Might CMS Move to Implicitly Mandate Health Data Exchange at Discharge, at the Federal Level? | Mark Hagland | Healthcare Blogs Skip to content Skip to navigation

Might CMS Move to Implicitly Mandate Health Data Exchange at Discharge, at the Federal Level?

April 26, 2018
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CMS officials make broad hints about data-sharing in their release of a new proposed rule

Tuesday’s announcement on the part of the federal Centers for Medicare and Medicaid Services (CMS) that the agency is planning to drastically overhaul the meaningful use program, even to the extent of changing its name, was a big one. As Healthcare Informatics Managing Editor Rajiv Leventhal noted in his report two days ago, “In a press release, the federal agency said that it will be proposing to re-name the meaningful use program to ‘Promoting Interoperability.’ CMS said 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.”

Further, Leventhal noted, “The meaningful use (Medicare and Medicaid EHR Incentive Programs) program has been around since 2011 with the intent to encourage eligible providers to demonstrate meaningful use of certified EHR (electronic health record) technology. Seven years later, with nearly all hospitals and most physician practices having implemented a certified EHR, CMS is proposing a shakeup of the initiative with a rethinking of industry priorities.  Broadly,” he wrote, “the proposed rule issued today proposes 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). According to CMS, the policies in the IPPS and LTCH PPS proposed rule ‘would further advance the agency’s priority of creating a patient-driven healthcare system by achieving greater price transparency and interoperability—essential components of value-based care— while also significantly reducing the burden for hospitals so they can operate with better flexibility and patients have the information they need to become active healthcare consumers.’”

Among other things, Leventhal wrote, “The proposed policies begin implementing core pieces of the government-wide MyHealthEData initiative through several steps to strengthen interoperability or the sharing of healthcare data between providers.” And his report included the statement made by CMS Administrator Seema Verma that was contained in the announcement. “We seek to ensure the healthcare system puts patients first,” Verma a statement. “Today’s proposed rule demonstrates our commitment to patient access to high quality care while removing outdated and redundant regulations on providers. We envision a system that rewards value over volume and where patients reap the benefits through more choices and better health outcomes. Secretary Azar has made such a value-based transformation in our healthcare system a top priority for HHS, and CMS is taking important, concrete steps toward achieving it.”

What’s more, as Leventhal and Healthcare Informatics Associate Editor Heather Landi reported this morning in their follow-up article, “CMS is proposing to re-name the meaningful use program, now calling it “promoting interoperability.” But just how far the federal agency will go beyond “promotion” remains to be seen. For instance, deep inside the rule, CMS wrote that it is seeking public comment, via an RFI (request for information) on whether participation in the 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.”

Their story notes that “Those who have been close to the early meetings on TEFCA—which is the Office of the National Coordinator’s (ONC’s) plan to jolt the sluggish pace of progress on interoperability between providers— have praised the fact that provider participation in the initiative is currently voluntary. But,” they note in their article from this morning, “Jeff Smith, vice president of public policy at AMIA (the American Medical Informatics Association), believes that providers might actually be forced to participate after all.” Indeed, Smith told them, “One of the really interesting things is that nestled away [in the RFI] is that it says CMS 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 that would require them to transfer medically necessary information upon a patient discharge or transfer to do so electronically. A few other phrases are [also] in there, such as requiring hospitals to send discharge information to a community provider via electronic means, if possible, and requiring hospitals to make information available to patients, or a specific third-party application via electronic means, if requested.”

Further, they report, “[E]ven more thought-provoking, adds Smith, is TEFCA possibly counting as an HIE measure and objective in the new program.” In fact, he told them, “This could be wildly overblown, but one of the critiques of TEFCA is that it is voluntary and if you make it too hard, [no one] will do it. I always thought that was flawed logic, as the ONC EHR [electronic health record] certification program is voluntary, but nobody treats it like it’s voluntary if they want to be part of this world.”

And, though Smith told them that he had always assumed that TEFCA participation would be “voluntary,” the government would figure out a way to encourage participation. “If you think about TEFCA as essentially requiring all these [activities], if they were to try to make Conditions of Participating align with the general outline of TEFCA, that would be a pretty strong motivation to participate. It sure seems to me that what’s outlined here—making information available to other facilities upon transfer or discharge, requiring discharge information go to community providers, and making sure that information is available to patients or third-party apps—is pretty much a large swath of what TEFCA is trying to accomplish,” he said.

Using the modifications to the IMPACT Act to compel data exchange?

So, now comes a question: might CMS officials end up, down the road, creating an implicit mandate for inpatient hospitals to participate in de facto health information exchange in routine discharges from inpatient stays, as a condition of participation in the Medicare and Medicaid programs, via modifications made to the IMPACT Act, above and beyond potentially giving providers “credit” for such data-sharing at the point of discharge, as part of the renamed “Promoting Interoperability” program? The question is a provocative one, but we’ll have to do some digging and pondering here.

It’s right there, on pages 1474-1477 of the proposed rule:

“In light of the widespread adoption of EHRs along with the increasing availability of health information exchange infrastructure predominantly among hospitals, we are interested in hearing from stakeholders on how we could use the CMS health and safety standards that are required for providers and suppliers participating in the Medicare and Medicaid programs (that is, the Conditions of Participation (CoPs) Conditions for Coverage (CfCs), and Requirements for Participation (RfPs) for Long Term Care Facilities) to further advance electronic exchange of information that supports safe, effective transitions of care between hospitals and community providers.  Specifically, CMS might consider revisions to the current CMS CoPs for hospitals such as: requiring that hospitals transferring medically necessary information to another facility upon a patient transfer or discharge do so electronically; requiring that hospitals electronically send required discharge information to a community provider via electronic means if  possible and if a community provider can be identified; and requiring that hospitals make  certain information available to patients or a specified third-party application (for example, required discharge instructions) via electronic means if requested.

On November 3, 2015, we published a proposed rule (80 FR 68126) to implement the provisions of the IMPACT Act and to revise the discharge planning CoP requirements that hospitals (including short-term acute care hospitals, long-term care hospitals (LTCHs), inpatient rehabilitation hospitals (IRFs), inpatient psychiatric hospitals (IPFs), children’s hospitals, and cancer hospitals), critical access hospitals (CAHs), and home health agencies (HHAs) must meet in order to participate in the Medicare and Medicaid programs.  This proposed rule has not been finalized yet. However, several of the proposed requirements directly address the issue of communication between providers and between providers and patients, as well as the issue of interoperability:

  • Hospitals and CAHs would be required to transfer certain necessary medical information and a copy of the discharge instructions and discharge summary to the patient’s practitioner, if the practitioner is known and has been clearly identified;
  • Hospitals and CAHs would be required to send certain necessary medical information to the receiving facility/post-acute care providers, at the time of discharge; and
  • Hospitals, CAHs and HHAs, would need to comply with the IMPACT Act requirements that would require hospitals, CAHs, and certain post-acute care providers to use data on quality measures and data on resource use measures to assist patients during the discharge planning process, while taking into account the patient’s goals of care and treatment preferences.

We published another proposed rule (81 FR 39448), on June 16, 2016, that updated a number of CoP requirements that hospitals and CAHs must meet in order to participate in the Medicare and Medicaid programs. This proposed rule has not been finalized yet.  One of the proposed hospital CoP revisions in that rule directly addresses the issues of communication between providers and patients, patient access to their medical records, and interoperability.  We proposed that patients have the right to access their medical records, upon an oral or written request, in the form and format requested by such patients, if it is readily producible in such form and format (including in an electronic form or format when such medical records are maintained electronically); or, if not, in a readable hard copy form or such other form and format as agreed to by the facility and the individual, including current medical records, within a reasonable timeframe.  The hospital must not frustrate the legitimate efforts of individuals to gain access to their own medical records and must actively seek to meet these requests as quickly as its record keeping system permits.”

Now, there are alternative ways of reading this. The most passive reading would be a kind of “blue-sky” reading: that senior CMS officials see some future opportunity to make changes to the IMPACT Act that would promote “Promoting Interoperability,” and those officials want to let everyone know that they’re “blue-sky”-ing that thought right now.

But really, that would be a rather Pollyanna-ish view, to be honest. After all, those officials went to the trouble of spilling three pages of (electronic) ink on the idea, in the proposed rule modifying what has been meaningful use, on Tuesday morning. Which means they’re very actively thinking about it.

So my interpretation, as of this moment, is that Seema Verma and her fellow senior CMS officials this week have signaled to hospital senior executives and other leaders that actively sharing key data with the appropriate post-acute-care providers at the point of discharge from inpatient stays, may come to be mandated, in effect, either through explicit changes to what had been called the Meaningful Use program and is now called the Promoting Interoperability program, or, more likely based on the text I’ve shared above from the new proposed rule, instead through rulemaking in the IMPACT Program. Certainly, all of this is supported by all the comments that senior federal healthcare officials have been making in recent months, and certainly is supported by the comments that Administrator Verma made in March at HIMSS18 in Las Vegas, when she announced the creation of the MyHealthEData initiative. So all of it hangs together conceptually, as well as, potentially, policy-wise.

And while all of this is “envisioned” right now in late April 2018, things that are “envisioned” by CMS officials often become concrete requirements quite soon. So, stay tuned—all of this is about to get even more interesting, sooner rather than later.





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Epic Plans Meeting for Non-Epic Users on Data Sharing Capabilities

August 16, 2018
by Heather Landi
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Verona, Wis.-based Epic is inviting healthcare provider organizations that don’t use Epic’s electronic health record (EHR) to its “un-Users Group Meeting” at its Verona headquarters to learn how to exchange data with Epic.

The event, planned for September 26, will provide information to healthcare provider organizations about how to exchange charts with providers in their community who use Epic, even if providers use a different EHR— or no EHR at all.

According to Epic’s unUGM website, the event is for “executives and strategic leaders of provider organizations who want to learn and discuss how to exchange with providers in their community who use Epic.”

“Access to a patient’s information, regardless of where he or she has been seen, helps providers deliver the best patient care. The first Un-Users Group Meeting (unUGM) is another way we’re reaching out to the leaders of health systems using other EHRs—or even no EHRs—to help them get connected to the Epic users in their communities,” Dave Fuhrmann, Epic’s vice president of interoperability, said in a prepared statement.

According to the event agenda, topics of discussion include options for exchanging patient data with providers through Carequality, Care Everywhere, health information exchange (HIE) and Direct messaging, as well as patient-directed options, including MyChart, Share Everywhere, Lucy, and Blue Button.

There will also be discussion about interoperability success stories, using both non-Epic and Epic EHRs, and the current state of coordinated care in the U.S. and the use of existing tools to close care gaps, improve communication, and reduce costs.

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Amazon, Google, IBM and Other Tech Giants Pledge to Remove Barriers to Interoperability

August 14, 2018
by Heather Landi
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Six of the world's biggest technology companies, including Microsoft, Google, IBM and Amazon, made a joint pledge at the White House Monday to remove interoperability barriers and to make progress on adoption of health data standards.

The announced came during the Blue Button 2.0 Developer Conference in Washington, D.C. where Microsoft joined with Amazon, Google, IBM, Salesforce and Oracle to jointly commit to support healthcare interoperability by advancing healthcare standards such as HL7 (Health Level Seven International), FHIR (Fast Healthcare Interoperability Resources), and the Argonaut Project. They also pledged to remove interoperability barriers, particularly as it relates to the adoption of technologies enabled through the cloud and artificial intelligence (AI).

Dean Garfield, president and CEO of the Information Technology Industry Council, said in a statement, “Today’s announcement will be a catalyst to creating better health outcomes for patients at a lower cost. As transformative technologies like cloud computing and artificial intelligence continue to advance, it is important that we work towards creating partnerships that embrace open standards and interoperability.

“We commend the White House Office of American Innovation for their leadership in being a catalyst for moving health care beyond siloed systems and varied data standards. As well, we celebrate Amazon, Google, IBM, Microsoft, Oracle, and Salesforce for their commitment to helping to advance open healthcare standard. The opportunity to unleash greater innovation in health care is here and working together we can seize it,” Garfield said.

In a joint statement, the technology companies made a commitment to remove barriers to “frictionless data exchange,” noting that they share “the common quest to unlock the potential in healthcare data, to deliver better outcomes at lower costs.”

The commitment specifically states:

“In engaging in this dialogue, we start from these foundational assumptions: The frictionless exchange of healthcare data, with appropriate permissions and controls, will lead to better patient care, higher user satisfaction, and lower costs across the entire health ecosystem.

Healthcare data interoperability, to be successful, must account for the needs of all global stakeholders, empowering patients, healthcare providers, payers, app developers, device and pharmaceuticals manufacturers, employers, researchers, citizen scientists, and many others who will develop, test, refine, and scale the deployment of new tools and services.

Open standards, open specifications, and open source tools are essential to facilitate frictionless data exchange. This requires a variety of technical strategies and ongoing collaboration for the industry to converge and embrace emerging standards for healthcare data interoperability, such as HL7 FHIR and the Argonaut Project.

We understand that achieving frictionless health data exchange is an ongoing process, and we commit to actively engaging among open source and open standards communities for the development of healthcare standards, and conformity assessment to foster agility to account for the accelerated pace of innovation.”

Gregory J. Moore M.D., Ph.D., vice president of healthcare, Google Cloud, said in a statement, “We are pleased to join others in the technology and healthcare ecosystem in this joint commitment to remove barriers and create solutions for the adoption of technologies for healthcare data interoperability. This will enable the delivery of high quality patient care, higher user satisfaction, and lower costs across the entire healthcare ecosystem.”

Patients should have access to their data, said Mark Dudman, head of global product and AI development, IBM Watson Health, in a statement following the announced commitment. Patients also should have the flexibility to use products and services across different healthcare systems, with confidence that they all are working seamlessly for their care, he said. “We are proud to participate in this pledge and look forward to working with industry and the developer community to ensure appropriate access to data and the use of that data to support vibrant communities and solve health challenges for people everywhere.”

In a blog post, Josh Mandel, chief architect, Microsoft Healthcare, notes that interoperability is an overlapping set of technical and policy challenges, from data access to common data models to information exchange to workflow integration – and these challenges often pose a barrier to healthcare innovation.

Mandel, who previously worked at Google Life Sciences and on the research faculty at Boston Children’s Hospital where he worked on the SMART Health IT Platform, notes that support for the Meaningful Use Common Clinical Data Set grows and it is becoming easier to plug new tools into clinical workflows, analyze clinical histories, collect new data, and coordinate care.” Many of these technical capabilities have been available within small, tight-knit health systems for a long time – but developing these capabilities has required complex, custom engineering and ongoing maintenance and support. Driving toward open architecture makes adoption faster, easier and cheaper,” he wrote.

True interoperability in healthcare requires end-to end solutions, rather than independent pieces, which may not work together, Mandel wrote. “Transforming healthcare means working together with organizations across the ecosystem. Today’s joint interoperability statement reflects the feedback from our healthcare customers and partners, and together we will lay a technical foundation to support value-based care.”


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Industry Stakeholders Urge ONC to Move Forward on Information Blocking Rules

August 8, 2018
by Heather Landi
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In a strongly worded letter to National Coordinator Donald Rucker, M.D., several healthcare and health IT industry groups expressed frustration with the Office of the National Coordinator for Health IT’s lack of progress in publishing information blocking regulations, as required in the 21st Century Cures Act.

“It has been 601 days since the 21st Century Cures Act was signed into law. Every day that the administration delays implementation of these critical provisions places patients at risk of harm,” the letter states. Stakeholders including Health IT Now, Research!America, Oracle, the American Medical Informatics Association (AMIA), the American Academy of Family Physicians, Cambia Health Solutions and Claim Your Health Data Coalition signed the letter dated August 6.

In the letter, addressed to both Dr. Rucker and Daniel Levinson, inspector general of the Department of Health and Human Services (HHS), the stakeholder groups note that the 21st Century Cures Act, which was enacted in December 2016, requires the HHS Secretary to “issue regulations to prevent information blocking and to also identify reasonable and necessary activities that do not constitute information blocking.” Further, the law requires ONC to implement a standardized process for the public to submit reports on claims of health information technology products or developers of such products not being interoperable or resulting in information blocking and actions that result in information blocking. “The Office of the Inspector General (OIG) has enforcement authority over vendors and providers who are found to engage in information blocking,” the letter states.

The stakeholder groups also contend that “information blocking poses a significant risk to patient safety and greatly contributes to increased costs and waste in the health care system.”

According to reporting from Politico, during ONC’s 2nd Interoperability Forum this week in Washington, D.C., Rucker told the form audience that ONC is still working on the rule. The rule’s release has been delayed several times and is not expected to be released in September.

“Rucker emphasized Monday that his goal is to make protocols and standards that would let large amounts of health data flow easily between health providers, not just individual patient charts. He and other officials emphasized that ONC’s work is all being done within the confines of HIPAA,” the Politico article stated. Rucker also noted that properly defining which behaviors do and don’t constitute information blocking is “hard to sort out,” and the rule is a “work in progress,” Politico reported.

In a separate statement regarding ONC's delay in issuing an information blocking proposed rule, Douglas Fridsma, M.D., Ph.D., AMIA president and CEO, said, "Information blocking is the absence of interoperability, and there are numerous reasons why information may not flow as intended. Some of these reasons are technical, others for business or policy reasons. The socio-technical interoperability stack is complex and so too is the task of identifying which among its layers is responsible for information blocking. This rule must be critically calibrated to account for these layers, and it must be part of a larger conversation about how we will address other aspects of the socio-technical interpretability stack. Now is the time to initiate this broad conversation through release of the proposed information blocking rule."

In the letter, the industry groups also cautioned that “information blocking impedes provider access to the most current, accurate or complete information on their patients. As the administration proposes and implements new rules related to open APIs and interoperability in Medicare’s payment rules for hospitals and doctors, the lack of clear rules of the road needlessly creates uncertainty for vendors and providers alike.”

“We understand the nuance required but feel that it is past time for a proposal to be made,” the stakeholder groups wrote in the letter.

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