Don't Recycle Bad EHR Measures Into MACRA, AMA Tells Feds

June 08, 2016

Interoperability of electronic health record (EHR) systems means more than one physician electronically dumping a ton of hard-to-decipher patient data into another physician's computer and then claiming to have satisfied a government requirement.

That's what organized medicine is telling the Centers for Medicare & Medicaid Services (CMS) as the agency is mulling over how to reward — or penalize — physicians for their use of EHRs under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). This bipartisan law, which killed off Medicare's sustainable growth rate formula for physician compensation, gradually shifts reimbursement from fee-for-service (FFS) to pay-for-performance, aka pay-for-value.

Medical societies contend that the new law needs new performance measures, not old recycled ones, when it comes to using EHRs to improve patient care and hold down costs. And demonstrating that different EHRs talk to one another should not pose an administrative burden to physicians, according to these groups.

The new law certainly has hatched new acronyms. It establishes the Quality Payment Program, which bifurcates into two more — the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models. Most physicians will participate in MIPS, the default track, when it debuts in 2019.

Physicians will receive a MIPS bonus or penalty based on their composite score across the performance categories of quality of care, cost of care, clinical practice improvement, and "Advancing Care Information (ACI)," a reincarnation of Medicare's incentive program for meaningful use of EHRs. In 2019, the bonuses and penalties are as high — or low — as 4% percent of Medicare FFS revenue. They increase to 9% in 2022 and beyond.

CMS says that the ACI component, which accounts for 25% of a physician's overall MIPS score, stresses interoperability — the ability of different information technology systems and software to share information. When that ability doesn't exist, Dr A can't transmit a patient record that automatically pops up on the screen of Dr B.

Interoperability characterizes five of the six objectives of the ACI category as outlined in proposed regulations implementing MACRA (the remaining objective pertains to protecting patient data):

  • Electronic prescribing

  • Patient electronic access

  • Coordination of care through patient engagement

  • Health information exchange

  • Public health and clinical data registry reporting

One performance measure of patient electronic access, for example, looks at how many patients view online or download their health information, or transmit it to a third party. Under coordination of care through patient engagement, CMS wants to know how many patients transmit health data from a personal device such as a glucometer to their physician's EHR. Health information exchange includes a measure of how many patient referrals or transfers were accompanied by an electronic summary-of-care record — the equivalent of mailing another physician a copy of a paper chart.

CMS noted in its draft MACRA regulations, issued April 27, that it adapted these objectives and measures from those in Stage 3 of its EHR meaningful use program.

Meaningful Use Said to Dumb Down Interoperability

About 2 weeks before the proposed MACRA regulations appeared, CMS invited the public, especially the medical community, to weigh in on creating interoperability metrics. Among other things, CMS asked what exactly should be measured, and whether Medicare claims can shed light on a physician's performance. In addition, how helpful are existing measures of data sharing found in the meaningful use program?

The answer from the American Medical Association (AMA) and 36 other national medical societies was that the government is off to a bad start. In a June 3 letter to CMS and the Office of the National Coordinator for Health information Technology (ONC), the societies criticized the carryover of "deficient" meaningful use measures of data exchange into MACRA, saying that these measures essentially have dumbed down interoperability.

"Despite claims by many health IT vendors that their products are interoperable, the vast majority only exchange static documents in a manner that satisfies minimum meaningful-use requirements," the medical societies said. "Many in healthcare view this level of exchange as little more than digital faxing."

The medical societies fault the meaningful use requirements for focusing too much on how many times "voluminous documents" are transmitted. "For medical professionals and patients alike," they said, "interoperability means the usefulness, timeliness, correctness and completeness of data, as well as the ease and cost of information access." They urged CMS and ONC to recast the ACI objectives in MACRA to emphasize quality of data instead of quantity of data.

Besides signing the AMA letter, the American Academy of Family Physicians (AAFP) submitted a separate response to the interoperability questions posed to the government. The AAFP recommended that if CMS continues to measure utilization of healthcare information technology, such as two physicians sharing patient data, it should not require physicians to report that activity. CMS instead should glean utilization data directly from EHRs or community networks for sharing health information.

Steven Waldren, MD, director of the AAFP's Alliance for eHealth Innovations, said in an interview with Medscape Medical News that the CMS emphasis on mere data exchange gives short shrift to the clinical relevance of the data. When a primary care physician refers a patient with diabetes to an endocrinologist, just some parts of the chart warrant sharing. Yet in the meaningful use era, physicians get more than they need — and good luck finding the key information, according to Dr Waldren.

"What we hear from our members is that they're getting these voluminous care summaries that hardly have any clinically relevant data," said Dr Waldren, adding, "I have to click through all this crap."

The letters from the AMA, the AAFP, and other groups to CMS on EHR interoperability aren't the last word on the subject. Medical societies and everyone else have until June 27 to submit comments on the proposed MACRA regulations, including those that define performance in the Advancing Care Information category of MIPS. The proposed regulations explain how to submit comments.

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