CMS Extends Timeline for EHR Incentive Program
A few weeks ago, the Centers for Medicare & Medicaid Services (CMS) proposed a new timeline for the implementation of meaningful use. The new timeline extends Stage 2 through 2016, and Stage 3 will begin in 2017 for providers who have completed at least two years in Stage 2. The extension was made for two reasons: one, to allow CMS “to focus efforts on the successful implementation of the enhanced patient engagement, interoperability and health information exchange requirements in Stage 2”; and, two, to have access to the data from Stage 2 to inform policy decisions for Stage 3.
The three stages are set up to transition participants, from creating information in Stage 1, to exchanging information in Stage 2, to improving outcomes in Stage 3. 

According to CMS, the new timeline would have several benefits:

• More analysis of feedback from Stage 2 
• More available data on Stage 2 adoption and measure calculations – especially on new patient engagement measures and health information exchange objective
• More consideration of potential Stage 3 requirements
• Additional time for preparation for enhanced Stage 3 requirements
• Ample time for developers to create and distribute certified EHR technology before Stage 3 begins, and incorporate lessons learned about usability and customization.

CMS plans to release a notice of proposed rulemaking for Stage 3 in the fall of 2014. The final rule with all requirements for Stage 3 would follow in the first half of 2015.  All comments from those individuals with a direct interest will be “reviewed and carefully considered” before the final rules are released.

What this means for Quillen Providers
Although this announcement doesn’t immediately affect us, it does give us a little more breathing room, as many of our providers were early participants in the program. For any provider who started the program in 2011, the new timeline will look similar to the following:

2011  Adopt, Implement, Upgrade
2012  Demonstrate 90 days of Stage 1
2013  Demonstrate a  Full Year of Stage 1
2014  Demonstrate 90 days of Stage 2
2015  Demonstrate a Full Year of Stage 2
2017 Begin Stage 3

Not all of our providers started in 2011, so your particular timeline may look a little different. CMS offers a timeline tool  that participants can use to see a personalized timeline.
As we enter a new year and start working on a new timeline, perhaps the song below won’t be as applicable, but just in case you are still in a panic about Meaningful Use, here’s a song for you!

I was panicking when I wrote this
Forgive me if it goes astray
But when I got to work this mornin'
Could of sworn it was Attestation Day.

The computer screen was all black
There were patients waitin’ everywhere
Tryin' to get relief from sickness
But CMS didn’t seem to care.

'Cause they say two thousand one three
Stage One is over, oops out of time
So today I’ve got to click like it's 2014
(Sorry, couldn’t make it rhyme)

I was panicking when I wrote this
So sue me if I go too fast
Stage 2 is not a party
And clicking is not a blast.

The EHR is all around us
My eyes say too much screen time
But if I gotta click
I'm gonna make it by the deadline.

Yeah, they say two thousand one three
Stage One is over, oops out of time
So today I’ve got to click like it's 2014.
(Sorry, couldn’t make it rhyme)

Lemme tell ya somethin'
If you didn't come to document
Don't bother seeing patients
We got CMS wanting data
And, doc, we’re runnin’ outta time!

In a recent Medscape Family Medicine article by Brandon Cohen, “Making EHRs Less Intrusive and Annoying for Patients,” Cohen points out an all too obvious fact, that some physicians see electronic health records (EHRs) as “a giant headache” and “a barrier to good relationships with patients.” Cohen adds, however, that other providers see the EHR as a valuable tool that helps with “efficiency and accuracy” and doesn’t have to impede the doctor/patient relationship. Some of the comments shared by frustrated physician EHR users may be echoed in your office:

• "EHR has turned us from MDs into data entry clerks! We have gone from being a medical practice to an IT firm." 
  
• "I feel less satisfied at the end of the day now. When patients are all gone, I'm typing, spell-checking, and doing autocorrections." 
• "The measures of quality [in EHR] are based on checked boxes, not real outcomes. They have to be, or it fails. Simple is always better!"
• "The most important keystroke is to push the PC aside and face the patient directly."
• "I live in a town that has passed legislation criminalizing texting and driving. A driver is more impaired and distracted when texting than when intoxicated. EHRs and the practice of medicine should be no different. Do you really believe that your physician is actually concentrating on the patient in front of them while their attention is primarily focused on entering data in a computer?"
• "It's time to tell the practice managers, insurance companies, and efficiency consultants that patients expect and deserve a real physician who is a caring human being and is able to take the time and provide the human element that is a major dimension of healing."

These sentiments of frustration are obviously felt nationwide, but what makes the difference for those physicians who appreciate having an EHR? Is it a different generation of users or a different specialty? Could it be the difference in the EHR system or the workflow set up? It may be that all of these factors affect attitudes, but Cohen shares some suggestions from other physicians for making EHR more patient friendly, and, to that end, more tolerable. 

Improving the EHR Experience
Doctors who have found satisfaction with their EHR product offered suggestions to their frustrated colleagues for making the EHR less intrusive. 

Let the patient interact with the computer, too. "[Older] patients feel much more comfortable with the computer when I pull up their actual scans on the monitor and use them to explain their disease...For many patients, the computer is not only an accepted but welcome presence." (Oncology)

Identify the benefits of using an EHR and what works well. "I have a lot of stuff in the current note that used to be buried in the chart (or omitted). Every patient gets a printout of today's interim history and the proposed plan, as well as a list of meds and diagnoses." (Psychiatry)Bigger might be better. "I have a 32-inch monitor screen on the wall and wireless keyboard and mouse. It sucks the patient into their record and is unmatched for patient education." (Primary Care)

Switch the workflow and take notes. "I leave the computer out of the exam room and take notes as necessary, then complete the EHR after the interview, while my assistant is performing her tasks with the patient." (Gastroenterology)

Enter what’s necessary first, then use pen and paper.  "I inform the new patient, 'I'm just going to get some background information, and then I will talk to you about why you are here.' Once the database is completed, I print off the sheets and conduct the history and physical in the same manner I have done for the past 38 years." (Internal Medicine)

Learn to touch-type. "I touch-type, which I highly recommend learning. I can maintain eye contact while entering their history." (Internal Medicine)

Cohen noted that most physicians are not completely satisfied with current EHR technology, but many users are hopeful about what the future will bring to healthcare technology, especially as improvements are made to free up the physician to interact with patients.  
Of course, as one physician pointed out, there is one generation of patients that probably aren’t bothered at all by the presence of the computer:
"They [teenagers] won't notice you looking at a screen because their peripheral vision isn't that good, and they never break their texting trance. ...This EHR [problem] may be a transient issue; it certainly doesn't bother the younger generation."
Perhaps the issue is transient, as the provider above suggests, especially as computers and other technologies saturate our society and lives, but insights from successful users may be beneficial as we transition to this new way of medical record keeping and documentation.