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whether or not I was really paying meaningful attention. When I make actual meaningful changes in the problem or medication list, correcting it, adding new problems, deleting resolved ones, something I can do only if I have reviewed the list, the computer program does not recognize this as my having “reviewed” it. I still have to make the extra mouse click, checking the proper box to “verify” that I have done what I have just done.
As I do this, sitting unavoidably with my back to the patient, I usually say, well, be patient, while I make the computer happy: there are some things I have
to do before you can check out. Often, at least for a surgeon, these required actions are not in the least bit meaningful in relation to the visit. Something has gone very wrong here: the “meaningful use” data is not going to be all that meaningful.
The EHR Gets Teeth
It was always envisioned that the meaningful use requirements, as detailed in the EHR Incentive Programs for Eligible Professionals (EP) tip sheets published by CMS, would evolve from the very simple first stage into second and third, more demanding stages over the ensuing 6 years.
Many of the laudable disease targets – obesity, smoking, high blood pressure – would remain the same however, the requirements would be stiffened. In 2014, simply recording height, weight and BMI
no longer sufficed. The recorded diagnosis of obesity, for example, now needed to be accom- panied by a follow up plan for any patients whose measurements were “outside parameters.” Smokers had to have “received cessation counseling intervention.” Screening for clinical depression had to be done “using an age appropriate standardized depression screening tool and a follow-up plan documented.” Did the folks at CMS really believe that filling in this information would lead to improvements in health status? Or were they just trying to impress the politicians?
The requirements described in the 2015 tip sheet are even more sophisticated and complicated.
To improve patient access to their own medical records, Patient Electronic Access, Measure 2 requires that “at least one patient seen by the
EP (eligible professional)...views, downloads,
or transmits to a third party his or her health information.” EP’s also now had to show that they were communicating back to referring physicians. EHR’s had to show that Patient Health Information (PHI) was secured through encryption and other security updates, and that they provide “decision
support interventions related to four or more clinical quality measures at a relevant point in patient care.” As the requirements were increasing in number
and complexity, the screws were also being tight- ened to comply: the “incentive” to encourage use of the EHR was turned into a penalty for not using it. This is unfortunately the way that politicians think, which is more or less the same way some still think a hickory switch is the best instrument for inducing desired behavior in classrooms. Unfortunately, neither punishment nor reward has even been successful in the long run in getting people to do things they find inherently worthless.
MACRA and MIPS Take the EHR to the Next Level
In 2016, Andrew Savitt, the CMS acting administrator, suggested publicly that meaningful use as we knew it was going to be phased out, but that
is not exactly what happened. What happened was that new legislation, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which establishes new ways to pay physicians for caring
for Medicare beneficiaries, was signed into law on April 16, 2015. It’s aimed at Part B payments and it’s complicated. A new acronym, MIPS – the Merit- Based Incentive Payment System -- was launched.
It incorporates both the meaningful use mandates (now renamed Advancing Care Information) and another acronymic program, PQRS – the Physician Quality Reporting System.
If you are not thoroughly confused by now, you are in good company, and there isn’t time or space here to try to make sense of all of these new requirements. Suffice it to say that CMS is trying
to improve health care quality by imposing experi- mental payment system changes onto every physician in an effort to induce them to do the right thing: reduce costs and improve quality. The EHR will now play a less prominent but nevertheless important role, because it is the medium through which data about care delivery are gathered and through which practice guidelines and other helpful suggestions can be communicated to health care professionals, and decisions about adjustments in reimbursements computed based on compliance. (See N Engl J Med 2017;376(8):708-10)
The billion-dollar question is: will this approach actually translate into real improvement. When I sit down at the computer during a patient visit, making sure I am complying with a guideline, reconciling medication lists, and other presumably meaningful things, what I am really thinking about?
Volume 69 • Number 3 Washtenaw County Medical Society BULLETIN 11

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