The Open Secret of Health IT – The Emperor Has No Clothes

Jim TateBy Jim Tate, EMR Advocate
Meaningful Use Audit Expert
Twitter: @JimTate, eMail:

You can tell a lot about a person by asking them what their favorite fairy tale was when they were a child. Was it The Frog Prince, Little Red Riding Hood, or maybe Sleeping Beauty? For me it was The Emperor’s New Clothes. I love the part at the end when a child cries out, “But he isn’t wearing anything at all.” Sometimes we don’t need the eyes of a child to tell us what is obvious. It is the elephant in the room that everyone sees but doesn’t mention. It is the Open Secret that everyone knows but strives to avoid.

CEHRT and Interoperability
Let me get right to the point. Everybody claims they support interoperability in health care data. The bandwagon is loaded with vendors, patient advocates, policy wonks, and government employees. You will not find anyone opposed to the benefits of data exchange. Over 35 billion dollars has been paid out to Eligible Providers and Eligible Professionals since 2011 through the CMS EHR Incentive Programs. Most of that money ended up in the pockets of large EHR vendors. The goal was to promote the meaningful use of certified electronic health records technology. CMS stated: “it is hoped that the meaningful use compliance will result in: better clinical outcomes; improved population health outcomes; increased transparency and efficiency; empowered individuals; and, more robust research data on health systems”.

Interoperability defined
The IEEE Standard Computer Dictionary defines interoperability as “the ability of two or more systems or components to exchange information and to use the information that has been exchanged.” Even I can understand that. It makes perfect sense for one EHR to be able to exchange information with another EHR or Health Information Exchange. 35 billion dollars has bought a conglomeration of systems that can sometimes do that if the wind is blowing just right. Even though it is moving at glacial speed, at least we can agree that progress on this type of interoperability is being made.

Where it falls apart
There is one critical area of interoperability that has been swept in the corner and ignored. For years, Clinical Quality Measure (CQM) reporting has been the Next Big Thing. It was going to bring analytics to health care and support better outcomes. What percent of patients receiving medication for hypertension can maintain acceptable blood pressures readings? What percent of patients over the age of 65 received their flu shot? Get the picture? You can’t imagine the number of existing CQMs and how many more are just over the horizon. CQMs are a big deal and we need them to be accurate, or everything falls apart. You would think with a “meaningful use certified EHR” it would be easy to gather, export, and use that data to meet the CMS goal of: “better clinical outcomes” and “improved population health outcomes.” Well, if you think that, you are wrong. The MACRA/MIPS Part B reimbursement scheme is heavily weighted to scoring well on CQMs. It is critical to retrieve accurate and timely data from an EHR to make strategic decisions that can improve CQM scores. If you can’t get the data, you are flying blind. Right now, almost everyone is, and that is the OPEN SECRET.

What is QRDA?
First, let me apologize. I must get a little dry and technical to make my point. The primary method to extract CQM data from an EHR is through the standardized Quality Reporting Document Architecture (QRDA). A QRDA Category I file contains data on an individual patient and a QRDA Category III file contains data on all of a provider’s patients. Both of these files were required to be generated during ONC 2014 Edition testing for certification of CQMs and are also required for 2015 Edition testing (Technical outcome – A user can create a data file for transmission of CQM data in QRDA Category I and Category III). Any certification from 2014 or 2015 Edition for CQMs demonstrated the ability to generate QRDA-I and QRDA-III files. The testing and certification process proved the functionality was present and the taxpayers shelled out 35 billion dollars for it. So where is it and why is it so hard to get that critical data out of existing systems?

Ask for QRDAs
I suggest that CMS, ONC, and all providers ask EHR vendors: How can QRDA-I and QRDA-III files be generated out of your system? Don’t accept responses like; It will take a special work order, or It will take 90 days, or What is a QRDA? The entire shift from pay for performance to pay for value is dependent on getting this data out of these systems. Repeat after me – We want our QRDAs!

I smell peanuts. I’m hoping you do too.

Jim Tate is known as the most experienced authority on the CMS Meaningful Use (MU) audit and appeal process. His unique combination of skills has brought successful outcomes to hospitals at risk of having their CMS EHR incentives recouped. He led the first appeal challenge in the nation for a client hospital that had received a negative audit determination. That appeal was decided in favor of the hospital. He has also been successful in leading the effort to reverse a failed appeal, even after the hospital had received notification of the failure with the statement, “This decision is final and not subject to further appeal”. That “final” decision was reversed in less than a week. If you are a hospital with questions or concerns about the meaningful use audit process, contact him at: This article was originally published on My Mips Score and is republished here with permission.