Tuesday, March 16, 2010

Partial Credit for Meaningful Use

Over the past few weeks, I've had the opportunity to review numerous NPRM comment letters from professional groups and hospitals. Although the issues vary widely depending on the size, IT sophistication, and resources of the commenting organizations, one theme is clear throughout - the desire for partial credit if meaningful use best efforts do not quite meet the threshold required for stimulus funding.

All believe that it is unfair to ask for 25 projects to be done perfectly in order to qualify for the first dollar of stimulus funding i.e. what if 23 projects are done perfectly but 2 are not achievable due to local market or infrastructure issues? What if 70% of all ambulatory prescriptions are e-prescribed instead of the required 75%?

Comments have included:
*The requirement that ALL measures be met will slow the adoption and meaningful use of EHRs
*The number of required measures is unrealistic for Stage 1
*The thresholds for measures are too high

All conclude CMS should maintain strong incentives for high levels of use, but eliminate the “all or none” thresholds for providers to qualify as meaningful users, at least for Stage 1.

I've seen two detailed proposals to address the partial credit problem - one from the HIT Policy Committee and one from the American Hospital Association.

The HIT Policy Committee has recommended a partial credit approach called the 3-1-1-1-0 proposal. You can read their recommendations on the ONC website.

The idea is that organizations should be permitted to defer fulfillment of a small number of meaningful use criteria and still qualify for incentive payment. The deferment would last until Stage 2 criteria apply. To prevent providers from bypassing an entire priority area (e.g., skip all of patient engagement), the 3-1-1-1-0 proposal allows professionals and hospitals to qualify for Stage 1 incentives if they defer no more than the specified number of objectives in each category, as indicated in this table.

The HIT Policy Committee idea includes the 2011 recommendations as they are written today and takes into account the fact that 2013 and 2015 recommendations are still a work in progress.

The American Hospital Association has recommended a different approach - suggesting that all criteria for meaningful use (stage 1,2,3) be specified now and enabling hospitals to travel a glide path of implementation from 25% to 100% until 2017 (the graphic above).

The logic is that software implementation life cycles take 24 months and it's hard to change software 3 times for 3 stages. Rather, working on all stages over a multi-year period provides time for technology, policy, and process changes to be coordinated in a phased way.

The only problem with this idea is that we really do not know what technology capabilities and policy priorities we'll have in 2017, so declaring them all now seems premature.

My opinion, aligned with the HIT Policy Committee recommendations, is that we should designate a core set of meaningful use requirements (i.e. 10 or so must haves), permit providers to select a given number of additional qualifying measures among a set of optional measures (i.e. choose any 5 from a menu of 10), and enable providers who meet substantially all of a measure to be considered meaningful users.

Furthermore, CMS could scale payment amounts to the level of use. For example, a provider who demonstrates ambulatory CPOE usage at 25% would receive partial credit for that metric. Usage at 50% ,75%, and 80% (the NPRM) goal would receive increasingly higher levels of credit.

Regardless of the approach chosen, it's clear that small and large providers alike want some provision for partial credit. I look forward to the CMS comment disposition process which will address this theme.


Michelle W said...

Thanks for the links to the two flexibility proposals. I too have been following the discussion with some interest. Everytime the committee met and discussed this issue I heard someone say partial payment wasn't an option, though I can't say why or who it was at the moment. It'll be interesting to see what changes we'll see on the NPRM now that the comment period is over.

Joe Stewart said...

It has been my experience that "partial credit" doesn't lead to the outcomes required.

I also acknowledge that defining "all" requirements up front isn't optimal.

So, my thinking is that credit is "all or nothing" against the minimum achievement standard where that standard has a set of "must-haves" and a subset of a menu of "additional options". Over the coming years, the "Additional Options" menu could be enlarged as technology and medical practice adapt.

Dirk Stanley, MD, MPH said...

I think it's reasonable for a "partial credit" response - So far, I haven't spoken to anyone (other than a few large academic centers with deep pockets) who feels confident about meaning the current MU criteria - This would certainly allow them to achieve part of the goal.