Tag Archives: CMS

Meaningful Use Regulations, CMS, HRSA FQHCs and the Stalled Push to Electronic Medical Records (EMRs)

According to Mother Jones, the United States has spent billions on electronic medical records (EMRs)* and we’ve got little to show for it. Digitizing healthcare records was supposed to save time, money, and lives. It hasn’t. That news resonates with us because we’ve written dozens of proposals, mostly for Health Resources and Services Administration (HRSA) and Centers for Medicare & Medicaid Services (CMS) RFPs that either explicitly or implicitly require a discussion of our clients’ use of EMR systems. These clients are usually hospitals, Federally Qualified Health Centers (FQHCs) or other primary care providers. From them we’ve heard numerous heard off-the-record stories about the fiascos that ensued for providers that have implemented EMRs. For example, we worked for a hospital in Southern California that interfaced with a much larger, nationally known hospital that attempted to implement a comprehensive EMR system. The large, famous hospital eventually scrapped a $30 million EMR system because the doctors simply refused to use it.

There seems to be no good solution to the EMR problem. EMRs have been touted for at least the last 15 years as a tech-based way of improving patient outcomes, while reducing healthcare costs or at least bending the cost curve downward (as health policy wonks like to say). EMRs got a got big push with huge amounts of EMR funding included in the 2009 “Stimulus Bill.” The advent of the Affordable Care Act (“ACA,” or, colloquially, “ObamaCare”) escalated the EMR drive. Various Federal and state agencies advocated and then effectively mandated EMRs.

But this well-meaning concept has at best moved sideways. HealthIT.gov promulgates the wonderfully bureaucratically named “Meaningful Use” regulations, which use a combination of incentives (e.g., higher Medicare/Medicaid reimbursements) and threats. The carrots are offered and the threats enforced primarily by CMS. Everyone is supposed to get to Stage 1 of Meaningful Use (data capturing and sharing) on a supposedly smooth trajectory to Stage 3 (improved outcomes). Stage 3 turns out to be like the intergalactic instantaneous travel through spacetime. We’ve yet to find an hospital, FQHC or other client that has reached Stage 3. Most are stuck at Stage 1, with a few bravely claiming Stage 2. We’ve never seen a client hit Stage 3, though they may be out there, perhaps in a galaxy far far away.

The problem is that EMRs are trying to map the extraordinary complexities of the real world into software. The complexity can be seen in the new International Classification of Diseases, ICD-10 Codes, published by our old friend CMS. ICD-10 codes are used by medical providers and billers to track patients and payments, based on the code or codes of the patient’s particular situation. When we talk to FQHCs, they invariably say that coding errors are among their major problems. ICD-10 has an astounding 68,000 individual codes, compared to only 14,000 codes in the previous ICD-9. In recent years, humans have invented or discovered an enormous number of new ways to get hurt. No one can remember more than a few hundred of these mysterious codes, which are easy to mistype into an EHR and/or be misunderstood by harried doctors and mid-level practitioners. The complexity of the codes, combined with human diversity and frailty, inherently generates huge numbers of mistakes.

Folks with too much time on their hands have published various funny ICD-10-CM codes. Some choice ones (we are not making these up) include: “V97.33XD: Sucked into jet engine, subsequent encounter;” Y92.146: “Swimming-pool of prison as the place of occurrence of the external cause” (how many prisons have swimming pools?); and my personal favorite, “R46.1: Bizarre personal appearance.” You can tweet your favorite bizarre ICD-10 codes to @healthcaredive.

Ask your doctor about their EMR system and you’ll likely here a lot of invective. I live with a doctor and so have heard the horror stories from her and her colleagues. Isaac’s primary care physician (PCP) hates EMRs but is more or less forced to use eClincalWorks, an EMR system that is also popular with our FQHC clients. Epic is another popular one. Still, however you feel about whether EMRs is efficacious or horrible or brilliant or whatever, pretty much every healthcare-related proposal has to mention EMRs, statistics, and tracking. That could be as minor as a project that works on childhood obesity or as major as a hospital chain implementing some new facet of EMRs.

Anyway, EMRs are a specialized case of a more general problem described in “Why Software Fails: We waste billions of dollars each year on entirely preventable mistakes.” EMRs, like other forms of software, have numerous moving parts and numerous human users. Anyone working in or around EMRs needs to read “Why Software Fails.” At Seliger + Associates, we expect to keep writing about EMRs for FQHCs and similar clients for years if not decades to come. In the real world, doing EHRs right is simply a Hard Problem—so hard that it deserves capital letters. EMRs are almost impossible to do “right” and yet have to be done right. They’re so hard that we don’t have a solution. “Why Software Fails” explains why a solution may not exist, no matter how badly HRSA or CMS wants one. As the Soviet Union discovered, mandates from above, no matter how strong, do not automatically translate into fixing problems from below.

* EMRs are alternatively referred to as Electronic Health Records (EHRs), particularly in HRSA and CMS RFPs. In ones types “EHR” into Word, or any other word processor, and the autocorrect feature will change it to “HER.” This in annoying, but does result in some unintentionally funny typos. When finished with proposal draft involving EHRs, always do a find and replace for “HER”.

More RFP Looney Tunes, This Time from the Centers for Medicare & Medicaid Services Health Care Innovation Award Program

Having been a grant writer since before the flood, I should not be flummoxed by a hopelessly inept RFP. I wasn’t flummoxed by the recently completed Centers for Medicare & Medicaid Services (CMS) Health Care Innovation (HCI) Awards Round Two process, but I was impressed by the sheer madness of it.

This Funding Opportunity Announcement (FOA, which is CMS-speak for “RFP”) was exceptionally obtuse and convoluted. I should expect this from an agency that uses 140,000 treatment reimbursement codes, apparently including nine codes for injuries caused by turkeys.

The HCI FOA was 41 single-spaced pages, which is fairly svelte by federal standards—but, in addition to the usual requirements for an abstract, project narrative, budget and budget narrative, it also includes links to templates for a Financial Plan, Operational Plan, Actuarial Certification and—my personal favorite—the Executive Overview. The Financial Plan was a fiendishly complex Excel workbook, while the Operational Plan and Executive Overview were locked Word files.

Since the Word documents were locked, spell check and find/replace didn’t work in the text input boxes. Every change had to be made manually. Charmingly, the Operational Plan template had no place to insert the applicant’s name or contact info. So when the file is printed for review, which I’m sure it will be, and gets dropped on the floor with several other proposals, which is possible, there’ll be no way to tell which Operational Plan is which.

This could be a problem in an Operational Plan.

My vote for the most fabulously miss-titled form is the “Executive Overview.” Remember: a one-page abstract was also required, so an Executive Overview seemed redundant until I realized it was 13 single-spaced pages, with tons of inscrutable drop-down menus and fixed-length text input boxes. It seems that CMS is confused as to the meaning of “overview.”

The Executive Overview was really another project narrative, disguised as a form. If one double-spaced the Executive Overview, it would be about 26 pages long. Although the FOA nominally allowed a 50-page project narrative, the length of the project narrative was effectively much shorter because of convoluted instructions that required the project narrative file to include other documents. Our project narrative ended up at 35 double-spaced pages—not all that much longer than the so-called Executive Overview.

This FOA also included four “innovation categories” that were obtuse and mostly interchangeable. The FOA required that the selected innovation category be listed four times, once in the abstract, twice in the project narrative and again in the Overview. Since the categories were confusing at best, our client changed their selection a couple of times during the drafting process, which meant it had to be changed in four different places each time.

The grant request amount had the same problem, except that it is also included in the Financial Plan, budget narrative, cover letter and Actuarial Certification, as well as the abstract, project narrative, and Overview. So when the budget changed—which it inevitably did—each change had to occur in seven places to maintain internal consistency.

CMS, of course, never thought to link the various templates so that global changes could be made. But then again, why would they? After all, the authors of this FOA don’t write proposals and aren’t concerned with simplifying the process, which brings me back to the nine categories of turkey injury treatment. I wonder who keeps stats on turkey injuries. I would like to meet the GS-13 in charge of domestic fowl attacks at the Department of Agriculture.