A Stage 2 MU Sound Off
By Ken Congdon, editor in chief, Health IT Outcomes
The open commenting period for CMS’ proposed rules for Stage 2 Meaningful Use closed on May 7, and a torrent of healthcare organizations and associations made their voices heard by offering their recommendations on how to improve upon the criteria. Most commenters express support for continued EHR adoption, but suggest particular modifications be made to the Stage 2 rules to make Meaningful Use more attainable for the majority of the healthcare industry.
For example, HIMSS (Health Information Management Systems Society) asked for timeline adjustments, suggesting a 90- to 180-day reporting period for Year 1 of Stage 2 in 2014. This would maximize the amount of time all eligible professionals (EPs), eligible hospitals (EHs), critical access hospitals (CAHs), and vendors have to prepare for Stage 2 Meaningful Use. AHIMA (American Health Information Management Association), on the other hand, called for a more consistent interoperability format nationwide and stressed the need for consensus-based quality measurement reporting.
Of all the formal comments submitted to CMS, I probably reviewed those issued by the AMA (American Medical Association) and AHA (American Hospital Association) with the most interest. This was due not only to the content contained in each one of these letters, but also because each of these associations represent the two most important stakeholders in determining EHR adoption and success — hospitals and physicians.
Physicians Question Interoperability Requirements
Let’s look first at the comments submitted by the AMA. For the most part, the AMA feels the current Stage 2 proposal includes too many criteria that are outside of a physician’s control, making it difficult for many doctors to successfully participate in the EHR program. The AMA sites physicians’ limited ability to exchange data with other healthcare partners due to a lack of affordable system interfaces as a key barrier to meeting many of the proposed Stage 2 criteria (e.g. incorporation of clinical lab test results, patient’s electronic access to health information, data submission to registries, etc.). As a result, the AMA asks that CMS delete the high thresholds associated with these measures.
Moreover, the AMA feels Stage 2 requirements need to provide more flexibility to foster widespread EHR adoption. In the AMA-issued press release on its Stage 2 comments, AMA Board Chair-elect Steven J. Stack, M.D. was quoted saying, “Physicians are at varying stages of implementing health IT into their practices and should get credit for making a good faith effort to meet the Meaningful Use requirements.”
The AMA’s stance is valid. Data exchange is in its infancy, and I can appreciate how difficult this aspect of Meaningful Use will be for physician’s practices. However, is eliminating the thresholds associated with data exchange really the answer? I don’t think so. Meaningful Use is designed to motivate the industry toward effective utilization of EHR technology. A big component of that ultimate outcome is the secure electronic exchange of patient data with external partners. Maybe CMS is setting the bar too high with its proposed rules, making it difficult for most stakeholders to realistically meet the objective. However, I’d argue that the AMA’s recommendation sets the bar too low. Without some impetus to drive progress in the area of data exchange, most physician practices will likely be content to make no strides in this area and our industry will move no closer to its common goal.
I also question the AMA’s definition of “flexible.” Obviously, Meaningful Use should be designed to foster widespread EHR adoption and use, but I don’t think we should reward “good faith efforts” with incentive dollars. Remember, there is real money being paid out here (more than $5 billion in incentive payments have been awarded since the program launched). This money should only be issued to those that can demonstrate that they’ve achieved the desired outcome, not those that gave it their best try and came up short. That would have been like giving someone the $8,000 first-time homebuyer credit if they didn’t purchase a house within the allotted timeframe, but could demonstrate that they tried to. That’s not the way stimulus payments work. If the current thresholds are unachievable, then the aim should be to make them more achievable, but incentives shouldn’t be awarded for trying. That being said, I am in favor of not penalizing physicians for a designated time period if they can demonstrate good faith efforts.
Is Meaningful Use Perpetuating The Digital Divide?
Let’s move on to the AHA’s Stage 2 comments, which have been met with scrutiny by much of the healthcare industry in recent days. I feel the AHA makes several good points in its comment letter. For example, like the AMA, the AHA believes CMS sets the bar too high with its proposed Stage 2 requirements. The AHA points out that the vast majority of hospitals (more than 80%) still haven’t met Stage 1 Meaningful Use due to the level of difficulty associated with the current requirements and the costs associated with implementing the required technology systems. The AHA also argues that the digital divide is widening as a result of Meaningful Use — with large urban hospitals reaching much higher rates of adoption than smaller rural facilities. AHA officials stress concern that the proposed Stage 2 rules could put regulatory requirements ahead of actual technology experience, which could produce several unintended negative consequences.
I echo the concerns of the AHA in this regard and feel CMS must walk a fine line to ensure Stage 2 Meaningful Use requirements are convincing enough to drive continued adoption, but not so strict that they compel healthcare facilities to hastily implement new technologies before they are ready for them from an organizational perspective. I feel the one-year delay in the start of Stage 2 already issued by CMS, and the 90- to 180-reporting periods recommended by the AHA, HIMSS and others are positive steps in this direction. My only argument with the above-mentioned AHA comments concerns the origin of the “digital divide” between urban and rural hospitals. I don’t believe Meaningful Use is perpetuating this trend. To the contrary, I feel Meaningful Use will help to narrow this divide in the coming years. I would argue that many urban hospitals were on the path to Meaningful Use long before the Stage 1 requirements were announced. Many had already invested and were using EHR technologies and didn’t have as far to go to successfully attest and receive incentive payments as rural hospitals that (for the most part) were much further behind in their EHR implementation strategies. Meaningful Use incentives should serve to motivate rural hospitals to begin investing and implementing these technologies now, which should help to close the divide.
Patient Engagement Key To Future Of Healthcare
Like most, my biggest point of contention with the AHA’s Stage 2 comments revolve around its stated position in regards to patient access to online health information. In its proposed Stage 2 rules, CMS provides incentives for hospitals that provide patients with the ability to view online, download, and transmit information about hospital admission. CMS would also require the information to be available within 36 hours of discharge and that 10% of all discharged patients view, download, or transmit their information to a third party during the reporting period for Meaningful Use. The AHA argues that this objective is counter to HIPAA privacy and security rules and recommends the objective be removed for two reasons: 1) CMS does not have regulatory authority over patient’ access to their health records; and 2) the objective is not feasible as specified.
The AHA has been widely criticized (and rightly so) for its stance against patient engagement. Many argue that the AHA’s position on this matter is based on cost avoidance and resistance to change rather than patient interests. However, I believe there’s more to it than that. Could it be that many hospitals view patient engagement as a threat to their business? Think about it. Currently, hospitals and physicians pretty much own and control patient data. Once patients are provided with open access to that information, it becomes much easier for a patient to take that data and shop around for alternate opinions, different treatment options, more competitive rates, higher-rated medical facilities, etc.
Furthermore, to put it bluntly, a more informed patient can sometimes be a pain in the neck for a physician or hospital. Just ask my wife’s OBGYN. When my wife was pregnant with our first child, she took to the Internet to gather as much information as she could on her pregnancy. She collected a ton of great data, but also got some misinformation. All this data filled her head with questions and led her to believe that some of the details of her pregnancy were symptomatic of problems. Many of our OBGYN appointments went a lot longer than expected because the physician needed to address many of my wife’s questions (some warranted and some unwarranted) about her health and the health of our child.
In an industry where revenue is largely based on the number of patients that can be evaluated or treated in a given day, I can see how a large number of these extended patient interactions could slow down the healthcare machine. However, a higher-level of physician/patient engagement is just what the industry needs. A patient empowered with his or her own health data is going to take a more active interest in their health. They will follow their treatment schedules more rigorously and take preventative measures to improve their overall wellness. These two outcomes should lead to fewer doctor’s visits and hospital stays which should help lower healthcare costs overall. While the AHA may not find it appealing from a business perspective, patient engagement is a crucial component to fixing our healthcare system.