Meaningful Use: The Pretend Program

The year 2015 was a big year for the Meaningful Use program (Medicare and Medicaid EHR Incentive Programs). It was the year when the Meaningful Use program unofficially became Meaningful Use: The Pretend Program.  Before 2015, the primary focus of the program was to distribute EHR (Electronic Health Record) incentive payments to private healthcare professionals and hospitals and not to providing patients with electronic health records that delivered Meaningful Use.  I could call this the Handing Out Incentive Money phase of the program, but I have chosen to dub it the Pretending to Populate EHRs phase.  Most of the incentive money has been paid out or allocated during this time.  The government called this Stage 1 Meaningful Use.  While handing out incentive money, the government pretended that the shareable files that were being placed in EHR patient portals would deliver Meaningful Use.  At the end of 2015, these electronic health records for improved coordination of care, reduced healthcare spending, and improved patient outcomes simply did not exist for the vast majority of patients.

In October 2015, the Centers for Medicare and Medicaid Services (CMS) put out its Final Rule and the Meaningful Use program went from the Pretending to Populate EHRs  to the Pretending to Share EHRs phase. CMS officially calls this new phase the Modified Stage 2.   After 2015, the primary focus of the program is to wind down the Meaningful Use effort because most of the program funds have been spent. I could call this the Get Out of Dodge phase of the program, but I have chosen to dub it the Pretending to Share EHRs phase to emphasize the impact on patients.  With the Meaningful Use Final Rule, sharing (“interoperability” in government-speak) has been watered down to mean one patient viewing, downloading, or transmitting incomplete Clinical Summary Reports with marginal Meaningful Use value.

Meaningful Use the Pretend Program

Pretending to Populate EHRs (2011-2014)

The first four years of the Medicare and Medicaid EHR Incentive Programs were largely spent convincing private healthcare businesses to make electronic copies of their health records available for sharing with patients.  These health records were largely in paper form or in Electronic Medical Record (EMR) software and inaccessible by patients or other healthcare providers.  The government effort would require the active cooperation of hundreds of thousands of healthcare businesses to deliver these shareable electronic health records in a form that provides Meaningful Use to others.  This was a tall order given that patients (and not the private healthcare businesses) were to be the primary beneficiaries of shareable electronic health records.  The program had to be designed with the financial interests of private healthcare businesses in mind as our government has learned from lessons in the past.  Incentive payments to cover some of the costs associated with the new certified EHR technology were provided to sweeten the deal and elements of program design were tailored to maximize cooperation.  Medicare and Medicaid reimbursement penalties for non-compliance were included in case the healthcare businesses dragged their feet or refused to cooperate.  I have summarized how the Meaningful Use program got its start in the graphic below.

Making of meaningful Use Program

To receive incentive payments (maximum of $44,000 per eligible professional over five years, more for Medicaid participation), healthcare professionals simply had to “self-attest” online that they were compliant with specific program requirements. Imagine if you could annually “self-attest” to your job performance at work or to your income in your tax forms every year!  Everyone (the honest and not so honest) would have a lot more money in your pockets today.  The regulators in charge of the Meaningful Use program (at the Office of the National Coordinator for Health Information Technology (ONC)) are much more trusting than either our employers or the IRS are of us.

Unfortunately for the regulators at ONC and America’s consumers of healthcare, extracting the shareable electronic health records from the healthcare providers and hospitals proved problematic. These private healthcare businesses simply did not cooperate.  Most healthcare businesses dragged their feet (four years should have been more than enough time) and complained at every step of the process.  In a Report on Health Information Blocking submitted to Congress in April, 2015, Regulators at ONC identified that there are healthcare providers who were intentionally blocking access to electronic health records and “knowingly interfering with exchange of information. Confronted with healthcare professionals intent on limiting how much of their health records saw the light of day, the ONC bureaucrats took the original Meaningful Use requirements and repeatedly watered them down. This situation is graphically shown below.

Pretending-to-Populate-EHRs in Meaningful Use

The the ideal Meaningful Use content of the shareable electronic health records would include copies of all the patient’s Protected Health Information (PHI) in the designated record set (guaranteed by HIPAA).  The actual files we have from the Pretending to Populate EHRs are incomplete Clinical Summary reports with dubious Meaningful Use value.

Pretending to Share (2015-2017)

At the end of 2014, 257,000 eligible professionals (a majority of the total participating) entered into the penalty phase and were notified that their reimbursements from Medicare would be cut by 1% because they weren’t using shareable electronic health records in a “meaningful” way.  Pretending to Populate EHRs is a lot easier than Pretending to Share EHRs because the latter requires that the former had been completed and there were patients who found incomplete Clinical Summaries worth sharing!   This created another dilemma for  ONC–with most of the incentive money already distributed or allocated, what was left to “incentivize” the eligible professionals to deliver Meaningful Use?   More importantly to the leadership at ONC, this sharing (Stage 2)  impasse was jeopardizing the successful conclusion of the entire Medicare and Medicaid EHR Incentive Programs?

As usual, ONC came to the rescue of the non-complying healthcare businesses–not by finding a way to make them deliver Meaningful Use, but rather by watering down the requirements further in the Meaningful Use Final Rule announced in October, 2015.  With a slight of hand, ONC decreed that all healthcare professionals stuck in Stage 1 Meaningful Use were to be reclassified to Modified Stage 2 Meaningful Use status. Eliminating Stage 1 means that ONC is moving from its Pretending to Populate EHRs to the Pretending to Share EHRs phase of the Medicare and Medicaid EHR Incentive Programs . “Grade inflation” to cover up inadequacies of the program has moved out of the public schools into the Meaningful Use effort and those hurt by the grade inflation are the patients!

In the watered down 2015-2016 requirement for sharing (called Stage 2 Measure 2), the healthcare business is only required to show that ONE patient viewed, downloaded or transmitted to a third party his or her information during the reporting period (90 days).  I thought the earlier 5% threshold requirement was low already!  If a requirement of only ONE patient isn’t Pretending to Share EHRs, then I don’t know what is.  The story gets even better.  Because proprietary software is generally not designed for interoperability, the sharing requirement can be satisfied by emailing the records instead of by direct transfer from one EHR patient portal to another.

I would like to think that the response by healthcare professionals to sharing electronic health records I describe above is not universal. A few healthcare professionals are probably embracing the spirit of shared electronic health records and are truly putting the best interests of the patient ahead of their own financial interests. Unfortunately, these healthcare professionals are probably employed by and not owners of private healthcare businesses.  Healthcare business owners who put their financial interests ahead of patients and the common good should have been treated like “hostile witnesses” in a court case rather than partners with the ONC in this effort to bring shareable electronic health records for the benefit of patients.

The Bottom Line

As the Medicare and Medicaid EHR Incentive Programs wind down because most of the incentive money has been handed out to healthcare professionals and hospitals, the patients (and taxpayers) quietly wait for the shareable electronic health records the programs were supposed to deliver.  These health records are supposed to be the foundation for improved coordination of care, reduced healthcare costs, and improved patient outcomes.  The private healthcare businesses have taken $33+ billion and counting in free taxpayer money to improve their health IT infrastructure without electronically sharing much of the health records they own.  The  medical software industry has grown tremendously when the market for lucrative EHR certified software packages exploded. The bureaucrats at ONC (past and present) have happily been employed for many years and several have moved on to bigger and better positions.  The only groups not smiling from this effort are the taxpayers and patients who still do not have access to shareable Electronic Healthcare Records that deliver Meaningful Use.

What are we, patients and taxpayers, doing about this situation?  Join BB’s Healthcare Brigade and become a foot soldier in our effort to bring our health records into the open where they can be used for our benefit.

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