Meaningful Use: Should I Stay or Should I Go?

I had the privilege of speaking to several audiences in New Orleans last week at the annual RPA meeting. One of the popular, and perhaps controversial, topics of conversation was related to the concept of nephrologists “opting out” of meaningful use. I touched on this subject last Monday, and my perspective has not changed. However, after conversations with many of you in the Crescent City this weekend, I think it wise to revisit the issue.

 

This indecision’s bugging me

 

I have had the opportunity to speak with folks at ONC and CMS about this topic and it is clear to me the meaningful use framework was never intended for nephrologists. The audience is very clearly the vast number of primary care providers in this country. By some estimates, classic primary care providers out number nephrologists by a ratio that exceeds 50:1. The challenge for us of course is the encounters we have with our ESRD patients. These encounters frequently take place in a dialysis facility, and this patient population is often seen multiple times during the month.

 

Dialysis facilities, like nursing homes and ambulatory surgery centers, were left out in the cold, so to speak, from a meaningful use perspective. Unlike docs and hospitals, there is no financial incentive available to influence the dialysis facility’s decision to deploy a certified EHR. Further, there is no clear path for the dialysis facility to pursue if the facility indeed wished to certify their dialysis information system for meaningful use. The dialysis venue of care represents a hybrid of sorts with some work flows resembling those that take place in your office, and others resembling work flows in the hospital setting. The lack of a clear certification path for the dialysis information system is perhaps best exemplified by the list of clinical quality measures (CQMs) available within both the hospital track and the office-based or ambulatory meaningful use track. None of the available CQMs were created with the ESRD patient population in mind. The Stage 2 clinical decision support objective is attached at the hip to the CQMs, and not surprisingly, the clinical decision support rules in a Stage 2 certified EHR would be of little use to patients seen within a dialysis facility.

 

If I go there will be trouble

 

One of the concerns I heard this weekend was related to the following scenario. The docs have jumped through the Stage 1 meaningful use hoops in the dialysis facility by capturing some components of the ESRD patient population within their office based EHR (effectively duplicating data entry as many of the Stage 1 core objectives are also captured by facility staff within the dialysis information system). These docs have appropriately collected the Stage 1 incentives for their efforts, which in many cases exceeded those of their primary care colleagues, in large part because they are often personally involved with capturing all of the data within the dialysis facility. In this setting, some folks I spoke with were nervous about filing for the hardship exception I mentioned last week (more than 50% of my encounters occur in the dialysis facility, and I do not control the decision to deploy a CEHRT in that venue of care). The concern basically revolves around the issue that the doc accessed his or her office-based EHR to qualify for Stage 1, but now elects not to do so for Stage 2. Will CMS ask for the doc’s Stage 1 money back? Will CMS penalize them anyway for not jumping through the hoops in the dialysis facility (accessing their office-based EHR from within the dialysis facility and continuing to duplicate data capture) for Stage 2?

 

And if I stay it will be double

 

Based on what I have read, what I have heard on the CMS open-forum calls, and direct conversations I have had with several folks, my belief is the answer to both questions is no. I think nephrologists who have successfully attested in an environment where they needed to include their ESRD encounters to clear the hurdle established by the “50% Rule” invested substantial resources to make this happen, resources that again most other providers were not required to use. Trying to continue down this path with the Stage 2 objectives will be close to impossible.

 

Take CPOE for example. If you are compelled to include the in-center HD encounters within the population of patients you are reporting for Stage 2, the task is that you record your medication, laboratory and radiology orders in your certified EHR. Note the orders will, of course, also be recorded in the dialysis facility medical record or information system. This degree of duplicate data entry is untenable.

 

Further, from the perspective of the dialysis facility, the dialysis facility information system is the patient’s medical record. Everyone, including the nephrologist, is compelled to record information about the patient within the dialysis facility’s medical record or information system. At the end of the day, I would suggest to you the dialysis facility’s medical record, not your office-based EHR, is the source of truth for your patients receiving care in that facility.

 

So you gotta let me know, should I stay or should I go

 

I think as each of you in this position (more than half of your outpatient encounters occur in a dialysis facility) considers this hardship exception, you should carefully review the related sections within the Stage 2 final rule. Quoting directly from that rule as published in the Federal Register:

 

“On the other hand, there are EPs who practice at multiple locations who truly have little to no control over whether CEHRT is available at their locations. These might include, surgeons using ambulatory surgery centers or physicians treating patients in a nursing home. In these cases, the surgeon or physician likely would bear the entire impact of any payment adjustment – and such adjustment would not affect the earnings of the ambulatory surgery center or nursing home. In addition, because the surgeon or physician merely sees patients at the center or home, and does not have any other interest in the facility, we believe they would exert little to no influence over whether the nursing home, center, or other similar outpatient site adopts and implements CEHRT.”

 

I believe the nephrologist seeing patients in a dialysis facility is no different than the surgeon using an ASC or the physician treating patients in a nursing home-with the exception of joint venture arrangements, the scenarios are almost identical. The Stage 2 final rule goes on further to state:

 

“We note that we already have in place an eligibility requirement that allows for an EP to still qualify as a meaningful EHR user even if up to 49.9 percent of the EP’s outpatient encounters are in locations that lack CEHRT. Thus, our exception would apply only in the case of EPs practicing in multiple locations where the lack of control (as discussed previously) exists for a majority (50 percent or more) of their outpatient encounters at such locations, causing such EPs to not be eligible to become meaningful EHR users.”

 

I think the message is clear, but each of you must decide, will you stay or will you go? Give it some thought and let us know. Drop us a comment and join the conversation.