Electronic Medical Record Successful Usage –Fact or Figment?

Recently Health and Human Services announced that it had exceeded its target of Electronic Medical Record (EMR) implementation by paying more that 50% of ‘Eligible Professionals’ almost $6 billion in incentive payments (with more to come)based on their ‘Meaningful Use’ of EMR systems. All of this effort is an outgrowth of the requirements in the American Recovery and Reinvestment Act of 2009 (ARRA), the so-called Stimulus Bill.

Indeed this can be seen as a milestone in the overarching effort to migrate the healthcare industry to EMRs but more importantly introduce interoperability between healthcare parties for EMR transmissions via Health Information Exchanges (HIEs).

Moreover the industry, which is the beneficiary of the incentive payments, has by and large endorsed the program.

But, is this an unqualified success? There do appear to be several considerations that might temper this ‘success’.

First, it has been noted in the November, 2012 report by the Inspector General of Health and Human Services in its analysis of the incentive program that… CMS (Medicare) is unable to verify that the ‘Meaningful Use’ claimed by Eligible Professionals for incentive payments is actually being performed. This results from the fact that some of the payment criteria for ‘Meaningful Use’ cannot or will not be audited—specifically criteria using ratios of EMR patients to total physician patient population and various yes/no criteria—all of which are not produced by the EMR systems. The Inspector General then goes on to critique the ONC (Office of National Coordinator) for allowing certification of EMR systems (through the $640 million Regional Extension Center Program) without regard to how information would be developed for later Meaningful Use criteria. The bottom line is that one cannot really be sure that the EMR systems are really being used, at least with respect to the criteria on which incentives are being paid.

So much for that. But,secondly we have another Inspector General Report dated May, 2013 (Office of Inspector General Department of Health and Human Services, ‘Improvements Needed to Ensure Provider Enumeration and Medicare Enrollment Data are Accurate, Complete and Consistent’ OEI-07-09-0040) which reaches the remarkable conclusion that ‘in NPPES (National Plan and Provider Enumeration System) provider data were inaccurate in 48% of records…Addresses, which are essential for contacting providers and identifying trends in fraud, waste and abuse were the source of most inaccuracies… finally CMS did not verify most provider information in NPPES. Since CMS relies on the NPPES and associated databases to effect payments to Providers, a possible implication is that one cannot really be sure that incentive payments are actually being paid to the users of EMRs.

Finally there could be a question about the number of ‘Eligible Professionals’ that CMS has used to calculate that over 50% are ‘Meaningfully Using’ EMRs. The higher the denominator, the lower the percentage of Eligibles participating. CMS incentive payments are to ‘non hospital based’ physicians (hospitals get their own independent incentives), which has been defined as those professionals spending at least 11% of their practice time outside of a hospital setting. They then go on to estimate that ‘non hospital based’ Professionals constitute 73% of the total Professional population. This again is not an auditable calculation and relies on personal attestation rather than any objective measure. But based on two facts –most ‘hospital based’ physicians excluded from the ‘denominator ’ also practice in settings other than a hospital (groups, solos, faculty plans, community centers, etc.) and in many cases these professionals would be hard pressed to define the amount of time spent in each setting. It is very easy to envision that they could legitimately claim to be eligible for individual incentives despite the preponderance of time in a hospital setting. In addition the definition of Eligible Professionals includes other healthcare categories such as Dentists, Chiropractors, Opticians, Podiatrists…and for Medicaid incentives-Certified Midwives, Physician Assistants, Nurse Practitioners, etc. and most of these Professionals are non hospital based. Using some different estimates of ‘Eligible Professionals’ the current paid incentive population may represent less than 30% of ‘Eligible Professionals’ and for physicians who are ‘Eligible Professionals’ perhaps less than 35%. There is just no way to ever know. But this could be a world of difference in terms of the overall acceptance and use of EMRs.

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November 2017
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