Cancel, Don’t Delay, Meaningful Use Stage 3 for Electronic Health Records

electronic-medical-record(A version of this Health Alert was published by Forbes.)

Over one quarter of the members of the U.S. House of Representatives – 116 of them – just signed a letter to the U.S. Secretary of Health & Human Services urging delay of the next step in the federal government’s struggling effort to impose uniform federal requirements for health information technology.

The rule in question is Meaningful Use Stage 3 (MU3), imposed by the federal government via the HITECH Act of 2009. The so-called “stimulus” act committed almost $30 billion to induce physicians and health facilities to install Electronic Health Records (EHRs) and move patient records beyond clipboards and manila file folders. These are worthy goals. Unfortunately, the $30 billion has pretty much all been spent, and there is precious little to show for it.

The cash windfall benefited companies selling EHRs. Cerner and athenahealth are two public EHR vendors. Cerner’s price has increased over six times, twice as much as the NASDAQ Index. Athenahealth has just slightly beat the NASDAQ Index. Other companies in adjacent business lines, such as Allscripts (which focuses on electronic prescribing) have also done very well. Many diverse IT businesses are expanding into health IT on the backs of this national investment in EHRs. IBM has made a very big push in health IT through its Watson super-computer business. IBM recently announced the friendly acquisition of Merge Healthcre, which digitally stores and analyzes medical images.

The EHRs were supposed to be interoperable – to speak to each other.  A new report from the Government Accountability Office (GAO) lists the most important benefits of interoperability:

  • Review results from diagnostic procedures conducted by other providers to avoid duplication;
  • Evaluate test results and treatment outcomes over time regardless of where the care was provided to better understand a patient’s medical history;
  • Share a basic set of patient information with specialists during referrals and receive updated information after the patient’s visit with the specialist to improve care coordination;
  • View complete medication lists to reduce the chance of duplicate therapy, drug interactions, medication abuse, and other adverse drug events; and
  • Identify important information, such as allergies or preexisting conditions, for unfamiliar patients during emergency treatment to reduce the risk of adverse events.

In an issue brief published by the National Center for Policy Analysis earlier this year, I discuss evidence that the imposition of centralized federal rules on EHRs has likely impeded, rather than encouraged, interoperability. And that is only after the first two stages of MU. MU3 is far worse.

Health IT consultant Margalit Gur-Arie has ridiculed it by suggesting (somewhat tongue-in-cheek) what physicians should do to ensure compliance:

  • Require each patient to provide an updated resume at least once a year, because you need to continuously collect and update work history, including positions held, and financial information.
  • In collaboration with your attorney, create a crosswalk based on State laws and meaningful use regulations regarding what you must ask or are barred from asking your patients. For example, in some states you are not allowed to ask about guns in the domicile, and for meaningful use you must inquire how often your patient goes to church, and whether he or she is a homosexual (regardless of your specialty). It’s a fine balance, and you don’t want to break any laws.

You get the picture. Further, although the carrots dangled to induce EHR adoption have been eaten, the sticks have just begun to swing. Medicare and Medicaid now punish physicians financially for failing to comply with MU. Even under the more lenient MU2 rule, 257,000 providers are already getting pay cuts. Many more will fail MU3.

Delaying MU3 saves some face for both the government and the providers who took that $30 billion. However, it would make more sense for the federal government to cancel MU3 and take a break from trying to impose a national standard, instead of allowing one to develop organically.

The health IT landscape is overwhelmingly complex, and it is unsurprising that the federal government struggles to create and implement appropriate incentives. This complexity is demonstrated in the recent GAO report, which surveyed 18 nonfederal initiatives towards interoperability of health data.

Of the 18, seven are developing technical solutions to interoperability. These solutions may include guidance on implementing standards, otherwise encouraging standardization, or providing services to vendors selling EHRs that allow them to test their interoperability. Five are developing less technical solutions, such as “encouraging” certain policies, promoting agreement, or tools that allow patients to aggregate their own data and share it themselves. The remaining six are actually operating or developing networks that will connect competing EHRs. Ten of the 18 initiatives began after January 2013. None are really fully launched.

Problems reported by the respondents include: Insufficient standards (especially lack of detail); variation in state privacy laws; accurately matching patients’ health records (for example, one system many use Social Security Numbers as identifiers, while another may not collect SSNs); costs (including legal fees); and the need for trust and governance among the entities.

Recall: This is after federal taxpayers have “invested” $30 billion in this show:

Conversely, representatives from two initiatives said that current federal work on standards duplicates existing private sector efforts, and representatives from a third initiative expressed concern that the government is not flexible enough to account for changing technologies and should therefore leave this issue to the private sector.

As for MU: “Representatives from 10 of the initiatives noted that efforts to meet the programs’ requirements divert resources and attention from other efforts to enable interoperability.”

In other words, federal intervention presents a distraction from the priorities the health IT workers on the ground think are more important. It is time for the federal government to get out of the way of health IT innovation and interoperability.

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