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Medical Economics sat down with John Halamka, MD, MS, to ask questions about the Centers for Medicare & Medicaid Services' issuing of a Final Rule for attesting to Stage 3 of Meaningful Use programs as well as physicians' demands for delays of the 2017 starting.
On October 16, the Centers for Medicare & Medicaid Services issued a Final Rule with requirements for attesting to Stage 3 of the Meaningful Use (MU) programs. Physicians’ organizations have called for Congress either to delay the 2017 starting date for MU3 or to scrap the program entirely, citing among other reasons the fact that only a small percentage of physicians have attested to Stage 2 of MU.
To get a sense of where the Meaningful Use program may be headed, and why so few physicians have participated beyond Stage 1, Medical Economics contacted John Halamka, MD, MS, chief information officer of Beth Israel Deaconess Medical Center in Boston, Massachusetts, chairman of the New England Healthcare Exchange Network (NEHEN), co-chair of the national HIT Standards Committee, and professor of medicine at Harvard Medical School. The transcript of our Q&A with Halamka appears below.
Medical Economics: Do you want to make any predictions as to the future of Meaningful Use 3?
Halamka: My sense, based on 111 provider organizations asking Congress to delay it, is that the folks at CMS-who are actually quite wise-put a 60-day comment period into MU3, and that is actually a very unusual action. A final rule is usually that-a final rule. So I think their wisdom was, we have this thing called MACRA, [the Medicare Access and CHIP Reauthorization Act of 2015] and we have this merit-based pay that is around the corner, and we have this regulation called the Stage 3 Final Rule that isn’t quite aligned with the future of pay for outcomes.
They had to get it out quickly, because Stage 2 needed to be refined. So there was urgency to get the first part of the Rule out. So my prediction: the Stage 2 refinements are good and appropriate, and the Stage 3 new requirements will be held, deferred, as we work together on this merit-based payment approach. We just needed more time to do that.
Medical Economics: It seems you are not entirely satisfied with the rule for Stage 3 of Meaningful Use or the overall direction of the Meaningful Use program. Can you explain why?
Halamka: I think there is a time for government regulatory action, and a time for the private sector to take charge. I look at the history of the Meaningful Use program. Stage 1 brought us to a foundation. And that was very good. A basic EHR should have a problem list, a medication list, an allergy list. I think there was very little argument with that.
Then as we moved to Stage 2, a challenge was it created an ecosystem need. If you’re going to change the way patients and doctors interact, or if you’re going to require data-sharing from provider to provider, there needs to be a set of infrastructure and applications to support that. A good analogy would be, ‘I’m going to ask you to drive a car, but we haven’t built roads yet.’ So it didn’t exactly work. And that’s why only 12% of doctors have attested to Meaningful Use Stage 2.
So then as you move forward from Stage 2 to 3, you haven’t really even completed the Stage 2 activities and you’re already leaping into some more advanced functions. Some of those functions require more infrastructure that doesn’t quite yet exist.
Related:MU2: Mission Impossible
An example: I’m an emergency physician, but of course during my training I worked in many inpatient settings. As you prepare to discharge a patient from a hospital, it’s very common for the discharge medications to change. I try to figure out what you came in on, what you got in the hospital, what you leave on. So for me to e-prescribe a discharge medication, I need to be able to issue a cancel transaction; that is, I want to change the medications I’m discharging you on.
It turns out that pharmacies in the United States don’t yet support that transaction. So Meaningful Use requires that 60% of discharges be done electronically when pharmacies can’t yet support the workflow. So probably a little bit too much, too fast.
Another example: I love patient and family engagement. I’ve been doing it for 20 years, and I love the idea that new standards like the FHIR standards, the Fast Healthcare Interoperability Resources standard will open up EHR products to allow more data flows. But Meaningful Use 3 regulations say that if a patient happens to get an app they can effectively knock on the hospital’s or doctor’s door, and any app that the patient brings must have data from the hospital or doctor’s office flow into it.
So in my conversation with CMS last week I said, ‘so let’s imagine the Chinese government invents an application called stealmydata.com. And a patient comes knocking at my door. Am I allowed to say no?’ And then CMS said, you know, we hadn’t really considered that. And so, wait, you have a regulation that has a demand for which we don’t have data governance, we don’t have any standards, we don’t have a ruling from the Office of Civil Rights as to whose responsibility it is to maintain the integrity of the data? It sounds like too much, too fast.
So I think the issue here is it’s time to just acknowledge that the Meaningful Use programs have served their purpose. We have accelerated EHR adoption to doctors and to hospitals. And now it’s time for the industry and payers, providers, patients, all to work together on the next set of activities. And it’s probably not a great idea to have a bunch of federal agencies deciding very prescriptively what we should be doing.
Medical Economics: You recommend replacing the MU program with alternative payment methods and the MIPS that’s going to be part of the MACRA program. How are those two related?
Halamka: Imagine as we move from fee-for-service to bundled payments, I tell you that you need to reduce admissions. You decide that you’re going to give every 80-year-old an Apple watch, and you’re going to monitor their activity, and you’re going to make home visits to those who decompensate the norm so that they actually stay out of the emergency department. Well, that’s great. You have achieved the reduction of admissions through the use of technology.
So to me, if you say you will now be paid based on achieving an outcome, it will enforce this idea of technology adoption in a complex workflow that’s appropriate for the setting. It aligns incentives.
Medical Economics: We do that in some regards with ACOs and alternative payment methods, right? It’s making information technology part of that larger goal of getting to the outcomes that we want?
Halamka: Exactly. In my accountable care organization, BIDCO (Beth Israel Deaconess Care Organization) we created a care management medical record. That’s not an EHR. What a care management medical record does is to take the raw data from multiple EHRs, combines it all together and says ‘Oh, you have diabetes. I see, in all the places you’ve been, you haven’t had an eye exam. I see your glucose is trending up based on your home glucometer data.’
So in a way this care management medical record is something we built because ACO risk-based contracting required it, not because there was a federal government program called certification and the federal government defined what a care management record had to be. The market drove it, and quality was the outcome.
Medical Economics: How do you aggregate the data from all the different providers?
Halamka: In our care organization, which has 3000 providers, there are 26 different EHRs. That’s the nature of the marketplace, right. So what we said was, ‘it’s OK if you have Athena, Epic, eClinicalWorks, it’s all OK, but you must be able to submit, at each transition of care, about 150 data elements back to the ACO so that we’re able to look at quality and performance and gaps in care. We aggregate the data in a single place and do all our analytics based on that aggregation.
Medical Economics: How’s it been working?
Halamka: We’re the number one ACO in New England, and the number three ACO in the United States, having saved over $50 million so far.
Medical Economics: This is obviously a very complex and challenging issue. It calls for everybody to work together and work smartly in order to get this to happen.
Halamka: I agree. I think the federal government has done us a great service in building a foundation, leveling the playing field, giving us some basic functionality. And now as we turn to the Affordable Care Act, to MACRA, to the next generation of pay-for-performance, I think we need new solutions, and I really do see the industry coming together that payers, providers, patients, governments, and healthcare IT developers can work together very positively in the new world of pay for outcomes.