Promoting Interoperability: MU Fades to Black
Seeking to liberate the industry from its self-created morass of siloed data and duplicative quality reporting programs, the Department of Health and Human Services (HHS) issued 1,883 pages of proposed changes to Medicare and Medicaid. It renamed the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs (known by all as Meaningful Use) to Promoting Interoperability Programs (PI).
As widely reported, it would eliminate some measures that acute care hospitals must report and remove redundant measures across the five hospital quality and value-based purchasing programs. It would also reduce the reporting period to 90 days. HHS will be taking comments until June 25, 2018.
HHS believes that APIs will solve all of the problems that patients and healthcare stakeholders have with data access. HHS also seems prepared to declare that TEFCA compliance and 2015 Edition CEHRT guarantees that those APIs are in place.
HHS believes that requiring hospitals to use 2015 Edition CEHRT in 2019 makes sense because such a large proportion of the hospitals are “ready to use” the 2015 Edition. Ready to use is not the same as using. 2015 Edition EHRs may not be as widely deployed as HHS indicates. The following 10 month old snapshot from ONC shows hospitals have not aggressively moved to adopt 2015 Edition CEHRT.
Current adoption levels by HCOs are undoubtedly better, and many vendors have 2015 Edition technology ready to go, but hospitals can only change so fast. The rush to get hospitals on the most current edition has to do with the most relevant difference between the 2014 and 2015 Editions – the API requirement. APIs will be the technical centerpiece of better, more modern interoperability but adoptions levels are still low. APIs, by themselves, offer the promise of better data liquidity. For this promise to become a reality, healthcare stakeholders need more than just a solid set of APIs.
HHS is also proposing that hospitals post standard charges and to update that list annually.
This is a nice thought, but it will take some heavy lifting to pull this off. For starters, HHS doesn’t even have a definition of “standard charge” and is seeking stakeholder input before the final rule is published. HHS also must determine how to display standard charges to patients, how much detail about out-of-pocket costs to include (for patients covered by public and private insurance), and what noncompliance penalties are appropriate.
Above all, there’s the thorny issue of establishing what a standard charge is in the first place. Charges vary by payer. Can a hospital truly state, without a doubt, the cost of an MRI or a colonoscopy? Most cannot – and technology alone will hardly solve this problem.
The existence of APIs will stand in the stead of the old view/download/transmit (VDT) requirement. Regarded as one of meaningful use’s most troublesome and fruitless requirements, this rule has been shed by HHS because of “ongoing concern with measures which require patient action for successful attestation.”
VDT is one of several MU Stage 3 requirements pertaining to patient engagement – along with providing secure messaging or patient-specific educational resources – that HHS has proposed dropping, under the pretense that it is “burdensome” to healthcare providers. While hospitals have struggled to get many patients to participate, the VDT requirement set the bar at one patient out of an entire population. What’s more, dropping the requirements fails to take into account how burdensome it is for patients to try to access their data, communicate with their physicians, and learn about their conditions and treatment options. It is also contrary to CMS Administrator Seema Verma’s remarks, first at HIMSS18 and again this week, indicating that the agency seeks to “put patients first.”
HHS says that third-party developed apps that use APIs will deliver “more flexibility and smoother workflow from various systems than what is often found in many current patient portals.” Whether such apps deliver “smoother workflow” is not a foregone conclusion.
HHS proposes “a new scoring methodology that reduces burden and provides greater flexibility to hospitals while focusing on increased interoperability and patient access.” The proposed scoring methodology uses a 100-point system (explained over 24 pages) in which attaining a score of at least 50 means there will be no Medicare (or Medicaid) payment reduction.
HHS is also mulling whether to abandon these measures altogether in favor of scores calculated at the objective level.
The biggest regulatory effort in recent months related to interoperability, other than this proposal, has been ONC’s proposed Trusted Exchange Framework and Common Agreement (TEFCA), required under the 21st Century Cures Act. TEFCA, well along in the planning stages, is a new set regulations from ONC whose goal is to catalyze better data availability using APIs. HHS in this regulation wants public comment on whether participation in a TEFCA-compliant network should replace the process measures in Health Information Exchange objective. Stated another way: Should TEFCA compliance replace 80 percent of the score for PI (75 percent in 2020)?
TEFCA is widely expected to provide a safe harbor from data blocking liability although ONC has been mum on this point. TEFCA then could do double duty: Eliminate the need to meet or report on health information exchange metrics and provide a shield from data blocking enforcement.
But there are, as yet, unanswered questions about TEFCA:
HHS is also considering doing away with Public Health and Clinical Data Exchange objective. It floated the idea that a provider that supports FHIR APIs for population-level data would not need to report on any of the measures under this objective. This would replace 90 percent of the score for PI (85 percent in 2020) when combined with the TEFCA knockout.
The specific API mentioned, called Flat FHIR and still in development, will probably contribute to part of the complex process of public health and registry reporting. This activity currently requires highly skilled data hunter-gatherers, usually with clinical credentials. In many organizations, these hunter-gatherers manually sift and collate multiple data sources to meet the varied requirements of the recipients of different registries. Flat FHIR, assuming it were production-ready, will certainly help, but it is unlikely that it could provide all, or even most, of the information needed for the range of public health reporting programs.
HHS acknowledges that providers are less than thrilled with aspects of the Quality Payment Program (QPP). HHS wants to know how PI for hospitals can better “align” with the requirements for eligible clinicians under MIPS and Advanced APMs. In particular, it wants ideas about how to reduce the reporting burden for hospital-based MIPS-eligible clinicians. It is undoubtedly looking for market-acceptable ideas to reduce the reporting burden where it is arguably more deeply felt – among non-hospital-based MIPS-eligible clinicians. While reducing or eliminating the reporting burden would help such providers, the big unanswered question, as it is with hospitals, is the burden of getting to 2015 Edition CEHRT.
HHS also asks the industry how it could use existing CMS health and safety regulations and standards to further advance electronic exchange of information. It is ready to change Conditions of Participation (CoPs), Conditions for Coverage (CfCs), and Requirements for Participation (RfPs) for Long Term Care Facilities regulations to this effect. It wants to know whether requiring electronic exchange of medically necessary information in these regulations would move the interoperability needle.
HHS believes that APIs will solve all of the problems that patients and healthcare stakeholders have with data access. HHS also seems prepared to declare that TEFCA compliance and 2015 Edition CEHRT guarantees that those APIs are in place. It roundly ignores the mesh of incentives that make stakeholders unwilling to share data and patients unable to access data. The industry has cried out for less process reporting and better insight into outcomes for years. This will accomplish the former but set the industry back with respect to the latter if interoperability is declared solved based on technology alone.
Matt Guldin · 1 year ago
Brian Eastwood · 2 months ago
Chilmark Team · 3 months ago
Brian Eastwood · 3 months ago
CMS Drops MACRA Rules – 5 Things to Know About MIPS
Big news this week when on Wednesday CMS dropped the draft rules for MACRA, all 962 pages worth. These rules are the outcome of legislation that passed a couple of years back to replace the flawed SGR reimbursement model for physicians and hospitals. In its place, CMS is proposing two dominant reimbursement models:
In the conference call on Wednesday, acting head of CMS, Andy Slavitt, made it clear that the intent of MACRA is to move towards a model that provides flexibility for physicians to deliver quality care and enable the free flow of information across the sector in support of patient care and more broadly population health.
Plenty to talk about regarding both APM and MIPS, but for brevity’s sake, let’s focus on MIPS and we’ll do a follow-up post on APM in near future.
Five Things to Know About MIPS
Unpacking 962 pages of proposed rules in not for the feint of heart. No, we have not gone over every little nuance of the rules but in our cursory review we have identified five key points that really are the crux of the rules for EPs as it pertains to MIPS. These are the things that define the intent of MIPS and also where we are likely to see some push-back, after all, these rules are not quite set in stone – yet.
1) Quality and information exchange are top priorities. MIPS reimbursement will be based on a composite score of four key components: quality, resource use, clinical practice improvement activity, and advancing care information. Quality and advancing care information will be 75% of total weighting. Thus, it is quite clear where CMS wants physicians to focus in the near term – improving quality of care delivered and accelerating the use of IT to facilitate the flow of PHI in support of care quality.
2) Move from highly prescriptive to more flexible model. Under MIPS, MU is effectively dead for EPs under Medicare – the odd twist though is that MU is still in place for hospitals and Medicaid EPs, though CMS has expressed its intent to modify these areas as well in the future. CMS is giving quite a bit of flexibility to EPs in reporting out what measures are most important and relevant to their practice. Gone are the prescriptive, strictly defined measures that were part and parcel of MU, measures that often did not align with other CMS programs.
3) Be careful what you wish for – flexibility may breed complexity. While physicians now have a range of options as to what they will report out on as part of MIPS, this flexibility has a way of compounding itself in a nearly exponential way. Eligible physicians will need to wade through the many permutations of MACRA reporting requirements to settle upon what is best for their practice. This will create a lucrative opportunity for consultants serving this market. We also wonder how CMS will keep track of all of this as well – this is a non-trivial issue.
4) No time to waste – one year reporting period, begins January 1, 2017. Due to legislative requirements, CMS’s hands are tied as to when the switch to MACRA begins – but Jan. 1 2017 is only a short six months or so away from when rules will be finalized. What CMS does have flexibility on is the reporting period and they have chosen to go with one year, versus the more popular 90-day reporting period. CMS will get some heavy pushback here and likely acquiesce to 90-day. Would also not be at all surprised if the whole program gets push back a full year – just remember what happened to switch from ICD-9 to ICD-10.
5) Trust then verify is the mantra. Under MACRA’s new reporting requirements CMS recognizes that it will need to trust EPs to do the right thing. That being said, the proposed rules also have a significant amount of language pertaining to surveillance. How that surveillance will occur, how much will big brother be looking over a physician’s shoulder is up for interpretation,
While there are aspects to MACRA that have cause for concern, as outlined above, we are quite impressed with what CMS has put together. Clearly, a lot of hard work has gone into these proposed rules. CMS has reconciled many of the past ills – from the defunct SGR reimbursement model, to the oft-maligned MU program – with the desire to align the program to how physicians actually practice care that will lead to improvement in quality of care provided and value for the U.S. citizen. This is a Herculean task and for that CMS, Andy Slavitt, Karen DeSalvo, and countless others that have contributed to this effort deserve applause.
Some Additional Resources:
HHS Secretary Burwell’s take, with a pretty slick video giving high level overview of MACRA
The proposed rules, all 962 pages
Nice, digestable summary of MACRA
Similar to previous, but takes closer look at Advancing Care Information – the replacement to MU
Politico’s, Dan Diamond’s, interview/podcast with Andy Slavitt about MACRA
WWBR Week of October 6, 2014
Dallas hospital blames ‘flaw’ in ‘workflow’ for release of Ebola patient as a more complete picture of his travels emerges
Lindsey Bever for The Washington Post
“The Ebola patient in the Dallas hospital seems to have been missed because workflow integration doesn’t mean much when workflows are separately integrated. An intake nurse documented the patient’s travel to Africa in the patient’s chart. That data appeared nowhere in the physician’s workflow. The hospital has hurriedly changed physician workflow to include travel history. Pity the poor IT departments that have to foresee all possible contingencies and build these into clinician workflows. Pity the poor clinicians who have to wade through documentation that has no current relevance. Is it realistic to expect every hospital, clinic, and office in the U.S. to have been ready to raise the alarm for the first patient to present with Ebola symptoms?” – Brian
Mass. Becomes First State To Require Price Tags For Health Care
Martha Bebinger for WBUR’s CommonHealth
“In another revolutionary move, MA became the first state to require that health plans divulge the prices of their information on public websites. As this piece points out, there are still wrinkles to iron out, including consistency of prices, common definitions of what’s included, and more. Yet this is a bold step we hope to see mirrored across the nation. Interestingly, health plans contracted with Castlight, Vitals, and others in order to get these lists up and running.” – Naveen
Walmart and the End of Employer-Based Health Care
David A. Graham for The Atlantic
“Wal-Mart announced that they are going to stop offering insurance coverage to ~30,000 part-time workers (workers who work 30 hours or less a week) and follow suit with other large employers including Target, Trader Joe’s, and Home Depot. Whether or not these part-time workers will be better off will largely depend on what state they live but it certainly marks a milestone in the inevitable decline in employer-sponsored health care in the U.S.” – Matt
A Need for Stage 3?
Greg Gillespie for Health Data Management
“As fallout from Stage 2 continues, HDM offers up a handful of questions to some leading CIOs around provider motivation, vendor readiness and the future of the program.” – Naveen
Few ACOs Pursue Innovative Models That Integrate Care For Mental Illness And Substance Abuse With Primary Care
Valerie A. Lewis, et al., in Health Affairs
“Survey results from a national survey of ACOs and followup detailed interviews with a select number of ACOs that looked at the issue of behavioral health and ACOs. While most ACOs are responsible for assuming behavioral health costs, there still remains a lot of work to improve the traditional siloed and fragmented approach of primary care and behavioral health. Some ACOs are practicing innovative care models to better integrate the two but only a small handful had fully integrated behavioral health programs in primary care services delivered by the ACO.” – Matt
Improving Medicare Post-Acute Care Transformation Act of 2014 (PDF link)
“Everyone know that Congress does nothing, right? Amazingly, two weeks ago the Senate passed something called “Improving Medicare Post-Acute Care Transformation Act of 2014”. This bill aims to standardize reporting for the major categories of post-acute care providers – home health, inpatient rehab, skilled nursing, and long-term care. It would standardize reporting for patient assessments, quality, and utilization across these disparate care disciplines. It is probably about time that more data be used to help determine the comparative effectiveness of these care venues and for which patients. The bill now goes to the President for his signature.” – Brian
Can Patrick Soon-Shiong, The World’s Richest Doctor, Fix Health Care?
Matthew Herper for Forbes
“An interesting deep-dive on LA billionaire-doctor Patrick Soon-Shiong. The author doesn’t include a whole lot of detail on Soon-Shiongs’s efforts at NantHealth, but it’s not for a lack of trying – as described by John Halamka in the article: ‘The marketing is three years ahead of the engineering.'” – Naveen
#WWBR Week of September 29, 2014
Doctors Find Barriers to Sharing Digital Medical Records
Julie Creswell for The New York Times
“A non-technical overview at the issue of Interoperability, with a focus on everyone’s favorite bad-guy vendor, Epic Systems. Nothing we don’t already know, but some of the details – like Epic’s recent hiring of a DC lobbyist – show just how far down interoperability truly is on their list of priorities.” – Naveen
“Yet another article about interoperability or lack thereof across the healthcare landscape. All share the blame here, from EHR vendors desiring high switching costs, to providers looking for low cost solutions but with poor interop capabilities, to administrators not investing in user training and regulators that did not make this a primary requirement from the beginning of the MU cycle. It will take years to sort this one out.” – John
“When articles about healthcare interoperability impossibilities make into mainstream newspapers, I always pay attention. This one quickly turned into a critique of Epic and its ambitions re the DOD’s HIT revamp. While it focuses on Epic, it does point out that it is but one of the EHR vendors to benefit from $24 billion in EHR incentives. I am pretty sure that this kind of coverage does not really cut through the noise of routine political coverage and engage the average non-healthcare reader.” – Brian
What’s Behind the Slowdown in Health Care Costs
Kimberly Leonard for US News
“A look ahead at future healthcare costs finds that the silver tsunami that many feared would completely crash the US economy, may not be so bad after all. What is surprising in this analysis is that the mix of spending remains constant.” – John
Changing my mind on SES Risk Adjustment
Ashish Jha An Ounce of Evidence (blog)
“Harvard professor, Ashish Jha, has a change of heart regarding the use of SES (social economic status) data for calculating readmission scores and subsequently penalties. A more nuanced topic than what appears at first blush.” – John
“A worthwhile read about how introducing SES data into the risk adjustment process might play out. As analytics engines develop capabilities to layer in additional data, reimbursement based on that deeper context will become the next step. The issue there is how to strike a balance between penalizing hospitals for seeing poorer (and sicker) patients, versus getting them off the hook for delivering substandard care just because someone is poor. ” – Naveen
The Payment Reform Landscape: Value-Oriented Payment Jumps, And Yet…
Suzanne Delbanco for Health Affairs Blog (see also: Forbes article on VBR)
“Insight blog post by Suzanne Delbanco regarding the 2014 National Scorecard on Payment Reform survey by the Catalyst for Healthcare Payment Reform. Survey found a huge shift in ‘valued-based payments’ among commercial plans to ~40% but also noted some key limitations too including that less than half of this was really risk-based (downside risk) and most of the payment reform has focused on hospital payments. Delbanco also points out that ‘pay for performance’ programs both in the US and UK over the past decade have had very mixed results. The other issue that it is quite difficult to evaluate the effects of these payment reforms because the current infrastructure to report and collect quality and safety information based upon actual clinical data is insufficient and burdensome.” – Matt
Hospital Group Sees Diseases of Rich Spurring Health Spending
Choong En Han for Bloomberg
“While we may not be in position to export US-style healthcare, we are apparently exporting US-style health concerns. This translates into opportunity for providers operating in economies where affluence-related obesity and metabolic disorders are increasing and where infectious diseases and malnutrition still are common. The sick who can pay are a growing segment of the population. We can only hope that the ongoing transformation of our healthcare system can help us turn care protocols for these problems into a legitimate export.” – Brian
Set Your EHR Data Free
Arcadia Solutions Blog
“For many healthcare organizations, predictive analytics may still sound like science fiction. But this post shows a few examples of how mining existing EHR data before an actual diagnosis is made, as indicated by claims data, can unlock existing value that goes deeper than crunching CCDs.” – Naveen
CMS: 44,000 Have Applied for Hardship Exemption
Gabriel Perna for Healthcare Informatics
“Approximately 44,000 eligible providers (EPs) have applied for a meaningful use exemption, the CMS or roughly ~14% of the EPs who have registered. The exemption is for providers who will not attest to meaningful use in 2015. CMS is sorting through the applications and notifying each provider of their status. CMS stated the majority of exemption requests are coming from first-time attestations that are experiencing issues with their 2014 certified electronic health record technology (CEHRT).” – Matt
HCA: The Bashful Giant
Jeff Goldsmith for The Healthcare Blog
“This short blog does a quick and dirty compare of HCA’s market approach to the rest of the world. It concludes that HCA is doing just fine even though it has not embraced many of the changes to care and payment. Could HCA be right?” – Brian
Benefits innovation ‘stuck in neutral’
Andrea Davis for Employee Benefits News
“Keynote speaker from a Benefits conference this week in Florida noted that employer wellness programs have seen little innovation of the past decade. Noted that these programs consist of the same components including biometric screenings, health risk assessments, telephonic coaching based on the results of the screening and HRA, and participation-based incentives and that ‘one size does not fit all’ in regards to wellness programs.” – Matt
What Lies Ahead for Meaningful Use?
After much speculation and mounting criticism of Meaningful Use (MU), two recent developments provided some clarity on the future direction of the program and indications of how rocky a road it will be for providers in stage 2.
After a summer filled with mounting criticism and a litany of responses & comments on how to modify the program, CMS issued their much anticipated new final rule for Meaningful Use (MU) Stage 2 on August 29th. For providers who were hoping for some relief, they did not get much.
While providers have greater flexibility for 2014 in terms of using 2011 or 2014 certified EHR technology (CEHRT) to meet the 2013 or 2014 objectives and measures, many were critical CMS did not go far enough in relaxing the rules for 2015. In 2015, providers will be required to use 2014 CHERT and report for the full year (vs. only one quarter in calendar year 2014).
Making matters worse, this is based on the federal calendar year which begins Oct. 1, 2014. This leaves providers with little time to get their bright shiny CEHRT for stage 2, in operation, workflows mapped to support new guidelines (more eCQMs) and staff trained to insure the right metrics are collected for future attestation. It also continues to place a heavy burden on providers who are struggling with MU menu objectives that relies upon cooperation from third parties (e.g. patients, labs, post-acute providers) to meet threshold objectives.
Tepid Attestation – Will it Continue?
Last Wednesday’s HIT Policy Committee monthly meeting also provided an update on electronic MU attestations thus far in 2014. Year-to-date figures showed noted improvement since the last meeting in August but overall adoption of stage 2 remains lackluster.
Through August 25th, 8,024 (vs. 2,823 as of July 1) eligible professionals had attested for the 2014 reporting year with 3,152 (vs. 972 as of July 1) attesting for stage 2. For eligible hospitals, 436 (vs. 128 as of July 1) had attested for the 2014 reporting year with 143 (vs. 10 as of July 1) attesting for Stage 2.
To put that in perspective, only ~3.5% of hospitals of eligible hospitals and ~2.5% of eligible providers who have successfully attested for MU stage 1 have attested for stage 2 to date. As of this writing, an estimated 85% of all hospitals in the US have yet to meet stage 2 requirements. That is a very big percentage.
Cloudy Forecast for MU
From a payment perspective, MU is entering a period where penalties will potentially become larger for hospitals than incentive payments. The numbers disclosed at the monthly HIT Policy Committee meetings will be very important to monitor through January. If stage 2 attestations remain tepid, it will be an early indicator of waning provider motivation regarding stage 2 MU and likely the whole MU program.
Several key questions regarding MU also remain. What happens if the initial funds that were authorized by the HITECH Act are exhausted this year? What is the political will today in Congress to actually implement the penalty phase of MU? Will the rumors of stage 3 being permanently shelved if stage 2 attestation rates remain low through 2015 come true? Then there is always the issue with a pending change in the administration and just how much the next administration will continue to invest political capital in this program, which frankly has met its initial objective of driving the adoption and use of EHRs.
The net takeaway is that these particular MU announcements will have little real impact on providers or health IT vendors. Providers committed to stage 2 MU will continue to invest in solutions and services through 2015 in order to attest. Providers who have yet to upgrade or purchase 2014 CEHRT technology or are struggling with quality reporting and meeting menu objective thresholds will face a difficult decision:
Is it worth the time and capital to get on the stage 2 bandwagon or place the bet that future penalties for not meeting stage 2 requirements will be small if not non-existent?
Regardless of what a provider/HCO may decide, health IT vendors who offer CEHRT-related solutions, will have to remain committed to spending a significant amount of their R&D budgets on MU for the foreseeable future. Vendors who cannot meet this requirement will have to make some difficult strategic decisions over the next year including whether to exit the market entirely.
Incentives, Regulations and Consequences
Good intentions do not always result, in the long-term, in good policy. Such may be the case with the HITECH Act that was passed as part of the huge stimulus bill ARRA in 2009. This bill launched the massive adoption of EHRs by physicians and hospitals across the country, with current adoption numbers of a basic EHR in hospitals at well over 55% from a paltry less than 10% pre-ARRA. Similar trends in EHR adoption can also be found among ambulatory practices.
There is no question that indeed, the HITECH Act has achieved one of its primary objectives – foster the adoption, via incentives, of certified EHR technology (CEHRT). This is truly a good thing, for only by digitizing health data can we then move on to further public health policy goals of beginning to understand what actually contributes to health and well-being (comparative effectiveness), and also move towards a model of personalized medicine and true patient engagement.
But at what point does the government’s role in fostering adoption of CERT end and market forces begin?
A Little History:
To foster adoption of CEHRT but also ensure that tax payers (after all we’re the ones footing the bill for these incentives) get value from said adoption, ONC pulled together a number of workgroups to define “meaningful use” requirements that physicians and hospitals would need to demonstrate to get their incentive payments. This was broken up into three “Stages” with each stage building upon the previous.
The first stage of “meaningful use” requirements were pretty simple as the plan was to just get the medical establishment to begin adopting CEHRT and familiarize them with usage of this tech. The incentive payments were also front-end loaded (receive more for meeting stage one than subsequent later stages) so low and behold, we saw strong adoption and attestation for stage one. Hip, hip hooray were the cheers heard at the Hubert Humphrey building in DC.
Where We Are Today:
But that low barrier to stage one adoption created a false market for EHR technology. There is now a plethora of EHR vendors, especially on ambulatory side that frankly should have never made it this far.
Meaningful use stage two requirements for certification are a significant hurdle for many of these EHR vendors who simply do not have the resources, nor technical chops to meet them. Sadly, a lot of ambulatory practices will suffer as a result. This in large part led to the proposed rule released this week by CMS to allow providers to postpone attesting with stage 2 CEHRT this year and allow them to attest with 2011 CEHRT. It is CMS’s hope that this delay will provide EHR vendors the time to get their act together and be certified for stage two as well as provide sufficient time for providers to adopt these updated systems to attest.
Time to Step Out of Way and Let Market Takeover:
But as often happens with government initiatives, initial policy to foster adoption of a given technology can have unintended consequences no matter how well meaning the original intent may be.
During my stint at MIT my research focus was diffusion of technology into regulated markets. At the time I was looking at the environmental market and what both the Clean Air Act and Clean Water Act did to foster technology adoption. What my research found was that the policies instituted by these Acts led to rapid adoption of technology to meet specific guidelines and subsequently contributed to a cleaner environment. However, these policies also led to a complete stalling of innovation as the policies were too prescriptive. Innovation did not return to these markets until policies had changed allowing market forces to dictate compliance. In the case of the Clean Air Act, it was the creation of a market for trading of COx, SOx and NOx emissions.
We are beginning to see something similar play-out in the HIT market. Stage one got the adoption ball rolling for EHRs. Again, this is a great victory for federal policy and public health. But we are now at a point where federal policy needs to take a back seat to market forces. The market itself will separate the winners from the losers.
The move to value-based reimbursement (VBR) will force healthcare organizations of all sizes to adopt some aspect of population health management. Interoperability, the big sore point today is not so much a technology issue as it is a market issue – and population health management is impossible without interoperability. While I know that the new ONC director, Karen DeSalvo is well-meaning in her intentions, interoperability is something that market needs to sort out, not ONC. My fear is that by letting ONC/CMS define interoperability, we will be left with highly prescriptive definitions and not innovative models, which this market desperately needs.
I applaud the hard work and efforts of all the public servants of HHS and volunteers who have worked tirelessly to get us to the point of where we are today. However, it is now time for them to refocus their efforts elsewhere. Maybe a good place to start is to assist all those ambulatory practices that have adopted a CEHRT under stage one to assist them in the transition to a more viable and stable EHR vendor for the long-term. Then again, maybe this is just an issue of caveat emptor.
Three Big Questions for Stage 3 & Patient Engagement
For many, the delay of Stage 3 of the Meaningful Use program evoked a collective sigh of relief, providing a much-needed extra year to focus on the challenging requirements for patient engagement and interoperability. As distant as 2017 may seem however, the preparation for Stage 3 is already underway in Washington; the vendor community and providers will soon be scrambling to follow suit.
Barring further delays, the timeline is as follows: This fall CMS will release the notice of proposed rulemaking (NPRM) for Stage 3 and the corresponding NPRM for the Standards and Certification Criteria. The former is the programmatic framework for what to expect – measures, percentages, reporting requirements, etc., while the latter is the technical product guidelines for software vendors to follow in order to receive ONC certification as a Stage 3 compliant solution that will enable their customers, if properly implemented and used, to collect those sought-after incentive dollars. The final rule is expected to drop sometime in Q1-Q2 of 2015 – just one year away.
But that doesn’t mean there’s a year to put off thinking about it. In a few short weeks, the Health IT Policy Committee (HITPC) is set to deliver an official recommendation on the topic of Stage 3’s patient engagement requirements to the ONC. From all indications, it appears this super-group of wonks will press for inclusion of patient-generated health data (PGHD – yet another #ONCronym for your twitter streams) into electronic health record systems. The technical experts have defined PGHD as follows:
“health-related data—including health history, symptoms, biometric data, treatment history, lifestyle choices, and other information—created, recorded, gathered, or inferred by or from patients or their designees (i.e., care partners or those who assist them) to help address a health concern.”
At first glance, this is a no-brainer, as we’ve been hearing the clarion calls for such inputs for the better part of the last decade. 60 percent of US adults claim to track their weight, diet, or exercise routine, according to the Pew Research Center’s data. Evidence for the positive impact of this data on quality, satisfaction, and in some cases cost is thin but growing.
But as we are learning through the first two stages of this program as well as the early headaches of ACA rollout, reams of sophisticated studies floated down from the ivory tower do not effective policies make. Despite the need for PGHD, when it is wonkified, ONCified, and held to the temple of the nation’s delivery system, there may be a small disaster in waiting. Below are three questions Chilmark is keenly tracking throughout the remainder of 2014:
What Constitutes PGHD?
The language used thus far raises much speculation about what exactly this inclusion will mean when it hits the front lines. The definition provides only a general description, leaving a lot of possibility for interpretation and application down the road. For many, PGHD evokes the notion of datastreams from the vast array of health and wellness devices such as fitbits and jawbones, Bluetooth medical devices, and of course, tracking apps. Yet the definition above makes PGHD seem to carry more of an health risk assessment (HRA)-like utility, where patients fill out a survey and have it sent to their doctors in advance. Yet another angle is the notion of patient-reported outcomes: clinically oriented inputs from patients with regard to their physical and psychosocial health status. Outfits like ATA, HIMSS and others are lobbying for full inclusion of patient-monitoring and home-health data.
Each of these use cases brings with it a unique set of programmatic and technical components. A popular example as of late is with biometric data: If a panel of diabetic patients are all given Bluetooth glucometers that input into respective EHRs, then what – Will someone monitor each of them? Or are HCOs expected to fit those data into an algorithm that alerts and ultimately predicts any aberrance? This has been referred to as providing doctors with ‘insight’ rather than raw data. That sounds snazzy, but can we realistically mandate the creation of insight?
Collecting data such as patient allergies or side effects appears a simpler use case on paper. Yet HITPC is appearing to use everyone’s favorite A+ students – IDN’s like Geisinger, Kaiser Permanente, and Group Health Cooperative among others as the basis for their recommendation. As one example, the report lauds GHC’s eHRA model, which is based on a shared EHR and shared clinical staff for data review. As nicely as that may work, Chilmark is skeptical that it’s reproducible in an average clinical setting. Generally, the innovators in the digital engagement space have been the insurers, not the providers. We understand the need to look at innovators in order to prescribe a path for the rest of the country, but in talking to regular folks at urban hospitals, community clinics, mid-sized IPAs –it’s more likely that fluid data is a byproduct of integrated systems, not the other way around.
How Will the Market Respond?
Despite its unpopularity in the C-suite, meaningful use has forced EHR vendors to pull their heads out of the sand and advance their product features. In addition to giving providers a break, part of the reason behind the Stage 3 delay was for vendors’ benefit: “[to provide] ample time for developers to create and distribute certified EHR technology…and incorporate lessons learned about usability and customization.” The Standards and Certification Criteria 2017 edition will play a big role in the next lurch forward, and one can be sure that those new mandated features will be all the rage at HIMSS 2015.
Yet at the broadest level, the evolution of EHRs (billing >> administration >> clinical) appears to be stalling. In exploring the patient engagement market and the to-date limited functionality of tethered patient portals despite Stage 2’s requirements one thing has become clear: EHR vendors will simply not just add new features for the sake of their customers (forget about patients). With new PGHD functionality emerging, we expect new companies to step up to the plate and seek modular ONC-ATCB certification
An example already underway is 3rd party data integration. Over the last few years, device manufacturers, startups, and third parties started seeing the value in injecting their data into EHRs. The emergence of middleware companies who provide integration as a service, such as Nanthealth, Corepoint, and Validic, will continue as PGHD requirements develop over the coming months. Similar companies will start (and already are) filling the void for HRA functionality, portal requirements, patient communication, and so on. We expect that this will only exacerbate the headache faced by CIOs & CMIOs with a long list of purchasing options. Startups take note: It should also set off a shopping spree by EHR companies and other enterprise vendors looking to buy rather than build. Allscripts acquisition last year of Jardogs is one such example.
Will Providers be Ready?
In a word, no. The inclusion of PGHD brings with it an avalanche of procedural and programmatic preparation: data review and quality assurance, governance models and new workflows, the prickly issue of data ownership, staff time and training, liability concerns, HIPAA extension of coverage, ever-increasing insurer coordination, clinician accountability, and of course, patient consent, onboarding, and marketing. With the last one, keep in mind that we now live in the post-Snowden era…
Of course, without details of the required measures, further hand-wringing is unwarranted at this point. But suffice to say there’s a small storm-a-comin.’ As the definitions, rules, and standards of patient-generated health data emerge, we look forward to what promises to be a rich commentary and response to the NPRM amidst the broader discussion in the health IT community throughout 2014.
What’s in Store for 2014?
That time of year once again where we collectively look into our crystal ball, or throw the sticks or maybe even look at the coffee grinds dripping down the sides on our coffee cup to see what may be in the year to come. Making these predictions for the coming year is almost a rite of passage for any self-respecting analyst firm and what the heck, from our vantage point, we may have a slightly better view into the future than most.
So in keeping with some sense of tradition here at Chilmark Research, the following are our ten predictions for 2014, plus one (think of it like a baker’s dozen).
Meaningful Use (MU) stage two delay provides little relief to IT departments. Many breathed a sigh of relief when HHS announced that stage two timeline would be extended. Yet despite that extension, IT departments will remain overwhelmed in 2014 coping with a host of other initiatives, from ICD-10 to HIPAA compliance to preparing the organization for changing models of reimbursement and of course MU 2.
Best-of-breed solutions proliferate. Despite the desire to have as few as possible IT vendors and their solutions within an organization, department heads take it upon themselves to adopt new solutions as IT departments are not able to meet all the needs of the organization at this time, nor are EHR vendors capable of delivering new offerings in a timely manner. We anticipate analytics and care coordination to be high among list of adopted best-of-breed solutions. This will create its own host of problems several years hence.
Consolidation continues unabated in mid-market. Much to the concern of payers, large provider organizations will continue to purchase their smaller brethren to extend their reach and improve care coordination. Payers will fight back with lawsuits (monopolistic tendencies of providers) and by making their own acquisitions. Payers will be particularly attracted to the dual eligible market.
Bloom is off the rose as physician dissatisfaction with chosen EHR rises. OK, yes this is a no-brainer as we have been seeing discontent rise throughout 2013. But this discontent will escalate as smaller organizations increasingly realize that their EHR is ill-suited to address the needs of tomorrow in a value-based reimbursement world.
Limitations of deployed HIE becomes increasingly apparent. It’s one thing to put in an HIE infrastructure, quite another to embed HIE capabilities into clinician workflow, especially across a heterogeneous EHR community. Couple that with a growing realization among leading HCOs that to truly support clinicians at point of care, far more data is required to flow through the network and you end up with a lot of future head scratching as to where the real value realization will be derived from the HIE now in use.
Re-prioritization moves patient engagement to back burner. Despite the strong efforts of ONC/HHS to promote the concept of patient engagement, providers, no longer having the stage two gun to their head, will reset priorities on other, more pressing matters.
One third of stage one, MU-certified EHRs do not or choose not to certify for stage two. The HITECH Act created a false market for EHRs that led to the proliferation of vendors and their solutions. Unfortunately for many an ambulatory practice, their chosen EHR vendor will not have the resources to refine their product for stage two certification leaving smaller practices with the unenviable task of having to find a new vendor. Thankfully, a price war is anticipated as vendors look to build customer bases and subsequently valuations before inevitable acquisition.
Clinical analytics remains a hot, yet immature market. Leading HCOs are all clamoring for analytics to help run their operations and improve care delivery processes. But despite the high demand for such solutions, EHR vendors are still behind the curve in delivering such capabilities, the buyers still are not quite sure exactly what they want and rarely have the resources to begin asking the right questions. The best of breed vendors themselves struggle to keep up with market demand, leading to longer then anticipated deployment times.
Cloud-based EHRs become de facto standard for small, ambulatory practices. Pricing pressure will grow fierce in the ambulatory market and in an effort to lower cost of sales, shorten product lifecycles and improve customer service, ambulatory EHR vendors will move to cloud-based services for their solutions. Some push-back will occur over concerns of data governance and privacy. Physicians taking this path will need to review terms and conditions of such contracts carefully.
Payers increasingly become part of HIE fabric. In mid-2013, payers became increasingly involved in the HIE market partnering with leading providers in some communities to share data and improve care coordination. While providers have instinctively been reluctant to partner up with payers, the move to value-based contracts and the strong skills and critical data that payers can provide is forcing providers to re-evaluate their previous stance.
Healthcare.gov falls short – payers wring their hands. Healthcare.gov has far more sign-ups than detractors anticipated but falls short of administration goals, especially for the young and healthy. This leads to payers to continue wringing their hands over adverse selection of new enrollees and the likely higher risk profile as a result.
There you have it folks. Now let’s see how the year plays out and just how close these predictions are to reality come early 2015. Either way, never a dull moment in this market for the foreseeable future.