William A. Hyman
Professor Emeritus, Biomedical Engineering
Texas A&M University, w-hyman@tamu.edu
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I think it is fair to say that EHRs, as we currently know them, are largely hated by their users, although no doubt beloved by their vendors. This might have been the expected result given that the adoption of EHRs was mandated by law and by CMS, and EHRs were then rolled out that were, and still are, often ill-suited to the actual practice of medicine. Of course, it was not just the EHR itself that plagued users but also its cousin, Meaningful Use. Here it should be remembered that Meaningful Use requires demonstrated compliance with specific use measures that may or may not have anything to do with actually improving real-world patient care. In this regard Meaningful Use did not necessarily correspond with using meaningfully. CMS itself notes, in the proposed rule discussed further below, that “We have received feedback from hospitals and hospital associations that the current meaningful use requirements are not always meaningful to them and detract from their ability to provide care to their patients”. In this context “feedback” may well have included somewhat harsh language.
Meaningful Use has already been rolled into MACRA and MIPS and VPRM and PQRS and eCQMs and QNet, because these things reduce the burden. These multiple initiatives and reporting schemes are described as having the goal of “Ultimately” resulting in “Better clinical outcomes, Improved population health outcomes, Increased transparency and efficiency, Empowered individuals, and More robust research data on health systems”. Here “ultimately” is a great word choice because it is very aspirational and has no time line. Moreover, these alleged benefits are not likely to receive systematic measurement, in part because there is no “before” data so even if “after” was measured in some way, there would be nothing to compare it to.
With there being little enthusiasm for where we have been and where we are now, CMS has introduced another name change. Henceforth the EHR incentive programs will be known as “Promoting Interoperability (PI)”. Under PI CMS intends to “empower patients through better access to hospital price information, improve patients’ access to their electronic health records, and make it easier for providers to spend time with their patients.” The proposed rule implementing this change is 1883 pages with the catchy title “Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Proposed Policy Changes and Fiscal Year 2019 Rates; Proposed Quality Reporting Requirements for Specific Providers; Proposed Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs (Promoting Interoperability Programs) Requirements for Eligible Hospitals, Critical Access Hospitals, and Eligible Professionals; Medicare Cost Reporting Requirements; and Physician Certification and Recertification of Claims”. The 1883 pages does not include certain tables available elsewhere. In addition, since this is a proposed rule there will ultimately be a final rule of more-or-less equal page length. This sounds like burden reduction already.
In some ways these kinds of changes remind me of the incomprehensible financial reports I used to get on my academic research accounts. But one day I got a report that was clear, it had all zeros because the account was closed. I mentioned to the CFO that I finally got a report I could understand. Before I could even explain why I understood it, he responded “Then it’s time to change them.”
Admittedly this proposed rule isn’t all PI, which is mentioned only 134 times. The parts that are PI focus on the reporting of Clinical Quality Measures (CQM), in part proposing a reduction in measures and/or thresholds, and in part adding new ones. CMS assures us that even if they drop a reporting element, the provider can continue to use it internally. In addition, there will be a PI numerical score calculated which will be interpreted as determining Meaningful Use. This score will be based on additive scoring of e-Prescribing, Health Information Exchange, Provider to Patient Exchange, and Public Health and Clinical Data Exchange, with several sub-elements in each, all of which will be subject to varying weights, which may be different from the weights previously used. By way of example, “A performance rate of 80 percent for the e-Prescribing measure would equate to a measure score of 8 points (performance rate * total possible measure points = points awarded toward the total PI score; 80 percent*10= 8 points).” It should also be noted that some possibly familiar objectives will get new names. For example, “Send a Summary of Care” will be renamed “Support Electronic Referral Loops by Sending Health Information”.
This kind of scoring includes the unstated effect that these categories can trade-off against each other such that if are good at a few its ok to be poor at the others. And overall you only need 50 points out of a 100 to be meaningful. The proposal already anticipates year-to-year changes, with the 2019 and 2020 scoring themes being different. But be assured CMS believes that “with this new proposed approach we are reducing administrative burden … allowing health care providers to focus more on their patients.”
Do you see the simplifications and potential impact yet?