Deven McGraw Gives Stage 3 Predictions (Part 1 of 2)

Jan. 29, 2015
In part one of a two-part interview series, Deven McGraw, a Washington D.C.-based partner in the healthcare practice of Manatt, Phelps & Phillips, gives her predictions for Stage 3 of meaningful use. She explains why “interoperability only” is an unrealistic proposal.

Deven McGraw is a name that should be familiar to most health IT policy followers.

McGraw, a Washington D.C.-based partner in the healthcare practice of Manatt, Phelps & Phillips, is a member of the Office of the National Coordinator for Health IT’s (ONC) Health IT Policy Committee and is Chair of the Privacy and Security Workgroup. Previously, she was the Director of the Health Privacy Project at the Center for Democracy & Technology (CDT), leading efforts to promote privacy and security protections for electronic personal health information.

Being immersed in D.C. conversations and meetings, McGraw has her finger on the pulse of major policy happenings in healthcare IT. With the Stage 3 proposed rule scheduled to be released in a few weeks at the beginning of March, Healthcare Informatics Senior Editor Gabriel Perna recently spoke with McGraw to see if she’d offer some predictions for our readers.

Below are excerpts from part one of this two-part interview series.

The Stage 3 proposed rule of meaningful use is coming soon. What are your expectations?

I think that based on the emphasis on the Office of the National Coordinator, [it will focus on] making sure the goals of interoperability are achieved, the capability to exchange data and for disparate systems to be able to take that data and consume it and use it to populate their electronic health record (EHR) systems. We’re not talking digital fax machines. We’re talking about the ability to meaningfully exchange data so the recipient can use it and also disclose it, so the real sharing of data envisioned by HITECH (the Health Information Technology for Economic and Clinical Health Act) and by the Affordable Care Act (ACA) can actually occur.

When we were talking about Stage 3 initially as a Health IT Policy Committee—we started the conversation well before Dr. DeSalvo came on board and the ONC started to double down on interoperability….and we as a policy committee thought it’s important that Stage 3 move towards more achievement of outcomes vs. necessarily the objectives that emphasize a lot process. This was a hard discussion. While there was recognition among the committee that this was indeed the ultimate goal of meaningful use, the trajectory of how you get there and if you take your foot off the foot of the gas of some of these process objectives, there was a lot less consensus on that. If you abandoned an objective entirely and just asked them to demonstrate good outcomes for diabetes patients, for example, there was concern we’d lose the progress we’d made process wise in Steps 1 and 2.

The Policy Committee’s Stage 3 was a thoughtful articulation of the tension between wanting to move to more outcome-based measures and concern about abandoning the incremental approach. After that discussion, the focus on interoperability occurred and that creates the imperative to think about the most important achievements that we need to get from the expenditure of the tax dollars of Stage 3. It’s less money than Stage 1 and 2, a lot less. And we always presume the program is going to have an escalator-type trajectory, rather than incrementally managing how providers do things.

I do suspect there will be more of a focus on interoperability and potentially a bit of relief in terms of the degree of specificity for the objectives and maybe some of the quality reporting measures. It’s hard to predict. CMS sets these measures, not ONC. I’m sure there is cross-office dialogue and I do sense from the way ONC has been proceeding, thinking through the roadmap to interoperability, they presume this is an all hands on deck exercise. I think that leads me to presume there will be a heightened focus on interoperability in Stage 3, and relief on some of the objectives providers complained about. 

What are some things you’ll be looking for from the Stage 3 proposed rule that pushes the industry forward on interoperability?

I think it will be interesting to see what comes out in the proposed rule. There was pushback and discomfort among the meaningful user community, the providers and hospitals participating in program, with how the objectives for the exchange of data were presented in Stage 2. This includes the certain percentages of exchange needing to happen, in terms of provider to provider exchange of data, the requirements that patients need to take advantage of view, download and transmit and at least take a look at their data or exchange in a secure email. That still feels like a check the box approach to achieving interoperability, as opposed to looking holistically at whether you’re care is better coordinated for your patients because you’ve able to exchange data with all the patients’ providers, regardless whether you’re seeing providers within your institution or outside of boundaries. The presumption is that in most cases, except for people who come into closed systems like Kaiser, patients, especially those with multiple chronic illnesses, are going to have multiple providers using multiple vendor systems. How do you reward the interoperable exchange of data, in a way that’s less check the box? There is not as many options as we’d like, outcomes measured is one way.

What about this notion that Stage 3 could be interoperability only?

I’ve heard that. I struggle with how you do that. How do you measure, in terms of results, interoperability where we don’t have as many measures as we would like that are about measuring outcomes rather than process? And where we do have process measures, how many of them reflect and incorporate the necessity of exchanging data in an interoperable way? It’s hard to wrap your arms around having a robust incentive program that is micro-focused on interoperability and interoperability alone.

One blunt way to do this is to look at the Stage 2 requirements that do focus on exchange, whether it’s exchange of providers or patients, and cut everything else. I’d be surprised if CMS went in that direction. That really says you’re going to abandon the escalator approach to increasing the requirements on the sort of day-to-day data capture of it. And maybe it’s time to do that on some areas of the objectives, but a wholesale sort of we’re going to stop measuring you on, for example, whether you’re keeping internal registries of your patients , and instead focusing on exchanging just seems hard to envision that approach would go out the window. Given the pressures the providers are under, the comments they’ve made about [this being] too much and the expectations are too high…I think that will be heard to some degree.

Stay tuned for part 2!

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