EHR interoperability, regulations top patient record concerns
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Healthcare CIOs and other health IT professionals reacted skeptically to a new rule CMS is proposing as part of Medicare payment changes that would require physicians and hospital systems to attest they are not engaging in information blocking.
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The sweeping changes would enact policies from the Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA) bill Congress passed last year, and move physicians toward value- and merit-based reimbursement.
Other than the mandate on information blocking, the provisions -- which would modify broad swaths of the existing meaningful use program for EHRs -- apply only to individual physicians and physician practices receiving Medicare funds, not hospitals or Medicaid.
When they unveiled the new programs to the media April 27, CMS and Office of the National Coordinator for Health Information Technology (ONC) officials said they will be talking with hospital groups over the next few months, but did not signal that reimbursement changes would necessarily extend to hospitals soon.
CHIME questions information-blocking rule
ONC defines information blocking as "when persons or entities knowingly and unreasonably interfere with the exchange or use of electronic health information." For some in the health IT world, this wording is ambiguous.
Leslie Krigsteinvice president of congressional affairs, CHIME
"Just the complexity and lack of clarity about what constitutes information blocking is going to be a big matter of discussion for our members," said Leslie Krigstein, vice president of congressional affairs at the College of Healthcare Information Management Executives (CHIME) in Ann Arbor, Mich. "The challenge is whether the definition is too narrow or too broad. There are so many unanswered questions."
Also under debate is how closely the new measures for using federally certified EHR technology hew to the meaningful use EHR incentive program inspired by the 2009 HITECH Act.
Both programs contain many of the same measures, including protecting the privacy of electronic protected health information (ePHI); performing a security risk analysis for ePHI; various forms of computerized order entry; and attesting that at least one patient has viewed, downloaded or transmitted ePHI.
Meaningful use still here, in part
While meaningful use stage 3 appears to have been replaced by the new Quality Payment Program starting in 2017, stage 2 is still in effect, and hundreds of hospitals and physicians are still attesting to it this year.
"Meaningful use has not gone away. It has not even been recast," said Jeff Smith, vice president of public policy for the American Medical Informatics Association in Bethesda, Md. "It's been rebranded."
Smith also said the information-blocking rule is troubling for his group's members. The issue has been a concern for them since ONC presented its report to Congress on information blocking last year, he said.
"I don't think there was a box to attest to not information blocking before this year. Now, there will be," Smith said. "They really need to flesh out what information blocking is."
Information blocking defined
The proposed rules, which have 60-day public comment period ending June 26, do lay out three broad areas for providers to demonstrate that they do not practice information blocking by:
- Knowingly taking action to restrict the interoperability of ONC-certified EHR technology and the exchange of electronic health data;
- Ensuring their EHR system allows patients timely access to their electronic health information, including the ability to view, download and transmit the information data, and allows bidirectional exchange of health data with other providers and different EHR systems; and
- Responding quickly and in good faith to requests to exchange or retrieve requests for health information from other providers, patients or others, without regard to the requestor's affiliation or technology vendor.
But Smith noted that even with these definition guidelines, it could be hard to pinpoint precisely where information blocking is occurring, particularly among providers, without specific cases to point to.
For example, Smith said, what if a hospital participated in three health information exchanges (HIE) to transmit data, but declined to take part in a fourth. Would that be information blocking?
Even in its information-blocking report to Congress, ONC did not attach names to possible practitioners.
However, many in health IT thought the agency had indirectly implicated EHR giant Epic Systems Corp. Epic appeared to confirm the suspicion by dropping its much-disliked transaction fee for interactions with its corporate HIE just a few days after the ONC report came out.
Meanwhile, the changes detailed in the MACRA-inspired notice of proposed rulemaking attempt to unify the patchwork of Medicare programs to measure the value and quality of healthcare.
They also seek to transition providers from payments based on volume and fee for service to value-based payments based on patient outcomes, satisfaction and quality of care.
New Medicare reimbursement models
The new Quality Care Program that streamlines the reimbursement programs includes two paths: the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models.
Under MIPS, physicians get higher reimbursement for providing high-value care in these performance categories: quality, advancing care information, clinical practice improvement and cost.
Meanwhile, Advanced Alternative Payment Models -- based, in part, on accountable care organization value-based reimbursement systems -- reward physicians who accept risk and provide coordinated care often associated with population health.
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