Electronic Health Reporter

As the comment period has come and gone (ended May 29, 2015) for meaningful use Stage 3, and as multiple organizations, like CHIME, and countless other individuals have taken the time to comment on the final rule, I thought it was a good time to ask the question: Does the meaningful use Stage 3 rule sail or sink?

Procuring responses to this question from a number of health IT insiders helps to identify some of the most pressing issues with the final stage of meaningful use, a topic that is almost second to none in regard to generating support or opposition from those in the sector.

The College of Healthcare Information Management Executives, in its comments on the rule, called federal plans for the third stage of meaningful use too ambitious and in need of several important changes, but still offered their support for a corresponding CMS proposal that would shorten meaningful use reporting in 2015 from a full year to any continuous 90-day period. In total, CHIME said meaningful use Stage 3 is “unworkable.”

“Were all requirements finalized as proposed, we doubt many providers could participate in 2018 successfully,” CHIME said. “And with so few providers having demonstrated Stage 2 capabilities, we question the underlying feasibility of many requirements and question the logic of building on deficient measures.”

Bennett Lauber, chief experience officer, at The Usability People offered a slightly different take: “The MU3 program contains some well-needed enhancements to the Safety-enhanced design portion of the 2015 certification criteria. They have also proposed significant changes to the Safety-enhanced Design (aka usability) testing requirements. These new requirements might seem burdensome to some of the smaller EHR vendors, as they require 17 and not seven items to be usability tested and finally set a minimum number of participants for these studies and more. With everyone complaining about the (lack of) usability of healthcare software these additional requirements should be welcome as they force the vendors to perform real summative usability tests and as a result it eventually might actually save lives.

David Muntz, former principal deputy director of the ONC and current CIO of GetWellNetwork adds, “Getting to a common stage is a good thing, but there is still some concern expressed by those who are struggling with the move from Stage 1 and Stage 2 to the future state. The limit on adding new elements is a positive, though some of the thresholds that need to be met will be a concern to many, particularly those that require a provider to affect behaviors in the patients. Standardizing quality measures and adjusting the reporting period are good moves, but the possibility of requiring all vendors to have a complete set will delay release dates.

“The encouragement to add APIs for data exchange is a positive. More thought, however, is needed to the areas where open APIs can prove beneficial. Secure messaging is great, but the threshold for usage is really based on patient preference and may be a bit aggressive. The greatest disappointment was the continued use of specific features and functions without an alternative to deem features and functions based on a combination of appropriate process and outcome measures. A deeming approach would have given the users a great deal of latitude in how to implement features and functions that would have produced favorable outcome.”

Tom Lee, CEO of SA Ignite, said, “Greater simplicity is good for providers: A single reporting period and a common version of MU starting 2018. The original charter for Stage 3 was to move to clinical outcomes-based measures. Although such a theme is not reflected in the meaningful use Stage 3 draft, the rise of value-based modifier, MSSP ACOs, and perhaps soon the MIPS with the SGR repeal bill (HR 2) assume that mantle. Stage 3 seems to solidify the specialization of MU on the usage and process-dimensions of EHRs, leaving to other programs to handle the clinical and outcomes-based measures underlying value-based payment.

Eric Rice, chief technology officer, Mach7 Technologies, adds, “’Because MU3 focuses on interoperability, it both enables and expedites the market adoption of thoughtful technology. Of course interoperability is core to patient safety and better patient outcomes because the more information a physician has in a record, the more comprehensive the diagnosis. As one of our customers said recently, “An EMR without images is like an art museum without the paintings.’ We never forget that there are real people counting on technology and their healthcare providers when they most need them.

“Rather than adding to the process, interoperability should lead to improved reimbursement rates for healthcare facilities and increased diagnostic efficiency along with improved tracking and error reduction.”

Finally, Karen Conway, industry relations director, GHX, says, “As with any 301-page government document, there are plenty of unexpected sink holes, but there are a few highlights worth noting. First, there is movement toward interoperability, which is critical to achieving one of the most important objectives of meaningful use: better care coordination. The myriad of providers involved in patient care cannot coordinate if they cannot share information. But it’s not enough to share, if the information is missing critical data. I applaud reference to the ONC’s proposal to include the unique device identifier (UDI) for implantable devices as part of the Common Critical Data Set. Manufacturers are spending millions individually and billions collectively to comply with the U.S. FDA’s UDI rule. By this September, all implantable devices, regardless of class, are expected to have assigned UDIs displayed on product labels. The ability to capture structured data about products implanted in patients can deliver a wide range of patient safety benefits, from avoiding potential complications during MRIs to being able to notify patients in the event of a recall. Inclusion of the UDI in EHRs is central to the FDA’s vision to improve post-market surveillance, while the identifiers can also move us closer to understanding the role of sophisticated technology in improving both the cost and quality of care.”

Getting back to CHIME, the organization has urged CMS to make several changes to the proposed rule for Stage 3, including:

• A 90-day reporting period for the first year of meaningful use Stage 3 compliance, at least for payment adjustment purposes;
• Modify requirements for and retain the 90-day reporting period for providers attesting to meaningful use requirements for the first time, whether in a Medicare or Medicaid context;
• Eliminate patient action thresholds for the care coordination objective;
• Reduce the number of required measures in multi-measure objectives, health information exchange and care coordination;
• Create hardship exceptions for providers switching vendors;
• Allow providers to take a 90-day reprieve during any program year for upgrades, planned downtown, bug fixes related to new technology or optimizing the use of new technology within new workflows; and
• Allow, in limited circumstances, paper-based means to achieve measure thresholds.

According to advocacy organization, patient action requirements related to care coordination and “unrealistic” thresholds for health information exchange requirements were of particular concern. Additionally, the organization said it was troubled over the requirement that all providers must attest to meaningful use Stage 3 by 2018, regardless of prior participation and experience with the program.

“While we acknowledge policymakers’ intention to make each Stage more difficult than the last, we are concerned with the strategy that envisions Stage 3 serving as both the apex of MU requirements and as a starting point for those providers with no experience at Stage 1 or Stage 2 of the EHR Incentive program,” CHIME stated. “We worry some of the objectives pose too great a stretch for seasoned meaningful users, let alone those who have never participated in the program.”

CHIME CEO and president Russell P. Branzell, FCHIME, CHCIO said though CMS has proposed limited flexibility for meeting objectives, many providers face a significant chance of falling short and incurring substantial penalties.

“In order to realize the network effects of meaningful use, we need as many providers as possible participating in the program,” he said. “As proposed, this rule may do more to deter, rather than encourage, on-going participation.”