Health IT associations have sent in their public comments on the Centers for Medicare & Medicaid Services’ (CMS) meaningful use rebranding proposed rule, with a key focus of the remarks centering around the government’s proposal to consider interoperability as a condition of Medicare participation.
A Review of the Proposal
For background, in late April, CMS proposed updates to Medicare payment policies and rates under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS). Included in the proposal was a re-naming of the meaningful use program to “Promoting Interoperability.” CMS said at the time that the goals of the new program will be to: make it more flexible and less burdensome; emphasize measures that require the exchange of health information between providers and patients, and incentivize providers to make it easier for patients to obtain their medical records electronically.
Drilling down, however, the proposed rule has several interoperability elements to it beyond just a name change—some of which would have a significant impact on providers. For instance, as Healthcare Informatics reported at the time of the rule’s release, CMS wrote that it would be seeking public comment, via an RFI (request for information) on whether participation in the Office of the National Coordinator’s (ONC’s) Trusted Exchange Framework and Common Agreement (TEFCA) should be considered a health IT activity that could count for credit within the health information exchange objective in lieu of reporting on measures for this objective.
Indeed, deep inside the rule, the federal agency suggested that it may consider revising the current CMS “Conditions of Participation” [which were originally proposed in the IMPACT Act and might be changed for future purposes] for hospitals, with the possibility of requiring providers to transfer medically necessary information upon a patient discharge or transfer to do so electronically.
What this means, according to experts who have analyzed the rule in depth, such as Jeff Smith, vice president of public policy at AMIA (the American Medical Informatics Association), who spoke to Healthcare Informatics in April, is that while the proposal does away with the meaningful use patient data access objective (view, download and transmit), “what this RFI [on the possibility of revising Conditions of Participations to revive interoperability] seems to be signaling is that they are not saying it’s not important to allow patients to view, download and transmit their information, but quite the opposite. CMS is signaling that they think it’s more important than participating in this little program that could cost you a percentage point or two in reimbursement. They think it’s so important that you don’t get participate in Medicare [if you don’t meet the Conditions of Participation],” Smith said at the time.
Health IT trade groups had until June 26 to send in their public comments on the rule, and after reviewing the remarks, there seems to be varied responses as it relates to requiring interoperability as a condition to participate in Medicare.
For one, the Ann Arbor, Mich.-based College of Healthcare Information Management Executives (CHIME) attested that CMS is taking the wrong approach. CHIME wrote in their comments, “Simply imposing regulatory requirements that make electronic data exchange a condition for providers to receive Medicare payment does not address the root issues at play. Addressing ongoing barriers is needed to speed greater progress around interoperability. Importantly too, a distinction must be drawn between speeding and increasing data exchange among providers and achieving a true state of interoperability. The two should not be conflated.”
The Chicago-based EHR (electronic health record) Association (EHRA) had similar sentiments as CHIME, noting that “We question the utility of new Conditions of Participation for Medicare around data sharing, especially in light of 21st Century Cures ongoing regulatory implementation. Further regulatory action on data sharing and interoperability should wait until the rulemaking mandated by 21st Century Cures is complete. For example, a CoP related to information blocking is contingent on ONC’s definitions on safe harbors.” EHRA added, “It is additionally unclear how interoperability expectations in the CoPs would be evaluated and audited, but it seems likely that evaluation and auditing of these items would generate additional hospital burden.”
The aforementioned AMIA, the Bethesda, Md.-based organization which sent in 38 pages of comments, pondered if CMS were to propose a new CoP standard to require electronic exchange of medically necessary information, would this help to reduce information blocking? In response to this question, AMIA wrote that it believes that clinicians do want to send important data and receive important data, but they acknowledge “this isn’t occurring consistently.” AMIA continued, “We recommend that CMS garner experience and insights under the Information Blocking rule, once finalized, before deciding to modify COP/CfC/RfPs. Further, we recommend CMS focus its inquiry on provider-to-patient information flows and calibrate its policies to ensure that all entities receiving Medicare funds provide patients 24x7x365 access to their information in a persistent manner and without special effort. We find the concept of ‘medically necessary information’ somewhat abstract and very context-dependent.”
Similarly, the Washington, D.C.-based American Hospital Association (AHA) said that CMS should not “implement a CoP/CfC to increase interoperability across the continuum of care because post-acute care providers were not provided the resources or incentives to adopt health IT, and creating this requirement would put another unfunded mandate on these organizations. Such a requirement would only be workable if all facilities were afforded the same opportunity to acquire certified EHRs that actually conformed to standards that enable the kind of interoperability CMS envisions.”
However, there are a plethora of stakeholders that feel differently. A letter signed by more than 50 organizations, representing plans, providers, patient groups, ACOs (accountable care organizations) and health IT companies, has called on CMS to take more aggressive action to promote interoperability and advance health information exchange. Some of these signed groups include prominent industry names such as Beth Israel Deaconess Care Organization, Blue Shield of California, the New York eHealth Collaborative, and Aledade, just to name a few.
In the letter, these organizations wrote, “We believe that tying information sharing to Conditions of Participation would be a tremendous benefit to millions of Medicare and Medicaid patients across the country. In addition, we recognize that CMS has other levers that should be used to facilitate greater data sharing and interoperability, including requiring the use of 2015 Edition Certified EHRs and aligning requirements in the Quality Payment Program, the Promoting Interoperability program, and other quality programs such as STAR ratings.”
Other Noteworthy Comments
Beyond commenting on the possibility of revising Conditions of Participations to further promote interoperability, the trade groups weighed in on many other issues as well. The Washington, D.C.-based Pew Charitable Trusts noted that via the rule, CMS has opportunities to improve interoperability by addressing factors that affect the exchange and utility of health data, such as: better patient matching; the use of simple and transparent application programming interfaces (APIs); and standardized clinical terminologies.
Furthermore, EHRA stressed the need for better timelines and stronger alignment, noting that: any program changes must be communicated with enough lead time to allow for education, testing, implementation, roll out, and certification; and that while it appreciates the alignment of program names, “this does not address much more significant challenges, such as the challenge associated with capturing and calculating measures differently for the Medicare and Medicaid programs. To avoid burden in certification and software development, CMS must keep individual measures consistent between their Medicare and Medicaid programs, even if the scoring approach varies,” EHRA commented.
CHIME, meanwhile, thanked CMS for removing the “pass/fail” element in the new Promoting Interoperability program, while also showing appreciation that CMS has given providers more time in 2018 to install and begin using their 2015 CEHRT.CHIME does, however, recommend that CMS make the reporting period for all programs that require the use of 2015 CEHRT—beyond just Promoting Interoperability—be 90 days in 2019.
What’s more, AHA wrote that it opposes the use of Stage 3 requirements in FY 2019, as it believes “the level of difficulty associated with meeting all of the Stage 3 current measures is overly burdensome.” The organization gave an example of how one Stage 3 objective requires the incorporation of patient-generated health data or data from a nonclinical setting for more than five percent of patients into an EHR. But as AHA noted, “The types of data to be integrated are not specified, the data sources range from social service organizations to consumer fitness devices, and the manner by which to incorporate the data into the EHR is not specified.”
AMIA’s other recommendations included: CMS should chart a course towards an end to numerator/denominator-driven measurement through the Promoting Interoperability program; CMS should abandon the construct of measure reporting in favor of an activity-based approach; and that CMS should initiate a broad and inclusive conversation regarding the contours and additional characteristics of acceptable IIAs (inpatient improvement activities).
It’s expected that a final rule will be published this fall.