Blog: Lawmakers protesting EHR program far off the mark in their letter to Sebelius

Four high-ranking members of Congress wrote a letter to HHS Secretary Kathleen Sebelius (PDF) last week urging her to halt federal electronic health-record incentive payments to hospitals and office-based physicians because of an alleged lack of interoperability spawned by weak rulemaking.

At the $7.1 billion mark in an estimated $27 billion program, what's up with that?

How about an honest difference of opinion?


Their argument was, at best, unfair and disingenuous. I'd call it dishonest.

In their letter, they compared performance thresholds for the interoperability measures of e-prescribing and medication reconciliation between the Stage 1 proposed rule with the Stage 2 final rule and then called the results proof that the Stage 2 rule is "weaker."

From that faulty premise, they leapt to a false conclusion—that the Stage 2 rule created "a less efficient system that squanders taxpayer dollars and does little if anything, to improve outcomes for Medicare."

Their argument is a calculated attempt to put four thumbs on the rhetorical scale. In doing so, they sought to distort the truth—that the EHR incentive payment program is, on balance, being well executed.

Their false conclusion about squandering money also spits on the hard work and impugns the integrity of so many members of the healthcare community who have poured their hearts into this effort to create a computerized, interoperable healthcare system for the benefit of patients.

Think back to 2009. Just 6.9% of office-based physicians, or about 22,500, had a fully functional EHR.

That same year, the American Recovery and Reinvestment Act passed—without one vote from the four Republican letter writers.

Members of the HIT Policy Committee and its meaningful-use workgroup (which the ARRA empowered) got a bit—what—fired up? That was perfectly understandable, given that the full weight and funding of the federal government had suddenly shifted to promote health IT, a field to which they had devoted their professional lives. So, some of their initial recommendations for meaningful-use rules were exuberant.

In their defense, these private-sector advisers saw an opportunity to step out boldly toward better patient care through the use of technology. Several of their bigger stretches were scaled back by the CMS in its Stage 1 proposed rule. But even this allegedly "weakened" proposed rule exceeded what provider and vendor leaders thought was doable, and after the public comment period on the proposed rule, the CMS dialed them down again in the Stage 1 final rule.

In listening to those voices from the market, CMS rule writers sought to strike a balance between the idealistic goals proffered by the advisory committee members and measures that many provider and vendor leaders were telling them were achievable under such short notice.

For their pains, CMS rulemakers are now being charged by these four epistlers with trying to “pad participation rates,” as if ubiquitous EHR usage were a bad thing and not a goal first enunciated by President George W. Bush back in 2004.

You can't have electronic interoperability without providers first having EHRs, just as you can't have much of a phone conversation without two people having phones -- unless you're Bob Newhart.

And complete EHR adoption is still not a fait accompli, though enormous strides have been made since 2009.

As of 2011, 16.8% of office-based physicians, or about 54,800, had a fully functional EHR, according to the National Center for Health Statistics. This year through August, more than 106,000 physicians, and maybe as many as 114,000, counting Medicare Advantage participants, have become meaningful users of EHRs, according to the CMS.

Most honest observers would conclude there's been a dramatic increase in EHR adoption since 2009, thanks to the ARRA and everyone's hard work.

As for interoperability requirements, using reality-based numbers—final rule numbers for both Stage 1 and Stage 2—the CPOE threshold for medication orders in hospitals moved from 30% in Stage 1 to 60% in Stage 2 and for electronically transmitted prescribing by physicians and other eligible professionals from 40% in Stage 1 to 50% in Stage 2.

Medication reconciliation thresholds stayed at 50% for both hospitals and for physicians and other eligible professionals, but they moved from the optional "menu" category in Stage 1 to the mandatory "core" measures category in Stage 2, so they'll be a stretch for some hospitals, physicians and other eligible professionals.

A fair assessment of these and all other Stage 2 metrics could produce, in my opinion, only one fair conclusion, that Stage 2 requirements are more stringent than those of Stage 1.

But was fairness what the letter writers had in mind?



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