There are many healthcare trade organizations and even more healthcare professionals who have expressed comments and concerns about the
interim final regulation (IFR) issued by Health & Human Services (HHS) and the proposed rule (NPRM) for
issued by the Centers for Medicare & Medicaid Services (CMS).
Although the public comment period for both have closed and government officials are busily trying to figure out what to change, some of the concerns or recommendations made by several of the healthcare trade organizations may be interesting to understand.
The purpose of this review is not to analyze each and every comment made by a selected group of associations. Instead, the purpose is to pick a few comments or recommendations from each in order to get a flavor of the perspectives. The selected organizations for this review pulls from various constituencies – physicians, hospital IT, healthcare standards, healthcare information management, etc.
In reading through the details from each of these organizations, there were several common themes and reactions as well as some key differences. Many of the differences are probably based on the interests of the professionals they represent.
Outlined below is a summary of the various perspectives:
Healthcare Information and Management Systems Society – HIMSS…
Highlights on the Meaningful Use NPRM and Healthcare Standards IFR include:
Expand, Not Limit, Physician Participation: As the proposed rule reads now, professional who work in an outpatient clinic setting of a hospital or integrated delivery system would be excluded from receiving the incentives. Estimates are that one-third of professionals would be excluded. Instead, participation should be expanded. The recommended change is if a hospital-based Eligible Provider (EP) is using an ambulatory-certified EHR, they would not be considered a hospital-based EP.
Lessen the Criteria for Meaningful Use: The Meaningful Use criteria contains many elements, including reporting on more than 20 functional measures, using CPOE, developing metrics based on a numerator and a denominator (i.e., as a percentage whereby some of the data is not within an EHR system), and reporting up to 43 summary quality measures for an eligible hospital. The call is for flexibility in meeting the requirements and lowering the benchmarks, especially in Stage 1. Some suggestions include:
Lowering CPOE order requirements to 50% (instead of 80% of all orders coming through CPOE)
Lowering electronic prescribing requirements to no higher than 50% (instead of 75%)
Lowering lab test results being electronically incorporated into a certified EHR is not practical based on many labs today do to create interfaces for smaller providers and it may present too much of a cost burden to do so
Incomplete Interoperability Roadmap: In general, the IFR does not outline a clear direction on how all the standards need to come together to support healthcare interoperability. There is too much vagueness for vendors to deliver functionality and providers to drive towards a realistic implementation. Some of the standards may not be mature enough, while some need to be phased out as others become the approved approach. Since many of the healthcare exchange requirements begin in later stages, there is time to provide clarity, and it is needed quickly. Without clarity, the later requirements will be in jeopardy.
Read the full HIMSS statements: Healthcare Standards IFR Statement and Meaningful Use NPRM Statement.
American Health Information Management Association – AHIMA …
AHIMA’s Highlights on the Meaningful Use NPRM include:
CPOE Requirement: Since CPOE is an “advanced EHR,” its required implementation should be delayed until Stage 2.
Code Sets: SNOMED CT® is the preferred standard for code sets, although ICD-9-CM works for Stage 1 since EHR vendors are not ready to implement SNOMED.
Appropriate Application: There are several instances where AHIMA states the EHR is not the appropriate application for a specific action or place to store specific data. For example, insurance eligibility and claims processing are not functions in most EHRs, according to AHIMA. The regulations need to be defined with the right application associated. In other words, the requirements should not place duplicative functionality in an EHR system when it is already done in a complimentary, separate application.
Progress Notes: Progress notes need to be included as part of Meaningful Use measurement criteria. Without progress notes, the patient care story is incomplete, triggering a “fundamental” workflow issue.
Read the full
American Medical Association – AMA in conjunction with other various physician organizations …
The AMA’s Highlights on the Meaningful Use NPRM include:
Timelines: The Stage 1 criteria for achieving Meaningful Use is too aggressive and will deter physicians from participating in Medicare and Medicaid programs. This runs counter to the intent of the HITECH provisions in the ARRA legislation. Additionally, the majority of physician practices have five or fewer physicians. Without less aggressive timelines, these practices will be challenged to participate fully in the objectives and incentives of HITECH.
Representation: Smaller physician practices need to have representation on the Health IT Policy Committee so that the guidelines take into account their requirements and challenges, especially since these practices account for 80% of all outpatient visits.
Hospital-based EP Definition: The current proposed rule would exclude many physicians from participating in this initiative. Hospital EPs who also deliver patient services within their office-based practice should be eligible for the incentives and the use of their qualifying EHR used in their office practice. Essentially, these physicians do not use the hospital’s EHR in their office-based practice. If they have a qualified EHR in their office-based practice, then these physicians should be eligible to participate in the incentive programs.
Use of CPOE in Stage 1: The benchmarks for CPOE use in Stage 1 are too high. CPOE has many benefits, but the implementation and adoption is complex. Furthermore, introducing new technologies can increase the possibility of errors. Given the patient safety concerns, implementing CPOE in deliberative manner with detailed training is necessary, so the usage benchmarks should reflect a slower implementation process.
Electronic Prescribing Stage 1 Benchmark: E-prescribing is fully supported, but the 75% threshold requirement for Stage 1 is unrealistic. There are many prescriptions that cannot be electronically transmitted due to technical barriers and patient preferences.
Lab Tests Electronically Communicated to EHRs: The 50% threshold requirement for Stage 1 is too high. The cost and burden of getting the interfaces in place is too much for many smaller practices.
Read the full AMA Statement.
Joint Statement from Various Radiology Associations (ACR, ABR, RSNA, and SIIM)…
Highlights on the Meaningful Use NPRM include:
Certified EHR Definitions – Modular versus Complete: Many radiologists perform services extensively in the Medicare program and about 74% of the active radiologists perform some of their services outside of the hospital setting. Consequently, they would be classified as an EP and eligible for incentives. EHR requirements need to be clinically relevant to a radiologist’s practice. Radiologists use certain modules of an EHR, but typically do use a complete EHR. To be eligible for the incentives, radiologists would need to implement modules which they would not use in their practice. The final definitions need to focus more on relevant EHR modules for a specific type of practice versus applying a generic or complete EHR definition across all specialties.
Vocabulary Standards Plus: RadLex needs to be adopted as a vocabulary standard in the healthcare standards regulations, just as LOINC is for lab tests. Radiology uses RadLex to unify other lexicons and standards. Additionally, radiation dose must be a core Meaningful Use requirement and needs to be incorporated into EHR certification requirements. For Stages 2 and 3, the electronic exchange of diagnostic images needs to be addressed and included in the healthcare interoperability initiatives. Finally, evidence-based guidance should be available for ordering physicians when requesting imaging procedures. These clinical decision support capabilities exist and should be required in use of CPOE systems in Stages 2 and 3. This will help the imaging overutilization concerns expressed by the Health IT Policy Committee and others.
Read the full Radiology Joint Statement.
American Academy of Family Physicians – AAFP…
AAFP’s Highlights on the Meaningful Use NPRM include:
No to CCR: According to ASTM, responsible for the Continuity of Care Record (CCR), “The CCR XML is not a persistent document, and it is not a messaging standard.” CCR highlighted deficiencies: lacks standard vocabulary data elements; cannot communicate relevant information such as ‘hospital course;’ creates ambiguities and removes important context; and cannot provide input into clinical decision support. CCR “cannot be realistically used to convey information from an inpatient setting…”
Yes to CDA and CCD: HL7 CDA should be used for exchanging documents and the HL7 CCD Implementation Guide as the starting point for patient care summaries. The use of CDA and CCD needs to be sorted out further since the CCD should not be used for discharge summaries; instead, other HL7 document types for CDA would be more appropriate. On vocabulary standards, SNOMED with CCD should be used since ICD codes have “too little clinical detail” to be used for clinical decision support systems.
Patient Identifier Gaps: EHR systems do not have the proper patient identity management requirements in place so that patients can be properly identified in health information exchange networks. A foundation or direction should be established in which EHR modules can identify patients with the following areas being addressed: patient identity techniques using key identifiers; matching algorithms; matching reliability; handling an alias; handling duplicates; and handling incorrect matched identities.
Read the full AAFP Statement.
Health Level International – HL7…
HL7’s Highlights on the Meaningful Use NPRM include:
Timing of Meaningful Use Requirements: Achieving the outlined criteria by 2011 and 2012 is unrealistic for the many smaller physician practices. Without making an adjustment, a big opportunity will be missed to include the many smaller practices in this initiative.
Percentages versus Counts: On the measurements outlined in the rules, there is a concern on the administrative burden to calculate the percentages in the specified measurements. Rather than use percentages, absolute counts should be the preferred reporting approach. Moreover, in the outcomes reporting, the high thresholds cause concern. Rather than having an absolute threshold, the measurement should be based on amount of improvement achieved within a certain benchmark range. For example, if the benchmark is 50% or less in achievement, then the practice must show a 25% improvement in their reporting in order to be eligible for an incentive payment.
Excluding Primary Care Physicians in Hospital Organizations: There are many physicians which serve as part of a larger hospital-based organization but make their own investments in health IT. Excluding these physicians from the program does not seem to match the legislative intent.
Electronic Prescribing: The threshold of 75% of prescriptions being sent electronically is unrealistic, especially since only 16% are sent in that manner today. Many mail order pharmacies do not have electronic capabilities.
Lab Test Results: It is not a requirement for labs to provide an EHR interface for lab test results. The burden of meeting this requirement is too much on some practices, so a hardship clause should be offered for those EPs which do not have access to electronic interfaces from labs.
Electronic Access to Health Information: Having a percentage of patients who are provided timely electronic access is challenging. Instead, an absolute number should be used with the objective of it being greater than one.
Read the full
HL7 Statement on the healthcare standards IFR. Also read the HL7 Statement on the Meaningful Use NPRM.
There are many other statements by various organizations which can be read and summarized. However, in reviewing the above organizational statements, common themes emerge, which may be similar to other organizations not covered by this review. The following themes came through fairly consistently:
Slow it down – don’t overwhelm the medical practices and hospitals. Meeting the HITECH goals is more important than rushing the implementation and losing participation or, worse, failing. Don’t forget that the
majority of physician practices are small (fewer than 5 doctors). Ensure the rules are designed so that they can meet the objectives and participate fully.
Focus the healthcare standards. Set a firm direction so as to eliminate re-work later and provide greater focus now. Electronic exchanges are needed, but
ensure the infrastructure and approach is present to support the goals.
Don’t exclude physicians who offer patient care in a hospital setting but have invested in implementing an EHR for their individual practice outside of the hospital.
Health IT reform is complex with many different perspectives, specialties, and organizations involved. Getting it all aligned and moving forward on a similar path will be challenging, to say the least. However, to get higher quality care as well as higher efficiency, there may be no other expedited way to achieve these goals.