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Should Doctors Reject the Government’s EHR Incentive Plan?—David Kibbe

It’s a big hill to climb for a carrot that may not be there when you reach the top.

Is health information technology (IT) being set up to fail? Might we be facing a lost generation of health IT investment? Will Kaiser Permanente and Mayo Clinic get windfall profits while small practices receive nothing but hassles? It’s beginning to seem that way.

Valid questions in this excellent article by Kibbe. A physician must consider many factors in coming to a decision on whether and when to participate in the HITECH incentives program.

HITECH Medicare Physician Incentives

HITECH Medicaid Physician Incentives

Physician incentives under the federal Medicare program are offered over five years. There is a penalty (percent of total Medicare reimbursements) for failure to adopt starting in 2015. Physician incentives under state Medicaid programs are offered over six year without penalties per se. However, any incentives are contingent upon the states’ voluntary participation—which are dependent upon states’ budgetary discretions.

Choice of product(s), certification, updates and upgrades to the product(s), ongoing certification, and the reliability and complexities of the governmental payouts over five (Medicare) to six (Medicaid) years may all contribute to turning any positive remunerations negative. The meaningful risk balancing equations are:

Medicare: reimbursement v. failure to adopt

Medicaid: reimbursement v. state’s failure to offer

The physician contemplating participation must weigh the meaningful risk of that participation v. non–participation.

Meaningful Risk

1. Incentives: governmental monetary–inducements to implement an electronic health record (EHR)
2. EHR
3. Certification: a process, conducted by a third–party entity (e.g., TJC), certifying that an EHR passes governmentally defined regulations and standards and capable of producing meaningful use.
4. Meaningful Use: the necessary work products of a certified EHR required to substantiate eligibility for governmental incentives.
5. Eligible Hospital or Professional: is a hospital or professional (e.g., physician) that is eligible to receive governmental incentives because their certified EHR produces meaningful use.
6. Risk: potential and real

Incentives–induced certified EHRs producing meaningful use (data) creates a closed loop or cycle—a meaningful use cycle (MUC). An MUC, if a machine, takes incentives and passes certification and produces data. We hope a physician’s MUC will be benefiical to his practice and his patients, but it’s neither guaranteed nor required. This cuts to the core of the physician’s meaningful risk—potential money for an EHR, potential value to the practice, and potential value for his patients.

Meaningful Separation

1. Incentives
2. EHR
3. Certification
4. Meaninful Use
5. Eligible Hospital or Professional
6. Risk
7. XaaS: everything (else provided) as a service

Can the MUC be separated and reassembled in a manner where the physician receives the benefits of an EHR service and the incentives? Can certification (obtaining and maintaining), meaningful use (data), and the offering of an EHR be provided as a competitive service? Such a reconfiguration would require a zero–footprint practice installation—everything (else provided) as a service (XaaS).

Such an XaaS might have the following features:

• no hardware to purchase, install, maintain, or replace;
• no software to purchase, install, update, upgrade, modify, or make compatible or legacy–resistant;
• created, stored, and backup data would be standards–based and external to the practice;
• web browser user interface allowing for the use of any device that can be secured and offers a standards–compliant browser;

Meaningful Integration

1. Incentives
2. EHR
3. Certification
4. Meaninful Use
5. Eligible Hospital or Professional
6. Risk
7. XaaS

A reconstituted MUC might be created where an XaaS is used to move real and potential risks facing the physician to the competitively procured XaaS provider. Because the XaaS only handles standards–based data this creates a low threshold to shop and change XaaS providers based upon competitive features. An underlying premise here is that health information (HI, data) should never be held hostage to a particular hardware, software, or data form.

Meaningful use might be extended beyond the originating EHR by an XaaS to such offerings as a personal health record (PHR) and deidentified uses in secondary data markets. As an XaaS scales in size, with the number of EHRs hosted, it begins to resemble a health information exchange (HIE). But with the striking difference that no exchange is necessary because it handles only standards–based data. A competitive aspect of a sufficiently sized XaaS provider might be in the cost savings (HIE infrastructure) that is created because no exchange in HI is required—only an exchange in content, not syntax nor semantics.

Meaningful Design

1. Incentives
2. EHR
3. Certification
4. Meaninful Use
5. Eligible Hospital or Professional Enterprise–Centric HI
6. Risk
7. XaaS
8. PHR (expanded to include participatory input: patient initiated, sensor initated)
9. Patient–Centric HI

Can a service be fashioned that addresses the health informational needs of the enterprise (eligible hospital or professional) and the patient? Can the risk, inherent with the adoption of present generations of health IT (including beliefs and practices), be shifted to a competitive third–party service model (XaaS)? Can anything be done with the massive costs coming as we attempt to integrate HI nationally across innumerable disparate data silos? Yes, but only with eyes that see farther than the present incentive–induced vision. The false horizon is 2015. The true horizon is beyond where the government’s carrots and sticks lie. The balancing is not the monetary cost equation of participation v. no participation, but balancing the design needed to accomplish what is much more than meaningful use.

Meaningful eXtras

The putative XaaS provider needs to address privacy and security practices found in HIPAA, state laws, and other applicable federal laws (e.g., Red Flag Rules). They will need to handle communications between enterprise–centric and patient–centric HI spaces, including the facilitation of person–to–person communications. The expectation will be for realtime (or just–in–time) communications (or deliveries).

As the XaaS scales up with increasing numbers of hosted EHRs and PHRs—the value of its informational stores will be greater than the sum of its constituent sources. It will be able to offer a near–complete representational rendering of a person’s HI derived from multiple sources. In a similar fashion the value of its deidentified data in secondary markets will be enhanced. Configured properly, it will be able to contribute to and compete against HIEs because its informational stores are standards–based and requires no exchange–step(s).

Tagged as: ehr, hie, meaningful use

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