The Englewood, Colo.-based Medical Group Management Association (MGMA) on Jan. 28 sent a letter to National Coordinator for Health IT Donald Rucker, M.D., asking Dr. Rucker and his colleagues at the Office of the National Coordinator (ONC) to consider carefully the needs of practicing physicians when moving forward on a variety of issues, including physician documentation, quality outcomes, and interoperability.
In the letter, MGMA wrote that “The Medical Group Management Association (MGMA) is pleased to submit the following comments in response to publication of the “Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Heath IT and EHRs.” MGMA supports the efforts of the Office of the National Coordinator for Health Information Technology (ONC) to facilitate the deployment and utilization of effective health information technology (IT) across providers and other stakeholders.”
The letter went on to detail a variety of actions that MGMA would like ONC to take, including addressing prior authorization; publishing electronic attachment standards; reducing general burdens that physicians are experiencing in the MIPS (Merit-based Incentive Payment System) program; modify the Promoting Interoperability program within MIPS; extend Stark law and anti-kickback harbors; explore the HL7 FHIR standard; and “consult with the physician practice community.”
With regard to prior authorization, for example, the MGMA letter stated that “Perhaps the most onerous administrative burden for physician practices, we urge the government to work toward reducing the volume of required authorization requests and increasing automation of prior authorization processes.” And, with regard to the publication of electronic attachment standards, the letter noted that “Significant burden is associated with manually transmitting clinical information from practices to health plans via fax, mail, or proprietary web portals. We recommend the government release the regulation establishing the X12 275 electronic attachment standard and supporting operating rules.”
Following the publication of that letter, Healthcare Innovation Editor-in-Chief Mark Hagland interviewed Robert M. Tennant, director of health information technology policy at MGMA.
Among other involvements, Tennant is a member of the board of directors of the Workgroup for Electronic Data Interchange (WEDI); a member of the Certification Commission for Health Information Technology EHR Expert Panel; a member of the American health Information Community Consumer empowerment Workgroup; a member of the National Uniform Claim Committee; a member of the e-Health Initiative’s Policy Steering Committee; a member of the Council for Affordable Quality Healthcare CORE initiative; and a member of the Healthcare Administrative Simplification Coalition (HASC). Below are excerpts from that interview.
Broadly speaking, what would you and your colleagues like to come out of these exchanges with ONC?
I’ll start at the 60,000-foot level. You and I have been around a long time, we’ve seen the work of several administrations. This administration has taken a very different approach from past administrations. From the beginning, they’ve said, we want to reduce burden and make healthcare move faster; from an IT perspective, they said, we want to listen to you. Patients over paperwork, the CMS [Centers for Medicare and Medicaid Services] initiative, cutting the red tape. They invited us to speak; it was a joint CMS-ONC meeting on reducing administrative burdens, nearly a year ago. And we went up there with our long shopping list of requests.
What’s interesting is that many of the issues dealt with in this RFI, I would argue, are out of scope for ONC. They get into reducing clinical documentation. Well, that was addressed directly in the physician fee scheduled, by CMS. So we’re addressing multiple audiences here. Of course, we’re addressing Dr. Rucker directly; but many of these issues will have to be addressed by Seema Verma. And even though it was an ONC document, they still had the HHS Secretary and CMS Administrator write introductions. So that tells us that they’re not looking strictly at HIT policy; so that’s sort of the background of our thinking, that we’re writing for multiple audiences.
Also, this is not the first time that we have responded to the government with a number of requests. So yes, it’s a new RFI [request for information], but the questions they’ve asked, they’ve asked many before. Our concern is that they keep asking questions, but we’re not seeing a lot of policy action. So we’re hoping this is the final time they go out to the industry. Now, absorb what the industry is telling you, and turn that into policy action; that’s our real hope, that they’re not just soliciting industry input. We’re hopeful, but the jury’s out.
One of the things they said was, it’s about reducing physician burden, but one of the first things they did was to make physician burden full-year, against everyone’s urgings. They summarily moved to 2015 CEHRT [EHR certification], which could prove a hardship to many smaller practices that don’t have the resources to invest in new software. And per MIPS, if you’ve made the investment in 2015 CEHRT, why don’t you just make that your 25 points. Why do you need to prove you’re using it, once you’ve invested in the technology? It’s highly unlikely that someone’s going to invest $100,000 or more, and then just turn it off. If there’s value in the technology, and I think there is, then physicians are going to use it. You can remember the days before the smartphone, if someone had said, you’ll have a computer in your hand, you would have laughed; but now it’s indispensable. EHRs are getting to that point. Yes, physicians could go back to paper, but they’d hate it.
And younger physicians would avoid joining paper-based practices, to begin with.
Absolutely! How would you convince a physician to come out of their residency, having used an EHR in a hospital, and then go back to paper? It’s not going to work. No one’s done a definitive study, but I’d suspect it’s 80-percent plus already, and as the older physicians retire, that 80 percent will jump to 90-plus in the next three to five years.
There seems to be an inconsistency among federal healthcare officials with regard to requiring year-long reporting under MIPS, versus their stated mantra about reducing physician burden. Your thoughts?
You’ve hit the nail on the head. We believe you should give the physician the option. If you have everything in place to do so and it’s not a burden, go ahead and report based on a full year. But going ahead into 2019 with 2015 CEHRT, that meant you had to have your 2015 CERHT locked and loaded by January 1. Because it could take a month or more to switch from one EHR to another, or even through an upgrade. It sends the wrong message to the physician community, that they’re really not engaged, not really involved in practically moving to reduce the physician burden. And we cover it in our letter—but if you see Verma lately, she’s started to beat the drum about reducing the use of fax machines; she wants to see fax machines eliminated by 2020. And we completely agree. But here’s the rub: if you think about why physicians still use fax machines today, there are three main reasons.
First, if the commercial health plan requires audits; and in many cases, there’s no easy way to submit the data electronically. Or you’ve submitted a claim, and the health plan demands the notes from the record. Third is for prior authorization. We want to put you on oxygen, but the health plan demands the clinical notes to support the need for oxygen. In 1996, HIPAA created the X12 275 transaction; we’ve yet to see a rule, and it’s been 19 years. The ACA actually re-mandated it, saying that HHS had to release a standard for that transaction by 2014, and they’ve dragged their heels. That would be for the health plan to ask the physician to send data from the EHR directly electronically. Those are two tangible areas where they could have taken action, and they failed to. We heard from CMS about a year ago, that they were interested in finally working on that standard, and we were all excited. They invited us, the AMA, the AHA, the dentists, Aetna, some of the Blues, etc., etc., and invited us all to participate. This is a case where all the major stakeholders went in and said exactly the same thing, we needed that standard.
We have yet to see the rule. They publish the CMS Unified Agenda, a document that gives a preview of the regs they plan to release. It came out about a year ago, and they said, we’ll put out a rule on attachments by August 2018; nothing. They said maybe December. So we’re hopeful to see something. Talk about an innovation—to be able to use this standard—it can be used not only between providers and health plans, but also between clinical sites in an ACO. It’s an elegant and secure way to move data. And the nice thing about the standard is that it can take any file format—Word, jpegs, PDFs, x-rays. It’s like a FedEx envelope.
Seema Verma keeps saying impatiently that providers need to move forward, but CMS doesn’t seem to be providing the building blocks to get where we need to get.
Yes, that’s right; MIPS is an example of that. The idea of MIPS is a good one. If you want to promote interoperability, you want physicians to acquire and use advanced technology, and you want patients to interact with them. But at the end of the day, the top physician groups who scored highest in MIPS got a 1.88 percent bump in pay. And especially but not limited to these smaller practices, and every day, you’re hearing about data breaches—breaches because the technology or the people and policy failed, or both. So if your public policy goal is X, then you have to make sure that the people who have to do it, have the resources available to them.
The requirement under MIPS that practices do their own data risk assessment, seems to be unrealistic, as one example, correct?
Yes, in fact, that’s been required since 2005 under the security rule. But we’re asking, give practices a definitive checklist that we can comply with. And allow that practice to hire a consultant or go through an accreditation, and be deemed to have met that requirement. And the OCR has done neither of those things. So it’s not only a challenge, it’s also nebulous. Especially has a small practice, you don’t even know if you’ve done the right thing. They’ve taken the negative approach of saying, oh, we’re going to fine you, instead of saying, we’ll help you and we’ll give you help. Let’s not go out and send out press releases about million-dollar fines. Let’s help people. And if you go onto the Wall of Shame, breaches involving 500 patients or more—if you go on there and scroll through there, very rarely will you see a small practice. These are large organizations with multi-million-dollar security budgets, and they’re challenged.
And among the four components in MIPS is improvement activities; you can score points by engaging in certain activities. Why not give bonus points to practices that go the extra mile on data security?
What do you hope to come out of your letter, and in this year, with ONC, CMS, and HHS?
There are some positive things. We’re expecting some new regs from ONC and CMS. One area is data blocking; we’re hoping they’ll put some pressure on the vendors. One of the problems is cost. We have to find ways to cut the costs out of practices trying to engage with other folks to share data. Cost for a small practice shouldn’t be the barrier for interoperability; that rule hopefully will spur that on. And there’s something exciting happening. Check out HL7 and their project called DaVinci, using FHIR to be able to move healthcare data. The analogy everybody uses is, you’ve got an iPhone, right? And you’ve got Expedia or Travelocity on your phone. You say, I’m sick of the cold weather, I want to go to Miami next Tuesday. And your app will pull data from all the airlines. That technology, that API technology, is what DaVinci is working on, and some offshoots, in healthcare. So in my EHR, I could pull payer data, lab data, hospital discharge data, and from the patient’s perspective, they could have their health app, which would pull from multiple sources, and put it in the palm of their hand. That offers significant promise for transformation. And one thing you’ll want to put on your radar screen. DRLS—Document Requirement Lookup Service: CMS is working on DRLS, an offshoot of DaVinci. So let’s say you say you’re a Medicare patient and you need oxygen. Well, oxygen requires a prior auth from Medicare. This service would tell the physician it requires a prior auth and then would give them the documentation template they’d need to fill out right in the EHR. I’m on the workgroup, and we’re moving ahead with it.
And then just last week, I sat through a demo from United Healthcare, using very similar technology, what they call point-of-care technology, pushing this data—prior auth, lag results, outstanding tests that need to be done—directly into the HER, for the clinician, at the point of care. So the doctor can get a prior auth immediately and electronically through the EHR. And ONC also has a workgroup in DaVinci, called P2. They’re heavily involved in this new movement.
So if there’s going to be a big change in healthcare, it’ll be through the lens of DaVinci. So that’s very exciting. But at the same time, we don’t want DaVinci and the FHIR standards to be mandated on practices until they’re fully baked. Any change is expansive. My brother-in-law is a family doc, and he says, Rob, every dollar I spend on changing my practice comes out of my child’s college fund. So if you just keep adding mandates, that’s a tough sell for physicians. The technology has to be of value to both physicians and patients, and has to be proven.
So it’s a promising year. I expect to see a lot of government action. There’s another RFI coming out on TEFCA [the Trusted Exchange Framework and Common Agreement]; the rumor is that it was held up because of the government shutdown. So I wouldn’t be surprised to see the data blocking rules come out.
