The United States Congress, with the passage of the HITECH Act in 2009, forever changed the face of medical information delivery. Despite the ubiquitous adoption of billing systems in the 1990s, and some early adopters of electronic health records (EHRs), healthcare remained sorely behind other industries in use of modern technologies for one reason: There was little business case to do so.
Then came the EHR Incentive Program, also known as Meaningful Use, which aimed to incite broad adoption and lay the groundwork for larger delivery system reforms. The legislation created a business case to adopt and use EHRs that applied to most (but not all) healthcare providers. The response across stakeholder groups was broadly positive, and the process to bring the idea to fruition began.
Now, five years into the program for Eligible Professionals (EPs) and Eligible Hospitals (EHs), healthcare has changed. Most hospitals and physician practices use an EHR today, and these adoption levels represent a huge success within the EHR Incentive Program. Essentially, we’ve constructed the information highway and are now focused on putting as many cars on it as possible.
However, we haven’t reached other initial goals of the program, and in some cases the regulatory fingerprint has had unintended consequences. Which begs the question: Is Meaningful Use still the most effective way to drive behaviors we want from healthcare institutions, clinicians, and patients?
The Centers for Medicare & Medicaid Services (CMS) has said that continuing Meaningful Use is necessary to transition the industry away from fee-for-service to fee-for-value. Some providers are still moving to an EHR or switching to a system that offers more advanced features, and some may still be motivated by the remaining Medicaid incentive dollars. CMS also makes a valid point when they say some providers haven’t yet embraced practices that will deliver great benefit to patients, such as a liberated exchange of information among providers, regardless of financial affiliation.
That said, now is the time to evaluate if the program’s current structure, execution, and statutory authority can satisfy the next goals: information exchange and outcomes improvement. Or would other policy levers be more effective in prompting consistent clinical information exchange and, ultimately, achieving a digitized, connected community of health?
At the advent of the program, focusing on functional and process measures made sense. It was a training program, in some ways, for most EPs and EHs going live on their first EHR or dramatically ramping up from basic EHR use. It ended up pushing EPs and EHs to incorporate clinical decision support into their workflow, for example, and provided valuable benefits from the medications-allergies cross-check functionality within EHRs. All of that was good progress.
However, CMS now expects program participants to do much more than Stage 1 requirements. The challenges with Stage 2 (and likely Stage 3) have caused many providers to resist continuing further. The EHR Incentive Program does not address the fundamental gap between what is best for patients (ensuring the availability of all necessary information) and the reality of what CMS actually pays healthcare professionals to do.
Until we address the complexity of interconnected factors of payments and delivery system mechanics, we limit our collective ability to advance interoperability and data exchange.
So what to do?
The Department of Health and Human Services (HHS) is taking its first step with the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) and is also evaluating the best paths forward for additional delivery system reform programs. It is also a perfect time to evaluate how the EHR Incentive Program will fit into this future.
Generally, there is a clear tie between payment policy and the choices professionals make. When fee schedules from government and commercial payers started to reward care coordination and information exchange, such behavior started to increase. After dabbling in payment and delivery reforms like accountable care organizations (ACOs) and patient-centered medical homes, we now have data to help evaluate what has worked, jettison what has not, and protect those who have done well from future penalties.
In fact, Secretary of Health and Human Services Sylvia Burwell has the authority to expand the successful payment models without Congress. There’s no need to navigate legislative gridlock or the yearly budgeting and appropriations process – instead, the CMS Innovation Center can expand what works at its own discretion.
The MACRA offers additional levers to drive change. CMS has a significant amount of discretion in how it formulates the program, and it can implement approaches that the market has been requesting. For example, when writing the detailed rules for the Merit-based Incentive Payment System (MIPS), the agency has an opportunity to revamp the EHR Incentive Program. CMS can tie incentives to outcomes-based measures and correct some of the most challenging elements of past regulations, such as the all-or-nothing approach to satisfying Meaningful Use requirements.
Further, the second option under MACRA – the Alternative Payment Models (APMs) – will open the door to creative policy-making that will present new opportunities to physicians and other caregivers. CMS will expand models that already exist, such as ACOs, and we can expect testing and formulation of new approaches in the next several years before and as the APM reporting period officially starts. For example, given the impact of cancer care and costs on the national landscape, it would be wise to fast-track payment reform for cancer. We should also scale up multi-payer state programs, which harmonize quality measurement efforts and prioritize electronic care coordination within a geography (addressing one of today’s main complaints from physicians and hospitals).
Most importantly, an intensified focus on payment and delivery-system reform enables actual market-focused use cases to drive interoperability efforts. Letting physicians and other caregivers prioritize efforts to exchange information where it will deliver the greatest value would have an immediate impact on interoperability success. Instead of executing what they must to satisfy regulatory requirements, providers would want to exchange information because it would be financially beneficial and clinically relevant to their patients. It would also help develop end-goal programs – such as establishing and expanding precision medicine, for example – enabling them to take root more quickly and effectively.
To realize success, the policy-making process must begin now. Some recommendations for consideration:
- View information exchange infrastructure as a public infrastructure. Address the questionable policies of the Office of the National Coordinator for Health Information Technology (ONC) of five years ago, which allowed states to set up data-exchange approaches without any requirement to adopt common standards. Fixing this issue will afford opportunities for all providers – regardless of geography.
- Significantly shift ONC’s focus to reviewing and promulgating standards and expanding privacy and security requirements. The ONC needs to move away from the overly prescriptive feature-function regulations of recent years, allowing software developers to make up ground by expanding the benefits of user-centered design.
- Similarly, it is time to recognize that certification of EHR products should not take the place of other more effective policy approaches. For example, CMS indicated in the Request for Information on the MACRA implementation that it is considering additional certification programs, which would likely expand the government’s influence on product development. Additionally, it is evaluating how EHRs could perform a variety of tasks that do not fall within the data-capture structure of the systems, such as patient-satisfaction survey results. Innovative healthcare technology should be limited as little as possible by government-dictated constructs, as this approach will negatively impact user workflows and ultimately program success.
- CMS must recognize the unique challenges of independent small practices that are barely skimming the surface of their technology in many instances, within MACRA regulations. It would be prudent to escalate requirements gradually, reflecting the need for an orderly transition to the new payment environment while also responsibly raising the bar on information exchange.
- The shift to a quality-based payment schema means two important things. First, the industry will need to work collectively to rapidly develop, test, incorporate, and train on a significant number of quality measures in the coming years so physicians and others feel confident that the measurement determining their Medicare payments is valid and clinically legitimate. Additionally, the measurement and reporting requirements will only continue to grow. While disruptive, they will provide an opportunity to address data-capture technologies and workflows creatively.
While Meaningful Use is required within the MACRA legislative language to be part of the MIPS program, it should not be part of the APM rules in coming years. It is sensible to require providers to use certified EHRs and continue to demonstrate a commitment to interoperability and privacy protections, but a prescriptive approach to Meaningful Use simply won’t make sense as APMs take hold at the end of this decade. Instead, it is more sensible to allow market forces – under new payment models within the APMs – to naturally drive information technology use where it delivers real value.
