Meaningful Use

Although the behavior of one EHR vendor was wrong, more serious problems are inflicted by government-run EHR certification criteria

This week eClinicalWorks resolved a lawsuit by agreeing to pay $155 million for falsely claiming it met Meaningful Use (MU) EHR certification criteria.   Although the alleged behavior of eClinicalWorks was wrong, we have much more serious problems inflicted by the government-run EHR certification criteria.  

The business of EHR vendors is to gain clients and earn profits.  Developing innovative tools that help physicians care for patients should be the primary focus of their business.  Instead, vendors are held hostage to government-run certification criteria that are constantly changing and sometimes ambiguous.  While I do not condone the apparent behavior of eClinicalWorks, I am much more concerned about the  certification processes that led to this situation.   

The certification process evolved out of the 2009 HITECH Act that promoted the use of EHR technologies by offering incentive payments to hospitals and physicians who successfully adopted and used EHRs.   This resulted in an unprecedented rush of business for EHR vendors.  While EHR vendors began ramping up resources to meet the demands of the sales cycle and EHR implementations, they were also hit with government-imposed EHR certification criteria--criteria that are still changing frequently and sometimes are ambiguous.  This exponential increase in EHR client demands along with rapidly changing certification criteria crushed EHR vendor resource availability.  This constraint on resources forced them to focus on developing and testing EHR products to meet the specific certification criteria required by the government.  In my opinion, the unintended consequence of overwhelmed EHR vendors is that they then did not have available resources to focus more on:

  1. Improving usability
  2. Identifying and managing patient safety risks inherent to EHR use
  3. Developing innovative tools and functions that actually improve how physicians care for patients 

As a result, EHRs were developed to meet MU EHR certification criteria, but failed to improve poor usability.  EHR products could meet certification criteria, yet fail to adequately address patient safety risks associated with implementation and use.  And the constraint on EHR vendor resource availability remains an impediment to the development of innovative tools and functionalities that EHR vendors really should be focusing on today.

Physicians do benefit from EHR certification by reducing risk during the EHR selection process.  That is why the Certification Commission for Health Information Technology (CCHIT) was created in 2006 as an independent, not-for-profit group.  CCHIT certification was based on a consensus of stakeholders who determined core functionalities that a basic EHR should provide.  I participated in that effort, albeit in a brief, very small way (providing some input on pediatric core criteria).  I recall we were careful to avoid requirements that could hinder EHR product innovation.  CCHIT ceased operations in 2014 after the government created the MU EHR Certification program.  

CCHIT certification was much less prescriptive than what the government imposes today.  Less prescriptive EHR certification was, in retrospect, the right approach to take.  And we did it without government involvement.  Government works at its own hindered pace, and that pace is much slower than what an unencumbered EHR market could accomplish.  I think the government needs to get out of the EHR certification business.   But whether government remains involved or not, the EHR certification process needs to learn from CCHIT and rely more heavily on building consensus of physician stakeholders.  We will do what is best for our patients.    

So, this week one vendor was called out by the government for false claims regarding EHR certification.  But that one vendor is really not the problem.  The real problem is that the development of all EHR products has been, and still is, impeded by the government's EHR certification program.  

Matt Murray, MD

cook children's health care system


Increasingly hazardous healthcare environment should urge Congress to create a National Health IT Safety Center

Discharge instructions for a child’s insulin dose were correctly entered into the electronic health record (EHR), but when the mother received the printed instructions there was a decimal point error resulting in a 10-times dosing error.  This error was fortunately noticed by the bedside nurse and corrected manually.  I reported this near-miss to the EHR vendor and they corrected the technical problem.  However, when I asked vendor representatives whether or not this problem was being corrected with other physician clients across the country, they informed  me that no other client had reported such a problem. 

This is analogous to a situation where an airbag explodes and sends shrapnel into your face.  You might ask the automaker whether this is a problem with their other vehicles.  They might tell you that they are not aware of others having the same problem.  However, in the transportation industry they are required to report safety incidents and near-misses.  These reports are collected, aggregated and analyzed by the National Transportation Safety Board (NTSB).  If NTSB notices a trend in airbag-induced shrapnel injuries, they will initiate an investigation.  When NTSB discovers a problem with a specific airbag that is used across multiple types of automobiles, not just the type you purchased in your own state, then they are authorized by Congress to make safety recommendations to help ensure the risk is appropriately managed across the industry.

This insulin dosing incident is one of many health IT-related patient safety risks I have encountered and resolved in collaboration with an EHR vendor.  When my experience is extrapolated to the experiences of all physicians and EHR vendors, the scope of health IT-related patient safety risks can be seen as immense.  But unlike the safety of interstate commerce produced by the auto industry that is overseen by the NTSB, the safety of interstate commerce produced by EHR vendors has no cohesive oversight mechanism.  

The lack of oversight for health IT-related patient safety incidents and near-misses creates a hazardous patient care environment that I believe is urgent for Congress to address. The threat is increasing because the Meaningful Use Program (MU) has led to an exponential increase in the use of EHRs and other technology.   As a result, physicians are assuming a higher level of risk and accountability for computer programs, networks and infrastructures that are increasingly used as tools to generate patient care actions and facilitate medical decisions.  Although health IT-related patient safety risks would best managed through a shared accountability between physicians and EHR vendors, the vendors are not currently held accountable for patient safety.  Furthermore, the aggressive MU timelines have required EHR vendors to make rapid changes to EHRs without sufficient time to align changes with efficient physician workflows or to improve the flow of data between systems.  As a result, EHRs are increasingly plagued by poor usability problems and  lack of interoperability between EHR systems--both of which are patient safety risks that physicians commonly encounter.

So it is time to urge Congress to create a National Health IT Safety Center that can implement an effective EHR safety program designed to reduce EHR-related patient safety risks.  Within this concept EHR vendors could be required to report patient safety incidents and near-misses to the Health IT Safety Center similar to how transportation safety incidents must be reported to the National Transportation Safety Board.   The Health IT Safety Center could collect, aggregate and analyze reported data.   It could have power to investigate incidents involving patient harm and require EHR vendors to make appropriate changes.  It could monitor near-misses to identify trends and risks.  It could coordinate with other agencies to develop and broadly disseminate educational information and tools that mitigate identified patient safety risks related to technology use.  

I also envision that this resolution would lead to an entity that has the authority and influence to drive improvements in EHR usability and

 
 

interoperability, which are the two most significant impediments to effective and meaningful use of electronic medical records.   

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Cultural Change at CMS is Needed to Mend Adversarial Relationship With Physicians

CMS has issued a request for information (RFI) and invited comments on the implementation of the Merit-Based Incentive Payment System (MIPS) as introduced in the MACRA legislation that repealed SGR last April.   The legislated "composite performance score" upon which "adjustments" to physician payments will be made under MIPS consists of four categories:  Quality, Resource Use, Clinical Practice Improvement Activities and Meaningful Use of CEHRT.   Comments are being sought on many topics, including certification of EHRs, technology standards, accountability for data integrity, management of "virtual groups"  and, yes, Meaningful Use (MU).

I have three overarching comments:

1.  Adversarial relationship with physicians:  Right now government programs such as MU and PQRS are generally viewed by physicians as requirements only, not as elements of best practices that lead to quality care.  I think it is vital to change this adversarial perception.  This will involve a cultural change at CMS.  Perhaps the most important tactical change to pursue is moving away from rewarding/penalizing the achievement of specific targets, and moving toward innovative programs that reward practices for making incremental improvements in quality care.

2.   Inhibition of Innovation:  Physicians support technology innovations developing in the consumer marketplace that have the potential to improve quality of care and lower healthcare costs.   While government regulations have the potential to catalyze innovations in the consumer marketplace, they also have the potential to inhibit innovation.    Regulations that strive for high-level outcomes are generally more likely to catalyze innovation, while regulations that impose specific limits or require specific actions, mechanisms and processes are more likely to inhibit inhibition.   I believe the Meaningful Use regulations have inhibited innovation--EHR vendors have been scrambling to meet specific requirements imposed by the regulations with no evidence that these requirements would result in higher quality of care or lower costs.    To change this, we need CMS to mindfully develop government regulations that maintain a high-level focus on the achievement of quality care outcomes while avoiding the development of limitations or specific requirements, methods and processes that discourage innovation. 

3.    Fair and ethical use of quality metrics for reimbursement:   The AMA has published guidelines on the Fair and Ethical Use of Quality Metrics.    The guidelines advocate for rewarding physician practices that make incremental improvements in quality care rather than rewarding/penalizing the achievement of specific levels of performance.   Although my opposition to the use of quality metrics to impose financial penalties is aligned with these guidelines, I concede that it is difficult for a value-based model of reimbursement to completely avoid penalties.    My alternative suggestion is for CMS to incorporate tiered levels of "performance achievement" instead of the "all-or-none" requirements put in place for the MU program.  Tiered levels of achievement, with lower levels of achievement designed to avoid certain penalties and higher levels designed to provide additional rewards, will help avoid the "drop-out" rate that the MU program has experienced after Stage 1 as the levels of expected performance were increased.  Many physicians just gave up.  Even though they could achieve all but one of the requirements, that one requirement eliminated the possibility of receiving any credit.  

I  would be interested in hearing your thoughts on the implementation of MIPS by CMS.


Keys to Gain Value from EHR Implementation and Use

Many physicians who use an electronic health record (EHR) are having difficulty realizing value in their investment.   A recent KLAS survey found that more than one out of every four physician practices are so dissatisfied with their EHR that they are considering replacing it.    Although many physician practices have earned a financial award by using an EHR to achieve “meaningful use”,  data is lacking on whether or not such efforts actually improve patient outcomes.  

I believe, anecdotally, that I practice higher quality medicine when using an EHR.    But I am a pediatric emergency medicine physician using a hospital EHR to document patient encounters in a children's hospital's emergency department, not a physician in private practice.  On the other hand, my past experience as a a Chief Medical Information Officer (CMIO) and Chief Information Officer (CIO) for my pediatric healthcare system provided opportunities to visit many private physician offices using a variety of ambulatory EHRs and to visit with many EHR vendors.  I met many physicians  who were happy with their EHRs and see the value.  Others I met were unhappy and see no value in their EHR.  Perhaps my most eye-opening experience came when I visited with a group of unhappy physicians who were using the same EHR as some happy physicians I had met one week earlier.   So what gives?

The answer is simple, but the explanation is complex.  

The simple answer is that the value gained from an EHR is dependent on how effectively it is implemented and used.   When well-implemented and well-used, an EHR provides clinical and financial value.   When poorly-implemented and poorly-used, EHRs detract from patient care and are a financial drain.  

The complex explanation might best be explained using examples.  So, based on my past visits with physicians who use various EHRs and on other personal research, I have created an outline of what I think are the key factors that allow physicians to gain value from their EHR.  I am in the process of writing a series of blogs with case studies to help explain each of these factors.  Stay tuned! 

Keys to Gain Value

 

cook children's

 

Dr. Matt Murray

Cook Children's


Mandating Physicians to Use SNOMED codes Has Higher Potential to Improve Healthcare Than ICD-10 Mandate

I have consistently advocated for skipping ICD-10 and initiating an unprecedented effort to accelerate the development of ICD-11-CM.  Although I still believe this strategy to be the one best aligned with quality care, I fear that the sunken ICD-10 costs are now so large that skipping ICD-10 is unpalatable for most organizations, even for some physicians, and is politically perilous.  Since we must do something, I have been thinking more about the proposal to replace ICD-9 with SNOMED in physician practices.  Leveraging SNOMED to improve care, lower costs and remove physician practices from the ICD conversion melees should be a serious national conversation at this point.  
 
After several delays CMS has established October 1, 2015 as the new implementation date for the replacement of ICD-9 code sets used by medical coders and billers to report healthcare diagnoses and procedures with ICD-10 codes   But another postponement remains a possibility--especially when one considers the unclear reasons for action taken by Congress earlier this year to call off the 2014 implementation.  ICD conversion delays are costly to the healthcare industry and action should be taken to address the impediments that increase the risk of such delays.   One of the major impediments to address is the adverse impact ICD conversions have on individual physician practices.    
 
So let's jump out of the box of conventional charged impulses propagating across our cerebrums (thinking) to consider how to make ICD-10 optional for physician practices while still achieving our goal of dispensing with obsolete ICD-9 code sets.  One alternative is to mandate physicians replace ICD-9 codes sets with SNOMED code sets and require EHRs to incorporate translator technology that converts SNOMED to ICD codes in the background.  Since it would not be practicable to expect EHR vendors to incorporate the translator technology into their products by October 1, 2015, there would need to be an interim period where physician practices are exempt from the requirement to use ICD-10 codes sets until their EHR incorporates the translator technology.    This alternative mandate allows the ICD-10 conversion to proceed for the rest of the healthcare industry including any physician practices who see value in completing their conversion.  This mandate would reduce the current and future adverse impacts that ICD conversions have on physician practices, has higher potential to improve care, is more cost effective, helps EHRs be more user-friendly to physicians and mitigates the risk of further delays to ICD-10 as well as future ICD-X conversions.
 
I would anticipate a two-year transitional period where the ICD-10 conversion would be optional for physician practices based on an assumption that EHR vendors will need until 2017 to upgrade their products.  
 
Some opposition among physicians is likely to be encountered due to their lack of familiarity with SNOMED as well as questions about how this alternative strategy adds value to patient care.   I base that on the responses I heard from some respected colleagues at this weekend's Texas Medical Association meeting.  The unfamiliarity issue can be addressed by pointing out that many of us are already using SNOMED, but that we just do not know it.  CMS mandates that the problem lists in EHRs use SNOMED codes, so when one selects "Exercise-induced asthma" from a pick list of problems in their certified EHR, they are actually using SNOMED. 
 
More difficult to articulate to physicians is how this proposal to convert from using ICD-9 to SNOMED codes in our EHRs would improve healthcare, how it would improve their work flow and how this is more cost effective for physicians as compared to complying with the current mandate.  So I have developed the following bullet list to use when describing this to my colleagues:
 
  • Informatics experts are in agreement that ICD-9 is obsolete, and that although ICD-10 has potential to improve healthcare, ICD-11 and SNOMED have higher potential to improve healthcare. 
  • SNOMED, which is interwoven in ICD-11's development, is inherently compatible with ICD-11 and is already required by CMS to be incorporated into certified EHRs for Problem Lists--thus, mandating use of SNOMED is not really new to physicians and will not result in an added cost to physicians
  • EHRs can be built with technology that automatically converts SNOMED codes into ICD codes--thus, mandating use of SNOMED is agnostic to the version of ICD-X being used; the cost to physicians of using the translating technology is very small as compared to the cost of finishing the conversion to ICD-10 and then converting to ICD-11 in the next 15 years.
  • After we convert to ICD-10 in 2015, discussions about implementing ICD-11 will ensue; since ICD-10 is over 20 years old and is less sophisticated than ICD-11, it will become apparent rather quickly that we need to convert to ICD-11 as soon as possible in order to improve healthcare (i.e. today's argument about ICD-9)
  • It takes the U.S. 7-10 years to refine the international version of ICD codes into the U.S. version we use--since the ICD-11 international version is expected to be completed in 2017, the earliest conversion to ICD-11 in the U.S. would be 2024 unless an unprecedented effort to accelerate development took place
  • In any case, converting to ICD-10 in 2015 will result in two ICD conversions in physician practices over the next 15 years.  The proposed alternative strategy to convert physicians one time from ICD-9 to SNOMED results in just one conversion with all future ICD conversions occurring in the background without significant impact on physician practices--thus, mandating the use of SNOMED to replace ICD-9  would be a significant cost savings to physicians.
  • SNOMED codes have been developed for the purpose of clinical input; ICD codes are developed for important administrative and financial output purposes-- thus, use of SNOMED codes for input will improve physician work flow because SNOMED is more intuitive to use for physicians to describe clinical encounters; this also preserves the use of ICD code sets for the important administrative and financial functions that our healthcare system currently depends on.
I believe that if CMS is going to maintain their mandate to move off of ICD-9, then we should move on to an available coding system that has the most potential to improve healthcare at the lowest cost:
 
  • Informatics experts agree that ICD-11 is more sophisticated and has more potential to improve healthcare than ICD-10, but the earliest that a US version of ICD-11 could be available is 2024 unless an unprecedented effort to accelerate development occurs
  • On the other hand, SNOMED is already incorporated in EHRs and being used by physicians
Thus, I believe the mandate to convert off of ICD-9 is more likely to improve healthcare, improve physician work flow and impose the lowest costs if we make the 2015 conversion to ICD-10 optional for physician practices and mandate physicians start using SNOMED (with the translator technology incorporated in EHRs) in 2017.    There will inevitably be tactical challenges involving diverse groups of healthcare stakeholders to work on, but if we remain aligned to the goal of improving quality care, I am confident we will find mutually agreeable solutions. 
 
cook children's healthcare system

Health IT-related patient safety risks should inspire Congress to create a national patient safety board

The idea’s time has come. The U.S. healthcare system needs a national, independent entity empowered by Congress to oversee health IT patient safety. Now.

In today's world a health IT-related patient safety issue that is identified by a physician practice or hospital is investigated and managed in a nontransparent manner by the individual provider and the EHR vendor.  

Although the issue may be escalated to a local accountable care organization (ACO) or patient safety organization (PSO) that providers are increasingly becoming associated with, neither the issue nor the results of the investigation are reported to a statewide or national oversight entity. The patient safety data is therefore not collected, aggregated and analyzed at a state or national level. Without such oversight we are missing out on the opportunity to identify known avoidable health IT risks to patient safety and failing to disseminate knowledge on how to manage those risks. For example, if an issue is resolved at the physician practice between the physicians and EHR vendor but is not addressed at other practices that use the same EHR, then patients at those other practices remain at risk. 

I have observed EHR vendors tune in to patient safety issues more keenly in the past decade and sometimes make more visible efforts to ensure identified issues are addressed with all customers and not just the ones who report issues. And let's be clear that a majority of EHR-related patient safety risks are related to how an EHR product is being used or implemented by their clients and not due to inherent technical flaws with the vendor's product. Nevertheless, patient safety should be viewed as a shared responsibility between the physicians, their practices or organizations and the health IT vendors. Identifying and managing patient safety risks is done most effectively when all cooperate in a team effort.

In Texas there had been discussions within the Texas Medical Association about establishing a central, statewide EHR patient safety entity to monitor and manage health IT-related patient safety issues. The data would be rolled up from hospitals, physician practices and patient safety organizations across the state for aggregation and analysis. However, it became evident during those discussions that it would be feasible and much more beneficial to establish governance at a national level.

So why does this need to be a new, independent national agency charged by Congress to oversee health IT patient safety? 

Today there are many government agencies and private entities that I believe could and should contribute to patient safety surveillance and improvements, but none have the expertise, assets and time that are necessary to coordinate a national effort. In addition to the complexity involved with collecting and analyzing data from hundreds of institutions and PSOs, there are hundreds of unrelated EHR vendor products being used. There is not yet any available registry of health IT products, many of which are subdivided into multiple versions that sometimes vary widely in their available functionality. As a result, I strongly agree with the observations and recommendations described in an article by Singh, Classen and Sittig (J Patient Saf, Dec 2011; 7(4): 169-174) calling for a national patient safety board that is an independent government agency structured similarly to the National Transportation Safety Board. This entity would be charged by Congress to oversee HIT patient safety and coordinate with other agencies who can contribute to improvement in patient safety such as the Office of the National Coordinator, the Federal Drug Administration, the National Institute of Standards and Technology, the Agency for Healthcare Research and Quality, the Center for Medicare and Medicaid Services, the National Quality Forum, local patient safety organizations, local healthcare organizations who collect patient safety data, other local EHR patient safety reporting entities and industrial (EHR and HIT) trade associations. All of these entities need to function in a cooperative fashion in order to effectively identify and manage health IT-related patient safety risks.

The recent health IT report from the Food and Drug Administration Safety Innovation Act (FDASIA Health IT Report) proposes a framework to improve health IT-related safety risks including a proposed National Patient Safety Center. 

I am concerned, however, that the proposal does not appear to provide this entity with enough authority to get the job done effectively. A national patient safety entity must have the authority to not only monitor activity and provide learning opportunities for vendors and providers, but also to regulate activities, investigate events, ensure issue resolution and require compliance. I do not see enough "teeth" given to the entity proposed by the FDASIA report. 

The primary focus of a national Health IT Patient Safety Center should be on the dedicated surveillance of HIT-related safety risks and to promote learning from identified issues, potential adverse events (“close calls”) and adverse events. But it must also have the authority to effectively manage identified risks and ensure compliance with best practices for health IT patient safety.


Ask Not What ICD-10 Can Do For Healthcare, Ask What Healthcare Can Do With SNOMED and ICD-11

ICD-10 is so “last century”.    The United States did not adopt ICD-10 twenty years ago when the standard was first developed.    The current version of ICD-10 that the United States is designated to adopt is based primarily on the international version of ICD-10 that the World Health Organization (WHO) published in 1990.    The international version was drafted by committees that began their work over thirty years ago in 1982 (see 2nd Edition of ICD-10 by WHO).    In other words, our version of ICD-10 is based on work done before use of the rich information space called the Internet became common and before the human genome was mapped.

ICD-11 is “this century”.    According to an article in Healthcare Financing News, Christopher Chute who is one of the leading informatics experts and a Chairman of an ICD-11 Revision Steering Group at the World Health Organization stated:

“ICD-11 will be significantly more sophisticated, both from a computer science perspective and from a medical content and description perspective…. Each rubric in ICD-11 will have a fairly rich information space and metadata around it. It will have an English language definition, it will have logical linkages with attributes to SNOMED, it will have applicable genomic information and underpinnings linked to HUGO, human genome standard representations. ICD-10, as a point of contrast, provides a title, a string, a number, inclusion terms and an index. No definitions. No linkages because it was created before the Internet, let alone the semantic web. No rich information space.”

ICD-x codes are used by non-clinicians for important administrative and financial purposes.    SNOMED-CT, on the other hand, is what physicians will actually use to communicate information about patients in their electronic health records (EHRs).    In fact, physicians must use SNOMED vocabulary in their EHRs, not ICD-x codes, for their problem lists in order to achieve Stage 2 Meaningful Use for incentive payments and to avoid Medicare penalties in the future.    Unlike ICD-10, ICD-11 is based on SNOMED.  And SNOMED includes over 311,000 concepts with unique meanings, making it more granular than ICD-10 or ICD-11.  

One way to think about the relationship is that SNOMED is the input and ICD-x is the output.  SNOMED is used by clinicians to input clinical information into the EHR at a high level of detail.  ICD-10 and ICD-11 aggregate that data into less detailed classifications that are more useful for output purposes such as quality reporting.    They really cannot replace each other.   But we could and should require EHRs to map in the background the SNOMED codes used by physicians into the ICD-x codes used by others.    No need to engage physicians in ICD-x debates or to learn new vocabularies each time WHO does their thing with the U.S. traditionally following way behind.

So what the HIT are we thinking?    Do we really believe that healthcare quality will be significantly improved based on ICD-10 that was developed out of work done over 30 years ago before the Internet was commonly used and before human genome coding was completed?    Or do we believe that we need to adopt ICD-11 for output purposes and to use SNOMED–CT in EHRs for input purposes in order to move the quality needle in the right direction?

I for one believe that we need to get to ICD-11 as soon as possible.     And I believe we should cut the umbilical cord to ICD-10 right now because:

  1. There is currently no information showing that a conversion to ICD-10 is required before ICD-11.
  2. It is intuitively obvious that the costs of going to ICD-11 directly from ICD-9 would be less than incurring the remaining costs of implementing ICD-10 in 2015 (or later) and then implementing ICD-11 sometime thereafter.    And that includes the sunken ICD-10 costs.    If you believe that this is an outrageous assumption, then prove it to be untrue.    Show the comparative costs of both pathways.    But don’t just comment or blog that it’s ridiculous without providing some kind of evidence.     Sometimes it’s wisest to go with intuition.
  3. The ICD-10 implementation has been so painful that it is unlikely the industry will have the stomach to move on to ICD-11 within a decade.    This will result in an excessively long delay to ICD-11 and an excessive period of time using a classification system from the previous century.
  4. There is consensus among leading informatics experts that ICD-11 is superior to ICD-10

 

Matt Murray, MD


Dangerous Precedent Set To Financially Penalize Doctors Who Fail to Influence Patient Behavior

I strongly oppose use of quality measures that incentivize or penalize physicians based on their ability to influence patient actions when those actions are beyond reasonable control of physicians or if there is no evidence linking such actions to improvements in patient outcomes.    That is why I believe there is a dangerous precedent being set in the Stage 2 electronic health record (EHR) incentive payment rule which will penalize physicians if they fail to influence patient behavior in a manner desired by the Centers for Medicare &  Medicaid Services (CMS).    

Two of the 17 Stage 2 core objectives hold physicians accountable for ensuring that their patients use technology at home.   One measure requires at least 5% of unique patients seen during the reporting period to send a secure message to the physician's practice using the electronic messaging function of the EHR.   A second measure requires at least 5% of unique patients seen during the reporting period electronically view, download or transmit their health information.   

In order to qualify for Medicare and/or Medicaid EHR incentive payments and avoid financial penalties, physicians must meet all 17 core measures as well as three from a menu of six additional measures.    Physicians must also report on nine of a total of 64 specific clinical quality measures.  Physicians who fail to do so by 2015 will not only fail to receive annual EHR incentive payments, but also be penalized by CMS through annual payment adjustments. 

In the final rule for the Stage 2 EHR Incentive Program CMS responded to public comments on these two new core objectives. CMS argued that physicians are in a unique position to strongly influence the use of technologies by patients "to improve their own care."    They did acknowledge a potential barrier of limited broadband internet access that could impact some physician practices and patients.   So in the final rule CMS lowered the threshold from 10% to 5% and added an exclusion for practices that are impacted by limited broadband access.   CMS summarized their response with, "We believe that this lower threshold, combined with the broadband exclusion detailed in the response, will allow all EPs (eligible physicians) to meet the measure of this objective."

I can agree with CMS that physicians should leverage the influence we have on patient behaviors as part of the care we provide.   We certainly are in a unique position to help patients become more engaged in and compliant with their healthcare.   I even agree with CMS that the lower thresholds should not be difficult to meet and that it is important for physicians to offer these technologies for patients to use.    

My key point of contention with CMS is with the presumption that use of these specific technologies at home allows patients to "improve their own care".    If use of these technologies were objectively linked to improved patient outcomes, I could understand the value in financially incentivizing physicians to move patients in that direction.   Without such evidence the government's relationship with physicians would be better served through a more tactful approach to promote the use of promising technologies by patients without the strong-armed threat of financial penalties on doctors. 

CMS misses the point on this one.    Precedent should not be set to penalize physicians based on measures of their ability to engineer desired patient behaviors when those behaviors are not objectively linked to improved patient outcomes.   I am not saying that we should not offer these technologies to our patients.    I am saying that we should promote their use and then study how that use impacts the quality of care

 

 


CMS Decision on ICD-10 Spurns Optional Path to ICD-11 Without Comparing Value

 

"The decision to mandate ICD-10 for covered entities has already been made."  

This response in the ICD-10 final rule published last Friday by the Department of Health and Human Services (HHS) bluntly spurns the option of foregoing ICD-10 to implement ICD-11.   HHS predictably argues that the considerable investments already made by healthcare organizations into ICD-10, the years of rulemaking with previous analyses of ICD-10 value/costs and the "uncertainties" over the timeline and value of ICD-11 all justify a decision to eliminate ICD-11 as an option.  

I am disappointed that HHS made no estimates on the comparative value of ICD-10 to ICD-11.   Instead of comparing the total cost of proceeding with ICD-10 and then implementing ICD-11 to the total cost of foregoing ICD-10 to implement ICD-11, HHS candidly explains that "we do not participate in this debate in this rule, except to say that we are convinced of the benefit of ICD-10 to health care delivery in this country."  There clearly was no intent to revisit a previous decision to implement ICD-10, even though there is an opportunity to gather and analyze new information to assure we make an informed decision on the optimal pathway to an inevitable ICD-11 implementation. 

The final rule dismisses the call from several commenters on the proposed rule for an analysis of the total costs of the two pathways to an ICD-11 implementation.   One argument made against such an analysis is that the "the disruption and costs of transitioning to ICD-11 are highly unlikely to be less those of transitioning to ICD-10."  I agree that each individual implementation may have comparable costs, but that does not compare the cost of the two pathways which are: 

  1. Implement ICD-10, then implement ICD-11 (two complete implementations)
  2. Forego ICD-10 to implement ICD-11 (one implementation + sunken ICD-10 investments)

What is the comparable cost of each pathway? A comparison of the cost and benefits could have a significant impact on the decision.  Let's learn from this for next time. 

By the way, there will soon be a next time.  I fear that this decision locks the U.S. into another cycle of the same-- using a diagnosis coding system that rapidly becomes archaic and leads to another decade of desperate efforts into the 2030s to upgrade after the rest of the world has already transitioned to ICD-11.

I also fear that that the burden will be excessive on healthcare organizations in 2014 to implement ICD-10 and meet the 2014 Stage 2 Meaningful Use requirements which were both announced by CMS this week.   This burden will be greatest on the small, individual physician practices are already throttled by meaningful use, 5010, e-prescribing and healthcare reform.  They are struggling to find the time and resources for the ICD-10 effort. Since the EHR Incentive Program has a specified timeline under ARRA, I believe this excessive burden is likely to trigger another delay of ICD-10, at least for small physician practices.  

Will we be left wondering why we didn't just stop investing in ICD-10 back in 2012?


Keep the data collection cart behind the trailblazing horse

In today's Health IT News there is an article expressing dissappointment with the recently released proposed rules for Stage 2 of the Electronic Health Record (EHR) Incentive Program.   Some alarming viewpoints are evident in this article regarding the collection of data for use by the federal government to improve public health .

The proposed rule for Meaningful Use Stage 2 on page 13702-13703 specifically states that the purpose of Stage 2 Meaningful use is to "“encourage the use of health IT for continuous quality improvement at the point of care and the exchange of information in the most structured format possible”.    No where in the rule does it state that the primary purpose of Stage 2 Meaningful Use is to collect data for use by the federal government as is suggested by concerns expressed in this article.   Let's keep the data collection cart behind the trailblazing horse so that it does not aimlessly roll down the steepest part of the hill instead of steering toward most beneficial path.   Stage 2 objectives draw a sensible roadmap to the next planned destination where we can finally begin realizing the maximum potential value of health IT and EHRs.   We currently have the horse trotting around potholes toward the widespread adoption and successful use of EHRs, the development of robust HIE networks, the maturation of EHR product functionalities and an improved understanding of safe EHR usage.   If we fail to align Stage 2 activities with Stage 2 goals by taking unplanned shortcuts to collect and use data in hopes of improving care now, I fear the cart will crash and cripple the momentum that Stage 1 has initiated.