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Ideas and Opinions |

A Tale of Two Angels

David Blumenthal, MD, MPP
[+] Article and Author Information

This article was published at www.annals.org on 12 February 2013.


From The Commonwealth Fund, New York, New York.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-0214.

Requests for Single Reprints: David Blumenthal MD, MPP, The Commonwealth Fund, 1 East 75th Street, New York, NY 10021; e-mail, db@cmwf.org.

Author Contributions: Drafting of the article: D. Blumenthal.

Final approval of the article: D. Blumenthal.


Ann Intern Med. 2013;158(6):489-490. doi:10.7326/0003-4819-158-6-201303190-00596
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This commentary discusses the Office of Inspector General's recommendation that the Centers for Medicare&Medicaid Services (CMS) issue guidance concerning the documentation providers should keep to justify their meaningful use payments and that CMS conduct prepayment audits for at least some providers before dispensing payments. The CMS rejected the latter over concerns about undue burden on providers and delayed incentive payments, and many providers share these concerns.

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Balancing the angels to benefit patients and clinicians
Posted on February 15, 2013
Stephen C Schoenbaum
Josiah Macy Jr. Foundation
Conflict of Interest: None Declared
This is an extremely clear and useful exposition of the issues involved in stimulating not just use, but meaningful use of health information technology (HIT). It appears that many cannot be “on the side of the angels” but must choose between the approaches of Angel 1 and Angel 2; whereas Dr. Blumenthal indicates the importance of finding a balance between the two. Having spent almost two decades at Harvard Community Health Plan (1981-1999), an organization that implemented its first electronic medical record in 1972, I, like Dr. Blumenthal, would prefer the approach of Angel 1 and think it is extremely important for patients, physicians, and all involved in health care delivery that we have robust HIT including excellent modes of information exchange. I am, however, chastened by the OIG’s statement: “Currently, CMS has not implemented strong prepayment safeguards, and its ability to safeguard incentive payments post-payment is also limited.” Being unfamiliar with the nuances of HITECH and whether there is federal monitoring of the Medicare incentive program, let alone substantial monitoring by the states in their Medicaid programs, I find it surprising that when I go to the CMS Official Web Site for the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs I cannot readily find information about monitoring. So, I too would argue for respecting the position of Angel 2 and finding a balance.I think an approach that might allow both angels to sleep comfortably at night would involve post-payment audits of a small sample of payees. Since all would know in advance that they might be audited, there would be a disincentive to fraud and abuse. This approach has worked in some other settings. More importantly, I believe, it would put trained persons doing the audits in contact with users. Given the concerns that many users voice about the burdens and inadequacies of their HIT systems, it could and should be used to obtain systematic collection of information that could lead to the design and deployment of more user-friendly systems. In short, paying some attention to the needs of Angel 2 could be beneficial to Angel 1’s objectives as well. Ultimately, the success of HIT in achieving more effective and efficient care must depend not just on meeting some requirements for “meaningful use” as defined by government but on providing user-friendly meaningful tools for providers and patients.
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