Higher hoops for IT in­cen­tive pay

Stage 2 regs fo­cus on elec­tronic ex­change of info

Modern Healthcare - - FRONT PAGE - Joseph Conn KEITH HORIST PHOTO

The CMS’ long-awaited and much de­layed set of pro­posed Stage 2 mean­ing­ful-use reg­u­la­tions re­leased last week is a mix of old paths and new trails. The pro­posed reg­u­la­tions, is­sued by HHS on Feb. 23, con­tain many cri­te­ria fa­mil­iar to providers that have achieved Stage 1 com­pli­ance un­der the Medi­care and Med­i­caid elec­tronic health-record in­cen­tive pay­ment pro­grams cre­ated un­der the Amer­i­can Re­cov­ery and Rein­vest­ment Act of 2009.

For many of these re­cy­cled cri­te­ria, how­ever, the pro­posed Stage 2 reg­u­la­tions would re­quire some­what higher or broader per­for­mance met­rics than in Stage 1. The reg­u­la­tions also would add a few new chal­lenges, most notably an in­creased em­pha­sis on the elec­tronic ex­change of in­for­ma­tion.

Com­bined, these new re­quire­ments repre- sent the climb providers would need to make to be­come mean­ing­ful users of EHR tech­nol­ogy and re­ceive pay­ments—or avoid penal­ties—un­der the Medi­care and Med­i­caid pro­grams. That climb to Stage 2 won’t be nec­es­sary un­til at least 2014, how­ever, thanks to a decision by HHS in Novem­ber to ex­tend the com­pli­ance dead­line for Stage 2 for an ad­di­tional year for providers who met mean­ing­ful use Stage 1 cri­te­ria in 2011.

HHS is ex­pected to pub­lish the pro­posed reg­u­la­tions in the March 7 Fed­eral Reg­is­ter with a 60-day public com­ment pe­riod be­fore mak­ing them final.

“We stayed the course,” said Dr. Farzad Mostashari, head of the Of­fice of the Na­tional Co­or­di­na­tor for Health In­for­ma­tion Tech­nol­ogy at HHS, who pre­viewed the pro­posed reg­u­la­tions on Feb. 22 at the Health­care In­for­ma­tion and Man­age­ment Sys­tems So­ci­ety 2012 con­fer­ence and ex­hi­bi­tion in Las Ve­gas. (Read more from the HIMSS meet­ing on p. 16.)

By that he meant CMS rule mak­ers leaned heav­ily on rec­om­men­da­tions from the fed­er­ally char­tered Health IT Pol­icy and Stan­dards com­mit­tees sub­mit­ted last sum­mer to the ONC. Those rec­om­men­da­tions in­cluded ratch­et­ing up the lev­els of com­pli­ance in Stage 2 with cer­tain mean­ing­ful-use met­rics in Stage 1.

For ex­am­ple, un­der the pro­posed Stage 2 stan­dards, to qual­ify for mean­ing­ful-use pay­ments, hos­pi­tals as well as physi­cians and other “el­i­gi­ble pro­fes­sion­als” would have to place or­ders through com­put­er­ized physi­cian-or­der en­try sys­tems, or CPOE, for more than 60% of their med­i­ca­tion, lab­o­ra­tory and ra­di­ol­ogy or­ders. Un­der Stage 1, there was a 30% CPOE thresh­old and only med­i­ca­tion or­ders were counted. These pro­posed higher per­for­mance met­rics com­port with the Health IT Pol­icy Com­mit­tee’s rec­om­men­da­tion for CPOE.

Mostashari also used the term “push” mul­ti­ple times to de­scribe the di­rec­tion of the pro­posed reg­u­la­tions, in­clud­ing go­ing be­yond the rec­om­men­da­tions of the ad­vi­sory pan­els in some in­stances, most promi­nently, in the use of spe­cific stan­dards for the elec­tronic

ex­change of in­for­ma­tion.

There are spec­i­fied stan­dards in the Stage 2 reg­u­la­tions for clin­i­cal mes­sag­ing that “will be­come a re­quired part of cer­ti­fied health in­for­ma­tion tech­nol­ogy,” Mostashari said. They in­clude the fed­er­ally de­vel­oped di­rect pro­to­col for provider-to-provider mes­sag­ing

The pro­posed reg­u­la­tions also would re­quire the use of spe­cific, sin­gle stan­dards for pa­tient­care sum­maries, for stor­ing and trans­mit­ting lab re­sults, and for record­ing prob­lem lists, rep­re­sent­ing “a very am­bi­tious tar­get for ac­tual ex­change, not just a test, across or­ga­ni­za­tional and ven­dor boundaries,” Mostashari said.

First-blush re­ac­tions to the pro­posed Stage 2 reg­u­la­tions ranged from sim­ple re­lief that they had fi­nally ar­rived to wary skep­ti­cism—views some­times expressed by the same per­son.

“Ini­tially, the first re­ac­tion from all of us is we’re glad to know what all of the rules are,” said Dr. Karen Bell, who lis­tened as Mostashari gave the IT com­mu­nity a sneak­peak pre­view of the rules at HIMSS. Bell is chair­woman of the Cer­ti­fi­ca­tion Com­mis­sion for Health In­for­ma­tion Tech­nol­ogy, a Chicago-based not-for-profit or­ga­ni­za­tion au­tho­rized by the ONC to test EHR sys­tems.

“The sec­ond take is there’s a lot here,” Bell said. The new em­pha­sis on in­ter­op­er­abil­ity “is huge,” she said. “With that in mind, I think there is go­ing to be a need for not only ven­dors, but public health part­ners, pri­vate labs and other en­ti­ties” not el­i­gi­ble for fed­eral in­cen­tive pay­ments “to step up and be a part of this,” Bell said.

And, just as the Stage 1 pro­posed reg­u­la­tions were greatly amended in the final reg­u­la­tions in re­sponse to public com­ments, the new pro­posed reg­u­la­tions likely will be rig­or­ously re­viewed and most likely amended as well, Bell said.

“We’re just go­ing to have to wait un­til this whole process is over be­fore we can see what Stage 2 will look like,” she said.

Dr. Steven Stack, board chair­man of the Amer­i­can Med­i­cal As­so­ci­a­tion, pledged in a state­ment that the AMA would “care­fully re­view” and sub­mit an of­fi­cial re­sponse within the 60-day public com­ment pe­riod. “To elim­i­nate road­blocks and en­cour­age greater physi­cian par­tic­i­pa­tion, it is im­por­tant that a full eval­u­a­tion of the EHR Stage 1 in­cen­tive pro­gram oc­curs prior to fi­nal­iz­ing Stage 2 re­quire­ments,” he said.

Chris­tine Bech­tel, vice pres­i­dent of the Na­tional Part­ner­ship for Women & Fam­i­lies, serves on the Health IT Pol­icy Com­mit­tee. Her lauda­tory com­ments, from a state­ment,

Mostashari called the Stage 2 reg­u­la­tions “pre­dictable,” ex­plain­ing

that they are gleaned from the rec­om­men­da­tions of the Health IT Pol­icy and Stan­dards com­mit­tees. fo­cused on the in­ter­op­er­abil­ity re­quire­ments in the pro­posed reg­u­la­tions, par­tic­u­larly those re­quir­ing ex­changes be­tween pa­tients and clin­i­cians.

“The pro­posed rule moves us to­ward a new day when pa­tients can down­load their health in­for­ma­tion from a range of providers to a se­cure place of their choos­ing, and trans­mit it to their care pro­fes­sion­als or up­load it to a mo­bile app,” Bech­tel said. “We are pleased that it will al­low pa­tients to send se­cure elec­tronic mes­sages to their doc­tors—that is long over­due. All these ad­vances will make life eas­ier for pa­tients and their fam­ily care­givers who are try­ing to nav­i­gate the health­care sys­tem, while also mak­ing care de­liv­ery more ef­fi­cient and ef­fec­tive for providers.”

—with Chris­tine Lafave Grace

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