During the May 12 federal Health IT Policy Committee meeting, the Interoperability and Health Information Exchange Workgroup raised some concerns and suggestions about the proposals in Stage 3 of meaningful use around transmission and reconciliation of data. In several instances, the workgroup suggested lowering thresholds.
Micky Tripathi, president and CEO of the Massachusetts eHeatlh Collaborative and co-chair of the workgroup, noted that in general the workgroup agrees with the direction and goals of the proposed rules around interoperability. “But we are concerned about setting thresholds that might be too high,” he said. “We don’t want to have to backtrack as we did with view, download and transmit, and we don’t want to penalize people for things beyond their control.”
Stage 3’s Objective 7 comprises three measures, and providers would have to meet only two out of three (but must report on all three):
• Measure 1: Send electronic summary of care record for 50 percent of outgoing transitions or referrals: The workgroup suggests lowering the threshold from 50 to 40 percent. Tripathi noted that there was some disagreement among workgroup members. Some clinicians say they find Consolidated-Clinical Document Architectures (C-CDAs) not particularly useful, so why increase the measure to 50 percent? (To deal with the C-CDA “bloat” issue, the work group recommends that CMS allow sending providers flexibility in what they are going to include, so it doesn’t have to include the entire common data set be populated if available.)
Tripathi said workgroup members felt they couldn’t recommend a measure below the experience reported with Stage 2, but he noted that Stage 2 data suggests that the average provider will be well below 50 percent, and that the 2014 exclusion allowance (by which 86 percent of eligible providers avoided the transition-of-care (TOC) requirement) has slowed market adoption of TOC functions.
Another recommendation by the workgroup that was hotly debated by the Policy Committee was that integrated delivery networks (IDNs) should not be allowed to count transitions that occur between providers on the same EHR database, commonly referred to as “selfies.” They noted that the information is already available in the EHR and in most cases probably accessed that way. CMS proposes allowing IDNs to count sending discharge summaries to ambulatory providers within a network, even though all the information is already available to them in their own EHRs. The workgroup suggests disallowing that practice and forcing the IDNs to achieve the 40 percent figure outside their networks. Several Policy Committee members from IDNs strongly objected to that idea.
• Measure 2: Receive and incorporate electronic summary of care record for 40 percent of incoming transitions or referrals: The workgroup suggests lower threshold to 25 percent, noting that it is a new measure with which the industry has no experience. “It is a very important measure,” Tripathi stressed. “It is a creative approach to query without having a full-blown query ecosystem available. We think 25 percent can be accomplished.”
• Measure 3: Reconcile clinical information for 80 percent of transitions or referrals, including medication allergies and problems. The workgroup recommends lowering the threshold for problems to 10 percent, or even making problems optional. The clinicians on the workgroup felt strongly that problem reconciliation is operationally very difficult and different in nature from medications and medication allergies reconciliation. Patients can report meds and med allergies in most cases. However, they are less able to reliably report on diagnoses. There is ambiguity in coding conventions – multiple ICD codes can cover single experience of illness, Tripathi noted. The workgroup recommends including problems at low level to give CMS the opportunity to increase it over time.
In addition, the workgroup suggests that CMS allow exclusions for some specialists. It noted that high levels of reconciliation are not appropriate for some specialties with narrow scopes of practice (low prescribers, orthopedists for whom problem list reconciliation is not clinically relevant, or the information is not available due to narrow scope of practice, etc.).
Once the workgroups get feedback from the HIT Policy Committee on their initial recommendations, they will fine-tune them for the full committee to later vote on approving.