AMA, CHIME air 'concerns' about Stage 3

Both call for evaluation of the MU program thus far, to ensure future goals are realistic
By Mike Miliard
08:57 PM
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The American Medical Association (AMA) and College of Healthcare Information Management Executives (CHIME) have both submitted comments to the Office of the National Coordinator for Health Information Technology (ONC), laying out their concerns about – and suggestions for – meaningful use Stage 3.

“The AMA shares the administration’s goal of widespread EHR adoption and use, but we again stress our continuing concern that the meaningful use program is moving forward without a comprehensive evaluation of previous stages to resolve existing problems,” said AMA Board Chair Steven J. Stack, MD, in a statement.

[See also: Federal panel begins work on Stage 3 meaningful use]

“A full evaluation of past stages and more flexible program requirements will help physicians in different specialties and practice arrangements successfully adopt and use EHRs," he added.

In its letter to National Coordinator Farzad Mostashari, MD, the AMA offered five concerns and recommendations to improve the meaningful use incentive program.

First, the association questioned the lack of an external, independent review process, which it insisted was necessary to improve and inform the future of meaningful use. The Centers for Medicare & Medicaid Services (CMS) and ONC "have not evaluated the meaningful use program," wrote AMA's executive vice president and CEO James Madara, MD. "Given the concerns raised with the current program, an external, independent evaluation is necessary to improve and inform the future of the program."

Moreover, he wrote, "We believe that it is a serious mistake to keep adding stages and requirements to the meaningful use program without evaluating Stage 1 of the program. In addition, an evaluation should occur between each stage of the meaningful use program and prior to finalizing the requirements for the next stage."

[See also: Stage 3 goes for more rigor]

AMA also argues that a 100 percent pass rate was the wrong approach. "The current and future meaningful use requirements are problematic, given that failing to meet just one measure by one percent would make a physician ineligible for incentives and subject to financial penalties. The measures for use of EHRs should be made reasonable and achievable and still have a meaningful impact."

Relatedly, the associaton is expressing qualms about ONC's "one-size-fits-all" approach, calling for more flexible program requirements that take different practice patterns and specialties into consideration.

"Under the current program, every physician regardless of their specialty must meet the same measures (i.e., core measures), and there are few exceptions," according to the letter. "The program requirements should be appropriately flexible and better structured to accommodate various practice patterns and specialties. Also, additional resources and time to develop and test e-specified electronic measures focused on outcomes must be allotted to ensure successful implementation of the meaningful use program."

Usability was another chief concern. AMA called for the EHR certification process to address physician's concerns about design and ease of use.

"Usability standards being included in the certification criteria will be critical for ensuring that physicians invest their resources in EHR, CPOE, as well as other health IT products that work for them," writes Madara. Physicians are worried about the viability of the systems in which they've invested, and are "concerned about potential liabilities from EHR system design and software flaws as well as lack of interoperability among EHR systems that could result in incomplete or missing information, which may lead to errors in patient diagnosis and treatment (e.g., patient matching)."

Finally, the AMA called for progress on breaking down infrastructure barriers that are hindering information exchange. "Improving the health IT infrastructure to allow physicians to readily and securely exchange patient data with other health care providers should be made a top priority and take precedence over the development of future stages of the meaningful use program."

While meaningful use has helped to jumpstart EHR adoption, "We are still in the early stage of progress due to technological, financial, operational and regulatory challenges," wrote Madara. "These challenges must be overcome in order to increase physician participation rates and maximize the benefits of this technology for our nation’s health care delivery system."

 Read the full AMA letter here

Don't "cram everything into" MU Stage 3
On Jan. 14, CHIME submitted its own comments to ONC officials, calling on them to reconsider the speed and scale planned for achieving Stage 3 meaningful use objectives by 2016.

CHIME, too, urged HIT Policy Committee to recommend "thorough evaluations of what has been accomplished thus far" so as to ensure that objectives for Stage 3 are realistic and achievable.

“We see no value in setting unrealistic performance thresholds or expectations before current evaluations of what we have accomplished have been undertaken,” said CHIME President and CEO Richard A. Correll and Board Chair George T. Hickman in their letter. “[E]very desirable EHR-related objective cannot feasibly be met by 2016, nor do we see any value in attempting the rushed adoption of various EHR uses by that time. Instead, verifiable and continuous progress should be the goal.”

“One of our main messages to regulators is that we shouldn’t look to cram everything into Stage 3,” said Pam McNutt, senior vice president and CIO at Dallas-based Methodist Hospital System, and member of CHIME’s Policy Steering Committee, in a statement.

“The modernization of America’s healthcare system is a decade-long progression," she added. "We need to make sure that the HIT Policy Committee is looking at more than just the Stage 2 measures and objectives when making recommendations to HHS; that’s why we strongly urged thorough evaluations of to-date accomplishments and progress.”

Among CHIME's other recommendations:

  • That actual and proven HIE operations and interoperability, combined with a standard and highly-reliable way to identify patients, be mandatory to achieve the goals of Stage 3, and even stage 2; Encourage that the time frames for Stage 3 be linked to and preceded by proven HIE capabilities.
  • That officials ensure EHR certification requirements yield vendor products that allow eligible providers and hospitals to fully and easily satisfy any meaningful use documentation and audit requirements—such functionality must be inherent to certified EHR technology;  Urge that audit measures be standardized to be based clearly on the certification requirements, and not subject to auditor variation.
  • That, in order to help mitigate disruption from discontinuity in the EHR vendor space due to vendor business failures, vendor consolidation, decisions not to seek certification or performance problems, officials consider protection or accommodation for hospitals and health professionals that must undertake such EHR product transitions at the same time that they are expected to progress from one stage of meaningful use to another.

As for clinical quality measures (CQM), the CHIME letter noted that over the past several years, CMS, ONC and other agencies inside HHS have demonstrated an increasing ability to convene public and private sector stakeholders to harmonize disparate health IT system requirements, technical standards and disseminate best practices. “Meaningful use is, perhaps, the best example of such policy approaches," it read. "However, CHIME believes that such harmonization with regards to CQMs is overdue – and we believe that time is of the essence.”

CHIME urged regulators to keep a handful of fundamental tenets in mind: future measure sets should always tie back to care delivery quality and clinical efficacy; they should be expansive enough to allow clinical flexibility based on population characteristics; and regulators across federal, state, local and private sector reporting organizations should convene to understand what collection and reporting requirements will allow for optimal care quality improvement.

“Even minute changes to specifications can present tremendous workflow and monetary burdens on providers,” said Liz Johnson, vice president of applied clinical informatics at Dallas-based Tenet Healthcare, in a statement. “A sensible approach to future measure set development allows for evolution in technology in a way that minimizes such burdens on providers. We need a concerted effort in the near-term that improves data collection, abstraction and reporting on current generation CQMs. This effort should include an absolute focus on harmonizing the current data specifications for similar measures."

[See also: ONC to solicit comments on MU Stage 3]