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Saturday, March 21, 2015

Meaningful Use Stage 3 proposed rule is now out

Stage 3 meaningful use proposed rule and certification criteria released
Aim to 'support the path to nationwide interoperability'

WASHINGTON | March 20, 2015, Healthcare IT News

The new Stage 3 meaningful use rules proposed by the Centers for Medicare & Medicaid Services seek to give providers more flexibility, simplify the program, drive interoperability among electronic health records and put the focus on improved patient outcomes.
  • The Stage 3 proposed rule can be read here.
  • New 2015 Edition IT certification criteria can be seen here.
CMS says the Stage 3 rules are meant to drive better-quality, more cost-effective and coordinated care by improving the way providers are paid and – crucially – bolstering better information sharing.

"The flow of information is fundamental to achieving a health system that delivers better care, smarter spending  and healthier people," said HHS Secretary Sylvia M. Burwell in a press statement. "The steps we are taking today will help to create more transparency on cost and quality information, bring electronic health information to inform care and decision making, and support population health."

CMS touts the proposed rule's "flexibility," and points to simplified requirements for providers that keep a focus on advanced use of EHRs – and scrap box-checking requirements that are no longer relevant.

Stage 3 "does three things: It helps simplify the meaningful use program, advances the use of health IT toward our vision for improving health delivery, and further aligns the program with other quality and value programs,” said Patrick Conway, MD, acting principal deputy administrator and chief medical officer at CMS, in a statement.

He added that, "in an effort to make reporting easier for health care providers, we will be proposing a new meaningful use reporting deadline soon."

Meanwhile, the Office of the National Coordinator for Health IT has proposed a new 2015 Edition Health IT Certification Criteria rule that aligns with the data exchange goals put forth in its Nationwide Interoperability Roadmap. The proposed rule includes new and updated IT functionality and provisions that support care improvement, cost reduction, and patient safety across the health system.

"The certification criteria we have proposed in the 2015 Edition will help achieve that vision through provisions that consider the range of health IT users and uses across the care continuum, including those focused on interoperable standards, data portability, improved transparency, privacy and security capabilities, and increased oversight," said National Coordinator Karen DeSalvo, MD, in a statement...
431 pages in the 2015 Certification Criteria. Some counts of keywords I find of immediate interest, randomly:
"Interoperability" -- 71
"API(s)" -- 65
"standards" -- 454
"meaningful use" -- 29
"innovation" -- 8
"market(s)" -- 5
"patient safety" -- 35
"workflow(s) -- 17
"usability" -- 14
"certification" -- 1,000+
Counts of the same keywords in the 301 page MU3 Proposed Rule:
"Interoperability" -- 6
"API(s)" -- 75
"standards" -- 56
"meaningful use" -- 380
"innovation" -- 6
"market(s)" -- 9
"patient safety" -- 10
"workflow(s) -- 18
"usability" -- 0
"certification" -- 78
A lot to study. From the 2015 Cert document:
I. Executive Summary

A. Purpose of Regulatory Action

Building on past rulemakings, this proposed rule further identifies how health IT certification can support the establishment of an interoperable nationwide health information infrastructure. It reflects stakeholder feedback received through various outreach initiatives, including the regulatory process, and is designed to broadly support the health care continuum through the use of certified health IT. To achieve this goal, this rule proposes to:

  • Improve interoperability for specific purposes by adopting new and updated vocabulary and content standards for the structured recording and exchange of health information, including a Common Clinical Data Set composed primarily of data expressed using adopted standards; and rigorously testing an identified content exchange standard (Consolidated Clinical Document Architecture (C-CDA)):
  • Facilitate the accessibility and exchange of data by including enhanced data portability, transitions of care, and application programming interface (API) capabilities in the 2015 Edition Base EHR definition;
  • Establish a framework that makes the ONC Health IT Certification Program open and accessible to more types of health IT, health IT that supports a variety of care and practice settings, various HHS programs, and public and private interests;
  • Support the Medicare and Medicaid EHR Incentive Programs (EHR Incentive Programs) through the adoption of a set of certification criteria that align with proposals for Stage 3;
  • Address health disparities by providing certification: to standards for the collection of social, psychological, and behavioral data; for the exchange of sensitive health information (Data Segmentation for Privacy); and for the accessibility of health IT;
  • Ensure all health IT presented for certification possess the relevant privacy and security capabilities;
  • Improve patient safety by: applying enhanced user-center design principles to health IT, enhancing patient matching, requiring relevant patient information to be exchanged (e.g., Unique Device Identifiers), improving the surveillance of certified health IT, and making more information about certified products publicly available and accessible;
  • Increase the reliability and transparency of certified health IT through surveillance and disclosure requirements; and
  • Provide health IT developers with more flexibility and opportunities for certification that support both interoperability and innovation.
From the MU3 Proposed Rule Executive Summary:
In this proposed rule, we specify the policies that would be applicable for Stage 3 of the Medicare and Medicaid EHR Incentive Programs. Under Stage 3, we are proposing a set of requirements that EPs, eligible hospitals, and CAHs must achieve in order to meet meaningful use, qualify for incentive payments under the Medicare and Medicaid EHR Incentive Programs, and avoid downward payment adjustments under Medicare. These Stage 3 requirements focus on the advanced use of certified EHR technology (CEHRT) to promote health information exchange and improved outcomes for patients.
Stage 3 of meaningful use is expected to be the final stage and would incorporate portions of the prior stages into its requirements. In addition, following a proposed optional year in 2017, beginning in 2018 all providers would report on the same definition of meaningful use at the Stage 3 level regardless of their prior participation, moving all participants in the EHR Incentive Programs to a single stage of meaningful use in 2018. The incorporation of the requirements into one stage for all providers is intended to respond to stakeholder input regarding the complexity of the program, the success of certain measures which are part of the meaningful use program to date, and the need to set a long-term, sustainable foundation based on a consolidated set of key advanced use objectives for the Medicare and Medicaid EHR Incentive Programs.

In addition, we propose changes to the EHR reporting period, timelines, and structure of the Medicare and Medicaid EHR Incentive Programs. We believe these changes would provide a flexible, clear framework to reduce provider burden, streamline reporting, and ensure future sustainability of the Medicare and Medicaid EHR Incentive Programs. These changes together lay a foundation for our broader efforts to support interoperability and quality initiatives focused on improving patient outcomes.
A lot to study.

Mixed Industry Response to Stage 3 Meaningful Use Rule

The proposed Stage 3 Meaningful Use rule released March 20 received early mixed reviews from two stakeholder associations.

The rule, focusing on advanced use of electronic health records with fewer objectives, is meant to provide more flexibility and simplify requirements for providers, according to the Centers for Medicare and Medicaid Services. It specifies the criteria that eligible professionals, eligible hospitals, and critical access hospitals must meet to qualify for Medicare and Medicaid EHR incentive payments and avoid financial penalties under Medicare for Stage 3 of the EHR Incentive Programs.

The rule proposes changes to the reporting period, timelines, and structure of the program to provide a “flexible, clear framework to reduce provider burden, streamline reporting, and ensure future sustainability of the Medicare and Medicaid EHR Incentive Programs,” according to CMS.

Specifically, the rule would “continue to encourage electronic submission of clinical quality measure (CQM) data for all providers where feasible in 2017, propose to require the electronic submission of CQMs where feasible in 2018, and establish requirements to transition the program to a single stage for meaningful use.” In addition, the Stage 3 proposed rule “would also change the EHR reporting period so that all providers would report under a full calendar year timeline with a limited exception under the Medicaid EHR Incentive Program for providers demonstrating meaningful use for the first time.”

In a written statement, the College of Healthcare Information Management Executives said it is closely evaluating the CMS Meaningful Use rule. Based on an initial review, CHIME said the organization is “pleased” to see flexibility built into the Stage 3 proposed objectives...

However, with eligible hospitals and professionals continuing to struggle to attest to Stage 2 MU and with Stage 3 MU not slated to begin until 2017, it’s difficult for some providers to look beyond their current challenges with the program.

Not surprisingly, the American Hospital Association was quick to condemn the proposed rule which the organization says demonstrates that CMS “continues to create policies for the future without fixing the problems the program faces today,” according to a written AHA statement.

“In January, CMS promised to provide much-needed flexibility for the 2015 reporting year, which is almost half over,” states AHA. “Instead, CMS released Stage 3 rules that pile additional requirements onto providers.  It is difficult to understand the rush to raise the bar yet again, when only 35 percent of hospitals and a small fraction of physicians have met the Stage 2 requirements.”...
Health IT stakeholders march on DC


In its first stage, the meaningful use program delivered billions of dollars to technology companies that specialize in manufacturing EHR software, and ensured that clinicians of all types are no longer wasting time and resources on individual flesh and blood patients, but instead are meticulously collecting computable data for the sharing economy. This preliminary phase saw an order of magnitude increase in the number of small EHR companies and public/private, not-for-profit, certification and accreditation enterprises, along with a sharp decrease in the number of small medical practices. The second phase of the program, weeded out most new entrants into the EHR software market, solidifying the gains for large technology vendors. Physicians became disenchanted, lost interest and lost joy in their profession. Participation in the program plummeted posing a real threat to desired outcomes. Not to worry though, there is enacted regulation and legislation pending to crack a bigger and better whip on dissenters.
The brand new third phase of the meaningful use program sports a “keep your eyes on the prize” attitude and is forging ahead towards the finish line, bravely oblivious to the difficulties experienced in previous stages. Of course, six years into the program, one would expect to see some results indicating that all this money we are spending is moving the needle towards meeting the stated “do no evil” targets. There are no such preliminary results, and we are told that it is too soon to ask, because we won’t be able to see real improvements until the entire program, which is getting bigger and more expensive with each passing day, is completed. In the meantime, we are advised to entertain ourselves with an interminable stream of roadmaps, peppered with gaudy infographics supported by toddler level cartoonish videos, and continue to pay our taxes, leaving the thinking and planning to smarter people.
I will not waste your time with point by point analysis of the new meaningful use regulations, because I am certain the “industry” will produce the customary collateral, and because it is basically more of the same...
If a clinician has 12 minutes to see a patient, be empathetic, document the entire visit with sufficient granularity to justify an ICD-10 code, achieve 140 quality measures, never commit malpractice, and broadly communicate among the care team, it's not clear how the provider has time to perform a "clinical information reconciliation" that includes not only medications and allergies, but also problem lists 80 percent of the time.

Maybe we need to reduce patient volumes to 10 per day? Maybe we need more scribes or team-based care? And who is going to pay for all that increased effort in an era with declining reimbursements/payment reform?

- John Halamka, "The good, the bad and the ugly of Stage 3 MU"

Meaningful use stage 3: Making mHealth tools a necessity?
March 27, 2015 | Eric Wicklund - Editor, mHealthNews
mHealth is coming of age, thanks to meaningful use Stage 3.

That's the consensus of thought one week after the release of the proposed guidelines by the Centers for Medicare and Medicaid Services. The 300+ page document, in fact, makes clear for the first time that mHealth technologies – from secure messaging platforms to mobile devices – play a specific role in bringing the provider up to speed with today's healthcare landscape.

"MU 3, welcome to the 21st century," Ricky Bloomfield, MD, Duke Medicine's director of mobile technology strategy – who's working with Apple's HealthKit platform – recently wrote in his blog, "The Mobile Doc."

But some are also wondering whether legislating mHealth – or putting overworked providers under more pressure to change their workflows – will make them any more willing to adopt it.

Patient-generated data had long been considered by the Office of the National Coordinator for Health IT in this third round of incentives for healthcare providers. And the proposed rule, issued March 20, expands the avenues by which providers can converse with patients to include apps, portals and direct messaging. It also makes provisions for provider use of patient-generated data – from apps and wearables, for example.

Some experts are wondering, though, whether the ONC is being too specific in pushing mHealth on the provider community...
I'm all for "mHealth," but this could end up being wildly out of control and unsuccessful.

More to come...

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