- Federal reporting requirements such as meaningful use have notoriously put a strain on healthcare organizations since the implementation of the HITECH Act of 2009, clouding the potential benefits of EHR technology with burdensome regulations that test providers’ patience and bottom line.
A Jacksonville, Florida-based practice consisting of two doctors and four staff members tried to get a jump on EHR adoption when the EHR Incentive Programs first went into effect. Business administrator Helen Jason and physician Rick Jason, DMP recently spoke to EHRIntelligence.com about how the well-intentioned federal incentive program quickly became an administrative nightmare.
“We embraced EHRs right away because we could see the potential,” said Helen Jason. “But it has fallen short of everyone’s expectations. Sure, you can talk to other doctors, and you can send everything electronically – but it wasn’t regulated well enough to make that happen.”
Apart from the burden imposed by federal requirements, Jason said she was satisfied with her EHR system’s level of usability.
“We’ve found EHRs are very good from an administrative standpoint – all the information is right at your fingertips,” she said.
The Jacksonville Foot Clinic adopted Health Fusion’s MediTouch EHR – a health IT offering that has since been absorbed by NextGen. Jason said the health IT company was thoroughly helpful during the implementation process and provided IT support to assist with setup. The EHR system was also equipped with tools to facilitate measurements for meeting requirements.
With sufficient IT assistance on hand and an EHR system specifically geared toward fulfilling meaningful use, Jason said the practice successfully survived the first year of the program.
However, mounting reporting requirements began to overshadow the technology’s benefits soon after the first year of meaningful use.
Keeping Up with Increasingly Challenging Requirements
While CMS intended the EHR Incentive Programs to reward meaningful use of EHR technology, negative side effects emerged soon after the program went into effect. Most notably, the stringency of meaningful use regulations compounded with poor EHR usability contributed to an industry-wide epidemic of physician burnout.
Furthermore, a recent study by the American Hospital Association (AHA) found federal programs, including meaningful use, have cost health systems and post-acute care (PAC) providers nearly $39 billion a year. Small practices in particular have been hit hard by the added costs and administrative burden brought on by changing regulations.
Jacksonville Foot Clinic managed to muddle through year one of meaningful use, but administration soon became fatigued and overwhelmed as federal entities ramped up requirements in later years.
“We embraced EHRs right away because we could see the potential.”
“We worked through year one and we got into year two,” she said. “Every year it just kept getting a little more challenging. I was required to work a lot more hours just to make sure everybody was on board each year, understanding what their role was, how they needed to do things, and how timely they needed to do things.”
While meaningful use was meant to reward rather than penalize physicians, Jason said regulations mostly achieved the latter.
“CMS basically said you don’t have to fulfill these requirements, but if you don’t do it, you’re going to lose income,” she said. “As a small practice – we’re in podiatry – we can’t afford to lose that income if we want to stay in business.”
After talking to other physicians, Jason learned she wasn’t alone in her frustrations.
“We’ve met several physicians that have decided to just take the loss because they didn’t have the staff member or couldn’t afford to hire a staff member to take on implementing and setting up everything to meet regulations,” she said.
A study earlier in 2017 surveying opinions of 15 health IT experts also highlighted the challenges small practices have faced as a result of federally-enforced EHR adoption. Experts showed concern that the requirements could lead to the loss of the small physician practice. One expert panelist had recently left a small practice for a larger one due to financial stress.
Jason has similarly felt as though regulations are pressuring physicians in small practices to merge with their larger counterparts.
“It’s almost as if they’ve structured these measures and the healthcare system to be even more challenging to inhibit the entrepreneur from staying in business,” she said. “We’re not exactly in a practice that suddenly wants to merge into the local hospital. I don’t think it would be good for patients.”
However, Jason believes federal entities initially had good intentions when designing and enforcing meaningful use.
“My take is that the government thought meaningful use was going to improve medicine and make it more affordable,” she reasoned. “But they may have gone overboard. It’s not improving medicine — it’s just putting more work on the staff.”
As federal entities such as CMS began listening to stakeholder feedback, federal regulations have changed so frequently that some providers are more confused and stressed than before.
“We’ve kept up and we’ve done what we needed to do and it’s taken a lot of hours — which costs money — to monitor everything and make sure it’s right,” said Jason. “Then the government comes out and says they’re changing regulations or they can’t agree on how to change things, or Congress has decided to change something. They’ll say hospitals are having a hard time, so we’ll give them a longer time to qualify. Meanwhile, we already bit the bullet, paid the dues, and paid the money to make it happen.”
For Jacksonville Foot Clinic and other practices that tried to get a headstart on fulfilling federal requirements, these sudden changes can mean wasted money, time, and effort.
In addition to frequent changes, Jason said administrative staff has also had trouble with some measures that have been especially difficult to fulfill.
“I've talked to other doctors' offices about this – when you got into meaningful use, one simple regulation was that all patients have to have access to the notes from their visit. I understand why they want patients to see physician notes and I think it's great,” she said.
Jacksonville Foot Clinic often deals with an elderly population. As a result, many of these patients are not familiar or comfortable going online and accessing their patient portal.
“They may know how to go online to keep up with their kids or look at Facebook, but they don't know how to use their portal,” Jason explained. “And so we have to print this information out. Do you know how much paper you use? It's an unbelievable amount, and we're supposed to be going to paperless.”
“They’ll say ‘ok, I’ll go in and check it,’” she continued. “And we’ll keep telling them we really need them to take a look at this and log on and look at their information. But how do you force a patient to do that?”
Penalizing physician practices for their patients’ behavior is not a logical way to promote health IT use, said Jason.
“Those are the kinds of measures that needed to be reevaluated,” she posited. “We know why they’re making these measures, but this isn’t the way to do it. Again, it puts more of a burden on the office. The government got some bad feedback about that measure and they changed it to one patient – originally it was five.”
While CMS and other entities have since made efforts to streamline reporting requirements for small practices, the burden of maintaining a read on the pulse of the industry and maintaining an EHR system has still weighed heavily on the clinic.
Adjusting to accommodate regulations
To keep pace with reporting requirements, the clinic hired a new administrative employee. The decision to take on another staff member has put added financial strain on the practice, but Jason said the investment was necessary.
“We had to create another position just to monitor and implement new regulations and make sure doctors are attesting correctly,” she explained.
The additional staff member has helped to significantly reduce administrative burden for Helen Jason and Dr. Rick Jason. However, not all small practices are willing to go to such lengths to accommodate regulations.
“Someone involved with making these changes should really shadow small doctors and hospitals and get a feel – especially when a program is rolling out – for what these practices are doing,” said Helen Jason.
Jason also recommended federal entities be more sensitive to the specific needs of small and specialty practices.
“We had to create another position just to monitor and implement new regulations and make sure doctors are attesting correctly."
“I think there needs to be more limitations in the level of participation for a small practice or smaller group versus larger groups is the first thing,” she said. “And within those limitations, I think they need to be more specific to just that area of medicine that a clinic is practicing.”
Presently, many measures do not apply to specialty practices. Measures that do apply often misalign with what small practices believe would improve clinical outcomes. More specific measures that apply to specialty practices could be easier to fulfill.
Furthermore, Jason suggested federal entities settle on a set of regulations – and stick to it.
“If they keep changing things, how long is our EHR company going to keep making these modifications and not charging us for them in order to track them?” she asked. “That's one concern that has always been there, and it had a lot to do with why I went with Health Fusion's MediTouch. They had a commitment right up front that they would not charge us for any changes to the system.”
“But I know not all EHRs are the same,” she continued. “And as our regulations keep coming and keep changing, that means they need to build new programs and modules into our systems, which is a lot of work for them, too.”
While meaningful use and other federal incentive programs may have been initially designed with providers’ needs in mind, complex regulations have grown more stifling than encouraging. Federal entities will need to keep requirements specific and minimal to help small practices avoid physician burnout and financial hardship.