With the release of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) final rule last week, healthcare leaders quickly turned to look at the regulation’s many provisions that directly relate to the use of certified electronic health record (EHR) technology and more broadly, health information technology.
Indeed, MACRA’s Quality Payment Program, which includes two tracks for eligible Medicare clinicians—the MIPS (Merit-Based Incentive Payment System) path, and the advanced alternative payment models (APMs) path— requires the use of certified EHR technology to exchange information across providers and with patients to support improved care delivery, including patient engagement and care coordination, federal officials noted in a fact sheet with the release of the Final rule last week. The idea is that the better providers are able to utilize and leverage health IT, the more likely Medicare’s value-based transformation for hundreds of thousands of physicians and other eligible clinicians will be successful.
In a call with health IT press on Oct. 14, Centers for Medicare & Medicaid Services (CMS) Acting Administrator Andy Slavitt said, “If the HITECH Act allowed big EHR companies to form and grow, MACRA is the next shift and arguably a much richer opportunity, where customer needs begin to takeover.”
On the MIPS front, the track that most participants will initially partake in early on in the program, doctors will be scored on Quality; Advancing Care Information; Clinical Practice Improvement Activities; and Cost (which begins in 2018).
When the proposed MACRA rule was released in April, much of the conversation centered on the Advancing Care Information (ACI) category, which effectively replaces Meaningful Use for Medicare physicians. The objectives of the ACI performance category of MIPS emphasize measures that support clinical effectiveness, information security and patient safety, patient engagement, and health information exchange, and computerized provider order entry (CPOE). The final rule does not require reporting on the clinical decision support and the measures. Additionally, the final rule reduces the number of measures clinicians must report to five measures that are focused on interoperability; this is reduced from 18 measures in Stage 3 of Meaningful Use and from 11 measures in the MACRA proposed rule.
On the call with HIT press, Slavitt said, “Many of you have heard me call out CMS for losing the hearts and minds of physicians. As we met with doctors around the country, we learned about how technology doesn’t support physicians,” noting that CMS reduced the number of ACI required measures from 11 to 5, and adding that the final rule offers flexibility so physicians can pick the quality measures to report on that are right for their practice.
Vindell Washington, M.D., National Coordinator for Health IT, added during the call, “Our collective goal is a simpler approach to technology that [will help] providers get better outcomes for patients. Health IT is foundational to providing quality care,” he said. Washington said it’s not just about implementing the health IT, but “unlocking the data within and putting it into work.” He added, “The health IT elements [of the final rule] are laser focused on making information sharing easier. We focused specifically on what will advance the broader view for the future in which electronic health information flows through the system wherever and whenever needed.”
Plenty of HIT Implications
Drilling down, MACRA participants will need their IT infrastructure to be ready for the big leagues. Tom Lee, Ph.D., founder of SA Ignite, a Chicago-based vendor firm whose software platform is focused on reimbursement analytics, says it is important to keep in mind that every MIPS point matters financially. “If you look at the financial and scoring rules in depth, you find that every incremental MIPS point translates into more dollars starting with next year. So having more efficient IT systems to give you a very tight and quick performance improvement feedback loop—in terms of capturing data, looking at where your performance is, and then quickly remediating and monitoring your score on a more frequent basis, which also relies on IT—will be absolutely critical to doing well in this program, he says. “You are still being rated against national benchmarks, and the people who are scoring higher will get more dollars,” Lee says.
One of the existing quality reporting programs that MACRA streamlines into the Quality Payment Program is PQRS (Physician Quality Reporting System), which is now labeled the “Quality” category under MIPS. Lee gives an example of one particular PQRS method—called the measure group method—that was used primarily by specialists and small providers and didn’t require a lot of IT. “You could basically get away with reporting on 20 patients,” Lee explains. But under the Final rule, the ‘measures group’ is being completely eliminated, so other quality reporting approaches will be required, which takes a higher IT requirement than simply reporting on 20 patients,” he says.
Another area of importance for providers is that the final rule incentivizes using a certified EHR. In the Quality category of the final MIPS rule, if a clinician uses a way of reporting quality measures that’s truly end-to-end electronic reporting—which almost always is rooted in using the EHR—he or she will get bonus points in that Quality category, Lee explains. “We have seen in the field that providers do have the ability [to report electronically]. The EHR certification program has been pushing for electronic clinical quality measures to be calculated in larger numbers out of EHRs. Meaningful Use required it from the beginning,” he says.
As such, in the final rule, CMS put in bonuses for providers to earn for electronic reporting, which Lee says is a direct result of their confidence in these systems. Speaking to this on the press call last week, Kate Goodrich, M.D., director at CMS’ center for clinical standards and quality, said that in the early years of PQRS, the only method of reporting was through claims, but the government has now seen a significant uptick in the number of solo doctors and groups who use electronic methods to report. “Large practices of 100 or more use the CMS engine to report, and we have seen an increase in reporting via the EHR or through the qualified clinical data registry mechanism. We recognized that in the MIPS path by allowing for bonuses for providers who choose that method,” Goodrich says.
Further regarding the ACI category, Jeff Smith, vice president of public policy at the American Medical Informatics Association (AMIA), notes that for the coordination of care, via patient engagement, measures—so the patient-generated health data, the view/download/transmit, and the secure messaging pieces—the first year of MIPS only requires “one unique patient” to perform the activity for the MIPS eligible clinician during the performance period.
But, Smith cautions that these thresholds will very likely rise going forward. “This is for 2017 and anyone who thinks this is where program will end up in two or three years from now is not reading the tea leaves correctly,” he says. Smith continues, “If we are trying to incorporate APIs [application program interfaces] into this, it’s a reflection of where the technology and standards are now, and how it fits into workflows. If you are a provider saying or thinking that you don’t have to do these [activities] anymore, that’s not the right attitude.”
To sum up, John David Goodson, M.D., staff internist at Massachusetts General Hospital (MGH) and associate professor at Harvard Medical School, says that the MACRA final rule will now undoubtedly command the attention of physicians. The key messages related to health technology are the following, Goodson said to Healthcare Informatics in an email exchange: “Be certain that your EHR has the capabilities required for modern patient care including intuitive physician directed panel analytics and perfected work flows for clinical task completion (if you have a clunky EHR, it's time to move on to a better product); develop the tools of empanelment including multiple options for patient communication, result follow-up, identification of outliers, and patient access; and be certain that every appropriate diagnosis is identified and reported since risk adjustment will have a profound impact on each physician’s composite performance score (CPS).”
Data Blocking Surveillance—A Big Deal?
Following the proposed rule release, some industry association groups took issue that MACRA requires both clinicians and hospitals to attest they are not “data blockers,” while CMS calls on providers to demonstrate that they have not knowingly and willfully taken action (such as disabling functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.
Nonetheless, not much about this changed in the Final rule, as “CMS reiterated its position on information blocking, saying providers and hospitals participating under the existing MU program are required to demonstrate cooperation with provisions concerning blocking the sharing of information and separately, to demonstrate engagement with activities that support providers with the performance of their certified EHR technology such as cooperation with ONC direct review of certified health information technologies,” as reported by Healthcare Informatics’ David Raths. To this end, the Office of the National Coordinator for Health Information Technology (ONC) also issued a final rule on Oct. 14 that gives the agency greater authority over surveillance and review of providers’ EHR systems.
While some in the industry see this as ONC overstepping its boundaries, Farzad Mostashari, M.D., founder of accountable care organization (ACO) Aledade and former ONC National Coordinator for Health IT himself, says that “Way too much is being made of [data blocking surveillance] in the rule. If you think about the number of practices this will affect, it’s [so small]. Ensuring the integrity of the EHR certification program and the EHR marketplace is very important. As far as it being an issue or burden for practices, it’s a non-issue,” he says.
Lee, meanwhile, says while he is not an expert in the area himself, he has listened to many CIOs how the government can operationally prove who is or isn’t blocking data, and if it’s the burden of the providers or the vendors. “A lot of the questions I heard were that there wasn’t a lot of specificity around accountability. There is less concern about these people suddenly being caught for data blocking, but more about how to prove this and whose responsibility is it at the end of the day?” AMIA’s Smith agrees: “[The surveillance] won’t be used as a witch-hunt to go track down [providers] and make trouble,” he says.
In the end, with all these health IT implications in mind, the onus will be on CIOs to continue to educate themselves and their clinicians on all of MACRA’s complexities, says Lee. “The C-suite has even more reason to make budgetary and staffing decisions based on what’s in the final rule compared to what was proposed.” Lee also warns clinicians to not “take it easy” in 2017, despite it being a transition year. “That treadmill is continuing to accelerate, so if you jump on the treadmill that’s already moving fast in 2018, you will get swept away by your competition,” he says.