Rule links MU with medical licensure

Starting in 2015, doctors in Massachusetts will have to show health IT meaningful use proficiency as a condition for medical licensing. The Massachusetts Medical Society is encouraging the state's Board of Registration in Medicine to broadly interpret the rule — Section 108 of the state’s 2012 healthcare cost reform law, known as Chapter 224 — with a variety of options for compliance, such as continuing education or certifications.

What concerns the medical society, said President Ronald Dunlap, MD, are potentially narrow interpretations of the section’s brief language: “proficiency, at a minimum shall mean that applicants demonstrate the skills to comply with the ‘meaningful use’ requirements.”

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“Basically, strictly speaking, it says that physicians need to meet the meaningful use standard to be licensed,” said Dunlap, a cardiologist who practices in Weymouth, a city south of Boston.

“Even though you’re using a certified system, there are a number of physicians who work in academic centers who don’t have office practices, and many physicians who have an EMR are in a practice with an ophthalmologist or dermatologist, and it’s not necessary for them to meet meaningful use," Dunlap explained. "If you don’t see a certain percentage of Medicaid patients, you wouldn’t be able to qualify because you don’t meet certain patient demographics."

By the medical society’s estimate, Dunlap said, “probably 70 or 80 percent of physicians in the state using computers are probably adept, yet at least more than half of them would not meet the meaningful use standard.”

“I think we’ve made some progress in trying to get the board to understand that, and our next step will be to meet with the legislature to see what we can do to get this changed or modified in such a way that it becomes more flexible for the great majority of physicians,” Dunlap said. “We’re also thinking about perhaps being more creative and getting people who haven’t adopted a grace period to attest or taking a [continuing medical education] course.”

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The provision’s main author in the Massachusetts legislature, though, thinks the concerns aren’t really warranted, and that the provision ensures caregivers across the state can meet standards for care coordination.

Instead, the provision is about having the skills necessary to meet meaningful use rather than actually being certified by a federal agency, said State Senator Richard Moore, a Democrat from the central Massachusetts town of Uxbridge. “Since the best standards available are the national standards for meaningful use that apply to many but not all physician practices, we thought that would be a good place to start.”

“We would be open to revisiting it, but not necessarily weakening it,” Moore added about the medical society's suggestion to amend the law. “My feeling is that every physician and nurse practitioner and others who are primary care providers need to be involved in and utilizing health information technology, and if they’re not, then I don’t think they’re practicing safe medicine.”

Massachusetts doctors are in some ways ahead of national trends on EHR adoption. According to estimates by the Massachusetts eHealth Institute, the meaningful use regional extension center, about 70 percent of the Commonwealth’s providers have an EMR, and about 9,000 — or one-third — have already been paid for completing meaningful use Stage 1.

And as required by a 2008 law, Massachusetts hospitals and community health centers had to be CPOE-interoperable by 2012 and have to be EHR-interoperable by 2015; before the meaningful use demonstration requirement for physician licensing, doctors were on track to show CPOE proficiency by 2015.

Dunlap and the medical society’s concern over the meaningful use demonstration requirement is part of their unease with the pace of health policy change in Massachusetts — that being insurance coverage reform enacted in 2006, amended in 2008 and 2010, and then Chapter 224, the cost containment law, enacted last August.

With the goal of saving almost $200 billion over the next 15 years through value-based reimbursement, Chapter 224 set a statewide cap on healthcare spending tied to the growth of the state’s economy, establishing 20 state commissions and task forces to help phase out fee-for-service, introduce accountable care models, and investigate healthcare quality (like the Diagnostic Accuracy Task Force).

The type of fixed-rate or global budgets that the law calls for may ultimately make the practice of medicine easier for caregivers, but in the short term, its complexity is going to be overwhelming for some, Dunlap said.

“The infrastructure you’ll have to have to be able to participate in the payment models requires a lot of investment, and a lot of smaller groups and doctors and even moderate-size groups may have trouble coming up with the capital to invest in the systems needed to meet all the quality standards,” Dunlap said.

Even large integrated health systems “will be challenged to measure quality,” said Dunlap, who came to medicine as an electrical engineer developing one of the first wireless electrocardiograms at Hewlett Packard and who recently helped found a doctor-owned health information exchange.

Moore, now the president of the Massachusetts Senate, helped design Chapter 224’s cost-containment requirements and thinks global budgeting should ultimately give doctors more financial security. “The fee-for-service system makes it more difficult,” he said.

“We also provided significant money and we probably will provide more money both from federal funds as well as state funds,” Moore said, noting Chapter 224’s $30 million appropriation to the state eHealth Institute Fund.