Tight Rope Walker

Will CMS Be Able to Achieve the Right Balance on Stage 2 Meaningful Use?

Today’s the day… All comments are due to CMS and ONC regarding the NPRMs for Stage 2 of Meaningful Use (MU). Judging from off-the-record conversations with colleagues, CMS and ONC are likely to receive a barrage of comments from many different perspectives.

Some of the likely areas of tension will be between and among:

  • Technology advocates who want to ensure that, while the leverage is present, the EHR industry is pushed to the maximum.
  • Patient advocates who want the promise of patient-centered care delivered as quickly as possible through the introduction of EHR features by placing requirements on EPs, EHs, & CAHs to motivate new actions (secure messaging; view/download/transmit) by the populations they serve or risk losing the EHR incentive payments.
  • EHR companies and health IT experts who raise concerns about the challenge of adding new functionality and features on top of new functionalities and features.
  • Healthcare professionals and societies who generally agree with the goals/objectives of MU but object to specific elements/metrics and take issue with the all or none scoring for MU incentives.
  • Quality measure developers and users who are concerned about the Clinical Quality Measures (CQMs) proposed and whether the measures could truly be captured through EHRs without adversely affecting health professional workflows and patient care.
  • Groups and individuals who question the pace of change being asked of EPs, EHs, and CAHs in the midst of other economic and market pressures.
  • Physicians and other health professionals who question the wisdom of linking the certification of new features/functions/requirements of EHRs to the almost simultaneous implementation of those same features/functions into practice — a potential unintended consequence of HITECH that could create patient safety issues.
  • Informaticists who are concerned about the standards being selected.

CMS and ONC will be challenged to find the appropriate balance between these and other perspectives.

Here is a sample from the publicly available comments regarding one particular measure, the View/Download/Transmit metric proposed for Stage 2 that illustrate the challenge CMS will have — just from this one measure. The content below is from letters posted online by mid-day May 7, 2012.

From the Society for Participatory Medicine comment letter to CMS:

Based on current use rates of PHRs, it seems that the proposed 10% threshold for patient engagement via PHR portals will not be easily attainable. The government is in a
position to mandate or recommend pathways to improve the usability of patient portals, thereby easing the ability of eligible providers to meet a higher threshold of patient
engagement under this measure.

With convenient secure access for patient advocates and on-line services, usability would improve, and meeting the 10% threshold will be made easier. It will also be more
likely that a higher threshold would be readily achievable under Stage 3 rules.

From the American Academy of Family Physicians this statement is from their letter to CMS:

This criterion mandates action by the patient (or their authorized representative). We cannot support this criterion in its current form and believe that
CMS should remove this requirement in the final rule.

Please understand that we have no objection to requiring Meaningful Users to be proactive in encouraging and assisting their patients to “view, download, or transmit to a
third party their health information.” We offer an alternative approach to the way the current objective is defined whereby EPs would be required to document that they have
the technology, that it provides connectivity with patients based on their ability/preferences for accessing it (secure provider website, patient health record, mobile
devices, paper, etc.), have reached out to patients to encourage their use of it, and have measured the extent to which it is being used.

From the American Hospital Association, this short section of a 68 page letter to CMS:

In addition to concerns about duplicative and contradictory regulations, we do not believe this objective is feasible as specified. Establishing a web portal or other mechanism to provide patients online access to this magnitude of data is unrealistic and premature. AHA survey data indicate that only 10 percent of hospitals had a patient portal of any kind in fall 2011. Our members report that none had anywhere near the functionality required by this objective. In canvassing vendors, they report no technology companies can currently support this volume of data or the listed functions. Further, the related measures in Stage 1 that this replaces were among the most challenging to establish, and for hospitals that have attested, there were high rates of exclusion: 68 percent claimed an exclusion of the Stage 1 e-copy of health information and 59 percent claimed an exclusion for the Stage 1 e-copy of discharge instructions. Given that the exclusions were provided if no patients asked for an ecopy of the information, it seems clear that patient demand for this information is not yet strong.

Note that while the National Partnership for Women & Families has not posted a letter to CMS as of this blog posting or a specific comment about the 10% view/download/transmit metric, Christine Bechtel took significant issue with the AHA’s letter to CMS in her blog post summarized in this Healthcare IT News article (note that the original blog post by Christine Bechtel was not accessible today through any of the previously published links, but this was the original link). In that blog post, Ms. Bechtel wrote that AHA “has little interest in advancing meaningful use criteria that would result in tangible benefits to patients.”

From the Patient-Centered Primary Care Collaborative (comment not posted to web yet, but this is from the final version):

The PCPCC supports the intent behind the proposed requirements to promote patient engagement using electronic technology to access personal health information and communicate with clinicians. For this to be achieved, the technology must be available to clinicians who in turn offer the technology to their patients (either because of a requirement or because of the intrinsic benefits) and patients must perceive that the use of the technology is beneficial, secure, and easy. The proposed requirements promote the use of this technology via the clinical practice, but as written require patients to engage in behavior that clinicians do not directly control. This is similar to other quality measures that depend heavily on patient behavior (for example, some prevention and disease control measures). An alternative approach would require clinicians to document they have the technology to enable connectivity with their patients based on their bility/preferences for accessing it (secure provider website, patient health record, mobile devices, paper, etc), they have engaged with patients to encourage their use of the technology, and they have measured the extent to which the technology is being used. One method of accomplishing this, as an example, would be to count as “compliant” those instances in which the clinical practice assists the patient with login onto the site where the information is available during an office visit.

From the American College of Physicians a section of ACP letter:

We fully support the right of all patients to have electronic access to their health information if desired. We also support the option clinicians have to withhold certain reports or documents when appropriate or required.

It is unreasonable to place the ability of EPs to achieve Meaningful Use in their ability to convince their patient to perform activities that patients may not wish to perform. Unless CMS has evidence that this is easy to achieve across a variety of settings and patient populations meaningful use payments should not hinge on the belief that 10% of patients will be willing and able to do so across all EP practices. If it adds value for patients, we won’t have to convince them to use it or count the number of patients who do so. Consider the challenge of convincing the patient to go online to see what was just talked about and provided to them a printed clinical visit summary. Why would they also bother to go online to view it? If the argument is that labs will be available in the future, many labs already send results via standard mail as a service to patients. Do we want EPs of such patients to ask labs to stop mailing results so that patients are more motivated to go online to view them as their only option for seeing their results?

The fact that some feel that a mandate is required to force this patient engagement activity is evidence that the market is not ready to accept this.

And this from the comment letter to CMS on the view/download/transmit metric:

We are proponents of the value of increased patient engagement and inclusion of robust patient engagement objectives and measures in Stage 2. We specifically support both the measure associated with ensuring patients have access to their information (view, download, and transmit) and the measure focused on increasing communication between patients and providers (secure messaging). At the same time, our detailed comments propose several refinements to the proposals, including ensuring that providers in fact have the flexibility that CMS proposes with regard to specific data transport methods, that they are not held responsible for the actions of their patients that are out of their control, and that the proposals for online patient image access be revised to reflect technical realities.

There are many other issues besides patient engagement and the view/download/transmit example used here to illustrate one particular area of tension. Issues such as the lock-step approach to certification of new EHR functions and implementation into practice; the thresholds of different measures; the quality of the CQMs; the ability of healthcare team members other than EPs to enter CPOE; the challenges of exchanging structured data for small practices… and the list goes on.

Despite the many different perspectives on the NPRM specifics, and the vigorous discussions already starting regarding Stage 3 of Meaningful Use (yes, the Federal Advisory Committee Act groups and subgroups of the Health IT Policy Committee and Health IT Standards Committee are now starting to muse about Stage 3), it is important that all advocates in this space be careful about questioning others’ motives for their positions. This is particularly important when it comes to the dynamic between consumer/patient advocates and healthcare professionals. We need to work together to make sure that the best health IT options are put forth in the most logical and safe manner possible, and that the enthusiasm to expedite patient and family-centered care does not lead to unintended consequences which could undermine the goals we all share.

Addendum (5/8/12; 7:35am ET): The American Medical Association posted its comments here.

This post is the personal opinion of the author and does not necessarily reflect the official policy or position of the American College of Physicians (ACP). ACP does not endorse a specific EHR brand or product and ACP makes no representations, warranties, or assurances as to the accuracy or completeness of the information provided herein.

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