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Some Inconvenient Truths for CMS

November 17, 2015
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AMIA says meaningful use has had ‘serious and unintended consequence’ of limiting the design, innovation of EHRs

In October, the Centers for Medicare & Medicaid Services asked for comments on its implementation of the Merit-based Incentive Payment System (MIPS) and the promotion of alternative payment models. This week the American Medical Informatics Association (AMIA) responded with specific suggestions, but also some insightful general comments about health IT and quality measurement in service of value-based payment.

For instance, AMIA notes that despite earnest efforts, quality measurement has not become “a by-product of care delivered,” as envisioned, but rather an end unto itself. The focus on collecting numerous, process measures that may not reflect a patient-centered perspective on quality needs to be replaced by focusing on a more targeted number of important outcome measures, it said.

AMIA recommends that federal officials do not “reflexively expand the current approach to quality measurement in developing these new policies.” Rather, opportunities should be sought to retire existing process-based measures while looking for ways to develop more outcomes-based measures, it said.

Noting the burden on physician workflow, AMIA recommends that new process-based measures should be added only after careful consideration and assurance that the value the measure will provide is greater than the burden imposed on physicians. AMIA wants CMS to pilot all new electronic clinical quality measurs (eCQMs) before their release for use; establish a regular cadence of updates/revisions to eCQMs; and ensure that all information and tools located in the eCQI Resource Center are complete and up-to-date.

AMIA said it is increasingly convinced that certification and meaningful use-related measurement requirements have had the serious and unintended consequence of limiting the design and innovation of EHRs. The developer community continues to warn that certification-related regulatory burdens inhibit their ability to make customer-prioritized functionality and usability enhancements to their products. Meanwhile, providers’ concerns over usability and interoperability are well documented. “We are concerned that a focus on conformance to certification criteria has inadvertently led to a “develop-to-the-test” approach, and has affected the functionality and usability of EHRs in ways not sought or prioritized by clinicians,” the letter states. “This dynamic is likely an important contributing factor to the challenges faced by vendors and providers alike, and it should be examined further as the federal health IT certification program evolves…. We are concerned that certification in this emerging area may hinder development of new features and functionalities that have not yet come to the marketplace.”

AMIA said it sees policy development for MIPS and APMs as not just an opportunity to change the payment system, but as an opportunity to revisit policies meant to spur adoption and guide use of health IT. In much the same way that fee-for-service era policies skewed incentives and provider behavior, overly prescriptive documentation and “use” requirements of the same era have influenced how health IT is developed, implemented and leveraged to improve care. AMIA recommends federal officials avoid overly prescriptive requirements to determine how providers use informatics tools, but rather focus on the outcomes sought by the use of such tools.

Finally, federal officials should develop a public implementation roadmap, aligned with HHS goals for shifting Medicare reimbursements from volume to value, AMIA recommends. “This roadmap should clearly articulate the CMS quality strategy, beginning with a focus on accurate, complete and valid eCQMs. If CMS continues its plan to require electronic submission of CQMs, and payment depends on those quality measures beginning in 2017, all stakeholders must be confident that those eCQMs represent an accurate picture of care delivered. Over time, iterative harmonization in the number of CQMs and data submission pathways can take place as stakeholders gain experience with these programs.”

That is a lot for CMS to chew on. But many of these criticisms of the unintended consequences of certification and process-related quality measures have been echoed by others for years. There is a lot of work to do in a short period of time if a clear pathway for outcome-focused eCQMS is going to be established.