Kudos to CMS for MU 2014 Proposed Rule

Lynn Scheps

Lynn Scheps

VP, Government Affairs & Consulting Services at SRS Health
Lynn Scheps is a leading resource on meaningful use and the EHR incentives. She is the SRS liaison with government policy makers. Representing the voice of high-performance physicians, she develops strategies to respond effectively to government initiatives.
Lynn Scheps

Doctors clappingYou can hear the sigh of relief—albeit mixed with a bit of uncertainty-driven anxiety—as physicians await publication of the final rule that will modify meaningful use in 2014. By relaxing the timeline, the government has finally acknowledged what so many stakeholders have been arguing for a while: Stage 2 and upgrading to a 2014 Certified EHR simply required too much of providers, too quickly. The paltry number of Stage 2 attestations to date is evidence enough—by May, only 50 physicians had attested to Stage 2; by June, just 447 had succeeded; and by July (mid-way into the year), the number had reached only 972. To put these numbers in context, over 378,000 providers have earned EHR incentives for Stage 1.

The major challenges that prompted the government’s reconsideration of the meaningful use timeline are reflected in the 1,184 comments submitted to CMS—some of which express frustration with the demands of the program in general, but almost all of which wholeheartedly support the proposed changes. (My comments, submitted on behalf of SRS physicians, are available here.) The following are the most common challenges cited:

  • Availability of 2014 Certified EHR Technology (CEHRT) – But it’s not just about the products that are not yet certified or about vendors with insufficient resources to keep up with the demand for implementations. Many of the products that have been certified were rushed out under overly aggressive and unrealistic timeframes, which has left physicians faced with not-ready-for-primetime software.
  • Overestimation of market readiness for interoperability – Sufficient infrastructure is not in place yet, so even physicians who have implemented the DIRECT messaging capability cannot find enough “trading partners” with whom they can connect to share information.
  • Dependence on non-participating parties – It takes an extraordinary amount of effort to successfully coordinate with labs, radiology providers, long-term care facilities, and registries, who are not required to conform to standards promulgated under meaningful use.
  • Reluctance of patients to embrace portal utilization – The two portal measures (patients accessing clinical information and sending messages to physicians) are cited by many commenters as the major obstacle to MU success. Changing patient behavior in this regard is turning out to be even harder to accomplish than previously anticipated.
  • Excessive workflow challenges – Meaningful use necessitates operational changes to practice workflows that are, in the words of one commenter, “daunting, at best.”

The options proposed in the rule are summarized in a handy CMS Decision Tool and include reporting Stage 1 again, instead of Stage 2, and attesting using either a 2011 or 2014 CEHRT.

So what can physicians expect and what would be a good strategy to pursue as they wait for the final rule? CMS is promising—or at least hoping—to publish the final rule in early September. The 60-day comment period ended on July 21, and CMS is obligated to read and consider all of the comments before issuing the final rule. However, I think it is reasonable for physicians to assume that the final rule will be at least as flexible as the proposed rule—maybe even more so. CMS has been asked by many commenters to definitively spell out the conditions under which physicians could avail themselves of the various reporting options, which would address the uncertainty created by the lack of clarity in the proposed rule.

In the meantime, physicians should plan to attest for any quarter during which they have met all of the requirements under one of the options provided for in the proposed rule. It can even be a quarter that precedes the publication of the final rule. They should then aggressively turn their attention to upgrading to 2014 CEHRT—if they have not done so already—and to preparing for Stage 2. Remember: as flexible as the rule may be, it only offers a 3-month reprieve. Physicians who were to be at Stage 2 in 2014 must now be ready to start a full year of reporting on Stage 2, using a 2014 CEHRT, on January 1, 2015.

How Much More Evidence Does CMS Need?

I was glad to see that CMS was concerned enough about the 17% meaningful use dropout rate to do some research into this rather alarming statistic. Some of what they discovered lends credence to the arguments put forth in the large—and growing—number of recent letters from stakeholder organizations suggesting that the meaningful use train is simply moving too fast.

In a recent presentation, CMS accounted for half of the non-returning providers as follows: 5% retired, 17% switched to a practice without an EHR, and 28% claimed to have simply forgotten or missed the deadline to attest.

The remaining 50% of the non-returners cited a number of reasons—some identifying more than one—that are quite revealing and can only lead to future falloffs in participation. The reasons given are presented in the CMS chart below:

How Much More Evidence Does CMS Need?

What more evidence do we need that physicians simply find meaningful use too complex, too time-consuming, and too costly? And that is only their assessment of Stage 1. Many of the non-returners were unable to meet one or more Stage 1 objectives, yet many Stage 2 measures will be considerably more challenging—for reasons other than increased thresholds. The Stage 1 menu measures that had the highest exclusion or deferral rates—i.e., the measures that most physicians did not select because they considered them to be most difficult—become required core measures in Stage 2. Compounding that challenge is the addition of totally new measures related to interoperability and patient engagement, all of which will require completely new workflows, staff training, and massive patient-education efforts.

Given the experience to date, the associated explanations provided by physicians, and the volume and passion of the requests pleading for some relief—from the burden of the requirements and from the impending penalties—some flexibility is clearly called for. How about at least backing off from the all-or-nothing requirement? Doesn’t it make sense for the long-term success of the EHR Incentive Program to offer physicians some flexibility at this critical juncture?

Physicians Benefit from CMS’ Harmonization of Program Rules

Physicians Benefit from CMS’ Harmonization of Program Rules width=Kudos to CMS for making good on its promise to align quality measure reporting and incentives across the various government programs with which physicians must contend. With the publication last week of the 2013 Medicare Professional Fee Schedule final rule, CMS delivered on the harmonization promised in the Meaningful Use Stage 2 final rule in August.

This is very good news for physicians. Without the compromises that CMS made in both rules, physicians would be confronted with the challenge of trying to participate in a minimum of 3 government programs that involve quality measure reporting—ePrescribing under MIPPA, meaningful use under ARRA, and PQRS—each with its own set of intricate requirements, timetables, populations on which to report, reporting mechanisms, and incentive/penalty schedules. Not only would this be incredibly complicated, but it could give rise to incongruous situations in which a physician might, for example, successfully ePrescribe as part of demonstrating meaningful use, and yet still be subject to a penalty for inadequately ePrescribing under MIPPA.

Among the key areas of alignment are the following:

  • Reporting for PQRS using the EHR reporting option (as opposed to claims or registry reporting) will satisfy the clinical-quality-measure-reporting component of meaningful use. PQRS EHR-based measures will be aligned with the measures available for reporting under the EHR incentive program.
  • Meaningful use clinical-quality-measure reporting via PQRS will only be on Medicare patients, while all other meaningful use measures will continue to apply to all patients, regardless of payer.
  • PQRS reporting will be done using the CEHRT (Certified EHR Technology) that is required for meaningful use, eliminating the current requirement to use a separately certified “PQRS-Qualified” system.
  • Successful ePrescribing under meaningful use will protect physicians from ePrescribing penalties under MIPPA.

The government programs remain complex—but there is no question that aligning them as the recent rules do will decrease the reporting burden on physicians, spare related administrative costs, and eliminate the costs associated with duplicate EHR certification requirements. Valuable physician resources will be better allocated to providing the quality of care these programs seek to measure.

Meaningful Use Stage 2: Did CMS Hear the Physicians? (Part 2)

Meaningful Use Stage 2: Did CMS Hear the Physicians? (Part 2)’ TimeIn my last post, I commended CMS for responding positively to many of the comments that were submitted regarding the Proposed Rule for Stage 2 of meaningful use. However, there were also troublesome areas that were acknowledged in the Final Rule, but addressed in a way that remains problematic for physicians. This post will review some of those issues.

Most notable are the two measures that make physicians’ incentives dependent on actions by patients—actions over which the physician does not have control. The Final Rule requires that:

  • More than 5% of all patients seen by the physician during the reporting period actually view, download, or transmit their available health information, and
  • More than 5% of patients seen send a secure message to the physician (containing health information, not just a request for an appointment).

The proposed rule had set the threshold at 10% for each of these measures. The response from the provider community was almost universal, arguing that no matter how much education, encouragement, and cajoling the practice provides to encourage this form of patient engagement, the physicians could not guarantee patient compliance. Alternatives were offered—my company suggested having the physician be the source of the messages, or holding him/her responsible for responding to a minimum percent of the messages received from patients. However, CMS held firm in its belief that it is incumbent upon the physician to encourage patients by offering an attractive, patient-friendly portal. By way of compromise, the Final Rule reduced the threshold from 10% to 5%, but this solution does not address the principle involved—i.e., the inequity of making the physician’s incentive dependent on the actions of patients. Just imagine if after successfully meeting all of the Stage 2 requirements for the 1,000 patients a physician saw during the reporting period, only 49 of the patients (instead of 50) actually viewed their information on the portal that the physician installed—his entire year’s incentive payment would be lost.

The menu set of measures is intended to afford physicians some flexibility—there are 6 measures from which they must select 3. Part of the rationale for this structure is to make meaningful use more meaningful for specialists. Yet in Stage 2, the menu measures that a physician is eligible to exclude will no longer count as being met, so many specialists will be left with no real choices at all—the menu measures become de facto core measures. Many specialists will find 3, or even 4, of the menu measures to be in that category—CMS acknowledges that syndromic surveillance is still premature, cancer registry reporting is likely irrelevant to most physicians, diagnostic images are only relevant to a few specialties, and many others will find no viable specialty registry to which to report so CMS “does not expect every EP to select this measure.” An ophthalmologist, for example, will have to report on the family history measure and the electronic progress note—not a measure they would choose if the menu were truly a menu.

Patient reminders is another measure that may be problematic for specialists who provide episodic care. Stage 2 requires the physician to send an appropriate reminder for follow-up or preventive care to 10% of the patients seen during the prior 24 months. No exclusion is available for physicians who see patients two or three times to treat a particular problem, but have no reason to ever recall the patient.

The above are examples of where CMS may have listened to the physicians, but didn’t really hear them. I hope that some further guidance related to these issues will be forthcoming to ensure that physicians are able to successfully demonstrate meaningful use in Stage 2.

Meaningful Use Stage 2: Did CMS Hear the Physicians?

Meaningful Use Stage 2: Did CMS Hear the Physicians?’ TimeKudos to CMS for responding positively and reasonably to many of the comments submitted by physicians and/or their professional organizations regarding the Proposed Rule for Stage 2 meaningful use. Of course, there were also a number of issues that could have been addressed more favorably from the providers’ perspective—and I will address those in my next EMR Straight Talk post—but I was pleasantly surprised to see the changes and the compromises that CMS did make that will benefit physicians.

The most significant concession was related to timing: in 2014, physicians will only report for a 90-day calendar quarter—rather than a full year, as originally intended. This should result in higher-quality, more-usable EHRs as vendors will have more time to develop, test, and certify their new versions. It also eliminates the fiasco that surely would have ensued for providers were they all to require upgrading by their vendors within a very small window of time. This new schedule also ensures that physicians will have the time they need to implement, and sufficiently train on, the new versions of their software, enhancing the likelihood that they will be able to successfully demonstrate meaningful use. The 90-day reporting period also provides some flexibility for those unfortunate physicians who hastily purchased an EHR in a rush to meet meaningful use and now find themselves dissatisfied with their decision—they will have down time that will make the replacement process easier.

I was also pleased to see several changes that address the reporting burden for physicians. Stage 2 offers a batch-reporting option—however, providers must still individually meet all of the meaningful use requirements—and it attempts to harmonize clinical quality measure reporting across the various government programs. These were two proposed concepts that physicians strongly endorsed in their comments.

Specialists particularly appreciate the Final Rule’s successful resolution to the challenges posed by the vital-signs measure currently in force—the new requirement unlinks the reporting of height and weight from the reporting of blood pressure. Beginning in 2013 (i.e., a year before Stage 2 even takes effect), physicians who find height and weight relevant to their practices (but not blood pressure) will be able to report the former while attesting to an exclusion for the latter. This will remove an irrelevant step in the workflow for many specialists.

While CMS did hear the physicians on these important issues, there are other areas that the Final Rule did not sufficiently address. I will discuss these in my next post.

Rome Wasn’t Built in a Day

In my last EMR Straight Talk post (Stage 2 Clinical Quality Measures—More Is Not Better), I maintained that simply adding a large number of new quality measures without addressing the underlying flaws in the reporting process will do little to advance the program towards its goals. So I was very interested in reading Joseph Goedert’s blog the following week in Health Data Management: “Why Must CMS Overreach on Rules?”

In discussing the proposed rule regarding Accountable Care Organizations (ACOs), Joe makes a similar argument to mine. He questions CMS’s proposal that, to share in an ACO’s savings, providers would have to report on 65 quality measures—including 28 new measures—when CMS will not even be ready in 2012 to electronically accept the considerably smaller number of quality measures associated with meaningful use.

In both cases, CMS is trying desperately to accomplish a long-term vision, albeit a noble one, in too short a timeframe. While formulating its proposal for Stage 2 meaningful use, the HIT Policy Committee had several intense discussions about the trade-off between (1) aggressively moving toward the end goal and losing people along the way because they were overwhelmed and feared failure, and (2) accepting a slower pace, but with a greater chance of success. The foundation of the programs have to be solid, or real progress will not be achieved.


Reader’s Correction/Clarification:

In my EMR Straight Talk post on August 10, (“HIE’s and Information Sharing—Physicians Feel the Pressure”), I incorrectly stated that without membership in NYU’s UPN (University Physicians Network), “physicians do not have access to the group’s favorably negotiated reimbursement rates.” I received a comment from Robert Goff, Executive Director of NYU’s UPN, stating that “UPN does not negotiate with any payer or health plan outside of fully compliant shared risk arrangements,” and that the requirement regarding physician information technology “is part of a broad initiative to promote enhanced quality and the delivery of more efficient health care.”

I apologize for the misstatement.

Meaningful Use Retrofit: Unintended Consequences

Question: What do you get when you try to retrofit a primary-care-focused government program to be relevant to specialists?
Answer: Unintended consequences.

In response to the outcry from specialists about the primary-care nature of meaningful use, CMS implemented some exclusions to make the program more workable for them—but these changes did little to make it more “meaningful.” In fact, there were some significant—and, I have to believe, unintended—consequences that will actually create challenges for many specialists:

  • Some physicians will have to add what they consider non-relevant vital signs to their workflow. Acknowledging that vital signs are not within the scope of practice for some specialties, CMS provided a potential exclusion for this measure. However, to take advantage of the exclusion, providers must attest that all three vital signs (height, weight, and blood pressure) do not apply to their practice. This leaves physicians who routinely record just one or two of the vital signs without a way to satisfy the measure, other than to add the non-relevant measurement, too—blood pressure for orthopaedists, height and weight for ENT specialists, etc. (For an explanation, read The All 3 Vital Signs Dilemma.)

Is it the government’s intention that orthopaedists take blood pressure on every patient? Perhaps—but if so, are these physicians then responsible for treating this condition? Some would argue that orthopaedists need to know their patients’ blood pressure if they are going to perform surgery—likely true, but why should this requirement also apply to non-surgical patients? It should not, but let’s remember: this is a primary-care-focused program, designed by primary-care physicians, and this type of analysis was never performed.

  • Some specialists will have to report on clinical quality measures (CQMs) that have no relevance to their practices—and in doing so will provide meaningless data. The accommodation for specialists in regard to reporting on CQMs was originally intended to allow them to identify non-relevant measures by reporting zero as the denominator. However, the meaningful use measure requires physicians to report CQMs using data that is directly generated by the EHR. This results in the inclusion of patients in the denominator of CQMs that are outside the scope of the reporting physicians’ specialties. Physicians will be forced to report on problems for which they did not treat the patients, reporting zeros as the numerators, but not the denominators. (For further details, see Clinical Quality Measures: Who Defines Relevance?)

This raises several issues. First, physicians are reluctant to go on record as not addressing a known problem, even when that problem is outside their specialty. In this litigious medical environment, this is not an unreasonable concern. Second, the data generated in this manner will be meaningless since numerous specialists will provide data on the same patients and on the same problems as are being treated by primary-care physicians—making it will appear that, on average, very little care is being provided for these problems. Some physicians will be trapped into providing data on measures that are not relevant to their practice, even though valid measures exist. For example, any pediatrician with even a few patients over 18 will have to report on those few older patients—using the core measures meant for adult populations—rather than report on his/her entire pediatric patient base, using the alternate core measures that were specifically added to capture valuable information regarding the pediatric population.

CMS acknowledges that the purpose of this particular requirement during Stage 1 is merely to get people comfortable with automated reporting—specifically stating that the government is not looking to gain valuable information about medical practices or the state of care being delivered. I am concerned, however, that the discussions to date about reporting on CQMs in Stage 2 do not advance us towards producing data that will be any more meaningful. To accomplish that, the entire structure would have to look more like PQRS, where physicians report only on measures directly relevant to their practices.

For meaningful use to be meaningful to specialists—beyond the financial value of the incentive money—the program needs to be restructured to fit their needs and practices. It is quite evident that trying to apply primary-care requirements to specialists is not effective.