Healthcare Technology Featured Article

April 17, 2014

What's Next for Meaningful Use?

Meaningful use (MU) is at an interesting place in its evolution — that funny space between the end of stage 2 and the beginning of stage 3. Speculation about its future was rampant at the 2014 annual meeting of the Healthcare Information Management and Systems Society (HIMSS). As nationally recognized experts on health information technology, Point of Care Partners (POCP) has some thoughts about the whys and next steps for MU.

When you think about it, MU stage 2 led several lives. In the beginning, stage 2 was bright with the hope that it would pave the way toward a better future for providers, payers and patients. That shine rapidly began to tarnish, in part because of the scope of the undertaking, the requirements themselves, tight timelines and the inexperience of policy makers, providers and vendors in going boldly where nobody had gone before.

Now we are at the end of stage 2, and the denouement is shaping up like this:

  • There is widespread dissatisfaction with electronic health records (EHRs). One in four medical practices using EHRs is thinking about replacing its system, according to a recent survey. Usability issues, lack of capabilities to support value-based care and limited interoperability are fueling this dissatisfaction.  
  • A large number of vendors are not yet certified for 2014. This is leaving many providers in the lurch because their systems are not up to snuff and they cannot implement MU stage 2. In addition, such providers would be liable for penalties of 2 percent or more if they do not implement a certified system by July 1. Recognizing that this is a problem, the federal government offered “2014 EHR vendor issues” as a reason for eligible providers and hospitals to apply for a fiscal year 2015 hardship exemption.
  • The decline in complete and modular EHRs certified to 2014 standards compared with 2011 certification is an indicator of consolidation that is now taking place in the vendor market. Many vendors do not have the resources to fund the complex development needed to support interoperability, decision support and patient engagement. 
  • Provider participation varies. Hospitals appear to be in the best shape, with 82 percent qualifying in November 2013, although we are hearing that many will experience significant delays in qualifying for stage 2. On the other hand, fewer than 80 percent of ambulatory physicians have registered for attestation and less than 50 percent have actually qualified. The rest have until the March 31 deadline, so it will be interesting to see the final numbers. If history is any indication, there could be a large number of dropouts. The General Accountability Office (GAO) found that a substantial percentage of providers that participated in 2011 did not participate in 2012. Attestations are increasing (14,000 qualified in January compared with 9,000 in December 2013). However, these are much lower than expected, with monthly numbers being about half of what they were a year ago.

The ultimate success of MU will be influenced by several factors going forward, including the stage 3 requirements and new legislation. 

Stage 3 requirements

A key driver for the future of MU is the stage 3 requirements themselves. At its March 11 meeting, the Health IT Policy Committee (HITPC) accepted its MU workgroup’s draft stage 3 recommendations. The recommendations are being sent to the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology. After digesting them, a notice of proposed rulemaking (NPRM) will be issued this fall by CMS. A final rule is on the radar for 2015.

The recommendations have caused quite a bit of consternation for HITPC members, according to media reports. Some are concerned that the recommendations were scaled back by 30 percent, with significant setbacks to the strategic goal of improving quality of care and safety, in particular. One troubling choice was the decision to remove a requirement related to Medication Adherence. (Click here for a deeper dive into this issue.) Excision of such criteria could be attributed, in part, to confusion on the part of stakeholders involved in implementing those objectives (e.g., access of images) or industry resistance to standards (e.g., pharmacy use of fill status to track adherence). Other HITPC participants called for even more pruning, saying providers and vendors are already overburdened. 

We believe the narrower set of criteria in the stage 3 recommendations is the right approach, especially if the result is more robust certified EHRs to support clinical decision support (CDS) and patient engagement. The HITPC is linking CDS quality measures to the National Quality Forum’s national priorities. This gives forward-thinking health care leaders the opportunity to focus on CDS that advances their organizations’ patient-centered care model and improved care coordination efforts — critical to success in an accountable care organization. Medication management has a central role in the CDS interventions, with advanced medication-related decision support and more complete medication lists highlighted.

Anyone hoping for relief on the patient engagement front will likely be disappointed. Stage 3 objectives and criteria raise the bar, requiring providers to demonstrate the receipt of provider-requested and patient-generated data. This requirement could finally push the envelope on the development of workable models for storing patient-generated data in EHRs. 

Our take is that the stage 3 revision process is far from complete; some self-examination and realignment will be necessary. More changes will occur in response to the NPRM. It will be interesting to see how this core set of requirements changes due to stakeholders’ concerns, and whether some are dropped and others are added in response to the comments received.

New legislation

The latest example of how new legislation would impact MU was the first round of legislation (H.R. 4015/S. 2000), which would have repealed Medicare’s sustainable growth rate (SGR) requirements.  As per usual with a lot of legislation, a bunch of health IT provisions were tucked inside: a mandate that all EHRs achieve interoperability by 2017; a prohibition for vendors from deliberately blocking information sharing with other EHR vendor products; and creating a reimbursement process for clinical imaging based on appropriate use criteria (Read more about the latter in this issue of HIT Perspectives).

In addition, the legislation would have rolled MU into a gigantic new program called the Merit-Based Incentive Payment System (MIPS) in 2017, along with the Physician Quality Reporting System (PQRS) and the Value-Based Modifier (VBM). This would have put most of the federal government’s quality-based pay-for-performance requirements in one place, with MIPS being the only Medicare quality reporting program.

Had it materialized, the MIPS implementation would have depended on a strong health IT backbone.  Beginning in 2018, MIPS would have provided bonuses ranging from 4 to 9 percent for physicians who scored well along the dimensions of quality, resource use, MU, and clinical practice improvement activities. Quality reporting was anticipated through EHRs or qualified clinical data registries. Participation in a qualified clinical data registry would also have counted as a clinical practice improvement activity.

All of these activities are very far-reaching, but will not happen. The proposed bills were supplanted by the Protecting Access to Medicare Act of 2014, which stripped out those health IT provisions. However, given the legislative process, they are likely to reappear in subsequent bills in one form or another. After all, Congress must take another shot at “fixing” the SGR formula issue next year, because this year’s legislation only staves off SGR-based payment cuts for Medicare physicians until March 2015.  (It should be pointed out that this year’s temporary SGR “fix” was the 17th such patch that Congress enacted since the SGR formula became law in 1997.)  And of course there will be plenty of legislation throughout the rest of the year that could be vehicles for health IT-related provisions.

The Protecting Access to Medicare Act also delayed ICD-10 implementation for a year.  While this temporarily relieves hospitals and physician organizations of the stress of implementing ICD-10 and meaningful use stage 2 requirements in parallel, the delay in ICD-10 implementation signals how things can play out due to delays or abrupt changes in program direction. First, this delay will be expensive. Many organizations have spent considerable time and money to get with the program. Code mapping and crosswalks have been underway for several years. The result: an additional $1-6.6 billion on top of what has already been incurred due to the previous implementation delays, according to the American Health Information Management Association. There also will be consternation among trading partners—those who have implemented and those who have not. While voluntary trading partner agreements are likely to be how things play out, it is not beyond the realm of possibility that the government will step in and issue some kind of regulatory guidance, as was with the case with the Health Insurance Portability and Accountability Act (HIPAA). Finally, delaying ICD-10 adds to the uncertainty and complexity of implementing the health IT infrastructure needed to support population health management and value-based reimbursement, which is not a good thing in our opinion.

POCP is closely monitoring developments with MU and on the legislative front. We are working with our clients as they: 1) align their MU compliance strategies with the broader strategic priorities of population health management, clinical integration and quality-based performance monitoring; 2) transform their organizations to succeed in a value-based payment environment. We would be happy to help your organization interpret the MU landscape and its impacts, as well as assist with the development of comment letters when the NPRM is issued in the fall.  

Edited by Alisen Downey
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