Early Reaction to the EHR Incentive NPRM

john halamkaCMS Notice of Proposed Rulemaking for EHR Incentive Programs

By John Halamka, MD

Last week, I posted the Notice of Proposed Rulemaking from CMS that offers flexibility to Meaningful Use attestation in 2014.

Since then, I’ve received hundreds of emails about it from my fellow CIOs across the country. Here’s a summary:

  1. To clarify, the NPRM offers flexibility for hospitals to attest to Stage 1 criteria for 2014 from July 1 to September 30. However, it offers no flexibility for 2015 which begins October 1, 2014. This means that hospitals which are struggling with Transition of Care summary exchange, Electronic Medication Admission Records (EMAR), and Patient Portals such that their implementations cannot be ready by July 1, must be fully ready by October 1, since 2015 requires a full year reporting period for attestation. Thus, the NPRM as written really only provides a 90 day delay from July 1 to October 1. It’s too little, too late for hospitals to achieve the business transformation, cultural changes, and workflow redesign needed.The solution – either relax the Transition of Care summary exchange requirements, EMAR requirements, and Patient Portal usage requirements or make the 2015 reporting period any 90 days in 2015 to enable more time for implementation.
  2. Even if a hospital has installed 2014 Edition software and can send Transition of Care summaries, most community-based physicians cannot receive them. Also, few communities have provider directories which enable discovery of Direct addresses to send to those physicians with receiving capabilities. Although the Transition of Care summary exchange requirement of Meaningful Use Stage 2 is a very noble policy goal, it requires an ecosystem of components that is not yet present in the US. The same is true with the transmit component of the patient view/download/transmit capability – there are few places that can receive patient transmissions.The solution – offer a hardship exemption if the hospital or physician office can send Transition of Care summaries, but there is no one to receive them or community provider directory infrastructure is lacking.
  3. Using Stage 1 criteria is helpful in that the Transition of Care summary exchange, EMAR, and Patient Portal criteria are relaxed, but does it require the use of Stage 1 Clinical Quality Measures? 2014 Edition software (or third party services providing quality measure computation) no longer support Stage 1 quality measures, so it is unlikely that Stage 1 quality measures can be submitted.The solution – Stage 1 attestation with 2014 Edition software should allow 2014 quality measures.

Note: My colleagues at CMS have clarified this issue. “In the EHR Incentive Program, pre and post this NPRM, the clinical quality measures are not linked to the Stage of MU but to the year (CY or FY). All participants using 2014 CEHRT, are reporting 2014 quality measures. It is ONLY if they use the 2011 CEHRT that they need to report the old CQMs. In other words, CQMs are already tied to the year of CEHRT in use, not to the stage of MU and that would not change under the proposal in the NPRM. ”

The NPRM is a good first step. It needs to be further revised to shorten the reporting period for 2015, enable the evolution of community infrastructure for Transition of Care summary exchange, and recognize that historical quality measures can no longer be computed.

One editorial comment – at some point we need to recognize that layering fixes on top of existing Meaningful Use regulation, some of which was written by CMS and some of which was written by ONC creates too much complexity. I have direct access to the authors of the regulations and email them on a daily basis. It’s getting to the point that even the authors cannot answer questions about the regulations because there are too many layers. I realize that we are reaching the end of the stimulus dollars, but as we head into Stage 3, I wonder if we can radically simplify the program, focusing on a few key policy goals such as interoperability, eliminating most of the existing certification requirements, and giving very clear direction to hospitals and professionals as to what must be done when.

If I were king for a day, I would consolidate the Meaningful Use program into the “Merit-based Incentive Payment System” as I wrote about in this post, offering incentives for those who achieve stretch goals, without penalties for those who do not. In my mind, Meaningful Use has achieved its goals of accelerating EHR adoption and fundamentally changing attitudes about the need for healthcare automation. At this point, we should learn from the challenges to achieve Meaningful Use Stage 2, provide a short term fix (revised as above), and then use Meaningful Use Stage 3 as an opportunity to simplify the program.

John D. Halamka, MD, MS, is Chief Information Officer of Beth Israel Deaconess Medical Center, Chairman of the New England Healthcare Exchange Network (NEHEN), Co-Chair of the HIT Standards Committee, a full Professor at Harvard Medical School, and a practicing Emergency Physician. This article was originally published in his blog Life as a Healthcare CIO and is reprinted here with permission.