Article – MU No More…Meet MACRA, MIPS and APMs

The death of Meaningful Use (MU) will not be mourned by many physicians.

While the overall program drove adoption of electronic medical record (EMR) systems, which is necessary for information accessibility, the measures required to be reported upon were viewed by many as misguided and not a reflection of the actual practice of medicine.

Also, many of the EMR systems implemented were criticized as being hard to use with limited capabilities to allow information interoperability with other systems.

Regardless of one’s views of MU, CMS is moving on.

With a keen focus on patient outcomes, CMS is looking to new models for reimbursement, such as the Medicare Access and CHIP Reauthorization Act (MACRA) legislation, introduced last year.

CMS is also intent on addressing the lack of interoperable patient record information.

“We’re deadly serious about interoperability. Technology companies that look for ways to practice data blocking in opposition to new regulations will find that it will not be tolerated.”

Andy Slavitt, acting administrator of the Centers for Medicare & Medicaid Services

The MACRA site provides an overview of Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs), which are sure to be popular acronyms to fill the void created by the decline of the use of MU in discussions.

Here is another article on Slavitt’s comments. And another article by HIMSS.

My previous posts on healthcare payment reform are herehere and here.

ACR: CMS Delays Clinical Decision Support (CDS) Implementation Requirement

ACR post (30-Oct-2015) is here.

Highlight…

…CMS states that they anticipate including further discussion and adopting policies regarding claims-based reporting requirements in the CY 2017 and CY 2018 rulemaking cycles. Therefore, they do not intend to require that ordering professionals meet this requirement by January 1, 2017

Article – First Look at Stage 3: CMS Sticks to Its Guns on APIs, Patient Engagement

Here is a good summary on what is new in Meaningful Use Stage 3 Rules.

This excerpt caught my eye:

As far as timing goes, CMS said it disagrees that the API functionality cannot be implemented successfully by 2018 “as the technology is already in widespread use in other industries and API functions already exist in the health IT industry.”

All of this should be a boon for the FHIR (Fast Healthcare Interoperability Resources) standard development community and the Argonaut Project, working on API-related standards, as well as for the broader community of mobile app and personal health record developers. With barriers to patient access to their data coming down, patients will finally be able to create their own portals, separate from any health system and share that data with whomever they want.

This is good news for everyone.

If we truly want so solve issues that require access to information where and how we need it, we must provide interoperability. This means not only the data needs to available be in a format that is understood and supported by common applications, it means the method of discovering and accessing that data needs to be understood and supported, as well.

FHIR® (clinical data) is built on the right web technologies and design methods, as is DICOMweb™ (imaging data). With these APIs, we can discover and access the necessary patient information and make it available in any care setting we need.

And these APIs will create the foundation of data liquidity to spark an explosion of innovation of applications—including traditional departmental and enterprise ones, but also web and mobile ones.

Without clearly defined, supported and accessible APIs, we (healthcare) had no hope of achieving the kind of system-wide change required. We have no more excuses now.

Article – The Healing Power of Your Own Medical Records

This NYT article tells the story of a very bright young man that took control over has health data and probably saved his own life. Few of us have the knowledge to do what he did, but most would agree that having the choice to access our health data is the right approach.

I suspect that as long as the risk of uninformed patients misusing the information they access and the risk of unauthorized access of protected health information outweigh the demand for access to the information, progress will be limited. How do we balance freedom of information and data liquidity with effective access controls and reasonable assignment of liability?

Previously, I blogged about my thoughts on patient privacy and its use as an excuse for an non-interoperable patient record.

Meaningful Use Stage 3 Rule and Imaging

At 3 pm ET on March 20, 2015, CMS released the Meaningful Use Stage 3 proposed rule to “specify the meaningful use criteria that eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) must meet in order to qualify for Medicare and Medicaid electronic health record (EHR) incentive payments and avoid downward payment adjustments under Medicare for Stage 3 of the EHR Incentive Programs.”

Here is a useful overview of MU Stage 3 (not just about imaging). And here is another MU Stage 3 overview. And here is an infographic.

A quick search for any mention of “imaging” (there are no instances of the word “images” in the 301 page PDF document; I checked), and here are the main excerpts.

Page 78

In alignment with the HHS National Quality Strategy goals, providers are encouraged to implement CDS related to quality measurement and improvement goals on the following areas:

Appropriateness of diagnostic orders or procedures such as labs, diagnostic imaging, genetic testing, pharmacogenetic and pharmacogenomic test result support or other diagnostic testing.

Page 81

Objective 4: Computerized Provider Order Entry

Proposed Objective: Use computerized provider order entry (CPOE) for medication, laboratory, and diagnostic imaging orders directly entered by any licensed healthcare professional, credentialed medical assistant, or a medical staff member credentialed to and performing the equivalent duties of a credentialed medical assistant; who can enter orders into the medical record per state, local, and professional guidelines.

Page 82

We propose to continue our policy from the Stage 2 final rule that the orders to be included in this objective are medication, laboratory, and radiology orders as such orders are commonly included in CPOE implementation and offer opportunity to maximize efficiencies for providers. However, for Stage 3, we are proposing to expand the objective to include diagnostic imaging, which is a broader category including other imaging tests such as ultrasound, magnetic resonance, and computed tomography in addition to traditional radiology. This change addresses the needs of specialists and allows for a wider variety of clinical orders relevant to particular specialists to be included for purposes of measurement.

Page 85

We also propose to maintain for Stage 3 the Stage 2 description of “radiologic services” as any imaging service that uses electronic product radiation (77 FR 53986). Even though we are proposing to expand the CPOE objective from radiology orders to all diagnostic imaging orders, this description would still apply for radiology services within the expanded objective.

Proposed Measures: An EP, eligible hospital or CAH must meet all three measures.

Proposed Measure 1: More than 80 percent of medication orders created by the EP or authorized providers of the eligible hospital’s or CAH’s inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry;

Proposed Measure 2: More than 60 percent of laboratory orders created by the EP or authorized providers of the eligible hospital’s or CAH’s inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry; and

Proposed Measure 3: More than 60 percent of diagnostic imaging orders created by the EP or authorized providers of the eligible hospital’s or CAH’s inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry.

Page 86

Based on our review of attestation data from Stages 1 and 2 demonstrating provider performance on the CPOE measures, we propose to increase the threshold for medication orders to 80 percent and to increase the threshold for diagnostic imaging orders and laboratory orders to 60 percent. Median performance for Stage 1 on medication orders is 95 percent for EPs and 93 percent for eligible hospitals and CAHs. Stage 2 median performance on laboratory and radiology orders is 80 percent and 83 percent for eligible hospitals and CAHs and 100 percent for EPs for both measures. We believe it is reasonable to expect the actual use of CPOE for medication orders to increase from 60 percent in Stage 2 to 80 percent in Stage 3 and the actual use of CPOE for diagnostic imaging and laboratory orders to increase from 30 percent in Stage 2 to 60 percent in Stage 3. We note that despite the expansion of the category for radiology orders to diagnostic imaging orders, we do not anticipate a negative impact on the ability of providers to meet the higher threshold as the adoption of the expanded functionality does not require additional workflow implementation and allows for inclusion of a wider range of orders already being captured by many providers. Therefore, for medication orders we propose the threshold at 80 percent and for diagnostic imaging and laboratory orders we propose the threshold at 60 percent for Stage 3.

Page 88

Proposed Measure 3

To calculate the percentage, CMS and ONC have worked together to define the following for this measure :

Denominator: Number of diagnostic imaging orders created by the EP or authorized providers in the eligible hospital’s or CAH’s inpatient or emergency department (POS 21 or 23) during the EHR reporting period.

Numerator: The number of orders in the denominator recorded using CPOE.
Threshold: The resulting percentage must be more than 60 percent in order for an EP, eligible hospital, or CAH to meet this measure.

Exclusion: Any EP who writes fewer than 100 diagnostic imaging orders during the EHR reporting period.

Page 221

A table lists the estimated time burden to attest for the CPOE rule (Measure 3 for Imaging), as 10 minutes for an EP and also 10 minutes for a hospital.

Article – Registries playing catch up with Stage 3

As Meaningful Use criteria advances to require sharing of population information with registries, this article explores some opinions on the readiness of public health agencies to accept and manage this data.

Is Radiology ready now? Check out all the ACR registries.

Article – CIOs push for patient ID progress

For those of you faced with connecting patient records with different patient ID domains across enterprises, or within an enterprise, this article is worth a read.

Some thoughts…

  • The need/want for privacy is not the real issue. The issue is the general lack of understanding in patient ID management and strategies for dealing with them.
  • I am interested to see what the ONC (through their new Patient Matching Initiative) does to solve this issue. Many enterprises have invested heavily to implement solutions (technical and staffing and policies) for dealing with multiple patient IDs. A new solution, however novel, will not be enthusiastically embraced by organizations that are committed to a path already.
  • Beyond cost and technical issues, there are societal ones. Not all people will be willing to be assigned a number by their government to track all their health data.
  • I believe observations that “nobody under 30 cares about privacy” are misguided and just wrong. It is true that younger people are more open about their social lives and personal interests, but that does not mean they want their sensitive health (or banking) information in the public domain.