After a weekend to read through the approximately 300 pages that make up the Centers for Medicare and Medicaid Services’ (CMS) proposed rule for Stage 3 of meaningful use, industry experts are starting to share their detailed opinions on it.
Overall, the reaction to CMS’ Stage 3 proposals is mixed. While some are concerned that CMS is upping the stakes considerably and establishing a single set of objectives and measure, tailored to eligible providers (EPs), eligible hospitals (EHs), and critical access hospitals (CAHs), which will be required in 2018, others are appreciative of the elements of flexibility that exist within the rule.
Erik Dahl, who analyzes whether or not a healthcare organization has hit on the meaningful use measures as part of his role as an IT auditor at Chan Healthcare, a consulting firm in Clayton, Mo that is a subsidiary of Crowe Horwath LLP., says it’s clear that CMS is trying to build in some flexibility, with how providers can report in 2017. For one, Stage 3 attestation is not required and for those who do attest, there are options on what certified electronic health record technology (CEHRT) can be used. However, he is concerned with some of the benchmarks that he says are “aggressive.”
Specifically, Dahl mentions the requirement from CMS that proposes 25 percent of the EH, EP or CAH’s patient view, download, or transmit their information. This is up from the 5 percent requirement in Stage 2. He says that many providers see this as something that’s beyond their control. “Can they encourage patient engagement? Absolutely. I think many providers are doing that. To jump from 5 to 25 percent…I don’t know if that’s a symptom of this being the last stage of meaningful use,” he says.
Naomi Levinthal, consultant, research and insights at The Advisory Board Company (Washington D.C.), says that the jump from getting 5 percent of patients to view, download, and transmit their data to the proposed 25 percent threshold in Stage 3 is a “game-changer.” Levinthal calls it “overestimation of the industry’s readiness,” while Bruce Eckert, national practice director, strategic advisory group at Beacon Partners (Boston), says that while all of the early word was that there would be a big emphasis on patient engagement, the level and amount of patient engagement envisioned by the proposal surprised him.
Jason Fortin, senior advisor at Impact Advisors, was floored by the jump to 25 percent. He said the threshold is really high, and even a counter-balance with the use of application programming interfaces (APIs), won’t make this a realistic number for most providers. “One of out of four patients is not going to actively engage with their health record. In some communities, they might get there. In most, they won’t,” he said.
Better received is the requirement which asks providers to send a message to 35 percent of their patents, Dahl says, because it’s more in their hands. Levinthal agrees, saying, “Right now, the threshold is 5 percent, but you can’t count provider-initiated messages,” she says. “This is a great example of where the threshold is higher, but the number is actually easier to achieve. So I see it as a step in the right direction.”
However, the patient-generated health data (PGHD) requirement, which asks providers to incorporate PGHD into the EHR for 15 percent of its patients is a huge question mark for most. “Are we really to the point where the technology is going to support that measure by 2017 and 2018?” Dahl wondered. Fortin agrees with this assessment, saying that it’s impossible to know what integration of PGHD and clinical data will look like, since it’s not a widespread capability today.
Eckert also feels it’s a stretch, despite the fact that industry is headed in a direction of more patient involvement and interaction. “These are certainly challenging percentages, though CMS has backed off some of those thresholds in years past. There is no guarantee if that this time though,” says Eckert. “Keep in mind that policymakers are looking ahead to 2018, so it’s a ways out in the future, and they want to intentionally making it challenging to help drive the industry towards more patient involvement. Technology is also evolving that way. But this percentage seems like it’s one of those that’s too much, too soon,” he says. Levinthal adds that it seems like the thresholds are “a huge step forward instead of just a little step forward.”
The health information exchange measures require providers to include a summary of care record and an electronic exchange of the summary of record in their EHR for 50 percent of referred patients or higher; an electronic summary of care document to be incorporated into the EHR for 40 percent of patient being referred; and clinical information reconciliation for 80 percent of patients or higher. Dahl predicts these “aggressive” thresholds will be an area of concern for most providers.
On the positive side of interoperability, CMS was applauded for including open APIs as a requirement for 2015 CEHRT. “With this rule, members of Premier remain hopeful that we will finally create strong policies that incent use of standard APIs to enable interoperability among disparate systems in healthcare. With interoperability standards, providers will be in a much better position to manage population health across the care continuum and support advanced payment initiatives such as shared savings and bundled payment,” stated Amanda Forster, vice president of public relations, at Premier, the Charlotte-based group purchasing organization.
An aspect of the proposed rule that is sure to create some controversy is the lack of a 90-day EHR reporting period in Stage 3, something that stakeholders have long pleaded for. In fact, CMS has previously said that it will likely implement a 90-day reporting period, rather than a 365-day one, for 2015, despite including nothing about a shorter reporting period in its Stage 3 rule.
Levinthal says that the federal agency seems to be working backwards when it comes to this aspect of meaningful use. “Typically before a new stage is out, CMS will give people time to on-board to the new stage, and the fact that they are not doing this is a huge surprise,” she says. “In order to support things such as APIs or do bi-directional information exchange, which is part of Stage 3, you will need 2015 certified products. Without a shorter reporting period to manage that type of upgrade, I don’t know how people will do a year-long reporting period, unless they are going to take time away from performance in order to suffer a little bit during implementation. That’s something I worry about,” she says.
Levinthal thinks that the Stage 3 rules were put to bed before CMS said they will consider a 90-day reporting period for 2015. “Once it hits the Office of Management and Budget (OMB), there isn’t really much time for heavy hands editing,” she says, urging the public to comment if they don’t get the shorter reporting period in 2015, a rule that Levinthal expects will come out before the annual Healthcare Information and Management Systems Society (HIMSS) conference next month. Eckert adds that he was surprised there was no mention of a shorter reporting period in 2015 in the Stage 3 rule, even though CMS warned it would be two separate rules. “If it does come, it will have to come soon. CMS officials have said they want all rulemaking out before HIMSS, so they better hurry,” Eckert says.
2018: Year of Alignment
Many are questioning CMS’ aforementioned decision to get everyone on the same timetable by 2018 and report in a full calendar year. The American College of Cardiology called the proposal a cause for concern. In a statement to the press, the American Hospital Association also expressed concern with this timeline.
“In January, CMS promised to provide much-needed flexibility for the 2015 reporting year, which is almost half over. Instead, CMS released Stage 3 rules that pile additional requirements onto providers. It is difficult to understand the rush to raise the bar yet again, when only 35 percent of hospitals and a small fraction of physicians have met the Stage 2 requirements,” Linda Fishman, AHA senior vice president of public policy analysis and development, said in a statement.
Both Levinthal and Eckert agreed that CMS made one thing clear by requiring providers to start Stage 3 by 2018: the losers are the late adopters to the program. “The fact is that you could never participate in any stage of this program, and if Stage 3 is your first stage, it is going to near impossible,” says Levinthal. Eckert adds that an unintended consequence of this will be more physician consolidation. “It will be impossible for new physicians to go into a solo or small practices. They will need to be part of a larger practice with the technology already in place,” he says.
Moving forward, both consultants feel that industry stakeholders will still be up in arms by parts of the proposed rule. “People struggle with yearly reporting periods, and rightly so,” Levinthal says. “Meaningful use can be very difficult for people to achieve when it has all-or-nothing aspects to it.” What’s more, Levinthal says that while CMS looked at Stage 2 attestation patterns, the data was limited. “Industry groups will applaud some part of this, but more needs to be done, especially in terms of the thresholds being really high compared to what everyone would say are a really limited data sets of folks who are probably super-users,” she says.
Fortin says it’s strange that CMS has taken the two most challenging aspects of Stage 2—patient engagement and HIE—and significantly upped the stakes for providers in Stage 3. Even though there is flexibility, allowing for providers to meet two of three, the thresholds in the proposed rule have the potential to cause some problems, he says.
Eckert adds that the rule will be controversial, largely because of the big step up in patient engagement requirements, even for the high performing organizations. “Perhaps the intent was to make it challenging for everyone. The concern I would have is that, for the lower performing segment of our industry, it might be de-motivating to some of them who have been struggling to reach Stage 2,” Eckert says, adding that he feels the feds have learned some from the “Stage 2 disaster.”
Levinthal notes that she wouldn’t expect the meaningful use program to end anytime soon, as there a bunch of places within the regulation where the agency says it will take the opportunity to adjust Stage 3 requirements as it monitors performance. “This doesn’t mean that it will be the last set of rules and proposals,” she says. There could quite possibly be a ‘Stage 3.1 and 3.2.’ Who knows? We get the question about meaningful use being over quite often. We still have no idea.”