Meaningful Use in Year Two and Beyond: Informing the Efforts of RECs

by Christopher Harle

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Physicians and other eligible health care professionals have shown broad interest in the meaningful use incentive program. As we enter year two of the program, it is informative to look back at first-year participation to inform efforts aimed at increasing electronic health record adoption in future years. According to CMS, in 2011, 29,344 eligible professionals received a total of $570,350,910 in incentive payments through either the Medicare or Medicaid incentive programs. Participation ramped up at the end of the year, with 50% of all eligible professionals receiving their payments in November and December of 2011.

Of note in the CMS statistics is that nearly 173,000 providers registered for the program, indicating far more interest than actual participation thus far. This is not necessarily surprising given the many known obstacles to successful EHR adoption. The well-documented barriers extend beyond the commonly cited financial obstacles that the meaningful use program tries to address. The non-financial barriers include time and information constraints, environmental and organizational factors, as well as social and psychological obstacles. Therefore, an important policy question is how can these non-monetary barriers be overcome as the meaningful use program evolves?

Regional extension centers are organizations funded by the government to assist eligible professionals in achieving meaningful use of EHRs and qualifying for incentive payments. Given the gap in the number of providers who registered with CMS relative to those who received incentive payments in the first year of the program, there is a need to further disseminate information that RECs and eligible professionals can use to help achieve widespread meaningful use of EHRs.

Obstacles to EHR Adoption and Meaningful Use

As indicated above, physicians and other health care professionals face numerous challenges in acquiring and using EHRs. In a recently published synthesis study, Albert Boonstra and Manda Broekhuis at the University of Groningen reviewed more than a decade of studies and identified eight categories of barriers to EHR adoption. Their synthesis of 22 previously published studies concluded that physicians most often cite financial barriers, technical barriers and time constraints.

The authors also point out a number of other barriers that are commonly cited by physicians and are related to the primary barriers. These include psychological, social and legal barriers, which encompass perceptions of limited EHR value, uncertainty about support from vendors, insurers and patients, and concerns about patient privacy. Boonstra and Broekhuis recommend that physician practices and policymakers pay particular attention to organizational and change process barriers, which include practice structure and uncertainty about culture, leadership and employee participation in EHR implementations.

With respect to meaningful use, we, along with colleagues, recently published an article that explored physicians' interest in -- and barriers to -- participating in the meaningful use program. While our study found that many physicians intended to seek meaningful use funding, 34% said they were unsure or would not seek funding. Among this group, the most common reasons given were the cost involved (62%), the need for more information about funding opportunities (42%), uncertainty about which system to purchase (38%) and uncertainty about implementation guidelines (30%). Our study also found that current EHR users were more likely to express interest in participating in the meaningful use program. Current EHR users also were less likely to cite concerns about EHR cost, privacy and security, and clinical relevance.

Overall, given this body of research, most barriers experienced by physicians are related to some form of uncertainty. Whether it is uncertainty about costs, uncertainty about how to select a product, uncertainty about the effects of EHRs on workflow or charge capture, or uncertainty in their staff members' ability migrate to a new EHR system, these are all issues that can be addressed by RECs.

What Can RECs Do?

RECs play a vital role in CMS' goal of widespread EHR adoption and meaningful use. Given the research described above, a large part of this role is to disseminate critical information that physicians need in order to reduce their uncertainty and make informed decisions when implementing EHRs. Indeed, successful RECs are currently engaged in this kind of dissemination. However, inevitably this information can be improved to be more germane, credible and focused on barriers identified in the most recent studies. Below are three recommendations for how RECs can help facilitate more widespread meaningful use of EHRs.

  • Recommendation No. 1: Sell the larger vision of EHRs in the context of meaningful use. RECs should strive to communicate the vision of a computerized U.S. health care system that will involve more reliable access to and sharing of health information, improved physician and patient decision-making and better care quality. This communication can help address psychological and social barriers to EHR adoption. Eligible professionals are more likely to buy in to the clinical relevance and value of EHR adoption if the overarching purpose of the meaningful use program is well explained.
  • Recommendation No. 2: Leverage known strategies in managing technological change. RECs should utilize physician champions who have successfully implemented and obtained benefits from EHRs. Champions can communicate firsthand knowledge of best practices and lessons learned in implementing EHRs successfully, including the effect on daily routines, patient-provider communication and charge capture. This can be achieved by recruiting current EHR users for direct contact with prospective EHR users or indirectly by "marketing" success stories from local physicians. RECs also should strive to detail the full complement of change management activities that are necessary for successful EHR implementation. These include purposeful review and selection of vendors, clinical workflow analysis and redesign, staff training and careful communication about the change with staff and patients. These strategies have been proven in and out of health care technology adoption and will help address technical, time, legal, psychological and social barriers by making the process of adopting an EHR system more understandable and manageable for physician practices of all sizes.
  • Recommendation No. 3: Don't forget financial barriers. While there are many other adoption barriers, paying for the selection, purchase, implementation and ongoing use of an EHR system still is a primary obstacle that eligible professionals must overcome. RECs should ensure that eligible professionals have comprehensive and precise estimates of short-term and long-term costs related to EHRs. These should be balanced with estimates of potential incentive payments and future penalties for non-adoption, as well estimates of other financial benefits that may be accrued. While exact estimates of EHR returns on investment are hard to come by, The Healthcare Information and Management Systems Society has attempted to provide guidance in this area with a calculator tool. RECs should use this tool when working with eligible professionals. They also should consider developing new tools that help eligible professionals more concretely assess the full set of financial implications associated with adopting an EHR.

The first year of the EHR meaningful use program saw tens of thousands of eligible professionals receive incentive payments, but that number was small compared with the number who registered for the program but have not yet fully participated. In upcoming years, it will be critical to support all eligible professionals in becoming meaningful users and maintaining that status.

RECs play a major role in this process and can benefit from the significant amount of research on health IT adoption and the management of technological change. The goal of nationwide EHR adoption depends not only on health care providers' ability to overcome primary financial barriers but also on their complete buy-in toward transforming their practices in accordance with best practices in change management, with the goal of more efficient and higher quality health care delivery.

Michael Milne
So only 173,000 out of a total of 800,000 doctors register and less than 87,000 apply for MU payment. That makes about 11% benefiting from MU. Since before MU more than than were claimed to be using an EMR, that means even those with a certified EMR couldn't care less. All this program has done is held back what needs to be done, let market forces let the innovative EMR products, some the real problem - crappy EMRs. Every excuse for a doc not using can be solved by the RIGHT technology. These bonehead government/legacy EMR lobbiest thought up solutions are nothing but a market effort to keep innovation out and corporate profits up. This is what is killing the US economy, whatever happened to innovation - and celebrating the new ideas and the hard workers - it is all about keeping the money now - this is a deadend for the US.
Bobby Gladd
Arggghhh... no typo edit function. :(
Bobby Gladd
"Just beyond the REC milestones of sign-ups & adoption, which has been celebrated by many for reaching, lie the true challenge & purpose of RECs -- helping PPCP to meaningful use." __ Uh, OK, Sarah Palin-esqe grammatical challenges aside, "helping PPCP to meaningful use" is -- by definition -- the 3rd MU milestone for RECs. Can you clarify your meaning here? " Meaningful Use" as YOU would interpret it vs the official CMS Attestation criteria? Our legislative and contractual mandates are those of the latter. BTW, Google the book "Medicine in Denial" for an exhaustive, erudite take on the noble broader inference (with which I could note agree more).
Bobby Lee
It will be interesting to reflect in few years to see whether RECs played critical, supportive or no role in effective adoption of Health IT & EHR across the country. Just beyond the REC milestones of sign-ups & adoption, which has been celebrated by many for reaching, lie the true challenge & purpose of RECs -- helping PPCP to meaningful use. I think 2012 will separate the thinkers from the doers.
Bobby Gladd
I'm sure all RECs appreciate the supportive information. I circulated this article link among our entire REC team, and will do so on the HITRC, and on my independent REC blog. It's been a contentious two years, and will only get more contentious, in my view. Nonetheless, a lot of people are doing a lot of good work on HIT, and will continue to do so.

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