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Standards Committee’s Take on MU Stage 3? Too Prescriptive!

March 26, 2014
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Halamka: Being too prescriptive could force some providers to re-engineer systems that already work quite well

The pushback against Stage 3 meaningful use proposals began in earnest Wednesday. Although they approved the measures two weeks ago, many on the Health IT Policy Committee were critical of the measures, saying they would put too great a burden on providers.

The March 26 Health IT Standards Committee meeting reviewed the Policy Committee’s Stage 3 recommendations. Led by Standards Task Force chair John Halamka, M.D., the committee covered a range of topics, including patient engagement and care coordination. The committee sought to determine the standards maturity and development effort involved in each measure. In many cases, the committee’s comments criticized the measures as too prescriptive.

After a discussion of how provider organizations should deal with patient-generated health data, Stan Huff, M.D., chief medical informatics officer at Intermountain Healthcare in Utah, said, “I like the fact that we are questioning these items. The approach I would like to see for all of these is that we focus on measuring outcomes, and we ask people to adhere to standards, and all the things that are invasive in terms of workflow are left to the discretion of implementers.”

Huff added that he could see a number of unintended consequences that could arise because the proposals haven’t been done in real working systems and their impact on workflows is unknown. “And the way they might be interpreted in certification, I am really in trepidation about what this could mean in terms of stifling other, better innovative ways of doing these things and we are locked into a highly prescriptive way that people have envisioned. I am almost terrified of the impact these things could have because we are being so prescriptive about the work flow and the implementation and the discretion that system developers should have but won’t have.”

Halamka agreed, pointing to the measure about secure messaging as an example of what Huff is concerned about. “In secure messaging, there are certification criteria that delineate precisely and prescriptively how secure messaging between clinicians, patients and families should work. It specifically states the capability to indicate whether a patient is expecting a response or not, and the capability of tracking a response to a patient message. No response, secure message response, telephone reply.”

Halamka noted that organizations such as Kaiser, Beth Israel Deaconess, and Relay Health have implemented a set of workflows around secure messaging. “Some of us have been doing this for 20 years, and have achieved a level of maturing in patient-clinician communication that is quite high and very satisfactory,” he said. “And in fact being too prescriptive, as this one seems to be, could actually quash innovation and force us to re-engineer and reverse systems that work quite well today. What we have said is if you are going to be prescriptive, you are not really going to be dealing with any mature standards around closed-loop messaging with feedback and a vocabulary that delineates where in the whole closed-loop messaging process the message may sit. The development effort would be high, but the industry has already implemented solutions that work well. So let us be extraordinarily supportive of the concept but remove the prescriptive specificity.”

Similar comments were made about the proposed requirement that providers send electronic notifications of significant healthcare events (admission to a hospital, for instance) within four hours to known members of the patient’s care team.

Halamka noted that the HL7 2.5.1 standards for that type of message are mature, but that is not the case when it comes to capturing at registration the information about who the care team members are and their Direct addresses and where consent is given and what should be sent to whom under what circumstances. There are very poor standards for capturing care team structure and Direct addresses at the moment, so the development effort would be quite high, he said. “This is a totally novel set of workflows, not on the HL7 and ADT type of messages, but on the delivery to an endpoint, where no such work flow currently exists.”

Cerner’s David McCallie Jr, noted that a fair amount of this activity already occurs, with physicians being notified when their patients are admitted to the hospital, “but it is on an ad-hoc basis in every case,” he said, “and there aren’t any standards. It is not the message, but knowing who to send it to.”