AMIA, MGMA, AMGA Offer Comments on CMS’ Latest E&M, Quality Payment Program Proposals | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

AMIA, MGMA, AMGA Offer Comments on CMS’ Latest E&M, Quality Payment Program Proposals

September 10, 2018
by Rajiv Leventhal, Managing Editor
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Leading health IT associations have varying sentiments and recommendations for the Centers for Medicare & Medicaid Services (CMS) regarding the federal agency’s Physician Fee Schedule (PFS) and the Quality Payment Program (QPP) proposed rule that was released in July.

On July 12, CMS proposed changes that the agency believes will “fundamentally improve the nation’s healthcare system and help restore the doctor-patient relationship by empowering clinicians to use their electronic health records (EHRs) to document clinically meaningful information.”

Included in the proposal were both changes to documentation requirements for Evaluation and Management (E&M) codes; modifications to how Medicare clinicians would be paid for virtual services rendered; as well as year three proposals for MACRA’s (the Medicare Access and CHIP Reauthorization Act of 2015) Quality Payment Program, including streamlining MIPS (Merit-based Incentive Payment System) participation, which includes the newly renamed Promoting Interoperability (PI) Program.

Healthcare Informatics covered the core takeaways from these proposals, particularly for how they impact the health IT community, in a story following the rule’s release in July

Now, in a letter delivered by the AMGA (formerly American Medical Group Association), the group noted that under the proposed rule, CMS would replace the current E/M codes with a new, single blended payment rate for E/M Level 2 through 5 visits. At the same time, CMS would apply a minimum documentation standard to provide Medicare Part B physicians with a choice of time, Medical Decision Making (MDM), or the use of the current 1995 or 1997 documentation guidelines. AMGA believes CMS is conflating two distinct or separate issues: documentation requirements and the complexity of a patient’s care needs represented by a billing code.

“Providing physicians with a choice in how to document beneficiary E/M visits would be a welcome development,” said AMGA President and CEO Jerry Penso, M.D. “It indicates CMS is serious about addressing administrative burden, particularly since these billing codes represent nearly one-third of all Medicare physician visits. Unfortunately, pairing paperwork reforms with a significant change in categorizing patient complexity and reimbursement may very likely undermine care quality and coordination and cause disruption in physician workflow and referral patterns.”   

What's more, in comments submitted CMS, the American Medical Informatics Association (AMIA) applauded federal officials “for aligning physician and hospital EHR requirements and advancing policies that further incentivize the adoption of health IT for patient care.” AMIA also supported CMS efforts to reduce documentation burden through new options to use time or Medical Decision Making as a basis to determine E&M visit level.

As part of E&M guideline reforms, CMS proposed to allow physicians the option to use time or MDM as a basis to determine E&M visit level. In its comments to CMS, AMIA said it supports both the use of MDM and time as alternative means to determine appropriate level of E/M visit. “However,” the group noted, “determining levels of MDM is a convoluted and complex task under current guidelines. This complexity must be addressed with an eye towards how IT and informatics can be leveraged so the simplicity of these solutions can be realized.”

AMIA specifically recommended that CMS support their proposed E&M reforms with focused and well-resourced efforts to leverage these current functions and develop emerging functions, such as natural language processing, medical device data, voice recognition software, and the use of sensors to capture clinical activity. “Acknowledging that these and other informatics tools are still early in development,” AMIA said, “CMS should support pilots and otherwise incentivize efforts meant to use these kinds of technologies and evaluate their use for documentation purposes.”

“Our current documentation paradigm is incompatible with the digital age,” noted Joseph Kannry, chair of AMIA’s public policy committee and lead technical informaticist at Mount Sinai Health System and Professor of Medicine Icahn School of Medicine at Mount Sinai. “While imperfect, CMS must proceed with E&M documentation reforms to address growing dissatisfaction and declining wellness among clinicians. Our billing-focused health IT ecosystem must be reoriented to patient care.”

Meanwhile, the Medical Group Management Association (MGMA), in its comments, said it “urges CMS to reconsider options for reducing documentation associated with E/M office visits to avoid harming physician practices that treat the sickest patients. This proposal oversimplifies the most common yet most diverse patient interactions while doing little to reduce paperwork.” Specifically, MGMA believes that CMS should not move forward with its proposal to collapse payment rates for eight office visits for new and established patients down to two each, as there are many unanswered questions and potential unintended consequences that would result, the group stated.

QPP Recommendations

AMIA said in its comments that by mirroring proposals finalized for hospitals in 2019, CMS would require the use of 2015 Edition CEHRT (certified EHR technology) 2019 and continue a 90-day EHR reporting period through 2020. The PI Program would also include a new points system scoring methodology and fewer required measures for hospitals to report. AMIA largely supported these proposals, while recognizing that important functionalities related to retired patient engagement measures, such as secure messaging, education, and use of patient-generated health data, must remain part of CEHRT, the group stated.

“Meaningful Use has served as a valuable vehicle to help digitize care delivery in the United States and thereby enable informatics-driven improvements in patient safety and clinical care,” said Peter J. Embi, M.D., AMIA board chair, and president and CEO, Regenstrief Institute. “But now is the time to think differently about how this program should evolve to meet the rapidly-changing, and often challenging, environment of care delivery. These new proposals position the program to build on progress made to-date, and our recommendations provide impetus for even more innovative changes focused on the ultimate goals of improving health and healthcare.”

MGMA, meanwhile, believes that CMS ought to simplify MIPS and reduce redundancies by awarding multi-category credit. As implemented, MGMA noted, “MIPS reflects a continuation of the agency’s historically siloed approach to quality reporting, consisting of four programs under one umbrella. To reduce burden, CMS should award credit in multiple categories for overlapping efforts, such as using clinical-decision support or capturing patient-reported outcomes.”

Related to MIPS, MGMA also attested that CMS should:

•             Permanently shorten the minimum reporting period to any 90 consecutive days;

•             Provide clear and actionable feedback about MIPS performance at least every calendar quarter;

•             Increase opportunities to participate in Advanced Alternative Payment Models (A-APMs);

•             Permit MIPS and APM participants to use 2014 or 2015 CEHRT in 2019 and 2020.

What's more, CMS, via the rule, is proposing an avenue for excluded clinicians who would like to participate voluntarily to “opt in,” which AMGA sees as a positive development. In addition, this policy improvement suggests CMS recognizes—as AMGA has argued—that excluding providers from the MIPS program is counterproductive for both those excluded and those included.

“Excluding providers from MIPS has a tangible impact on those clinicians who are working to succeed in the program,” said Penso. “AMGA members will continue to deliver high-value quality care, but these exclusions prevent MIPS from recognizing and rewarding their efforts to create value for Medicare.”

Virtual Care Proposals

Beginning in January 2019, CMS proposed to reimburse physicians for engaging in “virtual care,” for “brief communications,” “remote evaluation,” and “interprofessional consultation.” AMIA applauded CMS for recognizing the increased state of digitization in healthcare delivery and thus proposing to reimburse providers accordingly.

“We view these policies as addressing long-standing Medicare reimbursement barriers to widespread adoption of virtual care tools meant to reach more patients in more places, especially those in underserved and rural areas,” AMIA said. However, AMIA noted specific concerns related to the context of these new virtual care codes and encouraged CMS to consider issues related to clinical effectiveness, patient authentication, and proliferation of data silos derived from telehealth applications.

MGMA, meanwhile, noted in its comments, “MGMA supports CMS’ efforts to increase access to care by providing reimbursement for communications-based technology and telehealth services. This is a step in the right direction toward recognizing that medical practices connect with patients using new technologies.”

MGMA added that CMS “should modernize the Medicare program by finalizing coverage for virtual care, interprofessional consultation, and remote patient monitoring services. To facilitate widespread adoption of new non-face-to-face services, CMS should permit practices the flexibility to implement any new covered codes in a manner that best fits their practice and avoid overly restrictive billing requirements.”

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VA, Cerner Leaders Detail Progress on EHR Implementation, Interoperability Efforts

November 14, 2018
by Heather Landi, Associate Editor
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The U.S. Department of Veterans Affairs (VA)’s new $16-billion-dollar Cerner electronic health record (EHR) system will use open application programming interface (APIs) and Fast Healthcare Interoperability Resources (FHIR) standards to enable interoperability with the private sector, according to a Cerner executive, which potentially positions the VA as a leading force to drive interoperability forward in the healthcare industry.

The ability of the VA’s healthcare system to seamlessly share patient data with the U.S. Department of Defense (DoD) as well as health systems and physicians in the private sector continues to be a top concern among Congressional leaders as the VA is now six months in to its implementation of a new Cerner EHR, and the topic dominated a House oversight subcommittee hearing on Wednesday.

Congressional leaders pointed out that interoperability between VA and DoD and between VA and community providers would be key to the success of the VA electronic health record (EHR) modernization effort. “If you can’t make that step work, then this won’t work,” Rep. Phil Roe, M.D., (R-Tenn.) chairman of the House Veterans Affairs committee, said.

During the hearing, members of the House Veterans Affairs' technology modernization subcommittee reviewed the electronic health record modernization (EHRM) program’s accomplishments, to date, and questioned VA and Cerner leaders about implementation planning, strategic alignment with the DoD’s MHS Genesis project, as DoD also is rolling out a new Cerner EHR, as well as interoperability efforts.  

The VA signed its $10 billion contract with Cerner in May to replace VA’s 40-year-old legacy health information system—the Veterans Health Information Systems and Technology Architecture (VistA)—over the next 10 years with the new Cerner system, which is in the pilot phase at DoD. The VA project will begin with a set of test sites in the Pacific Northwest in March 2020.


Driving Success at Regional Health: Approaches and Challenges to Optimizing and Utilizing Real-Time Support

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In October, the U.S. Secretaries of the VA and DoD signaled their commitment to achieving interoperability between the two agencies by implementing a single, seamlessly integrated EHR, according to a joint statement both agencies issued. VA Secretary Robert Wilkie and Defense Secretary James N. Mattis signed a joint statement Sept. 26 pledging that their two departments will “align their plans, strategies and structures as they roll out a EHR system that will allow VA and DoD to share patient data seamlessly."

However, subcommittee chairman Jim Banks (R-Ind.) noted during the hearing, “Community provider interoperability has always been the elephant in the room. VA-DoD interoperability is very important, but VA is further behind in exchanging records with its community partners. There are helpful tools, such as health information exchanges (HIEs), but no out-of-the-box EHR system completely solves this problem.” Banks added, “Community interoperability is a very real problem, and for $16 billion, VA had better solve it.”

It is estimated that up to a third of VA patients receive care in the private sector.

"I’m not ready to sound the alarm, but I’ve heard very little on the subject [interoperability with DoD and community providers],” Banks said, noting that a review by industry experts indicated that VA and DoD need to be on the same instance of the Cerner EHR in order to achieve seamless interoperability. “That means both departments have to pull patient data from the same database. The two implementations have to be joined at the hip. It raises the stakes. It’s important to put this reality out in the open, and early.”

During her testimony, Laura Kroupa, M.D., acting chief medical officer with the VA’s Office of Electronic Health Record Modernization (OEHRM), noted that interoperability with community healthcare providers was a challenge that VA and Cerner leaders were working together to address.  “Going on the Cerner platform will allow us to utilize national systems in place for interoperability. Our community care councils also look at all the different workflows for how patients get referred into and out of the VA to make sure that information is exchanged and put into the system, not just as a piece of paper or image, but actually the data itself,” she said. Kroupa said project leaders are working to utilize interoperability mechanisms that Cerner currently has as well as HIE initiatives already in place, such as Carequality and CommonWell, to ensure interoperability between VA and the private sector.

John Windom, who leads the VA’s EHR modernization project as the executive director of VA’s OEHRM program, said, “There are two issues—one is technology-based which is solved, the HIEs, CommonWell, Carequality, allow seamless exchange of information. But, there is also another piece, the information has to be put in, and so that information has to be made accessible by the people on those networks; we’ve got the technology piece solved.”

Travis Dalton, president of government services at Cerner, testified that Cerner would use open APIs and FHIR-based integration to enable interoperability between VA and healthcare providers in the private sector.

“We’ve committed to that contractually. It’s going to happen, it’s technically possible and feasible,” Dalton said, adding, “What will be powerful to the industry and commercial partners is if VA and DoD choose a common standard. That will move the industry forward because this isn’t always a technical issue, it’s a standard-based issue. The power of the DoD and VA to make that choice to move it forward will influence the commercial marketplaces. The tools exist, through HIE and Direct exchange; it’s a standards issue.”

Congress created the technology modernization comittee to provide more rigorous oversight of the project amid concerns about the project’s cost and alignment with the defense department’s electronic health record roll-out.

There have been ongoing questions about VA leadership, specifically with regard to the EHR modernization project, beginning with the ouster of the previous VA Secretary, David Shulkin, M.D., earlier this year, as well as other shake-ups, including the resignation of Genevieve Morris only two months after she was tapped to lead the VA’s EHR project.

An investigation by ProPublica, detailed in a report published Nov. 1, asserts that VA’s EHR contract with Cerner has been plagued by multiple roadblocks during the past year, including personnel issues and changing expectations. According to that report, Cerner rated its EHR project with the VA at alert level "yellow trending towards red.” To investigate the underlying factors that have contributed to the EHR project's problems, the publication reviewed internal documents and conducted interviews with current and former VA officials, congressional staff and outside experts.

In parallel, Rep. Banks has expressed concerns with the VA’s “apparent loss of focus” on innovation, specifically as it relates to open APIs. In a letter to acting VA Deputy Secretary James Byrne dated Oct. 10, Banks noted that two years ago the VA initiated an open-API gateway interoperability platform concept, called Lighthouse. Back in March, during the HIMSS Conference, the VA also announced an open API pledge, with the launch of a “beta” version of its Lighthouse Lab, which offers software developers access to tools for creating mobile and web applications to help veterans better manage their care, services and benefits. Banks wrote that these efforts seem to have “lost momentum.”

In the letter, Banks noted that the VA needs a flexible platform to translate data coming in from multiple EHRs and on which to build, and so its private sector partners can build, interfaces to and from medical practice billing systems, insurance companies, external applications, veterans’ devices and one day Medicare and Tricare’s systems. “The need to ‘future-proof’ the technology that VA is acquiring is very real. Moving forward with the open-API gateway and sustaining the open API pledge are important steps to do that,” Banks wrote.

Progress Made in the First 180 Days

During the hearing, Windom outlined the EHRM program’s accomplishments, to date, including the establishment of 18 workflow councils and current state assessments of the initial implementation sites. VA and Cerner project leaders also completed an analysis report to assess the DoD’s MHS Genesis system as EHRM’s baseline. The workflow councils are mostly comprised of clinicians in the field who provide input to enable configuration of national standardized clinical and operational workflows for the VA's Cerner EHR system, Windom said.

Dalton said the site visits of the initial implementation sites provided important insights into VA’s IT needs. “VA has a unique patient population, you’ve got an older, sicker population, with unique needs, such as behavioral health. Some areas that we uncovered that we need to focus on now include telehealth, behavioral health and reporting. These are big content areas,” he said, adding, “I expect the work that we do will help to lead us into the future in that area. We expect that as we work closely together to meet the needs of the agency that will help to makes us better commercially.”

Dalton said the VA Cerner are committed to applying commercial best practices, as well as any lessons learned from our DoD experience, to the VA’s EHRM program.

“We learned some hard lessons with the DoD experience,” he said. “Transformation is always difficult. We’re doing things a lot differently—we’re engaging with sites early and often. We’re also doing more workshops up front, so it’s more of an iterative process.” And, he added, “This is a provider-led process. We have the 18 councils that are assisting us with validation of the workflow.”


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Driving Success at Regional Health: Approaches and Challenges to Optimizing and Utilizing Real-Time Support

Tuesday, December 11, 2018 | 3:00 p.m. ET, 2:00 p.m. CT

Regional Health knew providing leading EHR technology was not the only factor to be considered when looking to achieve successful adoption, clinician and patient satisfaction, and ultimately value from their investment.

Providing their clinicians across two states with real-time support during and after go-live to drive utilization and ensure efficiency with the EHR was important to drive success. In addition, their patients needed support to understand the value of the Epic MyChart patient portal and how to access the system.

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EHR Usability Issues Impact Pediatric Patient Safety, Research Finds

November 13, 2018
by Rajiv Leventhal, Managing Editor
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In an analysis of 9,000 pediatric patient safety reports from three healthcare organizations, researchers found that 36 percent of the reports were related to EHR (electronic health record) usability issues.

The research, published in the November issue of Health Affairs, and led by Raj Ratwani, Ph.D., director of the National Center for Human Factors in Healthcare, Washington, D.C.-based MedStar Health, and others, aimed to further understand the specific issues around why pediatric populations are uniquely vulnerable to the usability and safety challenges of EHRs particularly those related to medication.

To understand specific usability issues and medication errors in the care of children, the researchers analyzed 9,000 patient safety reports, over a five-year span, from three different healthcare institutions—two stand-alone pediatric institutions and one adult and pediatric institution that used Epic and Cerner EHRs (two institutions used Epic, and one used Cerner)—that were likely related to EHR use.

Of the 9,000 reports, 3,243 (36 percent) had a usability issue that contributed to the medication event, and 609 (18.8 percent) of the 3,243 might have resulted in patient harm, the researchers found.

“The general pattern of usability challenges and medication errors were the same across the three sites. The most common usability challenges were associated with system feedback and the visual display. The most common medication error was improper dosing,” the research revealed.

The researchers noted in the study that pediatric patients are uniquely vulnerable to EHR usability and safety challenges because of different physical characteristics, developmental issues, and dependence on parents and other care providers to prevent medical errors. For example, they offered, lower body weight and less developed immune systems make pediatric patients less able to tolerate even small errors in medication dosing or delays in care that could be a result of EHR usability and safety issues.

Although the Office of the National Coordinator for Health Information Technology (ONC) has policies to promote usability—such as requiring system developers to incorporate feedback from clinicians into software design and development and mandating the testing of twelve high-risk EHR functions that are primarily related to medication—the researchers noted that these policies have not made a distinction between adult and pediatric populations. However, the 21st Century Cures Act of 2016 requires ONC to establish new voluntary criteria unique to EHRs used in the care of children.

For this research, the 9,000 reports—3,000 from each site—were reviewed to verify whether the events were related to the EHR and medication; determine whether EHR usability contributed to the event and, if it did, identify what the specific usability challenge was; identify the type of medication error; and identify whether the event reached the patient.

Of the 9,000 patient safety event reports that were collected, 56 percent were confirmed as being related to both the EHR and medication. Of these 64 percent had a usability issue as a contributing factor to the safety event, which amounts to 36 percent of the total 9,000 reports analyzed.

Of the 3,243 reports (36 percent) that had usability as a contributing factor, 19 percent reached the patient. Of these, 33 percent did not cause harm and did not require monitoring, 18 percent required monitoring or an intervention to prevent harm, 3 percent resulted in temporary harm, and the consequence was unknown for 46 percent, the researchers revealed.

One example of a usability issue that caused some harm was when a when a physician ordered five times the recommended dose of a medication without receiving an alert from the EHR, although the prescribed dose was outside the recommended range. Both vendor design and development, as well as implementation and customization, may be contributing to the challenges associated with system feedback, the researchers stated.

“To address this systemic problem, vendors and providers should consider developing more comprehensive design guidelines and use generalizable tools to assess usability and safety. The Leapfrog [computerized provider order entry simulation] tool, which assesses clinical decision support functionality, is one example of the types of tools that could improve the safety of implemented EHR products,” they said.

The researchers concluded, “To better prevent usability-related medical errors, the ONC could include safety as part of the voluntary certification criteria of EHRs for use with children and implement usability-related measures to assess EHR performance. Vendors and providers should use rigorous test-case scenarios based on realistic clinician tasks. Finally, the Joint Commission should assess EHR safety as part of its hospital accreditation program. The implementation of approaches such as these is needed to reduce patient harm related to EHR use.”

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