(Note:  The following link is to the entire letter of appeal to CMS and ONC: An Appeal to CMS and ONC for a Temporary Exemption to Meaningful Use 2)

In order to encourage healthcare providers to adopt electronic medical records, the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator (ONC) of the Health Information Technology (HIT) of Health and Human Information Services (HHS), introduced a three-step program, entitled Meaningful Use 1, 2 and 3 (MU).  For successful performance in each stage, the Federal Government proposed to pay healthcare providers a fee.  In 2010, the Director of ONC was asked, “Is it possible for MU to slow or stop the deployment of EMRs rather than advance the use of EMRs?”

The intent of MU was to advance the use of EMRs, but an unintended consequence is taking place as we move into MU2.  While most EMR vendors were able to fulfill the requirements of MU1, only 21% fulfilled MU2.  Very few are expected to meet MU3 requirements.  It is speculated that MU2 and MU3 will result in 492 of the current 500 EMR vendors either being bought by other vendors, or going out of business. At the present time speculation is that only 8 EMR companies will survive.  The good news is that the EMR SETMA chose in 1998, is one of those 8. 

The area which is the most difficult for MU2 is interoperability which refers to one practice being able to send healthcare information to another practice and to have the information be deployed into the new practice’s EMR.  For instance, if a patient presents with the chief complaint of “sneezing,” MU2 requires that the EMR be able to code the symptom with a six-digit number so that the new EMR recognizes the symptom and drops it into the new EMR.  The same is true for history of present illness, review of systems, physician examination and other elements of the record.

Because SETMA has used the EMR since 1998 and because we have been using the EMR meaningfully for sixteen years, we were surprised recently to learn that our use of the EMR would not quality for MU2.  Furthermore, that while we can make our use of the EMR qualify for MU2, it will:

1. Take 6-12 months of full time work to achieve.
2. Require our suspending of our on-going improvement of the use of the EMR during this time.
3. Cost $500,000 to $1,000,000. 

While we will succeed in this process, it will not be without pain.  In addition, we are concerned that many of our colleagues will not be able to meet the standard resulting in their being penalized in the future.  As a result we have appealed to CMS and ONC for a temporary exclusion from the requirements of MU2.  The appeal is founded upon SETMA’s vision for transformation of healthcare, which is the path for dynamic and sustainable change.  Internalized values, a personal and collective vision and a generative passion for excellence in healthcare delivery, are the fuel and energy for transformation in medicine.  Reform is dependent upon external pressure, based on rules and regulations to sustain and guide change.  Reform requires financial reward and/or threat of financial penalties to drive the process, while transformation is driven by a creative tension between one’s vision and one’s current reality.  CMS and ONC will want to take care that attempts to improve care with reform does not adversely effect dramatic improvements through transformation.

Not being inherently creative, reform is dependent upon uniformity with all participants being required essentially to look alike; transformation will result in sustained, creative innovation, which will by its nature result in diversity.  Transformation will be trail blazing with rapid innovation producing advances in healthcare improvement.  Sometimes, reform will stifle creativity and transformation.  To avoid this potential negative impact of well-intentioned reform, thoughtful leaders will recognize the need for innovative leaders and organizations to receive temporary exemptions from the rules and regulations which are the tools of reform.

SETMA shares CMS’ and ONC’s desire for improving the patient’s experience of care, for improving the outcomes of care, and for making those changes sustainable.  We, also, believe in transforming healthcare through the creative use of technology and innovation.  We recognize that one of the frustrations with transformation by public policy leaders is that it by necessity is more difficult to control and often to measure. 

SETMA’s MU2 Dilemma

SETMA’s MU2 dilemma stems from the fact that when we began using the EHR in 1999, our vendor did not have a data base which could be used.  It further results from SETMA’s adopting the ideal of electronic patient management (EPM) in May, 1999, which set us on a rapid course of healthcare transformation in which we outpaced other organizations and certainly outpaced our vendor in healthcare transformation.  Now, we find ourselves in the position of using the EHR meaningfully as a transformative tool, but not being able to fulfill the requirements of healthcare reforms, which require uniformity in functionality.  We either have to suspend transformation of our healthcare delivery in order to conform to the rules and regulations demanded by healthcare reform, or suffer penalties now and in the future, which penalties are likely to become more onerous in the next ten years. 

After reading the MU Use Workshop Stage 3 Update (Paul Tang, Chair, Health IT Policy Committee), and seeing that almost all of the proposed elements are issues with which we have dealt in our achieve Patient-Centered Medical Home (PC-MH), I was encouraged that if we can resolve the problems with MU2, SETMA can continue on our 19-year journey to healthcare transformation.  At this time, SETMA is not only fulfilling the structural necessities of PC-MH; we have also achieved the functional and dynamic elements of medical home.  The ONC’s MU3 is probably going to require additional interoperability functions which will be a barrier to SETMA receiving recognition for the PC-MH work we are already doing.

In this context, I offer the following observations on SETMA and MU2.  On November 26, 2013, it was confirmed to SETMA that even though our EHR vendor is one of only twenty-one vendors which have met certification for MU2, because our use of that vendor’s platform is customized, we cannot use that certification to attest to SETMA’s meeting of MU2 standards.  Published reviews have suggested that the practices which are going to be “hurt” the most by MU2 are the early adapters like SETMA.  Remember, in March 1998, when we bought our vendor’s product, they had no knowledge base, so out of necessity we had to build our own.   This is the foundation of SETMA’s request for an exemption for four years. That exemption will give us time to continue our transformation and to make the changes to our EHR which will allow us to meet MU2 and 3.

In 1999, SETMA’s vision of EHR changed from simply being a tool for documenting a patient encounter, to being a tool for leveraging the power of electronics to improve care for individuals and to improve care of panels or populations.  Through all of this, SETMA rapidly and continually improved and expanded our tools for transforming care. All of those tools can be reviewed at Electronic Patient Management Tools  (EPM stands for “electronic patient management”).   These tools are made available to everyone and anyone without cost and even though these tools have great value, they are not copyrighted. Their purpose is to improve healthcare for anyone who wishes to use them. 

Part II will be published next week