After his speech at the J.P. Morgan Annual Health Care Conference,
and the ensuing tweet that rocked the #HITsm sphere:
In 2016, MU as it has existed– with MACRA– will now be effectively over and replaced with something better #JPM16
— Andy Slavitt (@ASlavitt) January 12, 2016
CMS Acting Administration Andy Slavitt, along with ONC Director Karen DeSalvo, released their latest declaration on the future of Meaningful Use. However, while the message boasted progress and promised reform, the ‘grand’ gesture left many unanswered questions. At face value, their strategy glazes over many of the more important criticisms pundits have launched against the EHR incentives program.
If we read between the lines, however, perhaps we can begin to decipher their clichéd ideology:
Where We’ve Been
As we mentioned in a speech last week, the Administration is working on an important transition for the Electronic Health Record (EHR) Incentive Program. We have been working side by side with physician organizations… [and] while we will be putting out additional details in the next few months, we wanted to provide an update today…
Okay, but getting to the point…
[Congress passed t]he Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which considers quality, cost, and clinical practice improvement activities in calculating how Medicare payments will be determined moving forward… [and] continues to require that physicians be measured on their “meaningful use” of certified EHR technology for purposes of determining their Medicare payments…
Sure, that sounds great—but what does that all mean? Give us something concrete.
As we move forward under MACRA, we will… be guided by several critical principles:
1. Rewarding providers for the outcomes technology helps them achieve with their patients.
2. Allowing providers the flexibility to customize health IT to their individual practice needs. Technology must be user-centered and support physicians.
3. Leveling the technology playing field to promote innovation, including for start-ups and new entrants, by unlocking electronic health information through open APIs…
4. Prioritizing interoperability by implementing federally recognized, national interoperability standards and focusing on real-world uses of technology…
This all sounds really familiar… Didn’t you say essentially the same thing back when this whole “Meaningful Use” was started, almost seven years ago?
1. “Measuring and reporting CQMs helps to ensure that our health care system is delivering effective, safe, efficient, patient-centered, equitable, and timely care.” – gov [Clinical Quality Measures Basics]
2. “Promote technical innovation using adopted standards” – July 22, 2010 [ONC for Health Information Technology Supporting Meaningful Use]
3. “Promote interoperability” – July 22, 2010 [ONC for Health Information Technology Supporting Meaningful Use]
4. “Encourage participation and adoption by all vendors, including small businesses…” – July 22, 2010 [ONC for Health Information Technology Supporting Meaningful Use]
If that’s the case, then how exactly we are ‘transitioning’ away from the current program?
The approach to meaningful use under MACRA won’t happen overnight. Our goal in communicating our principles now is to give everyone time to plan for what’s next and to continue to give us input…
We encourage you to look for the MACRA regulations this year; in the meantime, our existing regulations – including meaningful use Stage 3 – are still in effect.
So, for those of you following along at home, this is the brilliant plan to improve EHR usage: first, announce a ‘new’ strategy (which is basically a recycled version of the old strategy); then, have everyone adhere to the same old guidelines?
How will Meaningful Use be effectively ended and “replaced with something better,” if we can see no recognizable direction from the federal government?
Congress gave us new authority to streamline the process for granting hardship exception’s under meaningful use. This will allow groups of health care providers to apply for a hardship exception instead of each doctor applying individually.
Unfortunately, this doesn’t address any of the real problems. We need a concrete plan of action, not just principles and reiterations. What does it take to initiate a plan that actually works, instead of just making a patch job of what we have now?
I sense stall-tactics on the part of the CMS and the ONC. Maybe we have become complacent. Have we not put enough pressure on our leaders to take action? Whatever becomes of this ‘shake-up,’ surely the nonsense must end.
However, I can almost guarantee that the process will not be quick; and it certainly will not be painless.
The accompanying cartoon is property of the University of Pennsylvania, as it appeared in the Pennsylvania Gazette in February 2014.
[Slavitt, Andy, and Karen DeSalvo. “EHR Incentive Programs: Where We Go Next.” The CMS Blog. 19 Jan. 2016. Web. 04 Feb. 2016.]
User satisfaction is potential. It’s a building block for the future. It enables providers to derive maximum value from their electronic health records, ensuring success post-implementation. In order to truly ensure user satisfaction, however, EHRs must be flexible. They must be capable of adapting to present-state workflows in order to adequately address the needs of both patient and provider. Because of this, EHR flexibility is essential to user satisfaction—and the key to patient care.
Several important characteristics must converge in order to ensure EHR flexibility—specifically those pertaining to patient safety. Clinical decision support, patient management, workload management, and patient documentation are examples of functionality that should reflect the needs of the patient population. EHR flexibility ensures that providers are able to configure this functionality in a manner adequate to their unique clinical setting.
An EHR should reflect the needs of the provider population, in addition to the patient population. This is a largely misunderstood portion of the EHR process that is especially crucial when considering future adoption. The only way end users—doctors, nurses, pharmacists, and everyone else in between—may use this technology to positively impact patient care, is if they are satisfied with the tools at hand.
A flexibly-designed EHR transforms alongside providers, to advance their mission, even as technology and practices change. Systems must be capable of adapting to different workflow models, clinical disciplines, and communication methods, particularly due to the variant nature of health care providers. With the hyper-competitive nature of the health IT industry, providers must demand improvements in three key areas as a result of EHR deployments:
1. Provider Satisfaction
2. Clinical Efficiency
3. Patient Safety
Each of these areas is crucial to advance the mission of health care. However, like a house of cards, patient care is a delicately constructed hierarchy. It is important to remember that each of these points is important both independently, and in how it relates to the others.
The shortcomings of the “one-size-fits-all-EHR” mentality have finally come to light with the recent incentives shakeup—in spite of the mission to achieve “meaningful use.” In truth, the EHR incentives program has been in desperate need of reform since its inception; and the recent hardship exemptions bill is only symbolic of the apparent legislative indifference. It did nothing to address the problem of “minimum” requirements, made no attempt to encourage data uniformity and interoperability, and continues to neglect the importance of EHR flexibility.
Establishing standards for EHR flexibility is paramount. As functionality should conform to the client’s needs, things such as program interface engines, documentation, external reporting, decision support, and data sharing should be tailored individually for each client. Additionally, vendors should encourage implementation plans and system functionality that adhere uniquely to their clients’ realm of work. With the advent of what some consider the “Death of Meaningful Use,” providers must demand solutions capable of adapting to the unique needs of their environment.
In addition, the “all-or-nothing” approach to EHR incentive payments must be replaced by a more flexible, merit-based payment model. However, this logic must also be applied to forthcoming federal EHR laws. Incentives should be goals-oriented instead of structured as pass-fail. Furthermore, these goals should be appropriate to the provider’s patients and clinical workflow.
EHR flexibility will help to bridge the gaps created by a flawed incentives program, as it transcends several aspects of health care operations. It is meant to play an important role in improving patient care. Increasing EHR flexibility will enable providers with the means to embrace change—only then will they be able to use innovations in technology to truly transform patient care.
As we waited for the ball to drop on 2016, President Obama signed a bill into law that aimed to “ensure flexibility in applying the hardship exception for meaningful use.”
Congress’ proposal seemed a noble cause: relax federal impositions to encourage health technology development. As federal mandates have become extraneous, and even burdensome to certain health care providers, changes should be made to the EHR incentives program. At least, that was the argument.
So, when pressured multilaterally by providers, developers, and health care experts to actually do something, Congress did what it does best: (virtually) nothing at all.
Meaningful Use is in desperate need of reform. Its problems are inherent in its structure, which an adjustment to “hardship exceptions” hardly begins to address. Congress mandated payment adjustments for providers who are not meaningful users of Certified Electronic Health Record, essentially penalizing them, instead of encouraging future adoption.
However, the heart of the matter lies in the lack of flexibility given to providers, and lack of innovation afforded to EHR developers. By holding everybody to the same standard, the program has hampered the market’s collective ability to innovate.
Push-back has been consistent, most notably from the AMA. As recently as December 15, just three days before the bill was approved by congress, the AMA pleaded with CMS and the ONC to amend Meaningful Use restrictions, and not for first time:
Stage 3… continues to restrict innovations in technology for patients and physicians and creates barriers in moving to the new Merit-Based Incentive Payment System (MIPS) and alternative payment models (APMs)…
MU measures currently define patient engagement in a narrow manner without recognizing the vast opportunities of new technologies. Similarly, the MU program’s pass-fail structure is at odds with moving towards measuring and assessing care improvement.
The recently-signed Patient Access and Medicare Protection Act pushed back filing deadlines on hardship exemptions for eligible professionals until March 15, and eligible hospitals until April 1. It also granted the CMS the ability to batch process hardship applications by categories, instead of by the previous case-by-case method.
Detractors of the program have heralded flexibility as crucial to restoring success in EHR incentives. However, with a verifiably defunct Meaningful Use program, those calling for reform will continue to face an uphill battle. In the face of such criticism, and with such actionable room for improvement, the bill is really nothing more than half-hearted attempt at appeasement.
While Congress could have just as easily accepted its limitations and made the changes necessary to ensure future success, Meaningful Use is still in desperate need of reform. A whole laundry list of items could have been addressed: the pass-fail design, data uniformity, incentives structure, and more. Most importantly, replacing often arbitrary requirements with goals-based incentives would, more than anything else, drive improvements in care, and innovations in technology.
Most sane people would agree: when the government stifles innovation, the status quo must be changed. Yet, it seems lawmakers (and their beneficiaries) are either too ignorant, or too proud, to admit their shortcomings.
Customers love value—it keeps them happy. We even devised a whole day to “celebrate” the value of value—Black Friday; then expanded upon the madness with Cyber Monday. As such client-derived value is essential to every successful business, it should also, then, be important in the context of healthcare.
However, the ideal state of every business is to do more with less, without sacrificing quality or cutting corners. This requires the efficient and proactive delivery of quality service. Everybody wants a full return on their dollar, and in an age of hyper-connectivity, all businesses should adopt value-based models in order to survive amidst competition. In healthcare, this manifests itself in terms of value-based care.
Value-based care models deliver effective, appropriate, and safe patient care with lasting results, and at practical cost. Electronic systems enable value-based models of care by ensuring evidence-based medicine and the means to perform a critical analysis of patient data. Their deployment helps to improve healthcare across three crucial areas:
Health Information Exchange (HIE)
There really no result of value-based care more significant than improving patient care. When a patient enters the facility, it’s everyone’s job to ensure a positive outcome. The ability to quantify the variables that go into this outcome allows providers to identify deficiencies in care and potential improvements—the key to deriving maximum value for both patients and providers. This is essential to ensure ongoing positive outcomes.
The collection of data also increases provider accuracy, both though the use of clinical decision support technology and by improving care coordination. This is critical to enforcing responsible patient care and eliminating wasteful or harmful practices. These tools help to minimize patient risk, reduce fiscal irresponsibility, and hold providers
accountable for their clinical actions.
Lastly, value-based care is built upon principles of Health Information Exchange. The interoperability of patient data allows providers to optimize the business of healthcare on a largescale. HIE compels healthcare systems to operate more efficiently, and address the needs of populations more accurately. By positively influencing patient outcomes and quantifying results, providers are able to gain maximum value from every patient visit—and maximum patient (customer) satisfaction.
Value-based care sounds like another buzz word in healthcare—but don’t be fooled. It’s more than just a fad.
Value-based care is the necessary result of adapting to changes and advancements in medicine. Employing value-based care models should be of paramount concern to modern providers, regardless of his or her setting—hospital, physician practice, clinic, specialty care facility, ALL CARE PROVIDERS—because it transcends so many aspects of the patient care process.
In order to derive maximum value from each visit, providers must actively engage in the consistent improvement of patient care. The resulting in increase patient safety and clinical efficiency is essential to thriving as a modern healthcare enterprise, and delivering value-based care.
In this day and age, pharmacy processing has become so automated, efficient, and accurate that it begs the question: do we really need hospital pharmacists? In a typical inpatient setting, prescribers can place orders electronically, send them to a pharmacy tech for review, and subsequently to the nurse at the bedside, all without the intervention of registered pharmacist. Patient and order information is transmitted seamlessly, with warnings at every step to make sure that nothing is overlooked during treatment.
Hospital pharmacists are certainly no strangers to advancements in the field of health information technology. However, is it possible that pharmacy information systems (PIS) have outpaced those individuals they were initially designed to support? I’m not proposing that we get rid of them altogether; but do we really need that many hospital pharmacists?
The answer is a resounding… YES!!! Not only do we need our hospital pharmacists, but if anything, we need more. Too often, physician errors can go uncorrected, and bedside errors can go unnoticed. However, pharmacists provide an extra level of security when potentially harmful order details go unaddressed. Besides surgery, pharmacological intervention is the primary route of treatment in hospitals, and pharmacists ensure accuracy in this crucial area. Their expertise allows them to scrutinize order details above the level of a nurse, pharmacy tech, or even an attending physician.
Outside of hospital-acquired infections, adverse drug events (ADEs) comprise possibly the greatest threat to patient safety in an inpatient setting. These can be the result of anything ranging from transcription errors, drug-drug interactions, or simply human error. However, without a dedicated pharmacist to review each order, errors such as the following can devastate a patient’s chance of recovery:
Just last week we received a call… concerning a 72 year old female… with recent onset renal failure. We pulled up her patient profile, noted her calculated Creatinine clearance (20ml/min), and performed a lab inquiry. She had high potassium, phosphate, CPK, myoglobulin, and hypocalcemia levels.
Her medication profile had listed Simvastatin 80mg at bedtime. We reviewed her previous medication list via the cumulative profile function, and noted she was taking Simvastatin 10mg at bedtime on her prior admission.
With MetaCare we were able to determine that the patient’s status was due to simvastatin-induced Rhabdomyolysis. The physician discontinued the simvastatin, hydrated the patient, and her renal function slowly improved.
This real-life story from one Meta user shows how HIT may help to prevent ADEs. In this case, Meta’s PIS made the necessary information accessible for the hospital pharmacist to examine the causes of the ADE. However, it was ultimately the responsibility of the pharmacist to think analytically, in a way other clinicians may not have. Sometimes, a pharmacist’s judgment call could have a huge impact on a patient’s outcome.
So, do we really need hospital pharmacists? The answer is simple.
Of course we do.
A computer cannot replace the role pharmacists play when treating patients. However, this technology can, and should, provide hospital pharmacists with all the necessary tools to ensure patient safety during times of crisis.