Lowering the Meaningful Use Bar

The Healthcare IT writer at BNet, Ken Terry, recently posted a quote from David Brailer, former national health IT czar, about the final meaningful use rule and physician adoption of EMR:

Brailer, like a number of other observers, believes that federal overseers at the Department of Health and Human Services will lower the bar when the final regulations are published next month. “I expect the final rules will be softer, more developmental and incremental,” he said.

That would be good news for doctors and hospitals. Still, many physicians are reluctant to make the leap into health IT because they have to invest in it upfront, before getting any subsidies, and they worry that it will kill their productivity.

I agree that the final rule for meaningful use will have a lower bar. However, will it be a significantly lower bar or will it just have a few elements that lower the bar without any real meaningful changes?

The challenge is that HHS is faced with dealing with the legislative requirements that they’ve been given against the comments they’ve received. It seems like at this point that those two items are at odds and HHS is in a tough position with few ways out.

Either way, I think we can all agree that we’d all just love some meaningful details on how to get the EMR stimulus money. Good or bad, reasonable or unreasonable, it would just be nice to know the details so that we can make some informed decisions.

About the author

John Lynn

John Lynn

John Lynn is the Founder of the HealthcareScene.com, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference, EXPO.health, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.


  • John –
    I agree that the sooner that the federal government comes out with the “official/final” meaningful use criteria, the better it will be for all parties involved. The meaningful use criteria are the gateway through which providers will need to pass in order to access any of the incentives that the government is offering. Once these criteria are finalized, it will at least allow providers to critically evaluate the EHR systems to be sure that they can meet these thresholds before they commit to such a major purchase.

  • Frank MD,
    I agree with you 100%, the “official” criteria will allow everyone to start working together towards a true solution.
    As opposed to “lowering the bar”, I would rather the standards for the most part stay in place, but as Mr. Brailer says, have the rules be more “developemental and incremental.” The end result stated for much of the “proposed” criteria isn’t unreachable over good time. However, the timeline itself could be causing much of the issue.
    Trying to cram everything in place in such a short period of time will result in Doctors choosing not to participate. However, watering down the standards in order to get greater participation may result in a system with such loose standards that it is as inefficient as no system.
    If the approach is incremental though, how is that accomplished? As you said, there are legislative requirements that need to be met. Is it slowing everything down altogther? Is it identifying the “most important” aspects? Or is it the watered down approach that makes the targets easier to reach?

  • @ Dr. Frank … I suggest that you need to decide to implement an EHR for your practice based on how it will enhance your practice without considering whatever positive (or negative) incentives are established by the government.

    If you focus on aiming at “meaningful use” milestones you will find yourself jumping through hoops on behalf of bureaucrats instead of your patients, practice, and family.

    @ Tom C …

    Problem is that to this point before ARRA there has been only ~15% EHR adoption rate. Brailer is right to adopt standards which are more developmental and incremental.

    Value of an EHR must be reflected at the practice and community level. Focus needs to be on integration of PCPs with labs, pharmacies, consulting specialists, and local secondary HCOs. This focus will create “meaningful use” measured by the community need rather than faceless bureaucrats in DC who use “meaningful use” bars and milestones as a carrot/stick … as a poor substitute for what is best for real patients in real communities.

    I think vendors would be best served to create value for their provider clients who are the ones buying EHRs and protect against more complex solutions driven by unrealistic and bureaucraticly set standards and adoption schedules.

    If the focus is on artificial government standards … instead of meeting what the practitioners want … then we not working for the people who are paying us and their patients.

  • Should HHS materially dilute the Meaningful Use criteria, many more providers may opt out of using the federally subsidized Regional Extension Centers’ services (I work for one of them) — opening HHS up to the charge that they’re just wildly throwing deficit-spending money around incoherently, and that this initiative is in large measure just corporate welfare for IT vendors.

    I agree with Don Berry’s comment above that docs should decide on EHR adoption on the aggregate business case merits, which is relatively easy to make even absent the MU incentive money carrot.

  • Bobby,
    Interesting point of view. Although, I have to disagree. Mostly because if meaningful use is so hard that doctors just say forget about it, RECs will suffer from this. On top of that is that it’s not like HHS is going to make meaningful use easy. We’re just talking easier. Physicians will still be happy to have the help from RECs. Of course, this assumes that RECs do a good job.

  • John, it’s problematic, is it not?

    “Physicians will still be happy to have the help from RECs.”

    Not uniformly. We are WAY out front on this effort, and we are finding it many times be a very tough sell. I would have made REC engagement a requirement for MU incentive money eligibility.

  • You left off the most important part, “Of course, this assumes that RECs do a good job.”

    Maybe I should clarify that statement. If RECs provide something meaningful (I love abusing that word now) to the practices.

    Although, as I think about it, practices are all about the trust business. More than any other industry I’ve seen. So, to have some stranger (which many of the RECs are) come into their office wanting to “help” I can imagine it’s a hard thing to overcome if you haven’t built that trust in before. Maybe the tide will turn for RECs if they get some key people in a community to find them useful and essentially become advocates for what the RECs are doing.

    Of course, even this strategy hinges on the RECs providing these key people in the community something useful. Or I guess you could resort to bribery and other nefarious means.

  • @Bobby… To your reply to John’s “Physicians will still be happy to have the help of RECs” …

    “Not uniformly. We are WAY out front on this effort, and we are finding it many times be a very tough sell. I would have made REC engagement a requirement for MU incentive money eligibility.”

    I waited over night to post a reply not wanting to respond emotionally. May I suggest … RECs need to demonstrate practices that they can contribute and help. I can speak with authority that no practice is going to want to accept the help of a government paid group who does not work for us nor has not demonstrated that its priorities are to work for the benefit of the practice.

    Tell me … why should practices engage with a REC over hiring our own EHR IT consultancy that we can hold accountable?

    The idea that you would want to force practices to have to work through a government paid REC as a REQUIREMENT to receive MU incentive money is obscene.

    Your statement exactly justifies our opinion of RECs and their bigger concern for getting paid by the government by achieving their milestones than advancing health care quality and capacity.

  • I’m not sure how much we blame the RECs when the way the money’s given to the RECs is designed to make them go after numbers instead of “advancing health care quality and capacity.” It’s a kind of rock and hard place situation I think.

  • John … As you pointed out during our previous conversation on the “value of a REC” thread … the RECs wouldn’t exist except the government legislation created and funded them.

    It is not a “rock and a hard place” at all. We don’t need the RECs. RECs need the practices yet haven’t demonstrated any value.

    Practices would far prefer to engage private EHR HEIT consultants that work for the practice … and not for a government “body count”.

  • I am not so convinced there will be any changes on the Standards rules and not much on the EP meaningful use criteria. While Brailer has points I think the current ONC is the one to listen to. His recent interview and comment on the subject. “I take a longer-term view. My view is that electronic collection, storage, management and use of information is an inevitability in the 21st century, and that the federal government is trying to speed up the inevitable. This is a fairly calculated investment by the Congress not in adoption, but in a level of use that brings benefit. We shouldn’t spend the taxpayers’ hard-earned dollars for results that don’t meet the Congress’ standard, and that standard is meaningful use.” So the money is there but it looks like they aren’t going to throw it away on people who don’t want to play. I am a gambler and my money is on – not much change.

  • @Roberta …

    Who said practices “didn’t want to play”?

    Practices are keen to adopt means through which they can improve the quality and capacity of their practice. What has been disturbing to practices is that ARRA language and MU definition and standards have yet to be promulgated … and will not be until late this month. Supposedly.

    The HHS-driven initiative using positive and NEGATIVE carrots and sticks typifies how CMS operates. In the UK near universally the private primary care sector adopted EHRs from one of a handful of providers all without incentive. They did it because of the mutual value to the practices. The failure of EHR adoption in the UK is in the NHS standard secondary care system not the primary care component.

    Providers are in the best position to know what improves the quality and capacity of their practices… yet government bureaucrats seem to believe that they know better.

    The only thing that is being stimulated by ARRA’s incentives for EHR adoption are software vendors. The $18+ billion set aside for MU incentivization is smoke and mirrors. It is peanuts.

    Mayo, Cleveland, Brigham, and Intermountain are going to suck up that $18+ billion rapidly with their already established systems … leaving pennies to incentivize private primary care practices.

    The current ONC ought to be going back and get more money … and to look at the long term … which isn’t something that will be accomplished over night … let alone 2 years.

    We spent $3billion last summer in just ONE month through the Cash for Clunkers program. HEIT is supposed to be a 5 year program … given the $3bil in Cash for Clunkers … then the ARRA should have had at least $3bil x 12 x 5 = $180bil .. not 10% of that…

    … unless we are more concerned about GM’s and Chrysler’s unions than we are about health care quality and capacity.

  • @ DK Berry
    Wow, I am not sure how to respond to that? Can I assume you will be one that wants to play but won’t because you don’t like the rules of the game?

    Why does the government have to give you any money to play if you are so passionate about improving quality of health? Those would be the real practices that are “keen to adopt”. And there are plenty of them out there. Let me plug my physcian’s practice… Baylor Family Clinic in Houston.

  • DK Berry-

    “The idea that you would want to force practices to have to work through a government paid REC as a REQUIREMENT to receive MU incentive money is obscene.”

    “Obscene”? Perhaps you should have waited a bit longer to reply. Simplistic hyperbole, that.

    “Tell me … why should practices engage with a REC over hiring our own EHR IT consultancy that we can hold accountable?”

    [1] Cost. Our unsubsidized fee portion is perhaps 5% of what you’ll pay private consultants — AND, we don’t get to bill the nominal providers’ fees until AFTER they’ve hit MU. [2] “Accountability” is built into our federal milestone payment structure. They didn’t simply dump millions of dollars in our bank account up front. We have to hit a series of targets along the way or WE DON’T GET PAID. And, like any contract, there are escape clauses for non-performance. [3] While I can’t speak for the other RECs, ours has been a nationally respected QIO for decades, one staffed by physicians, nurses, statisticians, epidemiologists, IT specialists and clinical managers with prior EHR implementation experience, and experienced QA/QI personnel, most of them Master’s level and up.

    Why should you be “forced” to adhere to ANY MU criteria? No one’s forcing you, you can opt to pass it it’s so onerous.

    “Your statement exactly justifies our opinion of RECs and their bigger concern for getting paid by the government by achieving their milestones than advancing health care quality and capacity.”

    Again, we don’t get paid, and I won’t long have a job here, UNLESS we perform. Your opinion is reflexively uninformed.

    Having said that, I cannot take issue with your observation that this looks to a concerning degree to be corporate welfare for HIT vendors. Had you taken the time to review the rather exhaustive material I’ve posted on my policy blogs, you’d have seen that I too have many concerns about the entire HITECH model. As a quality professional of long, broad, and deep experience, my ONLY goal to to assist in improving health care quality.

  • @ Roberta … Playing or not must not depend on whether there is a positive or negative incentive program in place. Implementing or expanding the scope of an EHR must be based on how that implementation or upgrade enhances a practice’s ability serve more patients … and in doing so improve a practice’s top line and bottom line.

    to provide better quality medicine and service to patients and/or how it improves the capability of the practice to serve more

    We will “play” to the extent that we will update p

  • … not sure how that ‘snip’ loaded… sorry

    Please ignore the last 3 lines above.

    Continuing for Roberta … Baylor Health is a super system. Lived in the DFW metroplex for almost 10 years … and Baylor iss the major health services provider for good reason.

    You may be the ideal poster in another thread “Hospital EMR Offerings” … and how Baylor’s corporate IT integration to include EMR/EHR extends to its owned or affiliated primary care practices. This integration … driven by corporate goals for practice quality and operating efficiency are far more significant than ARRA incentivization toward improving quality and capacity as corporate objectives.

    To the original point … incorporating what I have said and what you have said from a Baylor perspective. We “do no harm” and therefore we must always look toward improving outcomes through improving quality and capacity to serve. We do these things for the right reason … not just to meet some checklist of bureaucratic objectives for which we get a check in the mail sometime down the road.

    I hope you can agree with this view.


    I apologize for using the inflamatory word … “obcene”. You are right I should have waited longer.

    I do not doubt that there are super resources available through the RECs ready and wanting to help practices adopt EHRs which improve medical quality and practice capacity.

    I simply believe that it is better for a business to hire its own advisor based on its needs than have one paid for it by the same entity that is paying out the incentive program. Practices have priorities that may be different or beyond government defined objectives. At the end of the day the practice’s owners are the ones that must determine the extent of outside involvement in their decisions. RECs are too much in the gray area. This may be part of the reason you are finding digging out a firm foothold in this business.

    What spun me up … and I apologize again … was the idea that to even qualify for MU incentivization that practices should have been required to work through a REC. If the RECs were to eliminate the independant consultants … that establishes too much risk where some RECs may not have the capacity or williness to work a practices priorities … because they don’t have to.

    Competition is good. It sounds like your program is quite extensive and has a great record. That ought to be attracting a lot of business. If it isn’t … then that says something about the prospective client market. They are apparently not getting the message you are trying to offer them.

    If I may suggest what might work better would be making the practices you approach believe that both you and the practice are both equally interested in quality and capacity … and both equally disinterested in how the government is incentivizing both you and the practice. If they do not think you are working on their behalf … but on your behalf … or the government’s behalf … then you may never get in the door.

    Hope this better defines my concern.

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