We are having hearings for the Quality Measures Workgroup of the Policy (and Standards) committees for ONC-HIT on 5/19 in DC (I believe audio streaming will be available if you’re interested).  The hearings will involve 1) EP’s (Eligible providers) who have implemented thus far (obviously NOT MPP) 2) Vendors 3) Public representatives.  The idea is to get on record and help the workgroup understand the challenges with MU1 and perceived concerns for MU2 and MU3.




Two of the many guiding principles in developing the measures are 1) Parsimony (i.e. frugality – that is a reasonable number of measures which are “cross cutting” across measure domains and EP groups [aka specialties]. 2) HIT sensitivity – that is, reasonable measures which utilize IT means of collecting data in a reasonable way.


As I’ve said, I am the only full time practicing clinician on this committee.  In fact in a teleconference meeting yesterday, one of the non-physicians  (a think tank guru) mentioned that we should be concerned about the “little docs in the sticks” (a quote).  I retorted that I was one of those folks!  Being the “lone wolf baying at the moon”, it has been hard to make sure they know how their decisions will affect real clinicians and their processes.



On May 19, McKesson has a seat on Panel 2 (Vendors) in Connie Moser – an analyst for McKesson.  Interestingly, Sarah Corley, MD (some of you remember Sarah as a former Practice Partner end-user) will be representing NextGen (she’s the CMO).  Comments also from Am.Coll Cardiology and Am. College of Physicians.  (AAFP is not testifying – unfortunately).


There are other primary care physicians on the committee (FP and IM) but they are either CMO’s(Allscripts) or CMO’s of large organizations (Geisinger, etc) or represent other organizations (AMA, National Quality Forum, etc).  All have good intentions but each has their own agenda and perspectives.


I want you guys to do me a favor before 5/19.  If you would be so kind as to give me your thoughtful and constructive reply, I WOULD APPRECIATE IT VERY MUCH! I will distill the responses and be ready to comment for public record if the opportunity presents itself (after all, the hearing is for the people invited to testify).



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  •  Tripp_Bradd: 

    Thanks for all your replies -- I was able to share personally some of the concerns with one of the chairman of the Quality Measures Workgroup.


    Thanks again,


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  •  Jamie_Loehr: 

    I'd like to offer a different perspective.  My take is that the government is providing incentives to get practices to adopt EMRs.  (They are actually putting their money where their mouth is!)  They are not focusing on those practices which are already achieving quality care, they are focusing on those practices which need a nudge to move from paper to electronics.  Most practices know that it is a good idea to move to EMRs but are daunted by the cost or the hassle factor.  With incentives, hesitant practices might make the move earlier than they would otherwise.

    So yes, the criteria might not be exactly what I would choose.  The actual wording for smoking status is silly but the concept that I am addressing smoking status is not silly.  And yes, it might be taking focus away from advancing the products.  But if another 30% of practices join the EMR revolution, would that end up providing better care for more patients than if they picked the best criteria for the most advanced practices?

    And for me personally, it is a small annoyance to meet the MU criteria but the $18,000 per physician is very much worth it.  I can't say that will be true with Level 2 and Level 3 (more hassle and less money each year) but for now, I look at this as extra money that pays me for some of the investment I made in the past.

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  •  Janet_Mullins: 

    I would echo all of the above.  Bottom line for us is that we are already doing 95% of MU work but as stated several times above, not in the format the government has required.  We are busy trying to provide efficient, quality, evidence based medicine to our patients and our Medicare population is small so we are not holding our breath for any $ and if we do get some will not begin to help with the costs we have incurred in transitions to EHR.  We did this for ourselves and our pateints and not for MU in the first place.  We have lost much of our enthusiasm for MU as is not a realistic goal for much monetary gain for small practices and is teeming with beaurocracy and unrealistic requirements for reporting. We could care for more patients if not so exhausted by updating our templates all the time with new government wording for what we are already doing!

    Bottom line--I think a lot of money and time going into something that will not really impact the quality of patient care much but will provide lots of government and corporate job for implementation and oversee--reminds me very much of all of the "todo" about 2001 and the beginning of HIPPA!!!

    Janet Mullins

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  •  Don_Stewart: 

    Hi Tripp,

    I would absolutely echo what Ted has said.

    As an EMR user since 1997, I have found the whole "meaningful use" process a tremendous disappointment and a big step backwards for practice automation. 

    Many of the Phase 1 requirements (such as the allowable choices for smoking status) have minimal clinical utility, and will require tremendous re-engineering effort on the part of users who have been saving useful smoking status data for years so we can "dumb down" our system to meet the MU requirements.  And, new implementors will have to develop additional data fields for smoking status, since the required fields have no clinical usefulness.

    Physicians who have been using their EMRs in a meaningful way for many years are basically forced to abandon projects that would actually result in improved patient care in order to re-engineer their systems (making them less efficient) to get dollars that are promised.

    EMR vendors have been totally distracted from actually improving their systems and making them more useful for patient care, having turned all of their development energy into meeting the MU requirements.

    For no possible purpose at all except to make money for pharmacy benefit managers and clearinghouses, physicians are forced to abandon a safe, reliable technology like electronic faxing of prescriptions and to adopt the new, unproved, unreliable, and error-prone technology of electronic prescribing, which often results in higher costs to patients for their medications, since the PBMs often charge the patients a higher co-pay for their prescriptions than would be the cash price if the prescription were filled without insurance information at Costco or Wallmart.

    The biggest challenge I see, actually, is the switch over to ICD-10 in two years.  Although I intend to meet the requirements for MU1 this year, it is not likely that I could find the hours to go further with MU2 and MU3 and also to make the switch over to ICD-10 in 2013.  While I realize that ICD-10 is not part of the Committee's purview, they must realize that the required switch to ICD-10 will be a terrible disruption to physician practices, and that it would be foolhardy to expect that physicians would be financially motivated for MU2 or MU3 incentives when failure to make the switch to ICD-10 will result in no income at all. For me to switch to ICD-10, I will need to spend on the order of 1,000 hours to inspect every single template and quick text in my system and make the necessary modifications to maintain my workflow. Although this may only require a few hundred hours of physician time in partialist practices, primary care physicians need to implement the entire scope of ICD-10 diagnoses.

    There are lots of "stakeholders" in the process of automating physician practices.  The EMR vendors want to sell more EMRs and want to be sure that their customers pay high fees for tech support and to upgrade so that they can meet ever-changing requirements. They see interfaces as a perpetual revenue stream.  The clearinghouses and PBMs want to lock in business so that they are indispensible.  The insurance companies want to reduce their overhead and to get new excuses for not paying claims. The government wants to collect data to justify its existance.  Physicians want to make their practices more efficient so that they can take better care of patients, and to reduce their overhead so they can take more money home. Ultimately, our goal should be for better population health, improved quality of care, and lower cost of care. These goals are not consistent with the goals of many of the stakeholders.

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  •  Ted_Shively: 

    Hello, Brad,

    Some thoughts and Concerns:

    1. The cost in terms of dollars and allocation of scarce resources (time and personnel) expended on behalf of pursuing MU on the part of small to mediaum sized primary care practice are impossible to justify.

    2. The government money in play has dramatically distorted the normal market forces.  Software developers have turned all avaialble resources into making sure their pproduct attains certified status at the expense of support, product enhancements, and alternative approaches to the clinical issues.

    3. Clinicians have, in response to the same forces, delayed alternative development strategies, expended a lot of their time and resources to achieve MU status, not because it was clinically appropriate, but because of the financial incentives.

    4. The unintended but forseeable consequence of this is that the barrier to entry into primary care, especially for "the small doc in ths stix" (arrogant bastard) has just gortten much bigger.  There will be fewer new primary practices opening up.  Smaller ones, not willing to play this game, will either be absorbed by larger practices or dissolve.  I have seen some authorities predict that a full 40% of the independent primary practices will no longer exist or be independent in just 2 years. This is a travisty.

    5. Tripp, you and I know this whole concept of EMR implementation is vastly overpromised in its benefits and the costs of successful implementation are underestimated by the unintiated. We probably have 400 hours of physician time in implementing order entry alone.  At the end of the day, we have the strong possibility of creating a whole new set of clinial errors as pathways replace judgement, formularies replace thoughtful consideration and only hospitalists can figure out how to mange the hospitals compicated EMR therby effectively outsting the patient's PCP in many cases.

    6.  In sum,  the costs do not justify the gains in many cases in my opinion.





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