Q&A: Dr. Steven Waldren On What's At Risk With E-Health Records

It's time for doctors to move on EHRs or get left behind, says head of American Academy of Family Physicians health information group.
InformationWeek: The meaningful use rules aren't finalized yet and assuming the final rules stay close to what's been proposed, what are the biggest hurdles for doctor practices to meet the criteria and be eligible for incentive payments from the federal government?

Waldren: The uncertainty right now is the biggest challenge. When we get the final rule, we still won't know what'll be required for Stage 2 in 2013 or Stage 3 in 2015. So as people are trying to select vendors, you can quickly say you can achieve Stage 1 compliance, but there's uncertainty you'll be able to do Stages 2 or 3.

Another big challenge with Stage 1 as the rule's proposed is the "all or nothing" rewards. I have to do all 25 HIT functions and potentially eight measures for primary care, and if I miss one of those, I get no money.

So, from the standpoint of the physician, if you purchased a product that's certified and you do everything, and you report it appropriately, you'll get your checks for five years. But if you miss one measure, you don't get 80% or 50%, you get zero. So physicians have to take on faith that they'll get to that point of getting $44,000 [the max incentive for Medicare doctors]. Some kind of partial payment or tiered approach is needed.

We've had a pretty poor track record with the Physician Quality Initiative, or PQI, [in which Medicare] was supposed to give docs 2% if they submit quality data. A lot of physicians submitted this data for a year and never received their checks or if they did, it was two years late. It's been a poorly managed process. And there's worry that this will be the same. We've talked to folks at Centers for Medicare and Medicaid Services and Office of National Coordinator, and they assure us that they recognize this problem, and they won't have that same problem with meaningful use. But doctors already have that sour taste in their mouths.

InformationWeek: What's at stake if doctors and hospitals don't achieve data exchange?

Waldren: When it comes to hospitals' readmission rates and the potential for "never events" where payers won't pay for them, that's the bigger financial impact to hospitals than the meaningful use bonus. So hospitals will be trying to figure out interoperability with those primary care practices so that when patients get discharged, they see their primary care doctors for appropriate follow-up care so that they're not back in the emergency room in 30 days. That's what will really drive this interoperability. That's what driving hospitals at a business level to buy these practices or partner with them because then you can put them under contract where you say, "if you don't see these discharged patients in 30 days, then there's a penalty associated with that." Or "you can get a bonus if you see so many patients within a two-week period after discharge."

InformationWeek: What’s your best estimate in the percentage of doctor practices meeting the meaningful use requirements and avoiding the penalties?

Waldren: Avoiding the penalties, I have no idea because they don't start till after people have to be moving to Stage 2. Where Stage 1 is defined now, I would say it will be very difficult for practices to achieve meaningful use, and I would put it in 5% to 15% of physicians will be able to qualify with the proposed rule. And I've heard this from many officials in CMS and ONC--the proposed rule is a trial balloon. It was a bit aggressive, and they knew it was open for comments and that they could refine it. So I think the final rule will change significantly from the proposed rule. But again, as it stands today, it will be very difficult for physicians to qualify for the proposed requirements.

InformationWeek: There are some groups pushing for the meaningful use deadlines to be pushed later to give healthcare providers more time. Do you think there's a chance that will happen?

Waldren: I don't think the timing will change much because there's so much in the law that restrains the regulations. I was pleased that they allowed for the first year of reporting to be only 90 days instead of the full year. That gives people almost an extra nine months to work on this.

InformationWeek: Will the maximum of $44,000 in incentives for Medicare doctors be enough to cover the cost of these technology investments by physicians?

Waldren: It will likely cover the technology itself, but the cost of the process adoption, probably not. But I think it would pay for a large chunk of that. The bottom line for me when I'm talking to our AAFP members is that they shouldn't be trying to achieve meaningful use to get to the $44,000. They should decide to move forward, because it's the right thing to do for their patients, their practice, and for them. Then say, "ok, now that I know what I want, I know what my vision is, I know what I want my practice to be and how technology folds into that, let's look at meaningful use and what I need to do. Then I step up my timetable to meet the meaningful use demands and required reporting to get the $44,000."

In my view, if you try to get the cheapest technology you can to meet the meaningful use Stage 1 check list, you'll probably spend more money than if you say "I want to deliver high quality care for my patients, and I want to use technology to do that."

$44,000 is a big chunk of money for a medium-sized practice; EHRs in client-server environments have cost $30,000 to $50,000 per physician. So it's an incentive physicians should try to gain access to.