EMR Fines Test Trump Administration’s Opposition to Bureaucracy

Earlier this week the Health and Human Services Office of Inspector General (OIG) released an audit report on $6.1 billion paid to 250,000 clinicians in the incentive program for meaningful use of electronic medical records (EMRs) (1). A random sample of 100 clinicians who had received at least one incentive payment revealed that 14 of them who had had not met all meaningful use requirements as they had attested (Table 1) (1,2).

Table 1. Meaningful use deficiencies identified in 14 of 100 clinicians.

• Six clinicians couldn't provide a mandatory analysis of security risks;
• Four clinicians couldn't prove that they had generated at least one list of patients-another requirement -who had the same condition;
• Three clinicians could not provide patient encounter data to document that they had met various meaningful use measures;
• One clinician had 90-days' worth of patient encounter data when a year's worth was needed;
• One clinician did not use certified EHR technology as much as required.

The OIG recommended that the Center for Medicare and Medicaid Services recover the $291,222 paid to the clinicians in the sample group and extrapolated the recovery to $729 million from the remaining clinicians based on this random sample. This is about 13% of the incentives paid to clinicians for the CMS EMR program. The decision to carry out the recommendation will ultimately fall to a US Department of Health and Human Services (HHS) secretary, Tom Price MD, who has opposed government programs that created regulatory hassles for physicians.

"We would protest if they went through with this," said Robert Tennant, director of health information technology policy at the Medical Group Management Association (MGMA). "Going after folks who tried to meet arbitrary government requirements, who made a good faith effort, isn't fair” (2). Tennant said that this complexity, made worse by evolving requirements, helps explain the deficiencies listed in the OIG audit. "I'm not surprised some providers found it daunting to keep up with the changes," he said. The requirement for a security risk analysis is a problem, Tennant noted, because CMS hasn't given clinicians sufficient guidance on how to meet the requirements. "This is a real stumbling block for smaller practices," he said. "They're not security experts, they're clinicians" (2). American College of Physicians Vice President of Governmental Affairs and Medical Practice Shari Erickson said that clinicians who originally attested to meaningful use lacked clear, specific guidance on what documentation they needed for each requirement (2).

CMS incentivized using EMRs because many clinicians were reluctant to initiate EMRs in their practices because of cost and efficiency considerations. Average costs to initiate an EMR were $163r,765 for a single practitioner and $233,298 for a practice with five physicians (3). Reimbursement under the EMR program was about $65,000 per provider (4). Furthermore, there was an 8% decrease in productivity after EMR initiation (3). In other words, if physicians wanted to see Medicare/Medicaid patients they were asked to use EMRs that cost them money and made them work harder.

The violations identified in the OIG audit seem fairly minor and are the type of trivial violations that the lawyers and bureaucrats seem to delight in identifying and excessively penalizing clinicians. In contrast, large health care organizations seem to go unpunished for more egregious violations. Witness the lack of action against Banner Healthcare for compromising 3.7 million medical records in 2016 (5). The average cost of data breach has been estimated at $398 per compromised record (2). Extrapolating, Banner should be fined nearly $1.5 billion.

Medicine is likely the most regulated industry in the US. Several of my colleagues have complained that the regulation seems more directed at them and not at the hospitals and insurance companies that seem to create most of the increase in cost and the violations. Some of the more paranoid clinicians viewed the EMR as nothing more than a tactic to gain further control of their practice and viewed Hillary Clinton as someone who would continue the onslaught on clinicians. These fines for EMR noncompliance are the first true test for the Trump administration in the area of healthcare regulation. Many of my colleagues are watching Trump and Price to see if their opposition to bureaucracy was merely lip service or has some backbone. 

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Levinson DR. Medicare paid hundreds of millions in electronic health record incentive payments that did not comply with federal requirements. Department of Health and Human Services. Office of the Inspector General. June 2017. Available at: https://oig.hhs.gov/oas/reports/region5/51400047.pdf (accessed 6/15/17).
2. Lowes R. Proposal to take back EHR bonuses galls med societies. Medscape. June 13, 2017. Available at: http://www.medscape.com/viewarticle/881563?nlid=115819_4502&src=wnl_dne_170615_mscpedit&uac=9273DT&impID=1368453&faf=1 (accessed 6/15/17). 6
3. Fleming NS, Aponte P, Ballard DJ, Becker E, Collinsworth A, Culler S, Kudyakov R, McCorkle R, Chang D. Exploring financial and non-financial costs and benefits of health information technology: the impact of an ambulatory electronic health record on financial and workflow in primary care practices and costs of implementation. The Agency for Healthcare Research and Quality (AHRQ). 2011. Available at: https://healthit.ahrq.gov/sites/default/files/docs/publication/R03HS018220-01Flemingfinalreport2011.pdf (accessed 6/15/17).
4. Hayes TO. Are electronic medical records worth the costs of implementation?American Action Forum. August 6, 2015. Available at: https://www.americanactionforum.org/research/are-electronic-medical-records-worth-the-costs-of-implementation/ (accessed 6/15/17).
5. Robbins RA. Banner hacked-3.7 million at risk. Southwest J Pulm Crit Care. 2016;13(2):80-1. [CrossRef]

Cite as: Robbins RA. EMR fines test Trump administration's opposition to bureaucracy. Southwest J Pulm Crit Care. 2017;14(6):312-4. doi: https://doi.org/10.13175/swjpcc079-17 PDF

Mitigating the “Life-Sucking” Power of the Electronic Health Record

An article in PulmCCM discussed “life-sucking” electronic health care records (EHR) (1). It is in turn based on an article in the Annals of Internal Medicine on the work time spent by physicians (2). The latter, funded by the American Medical Association, observed 57 physicians in internal medicine, family medicine, cardiology, and orthopedics over hundreds of hours. The study revealed that physicians spend almost two hours working on their electronic health record for every one hour of face-to-face patient time. Interestingly, physicians who used a documentation assistant or dictation spent more time with patients (31 and 44%) compared to those with no documentation support (23%).

The PulmCCM goes on to list some of the reasons that the EHR requires so much time:

• The best and brightest minds in software design don't go to work for Epic, Cerner, Allscripts, and whoever the other ones are.
• There's a high barrier to entry for competition now that most major health systems have implemented the big-name systems.
• The vendors can't easily improve the front-end design's user-friendliness (like web pages and consumer software have) because it rests on clunky, proprietary frameworks built in the 1990s and which can't be substantially changed for stability reasons. Think Microsoft Office, but way worse.
• Software designers are congenitally incapable of accepting the reality that a user would be better off the less they use the product, and designing it that way. They think their EHR is super cool, and can't fathom that it actually sucks to use.

Let me add another possibility. Those who demand implementation of the EHR see documentation as being most important because of the bottom line. It if comes at the price of physician efficiency so be it-as long as it does not hurt payment. Physicians are not paid for the required increased documentation much of which is unnecessary, redundant and, in some cases, downright silly (3). Furthermore, the concept that this improves patient outcomes largely seems to be a myth (4). Those manuscripts that report improved “quality” of care usually have examined meaningless surrogate metrics that often have little or even inverse relationships with patient outcomes (3). For example, high patient satisfaction seems to come at the price of increased mortality (5).

What is the solution-charge for the time. As it now stands, there is no downside to demanding pointless documentation. Third party payers can deny payment when something like the rarely beneficial family history is omitted. There should be a charge for seeing and caring for the patient and another “documentation fee” that is based on time. That would mean that a 20 minute office call would not be billed at 20 minutes but at the 1 hour of physician time the visit really consumes. Those physicians who use a documentation assistant or dictation can pay for these services by seeing more patients. Only in this way can the trend of wasting physicians’ most precious resource, their time, be mitigated.

Richard A. Robbins, MD*

Editor, SWJPCC

References

1. PulmCCM. Life-sucking power of electronic health records measured, reported, lamented. November 25, 2016. Available at: http://pulmccm.org/main/2016/outpatient-pulmonology-review/life-sucking-power-electronic-health-records-measured-reported-lamented/ (accessed 11/28/16).
2. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med. 2016 Sep 6. [Epub ahead of print] [CrossRef] [PubMed]
3. Robbins RA. Brief review: dangers of the electronic medical record. Southwest J Pulm Crit Care. 2015;10(4):184-9. [CrossRef]
4. Yanamadala S, Morrison D, Curtin C, McDonald K, Hernandez-Boussard T. Electronic health records and quality of care: an observational study modeling impact on mortality, readmissions, and complications. Medicine (Baltimore). 2016 May;95(19):e3332. [CrossRef] [PubMed]
5. Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med 2012;172:405-11. [CrossRef] [PubMed]

*The views expressed are those of the author and do not reflect the views of the Arizona, New Mexico, Colorado or California Thoracic Societies or the Mayo Clinic.

Cite as: Robbins RA. Mitigating the “life-sucking” power of the electronic health record. Southwest J Pulm Crit Care. 2016;13(5):255-6. doi: https://doi.org/10.13175/swjpcc125-16 PDF

Guidelines for Starting Today’s Private Practice

Starting a new practice may seem like a daunting task. The purpose of this editorial is to demystify the process of creating a new practice from the beginning. The cardinal rule is to keep costs low and not to outsource work that can easily be performed by any competent physician and staff. You do not need a manager, lawyer, business partner, coder or biller individually; you may be able to perform many of these services yourself. What you do need is a commitment to making your practice a success. 

Do not spend too much on your office space, furnishings or equipment. Start with the bare essentials. Immediately start applying to all insurance companies especially Medicare. Request an employer identification number. Set up a basic business banking account and submit the account number to the insurance companies you plan to work with.

You can purchase an entire electronic healthcare record (EHR) system or you can create your own EHR using basic word processing software, a free electronic prescription account and inexpensive billing software. Purchase malpractice, business and personal health insurance. Consider using a temp agency for staffing. 

High quality notes and good physician communication is paramount to success. Give community lectures and grand rounds at local hospitals. Introduce yourself to physicians by joining the local medical society, visiting other practices, applying for medical staff privileges and mailing an introduction letter. With the help of this paper you will be able to create your own private practice without delay.

Evan D. Schmitz, MD (evandschmitz@gmail.com)*

April Y. Schmitz, RN*

Hoan P. Tran, MD**

* The authors are in private practice in Richland, Washington and have no conflict of interest to declare.

** The author is in private practice in Yakima, Washington and has no conflict of interest to declare.

The views expressed are those of the authors and do not necessarily represent the views of the Arizona, New Mexico or Colorado Thoracic Socieities.

Reference as: Schmitz ED, Schmitz AY, Tran HP. Guidelines for starting today's private practice. Southwest J Pulm Crit Care 2012;5:229. PDF