Wednesday, November 18, 2015

A Followup on the MU Path Forward

After last week’s post about my suggested path forward for Meaningful Use,  I received a large number of comments.   I thought it would be useful to summarize them and clarify some of my opinions.

In general, 95% of commenters agreed that CMS should pivot the concept of Meaningful Use functional requirements into pay for performance rewards for achieving outcomes via MACRA.

Several commenters pointed out that the MU program has different approaches for Medicaid providers and Medicare providers.       Medicaid funding is available to help providers purchase technology.  Medicare providers received stimulus in the past and now are entering the penalty phase for not attesting to Meaningful Use.  I did not mean to suggest that Medicaid funding should cease before EHRs are fully deployed in Medicaid provider locations.    My suggestions referred to the Medicare programs and penalties for not implementing prescriptive functional requirements.

I was asked to clarify my thoughts about certification.    Today’s certification program includes onerous requirements that consume vast amounts of resources for items not related to interoperability.   If we focus on three goals (provider to provider push,  provider to provider pull, and patient pull), then a streamlined certification program validating those three functions would make sense.   Just as a DVD player includes a sticker guaranteeing “Blu-Ray” compliance, I can imagine a streamlined certification program that issues “stickers” for each of the three interoperability goals, reassuring clinicians that the health information exchange claimed is fully functional in the products they buy.

I was asked if I was criticizing CMS or ONC work.    I’m really not criticizing anyone.   I’m suggesting that the work done in the past was foundational, but the future requires a different approach - outcomes based incentives.    I’m confident that CMS and ONC staff can evolve existing programs into this new approach.

Finally, some have advocated for a transitional approach along the road to FHIR, since existing standards such as IHE XDS/XUA are already in the marketplace.     I realize that we cannot go from cars to jet planes without a few intermediate steps.  However, we have to proceed very carefully because for vendors, every OR becomes an AND.   If we say that you could use IHE XDS or FHIR, we will run into impedance mismatches. Not only will vendors have to implement every option, they will have to implement step up/step down conversions between organizations that use different options.   In general, optionality is the greatest impediment to interoperability.      If the entertainment industry decided that laser disc and Blu-Ray should be used simultaneously, our home systems would become very complex and hard to maintain.   While I understand that some optionality could be offered during a transition period, I am advocating for a move to FHIR/OAuth as the ONLY approach, with minimal optionality, as quickly as is practical.

I look forward to the continued comments - let’s keep the dialog going!

1 comment:

Adrian Gropper said...

It's amazing how far we have come when people like me that advocate for patient-centered health IT are able to evangelize your position. To be clear, I completely agree that MU3 needs to mandate and certify provider pull and patient pull via the FHIR API.

One more thing will be needed to achieve the kind of interoperability that we had in the phone and fax world, and it's the core message of the JASON reports. The HIPAA enforcement folks at OCR will need to provide guidance on the patient's right of access to a MU certified FHIR API. OCR must be clear that, although institutions can issue "black box" warnings to providers and patients about security as they perceive it, the institution cannot block "pull" by a patient-specified client or by a provider that is delegated access by the patient. This separation of storage from authorization was core to the JASON reports and needs to be clearly implemented in MU3 and related guidance.