ONC Set to Address Information Exchange, Compliance Burden

Ken Terry

July 11, 2017

Reducing the burden of electronic health records (EHRs) on physicians and promoting health information sharing will be the major priorities of the Office of the National Coordinator for Health Information Technology (ONC) going forward, Donald Rucker, MD, the new national coordinator, told reporters at a news conference today.

Interoperability between EHR systems has long been at the top of ONC's agenda, but the emphasis on EHR usability and lowering the administrative burden on small practices has not. Dr Rucker noted that, along with interoperability, this goal is very important to Tom Price, MD, Secretary of Health and Human Services (HHS). In introducing John Fleming, MD, deputy assistant secretary for health technology reform, HHS, at the press conference, Dr Rucker also observed that Dr Fleming, a former solo practitioner in Louisiana, is the first senior-level HHS appointee "who represents small practices."

Dr Fleming said that he'd heard many complaints from doctors and patients about physicians' inability to focus properly on patient care because of the administrative requirements they had to meet, including EHR documentation. One reason for this regulatory burden, he said, is Medicare's guidelines for documentation of evaluation and  management (E/M) codes, which were formulated in the 1990s, before most physicians had EHRs.

"Now that EHRs are online, we see how the two [EHRs and E/M coding guidelines] create even more problems: we get voluminous, sometimes nonsensical health notes that can be unreadable or make it difficult to determine where the real information is," he noted.

The challenge of improving EHR usability, Dr Fleming continued, goes beyond the technology itself: it also involves the fee-for-service reimbursement system, which forces doctors to document their work in certain ways in order to get paid.

Dr Rucker agreed. "The CPT [Common Procedural Technology] rules were done in an era before computers, so it's time to rethink that," he said. ONC, he added, is working with the Centers for Medicare and Medicaid Services (CMS) to look at how the burden on physicians might be reduced.

However, Dr Rucker noted, CMS has to balance EHR usability against "honest fair payments" to doctors and program integrity. Later, responding to a question from Medscape Medical News, he said, "Part of what [CMS] is looking at is the interaction of the coding system with the provision of care and the burden of documentation."

While he declined to say whether changes in the E/M coding system were being contemplated, he said CMS is considering how it could help developers design smarter EHRs that would make it easier to document visits.

In addition, Dr Rucker said, ONC is looking at ways to ease the burden on practices of quality reporting in the Merit-Based Incentive Payment System (MIPS). "For a lot of practices, this has become a challenge," he pointed out. "At some point, the expense of complying with the quality measures is much greater than the value of the quality measures."

Interoperability Plans

On the interoperability side, Dr Rucker described three major use cases on which ONC is concentrating its efforts:

  • Patient access. Can patients get their data from their providers and transfer it to other providers, and can clinicians obtain patient data from each other?

  • Enterprise accountability. Can third-party software vendors gain access to EHR data so they can analyze it for providers?

  • Competition in the modern age. This thrust is about using open application programming interfaces (APIs), which ONC views as essential to interoperability and improvements in efficiency.

Dr Rucker noted that the 21st Century Cures Act mandates that ONC pursue open APIs. The 21st Century Cures Act also requires ONC to lead a public-private initiative to create a trusted exchange network and a common agreement that will include a method of user authentication, rules for trusted exchange, and policies to enable data exchange.

The first meeting of stakeholders to provide ONC with input on this exchange network will take place July 24, said Genevieve Morris, principal deputy national coordinator, at the press conference. Two more listening sessions will be held, one in August or September and the other in the fall. A draft of the common agreement will be issued late in the year or early in 2018, and a final version next year, she said.

The 21st Century Cures Act also requires ONC to take reports of information blocking by providers and vendors, which the law prohibits. Dr Rucker said that ONC will devise language to define information blocking, which under the legislation, is punishable with large fines if conducted by technology vendors. But it is the HHS Office of Inspector General, not ONC, that will enforce the law.

Other Topics

A number of other topics were covered in the wide-ranging, 90-minute news conference.

Dr Rucker explained at one point that MIPS' advancing care information requirements are the successor to the meaningful use EHR incentive program, which no longer applies to doctors who participated in it through Medicare. (Eligible professionals who participate through Medicaid and hospitals are still meeting meaningful use requirements.) A reporter asked when Dr Rucker thought meaningful use would end. While the national coordinator could not give a date, he said, "The operational answer is when there's a broad perception that [electronic medical records] are working smoothly and there's not a need for this."

Morris said that ONC would continue to pursue the goals of its interoperability roadmap, although some of it must be revised in light of the 21st Century Cures Act. Asked whether ONC has the resources to perform all of the tasks assigned to it in that legislation, Dr Rucker said it did. However, he noted, in a reference to a severe cutback in ONC's budget proposed by the Trump administration, "Some of this we're not legally able to work on until Congress finishes working on the budget."

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