Web Site: http://www.allscripts.com
Bio: Leigh Burchell directs the Policy & Government Affairs function for Allscripts, including legislative advocacy and regulatory interpretation and comment. She advocates not only for the interests of the software development community but also the company's 180,000 physician clients, 2,500 hospitals and 17,000 post-acute organizations. Burchell is also active in many industry associations, including the Electronic Health Record Association (EHRA), where she serves as Chair; the eHealth Initiative, where she sits on the Leadership Council and the Policy Steering Committee; and HIMSS, where she is Vice Chair of the HIMSS Public Policy Committee.
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- How do we choose quality measures that will fairly reimburse providers in all care environments and specialties, while also reflecting new medical discoveries?
- How do we measure the value of work done by a team of providers caring for a patient in this new world of health information exchange?
- How will we – providers, technology developers and experts from the National Quality Forum (NQF) and the Agency for Health Research and Quality (AHRQ) – develop, test and implement what will likely be thousands of new measures?
Two years ago this month, I underwent a mastectomy at the age of 40. It’s ironic given that October is breast cancer awareness month, because for me, while cancer is always now semi-present in my mind, September is the month when the disease looms largest. That’s because it’s September when I go through the cadre of tests that are now a part of my annual experience, and it isn’t until those are in the rear view mirror with an “all clear” that I can breathe again.
I’ve worked in health IT for more than fifteen years, and thankfully, our family hadn’t had much of an encounter with intensive health care before 2013, which meant that technology’s role there was conceptual to me personally. Yes, I went to an OB practice that refused for nine years to go electronic, and it was annoying when my son’s surgical record couldn’t be shared with his pediatrician in 2008. Luckily, though, health has largely been our norm.
Recently, though, health IT has been personalized for me in an entirely different way, and I understand it from a new perspective. Thankfully, unlike many people who speak about the challenges they’re still encountering, my experience has largely been positive since becoming a breast cancer patient.
First and most importantly, unlike many others who face a harder path, my cancer treatment experience did not include chemotherapy or radiation. If I had been diagnosed several decades ago, that would not have been the case – the standard protocol for everyone was a double mastectomy, removal of all armpit lymph nodes, radiation and chemo. Because I was fortunate enough to be diagnosed in 2013, however, I have already benefited from the precision medicine experience.
That sneaky little tumor that caused so much upheaval for me and my family was sliced and diced for genomic testing (I do admit I get a little pleasure from that image), with the results dropped right into my electronic health record. The analysis of the tumor’s genetic markers came back in such a positive frame that my doctor was able to recommend surgery followed only by hormonal treatment. That was a really good day.
Now, in surveillance mode, I continue to think how lucky I am to be a patient in the electronic era. I connect with my care team via their new portal pretty easily, and my oncologist uses her system to pull up all kinds of research findings to facilitate our ongoing discussions about the best path forward.
My most recent intersection with health IT was just last week. I logged in late at night to find results from my recent mammogram and MRI saying I am cleared for another six months. Unlike even two years ago when I had to wait, sick with worry, for several weeks for some of my results, I was able to return to peace of mind in just four days because of electronic access to those results. I requested they be sent to my primary care provider, and more importantly, I could remove the worry from my husband and children who know what September means, too. And I went back to sleeping well.
You can imagine that I am hoping not to have any acute need for health IT any time in the near future. But if we do, I am most certainly grateful to have that option.
Nine years ago, when I started developing a government relations function at Allscripts, it was a different world. No HITECH, no CMMI, no significant government attention on health IT at all, really. To set my agenda, I learned from our clients what mattered most to them.
The number one answer I consistently heard? The repeal of the Sustainable Growth Rate (SGR), which has been the means by which the CMS has had to calculate payments to physicians since 1997. It was universally – by providers and policy makers alike – reviled.
In the years since, the number of healthcare IT topics in D.C. has grown exponentially, along with the associated level of interest by legislators and regulators alike. We’ve discussed the complexities and opportunities of interoperability, debated the challenges of building a trusted patient safety structure, explained the difference between population health and public health, and more and more frequently, reviewed what quality measurement really means in health care.
But the one topic that has been our steady companion – the question raised at the end of every meeting – was “What could we do to put the SGR in the rear view mirror?” We’ve advocated to repeal the SGR for years.
More recently, even as our contacts on Capitol Hill became more confident and started to point to possible action on this in recent months, I was skeptical. We had collectively been in this optimistic place many times before, and it just seemed too good to be true.
But on April 14, 2015, the U.S. Congress finally approved legislation to repeal the SGR. After almost 20 years of patching and extending and duct taping this legislation to avoid massive cuts in reimbursements for providers in the 45,000 physician practices across the country that we serve, they had done it.
So what does repealing the SGR mean?
Repealing the SGR goes beyond the Meaningful Use program, beyond the Innovation Center pilots and Accountable Care Organization (ACO) programs. It is arguably the most important thing that Congress will have done at any point in recent years to move us down the path to a healthcare payment system driven by quality and outcomes improvement.
It’s not prescriptive about technology like the Meaningful Use program, and it doesn’t really push innovation limits in payment model theory. Rather, this action will raise the volume on value-driven payment models because it is about the fundamental fees going to Medicare providers.
There aren’t classes of providers left out in the same way here; it isn’t about piloting starting with a few thousand doctors either. Instead, the legislation introduced merit-based incentive payment system (MIPS – an acronym everyone will soon be familiar with), which will lead to quality measures for almost all ambulatory providers. When you couple this change with advanced payment model adoption by both public and private sector payers, we are at a real turning point toward the data-informed, quality-driven, precise healthcare system we have been working toward for years.
Undoubtedly, the implementation of this effort is going to be monumental. There will be bumps in the road, as well as tremendously challenging work for all of us together. But ultimately, as even more providers adopt advanced health information technology and as we gather more information about which care delivers the strongest outcomes, there will be a clear beneficiary that we all care about: the patient. That feels really good.
So now, there’s just one question remaining: what is the next big healthcare IT priority for Congress? I have some ideas, but please share your thoughts in the comments below.
Medicare’s current state is not sustainable, and we must address it to help revive the larger U.S. fiscal environment. The good news is that we have an unusual opportunity to act at a lower price to the nation since the Congressional Budget Office recently announced the “bargain price” of only $138 billion to repeal the Sustainable Growth Rate. This has certainly spurred a lot of activity on Capitol Hill related to Medicare reform – three hearings last week alone.
Healthcare policies are stuck in the past
Almost one in three Medicare beneficiaries today is covered by a fee-for-service (FFS) plan that has not changed since the late 1950s – the days when beehive hairdos were all the rage and people couldn’t get enough TV dinners.
Another vestige that has not kept pace with healthcare today? The Sustainable Growth Rate (SGR), which was part of the Balanced Budget Act in 1997, woefully underestimated the rate at which healthcare costs would increase. Since then, Congress has had to repeatedly – sometimes more than once in a year – “patch” the SGR with legislation to avoid massive cuts in physician reimbursements. But no one has tried to permanently fix this problem.
The SGR’s ambiguity has wreaked havoc among Allscripts’ physician clients. Many clients want to apply the latest health IT solutions to optimize care and comply with Affordable Care Act payment reforms, but they are hesitant to adopt new solutions without certainty about their income from the Medicare program.
Now, many in Congress are proposing solutions, and a common refrain is “pay for quality.” Before we can shift Medicare to sustainability and replace the SGR with something that reflects healthcare delivery in this century, however, Congress must address some big questions.
What does “quality care” mean?
It is clear that not all healthcare stakeholders agree on what quality is. But if we are going to pay providers based on outcomes, we’ll need a standard set of quality measures.
The new quality measures must be standards-based and consistent across programs from CMS, state Medicaid agencies and private payers, which will make it easier to aggregate data and holistically evaluate care in this country.
And how much quality can we afford?
This re-engineering isn’t just about increasing quality or containing costs. It’s about finding value. In redirecting the cost curve for healthcare in this country, we must recognize that not every outcome is worth the expense.
For example, what if doctors could prevent all colds, but it would cost $1 million to treat each patient? Is that worth it? Maybe a FACA that would act transparently and operate by consensus, similar to the Health IT Policy and Standards Committees, could tackle this one…
Congress, it’s time to permanently repeal the SGR and replace it with a new payment and delivery paradigm that rewards good healthcare value. It’s time to stress quality over volume and develop a model for the private insurance industry, too. And it’s time to reward providers for improving the health of America’s seniors, the disabled and those with chronic issues, while reducing federal spending on unnecessary and uncoordinated care.
And remember, it’s a bargain right now at $138 billion!
A recent RAND study featured in the January issue of Health Affairs suggests that we are slow to achieve the cost-savings promise of health information technology. Authors suggest this is because the systems are not used widely enough, interconnected or fully embraced by the physicians who use them.
It’s true that U.S. healthcare hasn’t achieved the savings predicted by groups like RAND themselves (whose models were over-aggressive and questioned at the time by experts in the Congressional Budget Office). But the recent study still concluded that adoption presents the potential to save more than $80 billion annually.
Unfortunately, like the first RAND study published in 2005, this one takes the complex issues challenging healthcare providers, software developers and regulators alike and boils them down to simplistic analysis that ignores the size of the change we are collectively affecting here.
Big changes take time
Did you know that blood-letting persisted into the 20th century as a common medical treatment despite the fact that doctors were questioning the basics of the practice as far back as the early 1600s? In fact, George Washington died after being bled in response to a persistent sore throat! And yet, physicians promoted the practice of blood-letting to treat everything from acne to diabetes to migraines for centuries because the fact is, bad habits are hard to break. Sound like any bad habits that a few of today’s providers might be stuck on? Such as using paper records?
Authors of the RAND study indicate that adoption rates have been slow. While rates are uneven across segments of the market, with rural environments and small independent physician practices moving more slowly than others for varying reasons, overall adoption has actually risen at incredible rates since the passage of the HITECH Act. According to the CDC’s December 2012 report, 71.8% of ambulatory physicians used EMR/EHR (electronic medical record/electronic health record) systems in 2012, up from 48% in 2009.
The kind of change we’re talking about is significant. It involves noteworthy product changes by the vendor community. It also requires comprehensive adjustments on the part of the providers involved – in how they use the software, interact with their patients and report on their behavior. But again, moving from 48% adoption to 72% in just three years simply cannot be described as slow.
Reengineering care takes time, too
Even after a provider has moved forward with EHR adoption, there are some who cling to their old paper-based processes and don’t embrace the full potential of their EHR or get the training they need after they’ve implemented one. I understand that – change can be hard for anyone. This is, however, a real challenge for the industry. Working to change that behavior is important, too.
Primary care physicians who receive more technical assistance when using EHRs are more likely to achieve care quality improvements than physicians who receive little or no technical assistance (see Weill Cornell Medical College news). Those providers who try to take their paper process and simply drop that into an electronic workflow are going to find themselves frustrated and falling short of care improvement goals.
That said, most of our clients recognize that the new technology, while at first disruptive, ultimately helps them provide indisputably better care once they are proficient. Examples of people who appreciate the change outpace those who reject it (see videos from our recent client conference).
For example, physicians at the 972-bed Bronx-Lebanon Hospital Center in New York City used technology to reduce their patients’ average lengths of stay (ALOS). In an interview with Healthcare Informatics, the hospital credits technology with helping to achieve a 1.8 day reduction in length of stay in just five months. That’s not only good for patients but good for the nation’s pocketbook.
Lack of prolific data exchange
Most agree that much of the healthcare cost savings that can be facilitated through health IT adoption will come from information exchange between providers, and that we need to see more of it.
Authors of the RAND study suggest that interoperability can be achieved with better IT systems. Unquestionably, EHR systems must store data in such a way as to be easily retrievable and transmittable, and the Stage 2 requirements around transport mechanisms will advance the collective industry in only a matter of months.
However, even where our clients want to exchange information (and we have many doing it already), several systemic obstacles still exist.
- The fundamental reimbursement models in our country don’t currently encourage providers to cooperate with others in their area because they’re paid based on volume, rather than collaborating to improve patient care. Thankfully, we are making good progress towards new payment schema that focus on the quality of care, rather than only on the quantity of patients.
- State-level legislation and regulations around privacy and security are inconsistent and many times, in direct conflict with one another. In most cases, patient information doesn’t flow across state lines even when patients do.
- Patient identification remains a valid concern among clinicians. While the idea of a National Patient ID remains a political third rail, there are secure alternatives with significant industry backing, such as patient matching technologies. It shouldn’t be surprising that physicians want to feel secure that the data they are attributing to John Jones actually belongs to that John Jones.
- And most importantly, we do not have the infrastructure we need to exchange information easily and cost-effectively despite the fact that hundreds of millions of dollars have flowed to the states to build that pipeline for data – several years in, Health Information Exchange (HIE) is just getting started with any real momentum, and it will take continued support by the states, regions and municipalities – even as ONC funding runs out soon – before we can make even better progress.
In the end, let’s remember: It’s only been two years since the Meaningful Use program began paying incentives. That’s a blip on the screen of medicine and healthcare. Drastic and disruptive changes take time. And it’s worth the wait.
What do you think about the RAND study featured in Health Affairs? Do you agree or disagree?
The Health IT industry is abuzz with a recent Wall Street Journal op-ed by Professor Stephen Soumerai of Harvard Medical School and Professor Ross Koppel of the University of Pennsylvania. The opinion piece, “A Major Glitch for Digitized Health Care Records” (subscription required), transforms a timid literature review on the value of information technology for medication management into the final word on IT’s ability to deliver savings in healthcare.
The authors not only make sweeping pronouncements about the much-discussed ability of Electronic Health Records (EHR) to contain costs but go on to make equally questionable claims such as that the Meaningful Use program will cost $1 trillion – a figure they attribute to “installation, training and maintenance costs.” They also contend that the effort to share patient records between organizations has already been proven a failure, even as the industry is gearing up to meet the Stage 2 requirements of the Meaningful Use EHR Incentive Program.
Given that Soumerai and Koppel have published numerous papers and articles questioning everything from the functionality to the safety and efficiency of EHRs (as Health Data Management’s Joe Godert points out), it’s enough to make you wonder whether their attack on the Meaningful Use program is motivated by more than academic interest. Really, they seem to have a bit of an axe to grind, judging not only by the WSJ piece but also their heated response to a recent New England Journal of Medicine study that found EHRs improved diabetes care (Soumerai and Koppel’s critique was refuted by the study’s authors).
In a response to the WSJ op-ed, Ashish Jha, M.D., Professor of Health Policy and Management at the Harvard School of Public Health, argues that the study at the heart of the op-ed simply asked the wrong questions and wasn’t framed appropriately. I agree.
There are four factors that I think are critical to understanding this issue:
- Fundamental payment and delivery system reforms are needed to motivate physicians to worry about the cost of care. In today’s fee-for-service system, more care equals more dollars to their bottom line, and the use of an EHR in and of itself certainly isn’t going to fix this inherent flaw in our healthcare system. In fact, my own physician told me earlier this week in the middle of a combined exam and discussion of health policy (the hazards of having me for a patient) that she explicitly tries not to think about or even be aware of the cost of the care she’s delivering because she doesn’t want that to influence her decision. She meant it in a positive way – that she didn’t want to hold back on care just because of the cost – but it could also be seen as a negative because it means she isn’t mindful of unnecessary costs, either. In any case, I’d like to imagine that Professors Soumerai, Koppel and their academic brethren would see the value in devoting their talents to aiding the much-needed transformation of the U.S. healthcare system so that healthcare providers are motivated by both quality and cost.
- While demonstrate the benefits of EHR, it’s clear that the promised cost-savings cannot be fully achieved until data exchange and care coordination are mature enough to enable providers to reduce duplicate tests and other sources of waste. Unfortunately, the infrastructure for that information exchange is not yet in place on a wide scale, nor is the Direct Project widely utilized. Not to mention the challenges with governance that are obstructing information exchange even where the functionality exists in a given community.
- Relative to interoperability, the vendor community has been requesting clearer, more stringent information exchange standards for literally years. For proof, just read our public comments submitted on pretty much any regulation. We have consistently requested standards so that the work of building an interoperable, connected community of health can be completed and patient data can begin to flow.
- Most importantly, the vast majority of data the study’s authors reviewed were pre-Meaningful Use. I can’t really imagine why anyone assessing the value or efficacy of EHRs would look back to 1972 because the reality is that the health information technology industry today is hardly recognizable from the one that existed even one decade ago, much less 40 years. It’s almost like gauging the success of the Internet or its value to untold constituencies based on an evaluation of ARPANET or the state of TCP/IP in 1988.
Now, I know there are people out there who will discount what I say here because I work for a software vendor. So, I’ll let someone with credentials more impressive than mine – Dr. Jha at Harvard – close it out.
Dr. Jha suggests that the right question to ask at this stage in the dissemination of EHRs is not “Do EHRs save money,” but rather “How do we ensure that EHRs help improve quality and reduce healthcare costs?”
He goes on to write: “Now that we have made an important investment in EHRs, we need to figure out how to use this new technology to address the fact that the healthcare system is a mess. We need to figure out how EHRs can promote coordination of care across sites, seamless flow of good clinical information, and smart analytics, to name a few things. We simply can’t do that in a paper-based world. . . . The debate over whether we should have EHRs is over.”
I breathed a sigh of relief when CMS and ONC at last released the final rules on the second stage of the Meaningful Use EHR Incentive Program late last week. It had gotten to the point where people were asking me almost hourly if I had any idea when we’d have them. The rumor mill was in full swing … what was in and what was out?
And when we all finally got our hands on it, what was the first thing I looked for in the CMS rule?
You may recall that the program originally called for participants to report on 12 months of Meaningful Use activity to qualify for Stage 2 incentive payments. The problem, though, was that even with the proposed delay of the start of Stage 2 by one year, the length of time it was taking CMS and ONC to release the rules compressed the interval left for vendors and providers to execute. Requiring 12 months of reporting for 2014 was no longer plausible.
Why was this an issue? Most policy wonk-types don’t realize that it takes anywhere from six to 12 months for software vendors to develop, sufficiently test, and certify the software. And more importantly, it takes anywhere from three to 12 additional months for organizations to implement, test again and then train their providers to use it safely to a point where they can be successful “meaningful users.” Given all the time being eaten up by the regulatory development process over the last year, it was really a make-or-break issue, and we said so to anyone who’d listen.
Fortunately for providers, CMS took heed. We applaud CMS for reducing the reporting period for program participants in 2014 from 12 months to 90 days (the same reporting period required for Stage 1). The revised requirement gives providers flexibility when they implement their 2014 software edition, and in the meantime, they can focus on expanding their Stage 1 successes.
Hear, hear CMS!
One note of caution, though. Neither the quality measure specifications nor the test scripts that EHR providers need to move ahead with development are available, so the rules we have in hand aren’t exactly the “final package” needed for us to do the work to get our products ready. These detailed specifications are critical to our product development process, and while CMS halved the number of clinical quality measures for Stage 2 from what they’d proposed, we still estimate that complying with the rules will require thousands of hours of development work. And that doesn’t even address the certification test scripts…
Bottom line: Thank you to CMS and ONC for releasing the official rules, but please, keep it coming! None of us are done yet!
Do you think CMS did a fair job of handling the provider reporting period? Do you have other concerns about Stage 2? Register for our live webcast here, and leave a comment below.
Today’s historic ruling by the US Supreme Court upholding the vast majority of President Obama’s Affordable Care Act is good news for healthcare IT proponents who support the many key elements of the law already making a positive impact on healthcare.
While the media have focused their coverage of the law on the individual mandate and other political hot potatoes, they have largely ignored the many programs under the law that have nothing to do with insurance coverage but rather provide innovative new approaches to reimbursement.
For example, the Center for Medicare and Medicaid Innovation (CMMI), which was created by the Affordable Care Act, has launched several programs that have substantial promise in relation to delivery system reform. All Americans – all of us patients — can be thankful that these initiatives will now keep moving forward.
The good news, too, is that the view that we must reshape, reform and refund our healthcare delivery system is one that is generally supported by members of Congress, whether or not they agree that “Obamacare” accomplishes that goal. Allscripts works with government officials on both sides of the aisle and we have found that health information technology and its role in delivery system reform is not so much a bipartisan as non-partisan issue.
Why? Because elected officials of all political persuasions understand the gravity of the healthcare challenge in this country. They understand that we need to know what care is being provided to whom and how it turns out, in order to be able to apply a fix.
It’s worth pointing out, too, that the kind of reforms we’re talking about – a strategic shift in how we pay for healthcare – are spreading like wildfire well past Medicare. There are more initiatives than I can count taking place across the country – everything from Accountable Care Organizations (which, according to a new study by Leavitt Partners, have increased in number by 38 percent in the last six months alone, most of them commercial) to community health teams to medical homes specifically focused on the care delivered to patients who are dually eligible for both Medicare and Medicaid. I’m inspired by the Allscripts clients (from small physician practices to large integrated delivery networks) that have embraced the evolving reimbursement and delivery market that’s being built around them.
The high court’s Affordable Care Act decision will extend and empower these and other new and creative approaches to fixing the country’s systemic healthcare challenges, enabling us to keep moving further along the track of value-driven healthcare.
Question: What are your thoughts on today’s ruling? And how do you think it will impact the initiatives already underway or planned within your organization?
Where’s Paul Shaffer when you need some theme music?
Now that the comments on the Meaningful Use Stage 2 Notice of Proposed Rulemaking (NPRM) have been submitted by anyone with an opinion and Internet access, the media is making hay of all the negative feedback from industry stakeholders. There have clearly been some provocative conversations. There’s even a protest planned in response to one organization’s suggestions!
But there are also plenty of people who actually liked elements of the proposed Stage 2 program, including the leadership of Allscripts. It may not be as sexy to point out what we like, but even federal bureaucrats deserve kudos on occasion – especially when their proposals benefit patients and providers. So here we go …
The Top Ten Things We Like About Meaningful Use Stage 2
10. There’s so much more for specialists
CMS heard the complaints from Stage 1 participants that it was too heavy on primary care quality measures and general program structure, and they’ve added several different elements that should go a long way towards mitigating those concerns.
9. Public health is a big focus
The public health measures in Stage 1 are being expanded. We’ve advocated for a common national data submission standard because there is simply too much churn in the industry right now from non-standardized registry and public health interfaces. But we strongly support the effort to get more data flowing to benefit population health.
8. There’s recognition that MU might not be right for every provider
While the payment adjustments are becoming more clearly defined, CMS also asked for comment on whether there are certain provider types (i.e. certain specialists) who should be excluded from the penalties because of the program’s inapplicability to their clinical or business processes. While health IT is beneficial to every provider type, it is clear that the specifics of the Meaningful Use program may not work for anesthesiologists, for example, or hospitalists, and we applaud CMS’s consideration of their unique dynamics.
Allscripts strongly supports the introduction of the eMAR (electronic medication administration record) objective. We believe it will have clear and measurable benefits related to patient safety, and we think CMS got it exactly right as proposed.
6. Computerized provider order entry (CPOE) is being expanded
What started as only medication CPOE in Stage 1 is being expanded to labs and images in Stage 2. This will offer very clear benefit to patients. So while we’ve proposed a slightly different approach in measuring participation, this effort to push providers forward with CPOE is worthy of applause.
5. Clinical decision support is taking a big step forward
The most substantive benefits of health IT adoption are realized when healthcare professionals respond to appropriate, intelligent clinical information presented in a way that complements their workflow. The broad majority of our clients who already use clinical decision support say it has improved the care they deliver to their patients, and now the Meaningful Use program will likely accelerate that adoption at a rapid pace.
4. Lots and lots of clinical quality measures
Many people are complaining that the NPRM includes too many clinical quality measures (CQM). Realistically, the list should probably get a little smaller because some of the measures are being pushed too quickly without the necessary analysis and testing of the specifications. That said, clinical quality measurement is going to allow us a peek into what care is being delivered to whom and when; something that mere analysis of claims simply can’t deliver. That will be good for patients and good for the nation’s pocketbook.
3. Patient Engagement gets several boosts in the NPRM
This is a big bucket and really could be broken out into individual points, but generally speaking, we think CMS deserves a high-five for this one. The proposals are imperfect in some ways and require reengineering, but we hope that CMS keeps assertively moving forward in this area. Patient engagement is too important to soft pedal.
2. The one-year delay until the state of Stage 2
This is important. The prior timeline, which would have required Stage 2 to begin in October of this year, was simply untenable. It was unreasonable to expect that the Final Rules would be released this Summer and that the industry (software vendors and healthcare providers) would then conduct appropriate and safe product development, testing, implementation and training before going live in October 2013 (only four months later).
And the No. 1 Thing We Like about Meaningful Use Stage 2 is…
1. The interoperability football has been run down the field
If clinical data about patients isn’t flowing, the Meaningful Use program can’t deliver its full return on investment. CMS and ONC take very big steps forward in the Stage 2 NPRMs, both by pushing the technical elements of interoperability and by tackling some of the governance issues that are blocking data exchange today. It’s clear that some of the ideas aren’t practical, at least not in their current form, but we wholly support the NPRM’s approach to interoperability and hope that the Final Rule maintains that focus. This interoperability challenge is a make-or-break issue for the program and for the American healthcare system in this country, so while it may be hard, we’re all in.
What’s on your Top 10 List for Stage 2?
When I tell people that part of my job is to read regulations that were written by the government, the reactions I get vary from blank looks to sympathy to “better you than me.” And when I tell them that I actually enjoy that part of my responsibilities, most think I’m joking.
The truth is, I love the process of healthcare regulatory promulgation. As all of us who waited anxiously for the Meaningful Use Stage 2 NPRM can attest (pun intended), there is an awful lot of conversation that takes place as regulations are written. I find the back-and-forth invigorating. Before a regulation is written, there are numerous Federal Advisory Committee (FACA) meetings to listen to, carefully scripted presentations by ONC and CMS, and private meetings requested by various stakeholders and industry associations. It’s really a constant opportunity to learn and improve.
The face behind the Rule?
After getting to know some of the people who contributed to the Stage 2 process at ONC and CMS, I can occassionally convince myself that I see the stamp of a certain person in the Rule, or echoes of a conversation. For instance, you can clearly see the mark of the learnings gleaned so far from Stage 1 – how people who’ve already attested to Stage 1 did, what they deferred and what exclusions they filed. You can see areas that were identified as particularly challenging by stakeholders such as specialists, public health officials or those participating via Medicaid; where they agreed with the FACAs and where they didn’t; and even where ONC is feeling political pressure.
Most of all, though, in reading the hundreds of pages that make up the Meaningful Use Stage 2 proposed rule, you can see evidence that a great deal of thought and consideration went into what was ultimately published.
Hitting the mark
That isn’t to say that I agree with everything that is in the NPRM, of course. Allscripts will submit comments on many of the proposals, including the challenges we foresee with holding providers accountable for patient behavior … calling out the need for continued exclusions around registry reporting … as well as anywhere we see regulatory overreach within the Standards & Certification proposal.
However, I don’t think there is a page in the Rule that wasn’t reviewed by an entire team of people. As a result, there are numerous proposals that we believe are right on the money. For instance, the expansion of specialty-specific clinical quality measures … the focus on inter-vendor information exchange … and adding imaging and labs to the CPOE requirements.
I’m passionate about healthcare and the opportunity we all have in front of us during this unprecedented time of industry evolution. And since a proposed regulation is really elemental to the interesting, enthusiastic and occasionally exasperating conversation about the best way for us to move forward with fixing healthcare, honestly I can’t wait to get my hands on the next NPRM.
Many of us who are close to healthcare IT regulation will soon be heads-down reviewing, analyzing and generally mulling over the Proposed Rule on Stage 2 of the Meaningful Use program, now that CMS is set to release it. On top of late nights and a headache or two, there is one other thing we’re bracing for: the Great Debate as to whether CMS – with significant input from others – did a good job or missed the mark.
No matter what is in the Rule, some will argue that the proposed measures are too difficult, while others will insist CMS didn’t go far enough. It’s clear we can expect significant back-and-forth on the appropriate balance of the Rule’s many elements – the thresholds, the quality measures, the requirements for data connectivity, privacy elements, and how best to measure patient engagement in the process.
Following are a few predictions of what will stir the fires the most.
Clinical Quality Measures (CQM)
Clinical Quality Measures were in Stage 1, and I think they will also be in Stage 2. Some of the conversation has centered around the idea of whether the Rule should still maintain a Core vs. Menu approach, and others on how to appropriately bring in CQM that are relevant to specialists and sub-specialists. Others who are more focused on the technological underpinnings of the process have noted there are many steps in the process of developing new eMeasures that can be reported directly from an EHR, and it’s important to include only those CQM that have been tested and proven useful within clinical workflows.
Evaluating Providers Using Patient-Centric Measures
In trying to achieve the high level goals of HITECH, which aims to improve the quality of life for patients, it’s critical that we engage patients as well as providers with health information technology. Holding physicians and hospitals accountable for what their patients do at home, though (for instance, their use of a Personal Health Record to check test results), is a tough concept for most providers. Finding that balance is a knotty but important challenge.
Health Information Exchange
Given that US health information exchange infrastructure remains a work in progress, many observers are skeptical about HITECH requirements related to data exchange. I understand the concern, of course, given some of the challenges being faced by state HIEs and the lack of required infrastructure in rural or other underserved areas. Nonetheless, there are many other alternatives for information exchange, ranging from private HIEs sponsored by health systems or other collaboratives to the Direct protocol. The real power of health IT comes when the data is flowing broadly in a community for use by clinicians and analysis by public health officials. I hope that the voices pushing for more aggressive requirements on data exchange ultimately prevail here.
After watching the Stage 1 debate play out back in 2009, my sense is that while the conversation is important, ultimately we should aim high. It is vitally important to be sensitive to providers’ concerns. But it’s also important to remember that many who felt the Stage 1 requirements were too stringent ended up demonstrating through the attestation reports their ability to clear the thresholds by a significant margin.
My opinion: After the noise dies down and we get through implementation of Stage 2, we’ll find that it has brought us one step closer to the goal of a cost-efficient, quality-intensive healthcare system.
And that will have made the whole effort worthwhile.