benefits for patients," wrote Slavitt and National Karen DeSalvo, MD, MPH, MSc. "And while it helped us make progress, it has also created real concerns about placing too much of a burden on physicians and pulling their time away from caring for patients."

According to the two leaders, meaningful use is going to give way to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and its provisions for the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).

"The EHR Incentive Programs were designed in the initial years to encourage the adoption of new technology and measure the benefits for patients."

In coming to this conclusion, Slavitt and DeSalvo join the ranks of others who have argued that the EHR Incentive Programs had served their purpose and that the time is ripe for a dramatic change. Guiding the direction CMS (and ONC by extension) is taking are four principles, ranging from outcomes-based measures to advancing interoperability.

The changes may be months away, but they will be welcomed by eligible providers tasked with meaningful use reporting on top of other quality reporting programs. However, they do raise an important question from a health IT perspective: What does this decision-making mean for the current certified EHR technology (CEHRT) that was adopted for the sake of meaningful use?


Read: Ensuring Physician EHR Use Doesn’t Lead to Physician Burnout


Some healthcare organizations, such as Intermountain Healthcare, think meaningful use has already served its purpose
Some healthcare organizations, such as Intermountain Healthcare, think meaningful use has already served its purpose

Source: Intermountain Healthcare

Finding Value in Meaningful Use

As of November, CMS had disbursed upwards  of $19.6 billion for Stage 1 Meaningful Use and $1.5 billion for Stage 2 in EHR incentive payments to eligible professionals and hospitals. Nowhere within those figures are shown the costs incurred by eligible providers in selecting, purchasing, implementing, and maintaining EHR systems — otherwise known as total cost of ownership.

It is this financial aspect of meaningful use that Intermountain Healthcare Vice President and CIO Marc Probst views as ultimately an impediment to delivery care of the highest quality to patients.

"It was a good program to get technology rolled out," he tells EHRIntelligence.com. "There's no doubt that it achieved that. We have way more people using electronic medical records than we did before meaningful use. That's good. Now the but on that is it cost a lot of money and I'm not sure we got all the value out of it. That would be my strong opinion."

Probst's strong opinion was borne out of his experience balancing the priorities of Intermountain and the objectives of meaningful use.

"I believe my beliefs represent those of others," he continues. "I learned those beliefs by being at Intermountain Healthcare. They know what their priorities are and are very good about applying those priorities. Patient care is always, always at the top. We are fortunate because of decisions that have been made correctly and where we have been positioned financially."


Read: Breaking Down Stage 2 Meaningful Use Attestation in 2016


"We have way more people using electronic medical records than we did before meaningful use. That's good. Now the but on that is it cost a lot of money and I'm not sure we got all the value out of it."

A significant problem with the EHR Incentive Programs, Probst maintains, stems from the original approach taken by the those responsible for designing their requirements.

"We did some good things, but we spent a lot of money and probably didn't approach it the right way to get as much value as we could've if we just dealt with some basic issues like standards and interoperability before we thought about functionality," he says.

"We have way more people using electronic medical records than we did before meaningful use. That's good. Now the but on that is it cost a lot of money and I'm not sure we got all the value out of it."

For Intermountain, the value of EHR technology is closely tied to the healthcare organization's performance on national quality measures.

"We have been able to improve the value that this technology can bring to healthcare. We're still the lowest cost per capita provider in the country. If you go to just about any quality measure, if we're not in the top three then we're working really hard to be in the top three in those quality metrics. In most instances, we're one or two — whether it's cardiac care, neonatal care, or oncology."

"We really have proven that high quality lowers costs, and the way we have been both able to prove it and do it is through using electronic data and the systems that support it (and tailoring those systems to allow for that best practice care). We have been able to prove that over and over and we have lots of examples," he adds.

While an internal focus on quality has contributed to Intermountain's success as a care provider, it has come at the expense of missing out on EHR incentives. And Probst admits that the strategy is tenable for the likes of Intermountain and untenable for others.

"It would be a little arrogant of me to say that everyone should think the way we think," he claims. "There are people dealing with very tight margins and in instances losing money. Meaningful use can be the difference between keeping the doors open or not. We have to think about those folks. But here we're able to think the way that we do and we think it's the right direction."

Research bears out Probst's remarks. Last September, the Medical Group Management Association (MGMA) published findings from a survey of more than three thousand medical practices showing increased spending on health IT.

Between 2010 and 2014, MGMA reported an 33.97-percent increase in spending by physician practices on this technology. In 2014, these groups made investments of more than $20K for each full-time employee.

Back in 2011, IDC Health Insights anticipated that spending on EHR software to grow to $3.8 billion in 2015 — $1.4 billion for ambulatory EHR and $2.4 billion for inpatient EHR.

Clearly, provider expenditures and EHR incentives were not even.

Moving Beyond Meaningful Use

The decision by federal officials to shift gears will have serious consequences for eligible providers who have in good faith made significant investments in federally-approved EHR technology. What assurances then do these providers have that their current technology will be able to support the goals of their organizations in a world of value-based care? The answer to that question is one most providers won't want to hear.

"My guess is that it's going to be difficult," Probst maintains. "Where's the revenue going to come from now? The big vendors are getting most of that revenue and they can afford to continue to do R&D and enhance their products. For some of these smaller guys — and I'm talking mostly about physician offices at this point — it's going to be really difficult."

Presupposing this to be the case, eligible providers will be faced with a tough decision regarding their current technology.

"A lot of [certified EHR products] are not going to be able to survive, yet even those smaller products physicians are getting benefit from," Probst continues. "They are electronically documenting what they're doing with their patients. They are creating bills. They have an ability now with digitized data to share it with their patients. Is it really worth it to them to disengaged with whatever product they have and reinstall something different? It's obvious the answer is no. It's not worth it to them."

The EHR marketplace is a crowded one — and amongst CEHRT developers even more so. As far as eligible hospitals are concerned, several EHR vendors maintain dominance. These include Epic Systems and Cerner Corporation as well as the likes of MEDITECH, CPSI, and McKesson.

Certified EHR technology used by eligible hospitals for meaningful use attestation
Certified EHR technology used by eligible hospitals for meaningful use attestation

Source: Xtelligent Media


Read: Epic EHR Patient Portal Gets Interoperability Makeover, CEO Says


On the eligible professional side, the competition is more fierce but many of the same players still appear. Given the strength of companies such as Allscripts, athenahealth, Cerner, and Epic, their physician EHR end-users need not doubt about the future of these developers and their products. That being said, a total of 652 EHR and health IT vendors played a key part in helping providers demonstrate meaningful use successfully.

Certified EHR technology used by eligible professionals for meaningful use attestation
Certified EHR technology used by eligible professionals for meaningful use attestation

Source: Xtelligent Media

For its part, Intermountain recently decidedly to take a new approach to its EHR technology moving forward. Back in 2013, the health system entered into a strategic partnership with Cerner for the latter to become its EHR provider and host of choice.

According to Probst, the decision was made to move away from self-developed EHR technology so that Intermountain could increase its focus on care quality.

"Even with what we're doing with Cerner, the fact that we're being so deliberate in our implementation of it — that it isn't about speed but doing it correctly — we're trying to replicate a lot of that same capability within Cerner and it's actually why we selected Cerner because we felt that we could replicate a lot of it and have been able to."

"We will continue down that path," he elaborates. "Very little of that is driven by meaningful use. In fact, we have made some decisions that have cost us significant meaningful use dollars. It's not that we'll never do what meaningful use is asking for; it's just where we prioritized our activities."

LEGACY OF MEANINGFUL USE

In a report on the EHR Incentive Programs in 2011, the United States Government Accountability Office (GAO) pointed to numerous studies which indicated that that 78 percent of office-based physicians and 91 percent of hospitals had not adopted EHR technology.

The EHR Incentive Programs were responsible for three-quarters of eligible professionals and nine-tenths of eligible hospitals adopting CEHRT and demonstrating meaningful use. Those figures alone demonstrate how important meaningful use was to EHR adoption from 2011-onwards.

The legacy of meaningful use, however, is tarnished by developments over the past two years that saw eligible providers and EHR vendors struggle to keep pace with the demands of the EHR Incentive Programs.

Unable to hold fast to finalized regulation, CMS was forced to relent in several areas with regard to meaningful use requirements.

No longer do physicians and hospitals report according to different timelines. No longer do providers have to complete a full year of meaningful use reporting in 2015. What remains to be seen is what becomes of Stage 3 Meaningful Use whose future hangs in the balance.

"The process will be ongoing, not an instant fix and we must all commit to learning and improving and collaborating on the best solutions."

In describing the future of meaningful use, Slavitt and DeSalvo made four points clear.

First, statute requires meaningful use to continue although MACRA could ultimately lead to adjustments in how EHR incentives are dished out moving forward.

Second, the Medicare and Medicaid EHR Incentive Programs are distinct with the latter unaffected by MACRA regulation.

Third, CMS foresees a gradual transition coming to meaningful use.

Lastly, the federal agency has new powers to grant meaningful use hardship exceptions.

"The challenge with any change is moving from principles to reality," they wrote. "The process will be ongoing, not an instant fix and we must all commit to learning and improving and collaborating on the best solutions. Ultimately, we believe this is a process that will be most successful when physicians and innovators can work together directly to create the best tools to care for patients. We look forward to working collaboratively with stakeholders on advancing this change in the months ahead."

Whatever direction the EHR Incentive Programs and meaningful use requirements take, they are already responsible for compelling providers into making costly health IT purchases. And despite the willingness of federal officials to openly question the future of these programs, this moment of caprice does not minimize the financial risks taken by health systems, hospitals, and physicians toward a national mission of a learning health system.

Meaningful use isn't dead nor are the costs to providers likely to be forgotten until many years have past.

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