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By Michael Solomon, eCare Management Practice Lead
Meaningful use (MU) is at an interesting place in its evolution – that funny space between the end of stage 2 and the beginning of stage 3. Speculation about its future was rampant at the 2014 annual meeting of the Healthcare Information Management and Systems Society (HIMSS). As nationally recognized experts on health information technology (health IT), Point-of-Care Partners (POCP) has some thoughts about the whys and next steps for MU. The ultimate success of MU will be influenced by several factors moving forward, including stage 3 requirements and new legislation.
Stage 3 requirements. A key driver for the future of MU is the stage 3 requirements themselves. At its March 11 meeting, the Health IT Policy Committee (HITPC) accepted its MU workgroup’s draft stage 3 recommendations. The recommendations are being sent to the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology. After digesting them, a notice of proposed rulemaking (NPRM) will be issued this fall by CMS. A final rule is on the radar for 2015.
The recommendations have caused quite a bit of consternation for HITPC members, according to media reports. Some are concerned that the recommendations were scaled back by 30%, with significant setbacks to the strategic goal of improving quality of care and safety, in particular. One troubling choice was the decision to remove a requirement related to medication adherence. (Click here for a deeper dive into this issue.) Excision of such criteria could be attributed, in part, to confusion on the part of stakeholders involved in implementing those objectives (e.g., access of images) or industry resistance to standards (e.g., pharmacy use of fill status to track adherence). Other HITPC participants called for even more pruning, claiming that providers and vendors are already overburdened.
We believe the narrower set of criteria in the stage 3 recommendations is the right approach, especially if the result is more robust certified EHRs to support clinical decision support (CDS) and patient engagement. The HITPC is linking CDS quality measures to the National Quality Forum’s national priorities. This gives forward-thinking health care leaders the opportunity to focus on CDS that advances their organizations’ patient-centered care model and improved care coordination efforts – critical to success in an accountable care organization. Medication management has a central role in the CDS interventions, with advanced medication-related decision support and more complete medication lists highlighted.
Anyone hoping for relief on the patient engagement front will likely be disappointed. Stage 3 objectives and criteria raise the bar, requiring providers to demonstrate receipt of provider-requested and patient-generated data. This requirement could finally push the envelope on the development of workable models for storing patient-generated data in EHRs.
Our take is that the stage 3 revision process is far from complete; some self-examination and realignment will be necessary. More changes will occur in response to the NPRM. It will be interesting to see how this core set of requirements changes due to stakeholders’ concerns, and whether some are dropped and others are added in response to the comments received.
New legislation. The latest example of how new legislation would impact MU was the first round of legislation (H.R. 4015/S. 2000), which would have repealed Medicare’s sustainable growth rate (SGR) requirements. As per usual with much legislation, a number of health IT provisions were tucked inside: a mandate that all EHRs achieve interoperability by 2017, a prohibition for vendors from deliberately blocking information sharing with other EHR vendor products, and creating a reimbursement process for clinical imaging based on appropriate use criteria (click here to read more about the latter in HIT Perspectives).
In addition, the legislation would have rolled MU into a gigantic new program called the Merit-Based Incentive Payment System (MIPS) in 2017, along with the Physician Quality Reporting System (PQRS) and the Value-Based Modifier (VBM). This would have put most of the federal government’s quality-based pay-for-performance requirements in one place, with MIPS being the only Medicare quality reporting program.
Had it materialized, the MIPS implementation would have depended on a strong health IT backbone. Beginning in 2018, MIPS would have provided bonuses ranging from 4% to 9% for physicians who scored well along the dimensions of quality, resource use, MU, and clinical practice improvement activities. Quality reporting was anticipated through EHRs or qualified clinical data registries. Participation in a qualified clinical data registry would also have counted as a clinical practice improvement activity.
All of these activities are very far reaching, but will not happen. The proposed bills were supplanted by the Protecting Access to Medicare Act of 2014, which stripped out those health IT provisions. However, given the legislative process, they are likely to reappear in one form or another in subsequent bills. After all, Congress must take another shot at ‘fixing’ the SGR formula issue next year because this year’s legislation only staves off SGR-based payment cuts for Medicare physicians until March 2015. (It should be pointed out that this year’s temporary SGR ‘fix’ was the 17th such patch that Congress enacted since the SGR formula became law in 1997.) Of course, there will be plenty of legislation throughout the rest of the year that could be vehicles for health IT-related provisions.
The Protecting Access to Medicare Act also delayed International Classification of Diseases, 10th edition, (ICD-10) implementation for a year. While this temporarily relieves hospitals and physician organizations of the stress of implementing ICD-10 and MU stage 2 requirements in tandem, the delay in ICD-10 implementation signals how things can play out due to delays or abrupt changes in program direction. First, this delay will be expensive. Many organizations have spent considerable time and money to get with the program. Code mapping and crosswalks have been under way for several years. The result: an additional $1 billion to $6.6 billion on top of what has already been incurred due to the previous implementation delays, according to the American Health Information Management Association. There also will be consternation among trading partners – those that have implemented and those that have not. While voluntary trading partner agreements are likely to be the way things play out, it is not beyond the realm of possibility that the government will step in and issue some kind of regulatory guidance, as was the case with the Health Insurance Portability and Accountability Act. Finally, delaying ICD-10 adds to the uncertainty and complexity of implementing the health IT infrastructure needed to support population health management and value-based reimbursement, which is not a good thing in our opinion.
POCP is closely monitoring developments with MU and on the legislative front. We are working with our clients as they: 1) align their MU compliance strategies with the broader strategic priorities of population health management, clinical integration and quality-based performance monitoring; 2) transform their organizations to succeed in a value-based payment environment. We would be happy to help your organization interpret the MU landscape and its impacts, as well as assist with the development of comment letters when the NPRM is issued in the fall.