To assist and motivate physicians and hospitals to work towards Meaningful Use, the government has implemented a qualification program of incentive payments for Medicare and Medicaid participating providers through the Center for Medicare & Medicaid Services (CMS.gov, 2013).43 As part of the 19.2 billion dollar HITECH Act stimulus package, eligible participants who show Meaningful Use in converting their records to EHRs, may receive payments up to $44,000 dispersed over a five year adoption period through the Medicare EHR Incentive Program and up to $63,750 dispersed over a six year adoption period through the Medicaid EHR Incentive Program. Of course, providers must treat Medicare and Medicaid patients and must demonstrate prescribed standards of usage (Centers for Medicare and Medicaid Services, 2013). All eligible participants must therefore register for each of the EHR incentive
programs and then “attest” to meeting the requirements.44 This incentive system is designed in
stages for adoption and appropriately called “The Stages of Meaningful Use.”45
In brief, the stages, projected implementation deadlines, and general purposes are outlined as follows: Stage One (2011-2012) for data capturing and sharing; Stage Two (2014) for advance clinical processes; and Stage Three (2016) for improved outcomes. 46, 47 Final criteria for all three stages remains pending, with Stage One only finalizing specific criteria and beginning to accept proof of Meaningful Use as of July of 2010.
For Stage One, all eligible parties must be examined on 25 total criteria with 15 required core competencies and 5 out of 10 menu requirements. Although reaching Stage One Meaningful Use is currently voluntary and rewarded with maximum incentive payments, federal laws require that Medicare reimbursement rates for non-participating physicians will decrease for all eligible professionals who do not meet Stage One requirements by 2013 (technically within 90 days of the end of the fiscal year which is September 30, 2012) and will likely see at least a 1.5% Medicare pay reduction by 2015 or sooner (American Medical News, 2012). Some project deeper, longer lasting penalties in reimbursements for subsequent years by 2% in 2016, 3% in 2017, 4% in 2018, and as high as 95% in future years (MedicalRecords.com). There is no way of predicting for certain the extent of these penalties, but they will happen. Incentive
44 These programs are sometimes referred to together as the “Medicare and Medicaid EHR Incentive Program
Registration and Attestation System.”
45 The following link may be used for details concerning this program of “stages”: http://www.cms.gov/Regulations-
and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/.
46 See http://www.healthit.gov/policy-researchers-implementers/meaningful-use.
47 Discussion of the communication ramifications of these stages is in Section 1.1.3.3. For now this summary is
payments have motivated some, but penalties will likely motivate others either to begin EHRs or at worst drop out of the medical profession altogether (Pittman, 2013).48
Surprisingly, despite the backlash and resistance to Stage One Meaningful Use, the government surged ahead on requirements of Stage Two, which were already slated to begin application for reimbursement payments on January 1, 2014 for physicians and October 1, 2014 for hospitals. Many have questioned the aggressive push forward when not all eligible parties have even completed Stage One. In fact, the American Medical Association (AMA) and the American Hospital Association (AHA) currently challenge these dates, arguing that requirements are too stringent and too soon for adequate conversion for the vast majority of the users. Although the AMA and AHA support widespread adoption of EHR systems, they feel flexibility in the programs must be achieved in this already “over burdensome” set of laws (Commins, 2013).
A specific example of this resistance is recorded in the AMA’s “Proceedings of the 2011 Interim Meeting of the House of Delegates,” which were approved on June 17, 2012. In their “Reports of the Council on Medical Service” (American Medical Association, 2012, pp. 85-111), particular attention was given not only to the lack of readiness and pressure experienced by the healthcare profession in responding to the push of this new law but to the problems emerging with EHR safety, accuracy, and standardization (something that EHRs promised to rectify, not increase). It was further stated that “formats may impede the provision of quality patient care and impact patient safety” as the lack of a standardized report format [through EHR record-
48 According medpage.com, the 2013 Deloitte Survey of U.S. Physicians found that 62% of tested physicians stated
that their colleagues will retire earlier than planned in order to miss the Meaningful Use penalties. Others will reduce their work hours or simply go into a related field that does not see patients. (Pittman, 2013) For the original Deloitte Survey, the following link may be helpful: http://www.deloitte.com/view/en_US/us/Insights/centers/center-
keeping and transfer of data] “has the potential to increase interpretation errors and decrease efficiency as physicians review unfamiliar reports with varying layouts” (p. 91). In addition, it states, “While standardizing report formats and terminology hold the potential to reduce interpretation errors, improve quality of care and promote patient safety, there are concerns that standardization could overly simplify results and unintentionally omit critical information” (p. 91).
Ironically the AMA is arguing that standardization on one hand might increase interpretation errors with variable report formats while at the same time realizing this might increase errors because of the oversimplification of the formatting. That is to say both the lack of standardization and the abundance of it may lead to serious error. The system as it stands does not appear to be “fool proof” by any means. The AMA argues that further assessment of these stages is needed before rushing forward to subsequent stage requirements. In addition to these reservations concerning Stage One, the AMA argues that “Stage Two standards are too aggressive and burdensome for physicians” and that “the Meaningful Use EHR program will remain low unless the Stage Two requirements are made more flexible” (American Medical Association, 2012, p. 91). Certainly a “red flag” is being raised by the AMA warning governmental agencies to slow down (not speed up) the process for the sake of staying on the original schedule established by the HITECH Act.
Even the American Academy of Family Practice (AAFP) through a letter by Board Chair Glen Stream, MD to CMS Administrator Marilyn Tavenner on August 7, 2013 requested that Stage Two Meaningful Use be delayed by at least 12 months for fear that the program will “outstrip the capacity of many certified electronic health record technology vendors and ambulatory family medicine practices” (Leawood, 2013). Stream further argues that “2014
brings a perfect storm of regulatory compliance issues for family physicians that, we fear, may derail health information technology adoption and substantially interfere with our shared progress toward achieving better care for patients, better health for communities and lower costs through improvements to the health care system” (Leawood, 2013). And this is only one of the many professional medical academies who do voice their opinion on delaying this move forward. Despite these warnings, governmental agencies proceed forward, however, not without caution. On August 16, 2013, the Healthcare Information and Management Systems Society (HIMSS) called for changes in the Stage Two Meaningful Use timeline by suggesting that the attestation period be extended a full 18 month period (through April 2015 for eligible hospitals and June of 2015 for eligible physicians) to allow time for those who have purchased EHR systems to upgrade their technology versions of electronic records in time for the Stage Two deadlines. The AHA supports this as being the most realistic extension for attestation while allowing those ready to proceed forward to do so (Murphy, 2013).
With such concerns over the progress of Stages One and Two, plans for Stage Three remain on target but certainly far from finalized. At best the U.S. Department of Health and Human Services suggest that discussions at least continue with a three-part focus on Meaningful Use objectives and measures, quality measures, and, again, privacy and security. A preliminary and quite detailed document was created in October of 2012 called the “Meaningful Use Workgroup Stage Three Recommendations” (Tang & Hripcsak, 2012). The timeline outline is quite specific as well with a proposed approval of final Stage Three recommendations by April of 2013. This deadline was obviously not met. Further discussion and analysis of the entire Meaningful Use process remains open for continued review and revision. At the same time, it
must be restated that a very strong impetus for change and immediate change continues to exist throughout governmental offices with little sign of letting up.