As industry comments on the meaningful use (MU) program Stage 2 modifications and Stage 3 final rules came pouring in this week, the most common denominator amongst health IT stakeholders was that the requirements embedded inside the program offer providers very little flexibility. Healthcare groups such as the College of Healthcare Information Management Executives (CHIME), the American Hospital Association and the Healthcare Information and Management System Society (HIMSS), to name just a few, all asked the Centers for Medicare and Medicaid Services (CMS)to simplify and reduce the complexity of the program through a variety of different ways, some of which include: starting Stage 3 no earlier than 2019 and only after 75 percent of all eligible providers have met Stage 2; creating a 90-day reporting period for every year of the program, including the first year at Stage 3; and creating parity for both eligible providers (EPs) and eligible hospitals (EHs) by removing the existing pass/fail approach for meaningful use.
On the contrary, the Consumer Partnership for eHealth (CPeH), a Washington, D.C.-based patient advocacy group led by the National Partnership for Women & Families, recently released comments of their own on the final rules that sing a different tune. CPeH includes members from nearly 50 consumer, patient, and labor organizations working on both the national and local levels, and according to its officials, remains the only coalition comprised solely of consumer and patient advocates. Regarding CPeH’s meaningful use final rule comments, also signed by 24 other consumer and health organizations, the association has taken the opposite stance of many others, showing dissatisfaction with flexibilities allowed by CMS and giving support in some of the areas where the feds have stood their ground. Indeed, while many providers want to make significant changes to the program, CPeH argues that the current structure should be maintained.
While the Partnership doesn’t include providers themselves, Mark Savage, director of health information technology policy and programs for CPeH, says that they are in regular conversations with organizations such as AHA, the American Medication Association (AMA), and other physician-based groups. “We want physician perspectives,” Savage says. “In turn, they will sometimes try to persuade us to take different positions. It’s important for us to hear what they have to say, though. We have long-term working relationships with these provider groups,” he says. Savage recently spoke with HCI Managing Editor Rajiv Leventhal on the comments his organization made regarding the meaningful use final rules and why CPeH’s thoughts on the program are so different from many other health IT groups’ perspectives. Below are excerpts of that interview.
Many providers in the trenches say that the patient access requirements in MU are too reliant on factors outside clinicians’ control. What is your take on this?
The patient engagement measures that have been listed in our letters [to CMS] are about online access and secure messaging. Should patients be able to have online access to the information about them in the doctor’s record? It’s the same thing that’s important is in banking, voting, education, and shopping. It’s not any different in health.
With secure messaging, we’re talking about the ability to have two-way communication with your doctor whether it’s about convenient things such as lab tests or more fundamental things such as, Am I getting sick? Both of those, we say, and I think doctors would agree, are important things to be able to do. We did a survey last year that found that the more frequently people accessed their information, the more motivated they were to improve their health. This isn’t surprising when you think about it. This is what doctors and patients want, and it’s supposed to help reduce our 20 percent spend on GDP.
But are the thresholds for these measures too reliant on patients rather than physicians themselves?
[Note: In 2015 and 2016, CMS requires at least one patient to view, download, or transmit (VDT) his or her health data. This threshold increases to 5 percent in 2017, and 10 percent for Stage 3.]
It’s a partnership. Physicians may not be able to control 100 percent of what happens because it’s a partnership, meaning that it’s about the patients too. But doctors are certainly influential. If they explain why online access is available, and explain where you go to do it and why it’s important, that’s being influential. Doctors are among the most trusted people for patients, we know that. It’s an opportunity to help patients help doctors get them well. It’s a win-win situation.
Also, doctors were at the table in making the recommendations for these thresholds. They were part of the Health IT Policy Committee process. There were a lot of doctors, hospitals, and vendors at the table, but not many consumers. Those recommendations that were set were the consensus recommendations given to the Office of the National Coordinator for Health Information Technology (ONC) and CMS.
In Stage 2, when the 5 percent VDT threshold was made, the original recommendation had actually been 10 percent. CMS saw concern in the comments for that, so they backed it up to 5 percent. Again, doctors and vendors were at table with those recommendations. When you look at the Stage 3 comments, CMS reported that doctors and hospitals were doing far better than 5 percent in terms of online access and secure messaging.
ONC and CMS picked minimums that were designed to get these things to be worked into clinical workflows to try to ease people in. Five percent is the kind of threshold that does that. Let’s begin to establish those workflows so individuals and the nation benefits collectively. It’s certainly better for delivery system reform as well—how can an ACO [accountable care organization] coordinate if the one person who is not online is the patient? Our point is that looking on balance, the thresholds were set at imminently reasonable levels to make sure people would succeed, not fail, and we would be getting forward movement that the nation needs. We do take the position that those measures are good and the thresholds that say one patient for Stage 2 dismay us.
The logic the feds have given regarding the one patient requirement is that they want a phased-in approach for patient engagement. You seem to disagree with this strategy.
So for Stage 2, the requirement was 5 percent up until a short while ago. Then we had the unexpected proposal in April that would back it up to just one patient. If you look at it on a graph it’s a sharp drop, then it resumes back up in 2017. As a number, one patient is not enough. To go from 5 percent originally, then back to one patient, and for secure messaging, to just turn it on and then not having any patients use it, what kind of a message does that communicate to folks? That it’s important? No, it doesn’t; it suggests that the level of value has shifted in CMS’ mind. We laid out how important it is in communicating a message. We explained that this does telegraph the wrong message to the nation, as we are trying to get 21st century patients into the 21st century.
What do you think about the idea that more providers should be reaching Stage 2 before Stage 3 hits in 2018?
People who say that are not doing the right math. ONC and CMS have explained it repeatedly. Doctors find it more convenient to present it in the way they do. They have a position. ONC has asked, what percentage of doctors who are eligible for Stage 2, have attested? That 12 percent number that’s being circulated is one that includes all providers, not just the ones that are eligible for Stage 2. So it includes providers who are in Stage 1, for example, and couldn’t be attesting to Stage 2 anyway. The actual number of providers who are eligible for Stage 2, who have reached Stage 2, is around 50 percent, despite what’s being reported. The Stage 2 modification rule describes a modified (and simplified) Stage 2 for all EPs and EHs in 2015, 2016 and 2017, as a prelude to Stage 3 in 2018. So, for example, the provider in Stage 1 goes through a modified Stage 2 in 2016 and 2017 to a simplified Stage 3 in 2018.
CMS data on Stage 2 attestations
Does MU’s pass/fail approach bother you?
It doesn’t in this structure, because the thresholds that are indentified with the measures are minimums, not maximums that are designed to be difficult for people to achieve. Minimums are designed to help the nation progress, and that’s the aim of the MU program. If we were talking about measures that said you had to do 90 percent of something across the board, you could have a different thought about that. But when you talk about just one patient or 5 percent of patients, it does not concern to me to say that these are 10 important things that one should be able to do to get $60,000 in incentive payments and to help improve the quality of care across the country. It’s asking to show that you move the needle and improve at minimum levels. We do the same thing with teachers and education. We are used to setting minimums for people, and this is no different.
Collectively, providers have pleaded for 90-day reporting periods. Why do you support a 365-day reporting period instead?
With things like interoperability, online access, the need to reach out to your doctor, and the need to see the results on your lab test, those needs don’t turn off at end of 90 days—they are 365-day needs. The function should be for the full time. With 90-day reporting periods, people work on the issue for 90 days, but don’t work on it for the 270 other days. There have been times where CMS has allowed 90-day periods for various reasons, but as a structural matter, it should be a 365-day reporting period. You can imagine what happens on interoperability if one system chooses one 90-day reporting period, but another system chooses another 90-day period and they don’t sync up.
A counter to that would be that organizations need time to plan for upgrades, technology fixes, and optimizing technology. In a 365-day reporting period, you don’t get that flexibility, do you?
We did say in the letter that there are flexibilities woven in, in many different ways. I would call low thresholds as an example of flexibility. Lots of people are coming in way above those thresholds. Even though the average is far higher than the thresholds, the minimums are still low. There is also flexibility in the exemptions that say if you don’t meet these criteria, you don’t have to report on it in the first place. There are also hardship exemptions for software upgrades not getting done by vendors. There is a lot of flexibility in the system already. With all of that, we don’t think that a 90-day reporting makes sense.
Another complaint from providers is that the MU program is reliant on EHR systems that have too many usability issues. Is that something you agree with?
Doctors have raised usability issues, and ONC is working with doctors and vendors who are at the table making these recommendations to ONC on how to fix these issues. They testify at the hearings and the results are based on the advice that they are giving. Even with doctors’ and vendors’ own good thinking, there are still usability issues. We are at the beginning of some major improvements in healthcare in the nation, and that’s what Congress wanted with HITECH. When you have systemic change like we have had, what gets developed at the beginning won’t be the same as what you see at the end. There are usability issues, sure—that doesn’t mean we can’t keep moving forward. What happens when it’s the patient who catches the error in the doctor’s record that says “no allergies,” but the patient is actually allergic to Penicillin? The patient just saved a major problem. The online access, as one example, will move us in the right direction. You can’t pause the system—it’s overdue.