Every year Galen carves out a few days to regroup internally, looking towards the future of the healthcare IT industry, as well as recapping where we’ve come from. As we do this, I’d like to do the same with Meaningful Use (MU) – reflecting on lessons learned from the past four years, as well as looking forward to MU Stage 3.
The goals for the three MU stages can be summarized as:
Stage 1: Data capture and sharing
Stage 2: Advanced clinical processes and decision support
Stage 3: Improved outcomes
The three stages were originally geared to support the healthcare industry’s move towards controlling costs, increasing quality, and improving patient health outcomes. Since the start of the meaningful use initiative in 2011, the healthcare industry has experienced significant changes with a particular shift toward Accountable Care Organizations (ACOs), where providers specialize in managing outcome risks for patient populations through patient care coordination.
Last month, the Office of the National Coordinator for Health Information Technology (ONC) and the Centers for Medicare & Medicaid Services (CMS) announced a delay to the start of MU Stage 3 to 2017, listing the following benefits for the changes to the MU Stage 3 timeline:
- More analysis of feedback from stakeholders on Stage 2 progress and outcomes;
- More available data on Stage 2 adoption and measure calculations – especially on new patient engagement measures and health information exchange objectives;
- More consideration of potential Stage 3 requirements;
- Additional time for preparation for enhanced Stage 3 requirements;
- Ample time for developers to create and distribute certified EHR technology before Stage 3 begins, and incorporate lessons learned about usability and customization.
The delay impacts participants who began MU Stage 1 in 2011 or 2012, as they will now demonstrate MU Stage 2 for a third program year in 2016 before proceeding to MU Stage 3 in 2017. For those who did not begin in 2011 or 2012, the last year to start participation and receive a payment was 2014. Beginning January 1, 2015, eligible providers (EP) who do not successfully demonstrate meaningful use are subject to a negative payment adjustment. EPs who attest for the first time in 2015 will not receive an incentive payment, but can still avoid the penalty.
ONC and CMS have also proposed a new approach to the Certified EHR Technology (CEHRT) certification process, though the “2014 Edition” will still remain the baseline. Vendors who have certified applications to the 2014 Edition will not need to recertify their products, and providers participating in incentive programs will not be required to upgrade beyond a 2014 Edition CEHRT application. Per CMS, the goal of the new approach is to “to provide public input on policy proposals, enable our certification processes to more quickly adapt to include newer industry standards that can lead to greater interoperability, and add more predictability for EHR technology developers”, all the while allowing vendors more time to react.
As of January 12, 2015, CMS has not released a notice of proposed rulemaking (NPRM) for Stage 3, or the corresponding ONC NPRM for the 2017 Edition, or proposed interim 2015 Edition of the ONC Standards and Certification Criteria. They document current recommendations for Stage 3 on their website.
CMS and ONC will continue to review all stakeholder comments before the final rules are published. The following is a sampling of feedback that has already been presented.
Stage 1 Lessons Learned
In the beginning, providers and healthcare organizations were challenged to understand what was needed. It took the organizations time to assemble teams with the right skills, build the infrastructures, and learn new processes to support Stage 1 requirements. And while the incentive money has been a valuable motivational tool for providers and organizations, it took time to gain their attentions and to learn new requirements.
Stage 2 Lessons Learned
Transitions of care require community infrastructure and cooperation, with a reliance on patient actions and costly technology. To meet the new criteria, organizations have had to define new strategies, processes, and workflows for referrals and transitions of care. It was, and still is, challenging to implement additional technical and organizational infrastructure in time for attestation.
Resource needs are greater in Stage 2 to develop the understanding of the requirements of the multiple activities and the coordination between the multiple vendors (MU, ICD10, PQRS, eRx, Direct Message IDs, etc.).
Key Takeaways and Recommendations for Stage 3
One of the biggest lessons learned is to allow enough time, especially when the objective is to improve outcomes and reduce costs, all the while emphasizing interoperability, care coordination, and quality of care.
Stage 1 and 2 are two-year reporting cycles, but the implementation required more, sometimes up to five years. The Stage 3 implementation could take even longer considering the stricter vendor requirements, higher user adoption, the fact that obsolete systems must be replaced, and that new systems must be integrated to support these measures. CMS and ONC need to allow sufficient time for those changes in organizational infrastructure and workflows, meaning all required materials, such as CQM specifications, need to be available at least eighteen months before the start of Stage 3.
In addition to important time considerations, recommendations from providers and healthcare organizations include:
- Providing additional incentives for interoperability.
- Improving financial incentives for ACOs to assume risk and reward providers that do share risks.
- Streamlining high-value quality measures.
- Considerations for the impact on usability, development and implementation costs.
- Reconsideration of the “all or nothing” approach to attestation and full year reporting.
- Allowances for group reporting as is done with PQRS.
- Avoiding measures that require third party action (patients and other care settings). Engage patients, but do not force their engagement.
Healthcare organizations and EPs have gone through many challenges since the beginning of MU. CMS and ONC responded to the providers’ feedback by delaying the start of Stage 3, and their intent is to deliver a final rule with smaller, more incremental changes that will be smoother for organizations to adopt. In addition to incorporating the lessons learned from Stages 1 and 2, organizations recommended that Stage 3 align with other pertinent healthcare initiatives such as ACOs. We look forward to receiving the Stage 3 final rule sometime in Q1 or Q2, with new requirements that will hopefully result in the adoption of positive, manageable changes for healthcare organizations.