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AMA’s Stack: CMS Should Have Declared Victory After Stage 1, Gotten Out of the Way

March 2, 2015
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AMA's president-elect urges CMS to abandon meaningful use program’s one size fits all and all-or-nothing paradigm

Healthcare Informatics has run several stories recently based on the American Medical Association’s stated concerns about the meaningful use program. The AMA announcements usually contain prepared statements by Steven Stack, M.D., an emergency room physician and AMA’s president-elect. I had the chance to hear Dr. Stack speak a few weeks ago at the eHealth Initiative conference in Washington in early February, and I thought he made a strong case that physicians want EHRs to function well in support of their work, and they want to collaborate with other stakeholders to improve systems and quality measurement programs. But he did have some sharp criticisms for the meaningful use program, and I found myself agreeing with many of his points. He could speak from his own experiences about the frustration of trying to read through 70-page transition-of-care documents. I thought readers might be interested in some of the highlights of his talk, from the notes I took that day.

Stack started off by noting that in 2013, the AMA contracted with RAND Corp. on a study that was intended to find some of the pressure points in doctors’ lives. The initial study design had nothing to do with electronic health records, because the initial design was before the HITECH Act. But when the researchers did the initial fieldwork to gauge the value of the survey, talk of EHRs came up so much that to not modify the survey would have been a complete misuse of the tool, he said. They added some questions and asked for open-ended feedback. What they found when they released the results last fall was that  “80 percent of physicians don’t want to go backwards,” Stack said. “They want electronic health records to work. They get that managing a fifth of the economy and the most important information to personal well being in an archaic paper-and-pencil world is not consistent with the way we manage information in other sectors of society. They get that. But they utterly despise their EHR experience. They don’t want to go back. But they are miserable with what they have now.”

Stack said there were many reasons, both technological and policy-related, that EHRs were not being adopted years ago, With the HITECH Act, he said, the federal government “didn’t let a crisis go to waste and I think we should be very thankful in many ways,” he added. “We have made great progress. We now have a vibrant sector of health IT that was not vibrant before HITECH and meaningful use.”

But he noted that one of the things the government doesn't do well is course-correct. “It is so hard to get things in place that once they are in place, they are almost chiseled in stone,” he said. “In the case of meaningful use, the government should have declared victory. We need people to adopt all these things and reach network effect and scale and then the government probably needs to get out of the way,” so that health IT vendors can respond to the physician and hospital and patients as customers. “But what we have now is a situation where the government has replaced the physician and end-user as the customer.” Because EHR vendors are designing products to fulfill certification requirements directly tied to meaningful use that are not tied very well to what clinical care is and disrupts the lives of physicians. It adds a lot of stress to physicians when they are already under a lot of other stresses, he said.

Stack said he has the impression that a lot of folks who would like to pretend meaningful use is yesterday’s news and move on. “We are talking about moving to value-based payment and population health management. Those are all very important things. We agree with them as concepts. But the reality is that meaningful use as a policy tool is alive. I am not sure it is well, but it is alive. And what’s happening in 2015 is that out of 491,000 Medicare-eligible providers, 257,000 or 52 percent are going to get a 1 percent penalty on 100 percent of their Medicare payments.”

“Fifty-two percent is not an obstinate few,” Stack said. Fifty-two percent is a design problem, a systems problem, he said, adding that CMS should abandon the program’s one size fits all and all-or-nothing paradigm. “You have all taken a lot of tests,” he said to the audience. “Have you ever taken one where 99 percent or less is fail? Someone once said it is a test where you get an A or an F. They need to abandon one size fits all in order for it to be useful for physicians.”

Yet despite all the criticisms of meaningful use, Stack stresses that physicians really do want EHRs to work well and interoperate. “There are always going to be pain-in-the-keister doctors just like there are pain-in-the-keister EHR execs and hospital execs,” he said. “I don’t really worry about the outliers as much as the bell shape. The bell shape folks are a lot of people trying to do the right thing. The truth is that if you build quality programs to pay for quality, and the programs themselves are completely flawed, you can’t look me straight in the face and tell me you are paying for quality. We really do care and enjoy working with other stakeholders. We really have made a lot of progress and we are going to make a lot more. We have a lot of big things we can work on right now that are really important to our success.”