Wednesday, May 28, 2014

Early reaction to the Electronic Health Record Incentive NPRM

Last week, I posted the Notice of Proposed Rulemaking from CMS that offers flexibility to Meaningful Use attestation in 2014 .

Since then, I’ve received hundreds of emails about it from my fellow CIOs across the country.   Here’s a summary:

1.  To clarify, the NPRM offers flexibility for hospitals to attest to Stage 1 criteria for 2014 from July 1 to September 30.   However, it offers no flexibility for 2015 which begins October 1, 2014.    This means that hospitals which are struggling with Transition of Care summary exchange, Electronic Medication Admission Records (EMAR), and Patient Portals such that their implementations cannot be ready by July 1, must be fully ready by October 1, since 2015 requires a full year reporting period for attestation.     Thus, the NPRM as written really only provides a 90 day delay from July 1 to October 1.   It’s too little, too late for hospitals to achieve the business transformation, cultural changes, and workflow redesign needed.  

The solution - either relax the Transition of Care summary exchange requirements, EMAR requirements, and Patient Portal usage requirements or make the 2015 reporting period any 90 days in 2015 to enable more time for implementation.

2.   Even if a hospital has installed 2014 Edition software and can send Transition of Care summaries, most community-based physicians cannot receive them.   Also, few communities have provider directories which enable discovery of Direct addresses to send to those physicians with receiving capabilities.   Although the Transition of Care summary exchange requirement of Meaningful Use Stage 2 is a very noble policy goal, it requires an ecosystem of components that is not yet present in the US.   The same is true with the transmit component of the patient view/download/transmit capability - there are few places that can receive patient transmissions.

The solution - offer a hardship exemption if the hospital or physician office can send Transition of Care summaries, but there is no one to receive them or community provider directory infrastructure is lacking.

3.  Using Stage 1 criteria is helpful in that the Transition of Care summary exchange, EMAR, and Patient Portal criteria are relaxed, but does it require the use of Stage 1 Clinical Quality Measures?   2014 Edition software (or third party services providing quality measure computation) no longer support Stage 1 quality measures, so it is unlikely that Stage 1 quality measures can be submitted.

The solution - Stage 1 attestation with 2014 Edition software should allow 2014 quality measures.

Note:  My colleagues at CMS have clarified this issue.  "In the EHR Incentive Program, pre and post this NPRM, the clinical quality measures are not linked to the Stage of MU but to the year (CY or FY).  All participants using 2014 CEHRT, are reporting 2014 quality measures. It is ONLY if they use the 2011 CEHRT that they need to report the old CQMs. In other words, CQMs are already tied to the year of CEHRT in use, not to the stage of MU and that would not change under the proposal in the NPRM. "

The NPRM is a good first step.   It needs to be further revised to shorten the reporting period for 2015, enable the evolution of community infrastructure for Transition of Care summary exchange, and recognize that historical quality measures can no longer be computed.

One editorial comment - at some point we need to recognize that layering fixes on top of existing Meaningful Use regulation, some of which was written by CMS and some of which was written by ONC creates too much complexity.   I have direct access to the authors of the regulations and email them on a daily basis.   It’s getting to the point that even the authors cannot answer questions about the regulations because there are too many layers.  I realize that we are reaching the end of the stimulus dollars, but as we head into Stage 3, I wonder if we can radically simplify the program, focusing on a few key policy goals such as interoperability, eliminating most of the existing certification requirements, and giving very clear direction to hospitals and professionals as to what must be done when.

If I were king for a day, I would consolidate the Meaningful Use program into the “Merit-based Incentive Payment System” as I wrote about in this post, offering incentives for those who achieve stretch goals, without penalties for those who do not.    In my mind, Meaningful Use has achieved its goals of accelerating EHR adoption and  fundamentally changing attitudes about the need for healthcare automation.   At this point, we should learn from the challenges to achieve Meaningful Use Stage 2, provide a short term fix (revised as above), and then use Meaningful Use Stage 3 as an opportunity to simplify the program.


Joe Stewart said...

What gets measured gets better.

What matters is patient outcomes.

I'm in agreement with your conclusion - let's make sure that simplification addresses "what gets measured" and focuses on "patient outcomes." Losing sight of either will continue the drift toward bureaucracy.

Unknown said...

"2014 Edition software (or third party services providing quality measure computation) no longer support Stage 1 quality measures, so it is unlikely that Stage 1 quality measures can be submitted."

Not true in all cases, at least not ours. We continue to support all CQMs for all years for all of our customers.

I will leave our name off of this to avoid turning this into a marketing campaign but would simply advise providers to consult with their vendors to determine their available options.

Unknown said...

Thanks for the great post, John!

There is language in the proposed rule that addresses the CQM misalignment between 2011 and 2014 CEHRT. . ."Because of the differences in how CQMs are calculated and tested between the 2011 and the 2014 Editions of CEHRT, we are further proposing that a provider may attest to data for the CQMs derived exclusively from the 2011 Edition CEHRT for the portion of the reporting period in which 2011 Edition CEHRT was in place."

However, thanks for bringing up a very valid point as there is no provision for reporting on 2013 Stage 1 measures with 2014 CEHRT. There are only a few changes between 2013 & 2014 S1 but attestation is all or nothing so one "miss" is all it takes.

Anonymous said...

Hello John,
I agree with your thoughts about MU, but it still scares me that I have no idea about all these acronyms you use. And I am a physician/owner of a 4 MD orthopedic practice. We use a non-MU custom EMR/PACS/PMS system and we are effectively shut out of participating in anything MU now. We are able to do anything with our EMR so we COULD do it, but since we do not want to go thru certification hassles, we have opted out of MU. Therefore don't have to worry about audits, and all the meaningLESS parts of MU that would make it more costly, inefficient and potentially unsafe to use. We have many aspects of MU in our system, but none of the fluff and non workable items. We also have many extra features that we use that make use even more safe, effective, communicative with our patients. We don't want to give that up. If MU were radically simplified, we would consider participating. But only if we could customize to our needs. Right now EMRs are trying to do everything for MU and forget doing anything for actual end users. They are just sprinting to keep up with the MU program, no matter if its what providers are asking for or not. You do realize that interoperability is a farce, right? It takes massive cost and infrastructure change to get connected from your EMR to HIE. And HIE's don't have everything, and they flood the EMR system with a boat load of crap that would take 3 FTEs to just make sense of. Its information, but a blithering amount of it. For us, the most important thing we need from interoperability is access to patient's actual images from other institutions which appears to be a pipe dream at this point. It would be nice to see other notes, op notes, and labs, but even from MU certified products, that appears to be a manual transaction anyway, so whats the point. Since we have been using our EMR since 2002, we a vast experience with using such a system. I can tell you that it is costly, requires constant vigilance and updates, and though its way more efficient than paper, it took a ton of customization to get it to work just for us. So when we saw what was being offered from MU vendors, I can tell you we saw all the issues that were going to occur even before all the experts did. A lot has been asked of current providers with workflow disruption, learning systems and such. I have been through this with the hospital's EMR. There are not improved outcomes with this. And its frighteningly costly. To continue on this frenzied pace will fail for sure. I feel that even though the puffery and stats are pumped out of the ONC and CMS for showing how successful the MU program is, I can tell you that on the streets, in the real provider world, the program is dead. Its just too complex for a regular provider to understand, there is no money left to support it, and the shift will be from MU to making the system work for EPs now, not MU. The costs of keeping even a basic system going is going to be heavy and disruptive. The backlash is just beginning. I predict and stampede away from MU, so now is a good time to put in for a radical reboot. I like the idea of those that want to continue the MU path, they can get a financial incentive, but to penalize the rest of us, just trying to take care of our patients, that will foster even more resentment to the MU program.

Anonymous said...

The longer I have been involved with this, the more obvious it is that MU and the Medicare incentives were, from the beginning, a way for the Feds to transfer dollars to the IT industry at the height of the recession. Just like what the banking industry got in terms of a bailout. Not surprising given that IT is localized in California and other states that gave Obama his victory in 2008. (Note: this is not stated as some anti-Obama rant. Just a demographic and political fact of life.) I have seen the results of 2 botched installations of "big name" EHR systems (no, I was not there for the installs) in mid-size, otherwise successful specialty practices, each of which cost in excess of $1 million. Reduced physician productivity, increased staffing, non-stop expense tending the systems, never-ending upgrades that do not fix underlying problems, and never-ending frustration. No other industry in this country, and no other health care system in any other major country, would tolerate this folly. My individual perspective is that MU, both incentives and penalties, but especially penalties, should be delayed at least a year, probably 2, until the technology has caught up. And then yes, as Dr. John has said, any future endeavors should be toward the development of clinically meaningful processes, not meaningless counting in an attempt by CMS to micromanage all aspects of healthcare.

Anonymous said...

@Joe Stewart:
"What gets measured gets better." Use with caution- apply only a thin layer. Truth: when measures are unrealistic and unachievable "What gets measured gets better at cost of something else including integrity." Look no further than Phoenix VAMC scandal that tarnished image of an outstanding organization.