EHR regulations, interoperability top patient record concerns
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WASHINGTON, D.C. -- The Acting National Coordinator for Health Information Technology Jacob Reider, M.D., and the CMS Office of E-Health Standards and Services Director Robert Tagalicod jointly proposed in a blog post that meaningful use stage 2 be extended through 2016, and stage 3 be delayed until 2017.
They also said that the Office of the National Coordinator's (ONC) EHR certification standards would move on a separate schedule from the CMS meaningful use standards; currently they're released simultaneously every few years. At the 2013 mHealth Summit, Reider sat down with SearchHealthIT to discuss these decisions.
How have things been going since Farzad Mostashari, M.D., left and you took over as coordinator? You've been busy.
Jacob Reider: It's great. We have a great team, great people and important work. Good times.
Do you have any updates on the selection process for the next coordinator -- whether it's you or someone else?
Reider: I have nothing to share.
How official is the delay of stage 3 and the extension of stage 2? Right now those timelines are being proposed, and then there are comment and waiting periods before rules go final.
Reider: The reason that it might have sounded [unofficial] is that the words are chosen carefully. Our lawyers help us say things very precisely because this wasn't a regulation we were putting out; it was an announcement of an intent to change the regulatory timeline. So I would say there's a very high likelihood that that's what [will happen].
Was there any particular stakeholder or group, such as vendors or healthcare providers, who helped sway the decision?
Reider: No. And to be clear, the extension of stage 2 is for the CMS program. The ONC has a role in advising CMS and collaborating to make these decisions, but it's their decision and their program.
How did we make this decision together? This was an obvious next step. If we look at where we are with stage 2, and when we would start to do rulemaking for stage 3, we wouldn't have sufficient data to understand which parts of stage 2 were going well -- and which parts weren't going well -- until too late in the process. We were called on by many vectors of the care delivery community to withhold rulemaking, so [CMS Administrator] Marilyn Tavenner at HIMSS last year announced there would be no rulemaking in 2013.
That was the first step here; she messaged to the community a little bit implicitly, but in saying there would be no rulemaking in 2013, that meant the next would be in 2014. That is what will happen; we will have proposed rules for stage 3 in late 2014. ONC will have a proposed rule for certification that will align with that.
At what point will CMS meaningful use and ONC certification standards be decoupled, schedule-wise?
Reider: Before that. What we also announced on Friday was that 2015 certification standards will precede meaningful use stage 3 activity. The reason for that is we want to shift ONC certification to an annual process. Software developers make decisions about their software development lifecycles, essentially, annually. John Halamka, M.D., [chief information officer of the Beth Israel Deaconess Medical Center] described this as "going from waterfall to agile."
This is hard work. It's worth it. Our patients deserve it. This is how we're going to improve the quality of care.
Acting National Coordinator for Health IT Jacob Reider, M.D.
In waterfall, you spend a year, you write your specs, you put it in a three-ring binder, and you hand it off to your developers, and they take another year to write the code … and when you release it, it's two years later and you're writing code based on two-year-old ideas. That doesn't make sense in writing software. If you're building a rocket ship, maybe it makes sense, because you can't rebuild it on the way up to the moon.
[Agile] is a more iterative process, and it gives the software developer community a heads-up about what we're going to be doing sooner, and that's very important.
Explain the voluntary piece of 2015 certification standards.
Reider: Certification is voluntary, period. Nobody is mandating meaningful use. Nobody is mandating certification. But if you're selling into a market that wants to use a product in a program that references certified EHR technology, then your market is going to want certified products.
So they'll have to keep up, year by year, for providers to keep receiving incentives.
Reider: For meaningful use stage 3, there will be no requirement that 2015 certification be achieved; there would be a requirement that that year's certification -- let's call it 2017, if we decide it will be that year – [be achieved]. For meaningful use stage 2, there will be no requirement that eligible providers use 2015-certified products. They could, but there may be other programs that reference 2015 products. [For example], CMS has annual updates to the PQRS program. It's possible, and I'm not predicting this, that since we are making it available, that CMS -- through the PQRS or CMMI programs -- might reference 2015 certification. They might say, 'You need 2015 interoperability in order to [participate] in this program.'
So [2015 certification] will be available, but not mandatory.
We hear from provider chief information officers (CIOs) that they feel under the gun with the ICD-10, HIPAA data security and meaningful use initiatives all coming down in 2014. The rescheduling of stages 2 and 3 doesn't really give them a break, as they can't take 2014 off and stay on the EHR incentive train, and they have to attest for a 90-day period.
Reider: That's right. Or stage 1. If they were a first-year stage 1 attester in 2013, they have to attest to stage 1 in 2014 -- but they need to upgrade to 2014 [certified EHRs], and that's not something that everybody is remembering.
What is your advice for them to deal with all these initiatives at once? Or, at least encouragement.
Reider: This is a high bar. This is hard work. It's worth it. Our patients deserve it. This is how we're going to improve the quality of care. Those of us who work in this industry, we are all optimists. We all believe that what we are doing will enhance the quality and efficiency of care and reduce the cost of care that we are providing. We believe that to be so.
I think there's good evidence that health information technology is the facilitator of all of those things. We know it's hard. That's why there's an incentive program that's paying out billions of dollars. This incentive program is supposed to be hard work, but it's through that hard work that we are motivating a community toward better health, better care and lower cost. That's how we're doing it. It's not meant to be a handout. This was meant to be a motivator to do that hard work, to stay committed, to stay the course.
My son, who's a senior in college, texted me this morning about a decision he has to make and the right fork in the road is, 'take it easy.' The left fork is in the road is, 'work harder.' There's value in working harder. That's what's going to make you a stronger person; it's what's going to make you a more significant contributor to the world. It's going to make you learn and grow. That's a full life. But it's hard. Sometimes you need a carrot to remind you to take that fork in the road is the right choice.
So my encouragement [to CIOs] is to continue to make the right choices, even if they don't feel like they're the easy choices, because that's what's going to make us take better care of our patients.