Rob Anthony, health insurance specialist in the CMS's Office of E-Health Standards and Services, or OESS, provides a deeper look into some of the requirements and considerations that went into the final meaningful use stage 2 rule. Read the first part of this interview here.
Syndromic surveillance is a core requirement for hospitals, but a menu requirement for providers. Is that because physicians don't normally do it, or because you want to but the infrastructure isn't there to hook up doctors with public health agencies?
Anthony: There aren't a lot of syndromic surveillance databases that accept [physician] submissions. Where they're available, they're primarily available for hospitals.
Is that because it just isn't built, or because it just isn't needed? That is, individual physicians less frequently run into SARS, West Nile, Avian flu, etc.?
Anthony: I think more of them are being built. When you focus on large public-health reporting of syndromic conditions, it's exactly what you're talking about. Public health agencies focus on hospitals, which are going to see a large number of these cases.
One of the things we did include for specialists was focus on health reporting [in the menu items, there's a measure for submitting to specialized registries], so we have an option for submitting to cancer registries or any specialized registry as a part of public health reporting.
How hard is it to write rules requiring health information exchange when so much of the country is in various states of HIE construction? Where it's mostly built, you want to challenge providers, but you don't want to exclude participation from places that have more rudimentary HIE capabilities. Is it simply a matter of lowest common denominator?
Anthony: That's the fine line you walk when trying to put all of these things together. You want to come up with something that raises the bar and pushes people forward -- a "stretch goal," for lack of a better term. At the same time you don't want to put it out of reach for those folks who are coming late to the party.
The challenge is making sure that the right information is going, in the right way.
CMS meaningful use policy specialist
It's easy for the people who are already robust exchangers of information, who are working with a network of HIEs connected. A number of HMOs [health maintenance organizations] have something similar. However, for some of these smaller practices who are really just getting their feet wet, you want to make a goal that is attainable for them as well.
Part of the challenge -- and I think the CMS and ONC rules really address this -- was establishing the standards for transport of all of these things: What's going to be sent, how it's going to be sent, the format in which it's going to be sent ... so you're able to move that data from EHR to EHR regardless of how you actually accomplish that, whether it's through direct or a physical HIE or a vendor network or whatever. The challenge is making sure that the right information is going, in the right way.
How does a provider or hospital prove to CMS that the 5% of patients accessed their health information, and that it was made available electronically to more than half? HIPAA audit logs or something?
Anthony: Right now, the EHR incentive programs are by attestation. A provider comes in and legally attests to having accomplished these goals. We do conduct an audit program for oversight and to prevent fraud and abuse. Under the audit program, they will ask for different things to prove that particular actions have been taken or particular functions have been enabled in order to show that those providers have actually met those objectives.
Some early adopters will get a deadline extension for stage 2 compliance, extended from 2013 to 2014. How much of that extension was wired into stage 2 for the benefit of vendors to catch up with their certification process?
Anthony: Actually, we heard from both. During the comment period and throughout [the rulemaking process for stages 1 and 2] we had a lot of vendors who came to us and said, "We need ample time to develop these -- not rush through these and discover mistakes later after people are using them." We have providers who came to us and said, "It's not as easy as flipping a switch, we need time to actually onboard to a new edition of certified EHR."
Everybody's [upgrading to the 2014 certification standards, and certified EHRs] at the same time, and that's potentially a lot of people coming on board at the same time. We wanted to avoid "the funnel effect" of everybody trying to get on board at the same moment and people getting crowded out of meaningful use because there wasn't capacity to do that.
One analyst we frequently talk to feels National HIT Coordinator Dr. Farzad Mostashari was disingenuous when he said stage 2 lowers compliance burdens, because more measures were moved from menu to core, threshold percentages were raised, etc. How do you describe CMS's efforts to reduce compliance burdens in the final rule?
Anthony: We really did aim to reduce burden. I don't know about regulatory burden, but burden on providers. I definitely think that was something foremost in our mind. As you move into 2014, the obvious and big thing in mind is going to be electronic reporting of clinical quality measures. Not to have to go through, create a report and transcribe that information -- field by field, line by line -- into an attestation system makes a big difference.
One of the other things we indicated that we're going to have available for 2014 is a batch reporting system for meaningful use objectives. So if you're a large multi-specialty practice, or even if you're not, you can put all of the information for all of your eligible providers in a single file and you can upload all of that attestation information for all of your EPs. Currently, you have to have somebody go in for every EP and enter in every EP's individual data.
I think those two things alone are going to be incredible time-savers for practices.