EHR

A recent opinion piece and blog post take different positions on the overall success and potential effects of the meaningful use program.

Under the 2009 economic stimulus package, providers who demonstrate meaningful use of certified electronic health records can qualify for Medicaid and Medicare incentive payments.

Washington Post Opinion Piece

Charles Krauthammer in a Washington Post opinion piece argues that the federal government's EHR "mandate" has "degraded medicine" and has even driven some physicians to leave the profession.

Krauthammer -- a former health care provider -- writes that the Obama administration's 2009 promise that EHRs would save $77 billion per year "became a joke," and the $27 billion that was allocated for the transition "is gone." Moreover, he adds that a 2014 HHS Office of Inspector General report found that "'EHR technology can make it easier to commit fraud,' as in Medicare fraud."

Krauthammer cites a former medical school classmate who wrote in their school's 40th reunion report that adopting EHRs at his office has meant that he "can only see about three-quarters of the patients [he] could before, and has prompted [him] to seriously consider leaving for the first time."

Krauthammer also cites an American Journal of Emergency Medicine study that found emergency department physicians "spend 43% of their time entering electronic records information, 28% with patients" and a JAMA Internal Medicine study that showed "family-practice physicians spend on average 48 minutes a day just entering clinical data."

Krauthammer adds, "That's just the beginning of the losses. Consider the myriad small practices ... facing ruinous transition costs in equipment, software, training and time, have closed shop, gone bankrupt or been swallowed by some larger entity." In addition, he notes, that providers who had not adopted EHRs by January will receive lower Medicare payments.

Krauthammer concludes that while "many ... feasted" on the initial investment in the government's push to adopt EHRs, "the rest is waste: money squandered, patients neglected, good physicians demoralized" (Krauthammer, Washington Post, 5/28).

HIMSS Blog Post

In response to Krauthammer's piece, Tom Leary, vice president of government relations for the Healthcare Information and Management Systems Society, in a blog post writes that while the "[c]hallenges" to EHR adoption "are still evident ... the meaningful use program is lining up to have a long-term positive impact on health care delivery in the U.S."

He notes that Krauthammer's "implication that digitizing patient records has been anything but a bipartisan imperative for the country fails to acknowledge health IT as a critical tool for supporting health care transformation by improving  quality and controlling the cost of care delivery." He adds that the "march to meaningful use" started in January 2004 when then President George W. Bush (R) "declared that most Americans would have access to their electronic health record within 10 years."

Leary also highlights the benefits of health IT, noting that investments in the area "will ensure better quality data are available to providers, so they can make informed decisions about the right patient at the right time."

Leary points to recent data from HIMSS Analytics that suggests "over 70% of hospitals have made positive progress in the advancement of their EHR capabilities over the last five years, and over 60% of ambulatory facilities have shown positive progress in just the last three years." He also cites examples of "smaller practices using health IT solutions to make positive change for their patients," such as Fremont Family Care, which saw the number of patients who needed hospitalization for pneumonia drop by half after it implemented an EHR system.

Leary acknowledges that there is still "work to do," in terms of health information exchange and meaningful use of health IT. However, he concludes, "We know IT improves health, and we will continue to educate the public on its benefits" (Leary, HIMSS blog post, 6/3).

Computerized clinical decision-support tools can help to reduce the amount of inappropriate advanced imaging tests ordered, but more work remains to improve the tools, according to a study published in the Journal of the American Medical Association, Healthcare Informatics reports (Perna, Healthcare Informatics, 6/2).

Background

According to Healthcare IT News, the overuse of imaging tests, such as MRI and CT scans, plays a key role in the rising cost of health care (Miliard, Healthcare IT News, 6/2). Beginning in 2017, CMS -- which sponsored the study -- will require the use of clinical decision-support before ordering any advanced diagnostic imaging tests that Medicare covers.

Study Details

For the study, researchers from the RAND Corporation sought to determine whether physician guidelines for the appropriateness of advanced imaging could help to reduce unnecessary tests for Medicare beneficiaries.

The study involved a total of 3,340 clinicians who worked at organizations located in eight states. The participating organizations included:

• Three academic medical centers;
• Two integrated delivery systems;
• One group of independent practices in a single geographic area; and
• One group of independent practices recruited by a radiology benefits management organization (Healthcare Informatics, 6/2).

The researchers relied on several medical specialty societies to review research and develop a structured rating process for the appropriateness criteria, which were loaded into the clinical decision-support tools at all participating organizations.

Study Findings

During the two-year study period, participating clinicians placed 117,348 orders for advanced diagnostic imaging procedures (Healthcare IT News, 6/2).

Overall, the researchers found that the clinical decision-support tools, which matched a patient's characteristics against treatment criteria and recommended treatment options, increased the proportion of appropriate tests (Healthcare Informatics, 6/2). That means fewer patients were exposed to potentially costly, harmful tests.

However, the study showed that a majority of orders placed were unable to be assigned appropriateness ratings by the clinical decision-support tools because:

• No such criteria were available; or
• The clinical decision-support tool was unable to find the appropriate criteria (Healthcare IT News, 6/2).

In a statement, RAND senior policy researcher Peter Hussey, said, "The increase in orders rated as appropriate is promising, but the number of tests that were not rated indicates there is room for further improvement of these tools" (Healthcare Informatics, 6/2).

RAND is delivering a report to Congress on the findings. Hussey said the company has "outlined a series of improvements" to the clinical decision-support tools for lawmakers, such as "more-comprehensive set of evidence-based guidelines that cover a greater proportion of advanced imaging orders for Medicare patients" (Healthcare IT News, 6/2).

Fast Healthcare Interoperability Resources (FHIR), a new standards framework from HL7, is starting to get traction in the industry as the latest focus of interoperability efforts. According to proponents of the rapidly evolving approach, FHIR promises to facilitate health information exchange, broaden the capabilities of electronic health records and accelerate innovation in mobile health applications.

In essence, FHIR uses snippets of data known as resources to represent clinical entities within EHRs. Certain application programming interfaces (APIs), otherwise known as plug-ins, can connect applications to FHIR-enabled EHRs without customized interfaces. A security standard known as OAuth gives patients the ability to access the EHR data themselves or grant access to providers and others.

FHIR has already gotten the attention of EHR vendors, some of whom are participating in the Argonaut Project. The coalition of 40-plus EHR suppliers, health care organizations and other stakeholders is implementing and testing the initial FHIR profiles. Among the EHR developers participating in the project are:

• athenahealth;
• Cerner;
• Epic;
• GE;
• McKesson;
• Meditech;
• NextGen; and
• Practice Fusion.

David McCallie, Jr., senior vice president of medical informatics for Cerner, said these vendors are expected to "go into production" on a subset of FHIR profiles within the next six to 12 months. "Hopefully, they'll all implement these core services for things like problems, medications and allergies," he said

EHR developers are taking notice of FHIR partly because the government might make it mandatory, McCallie noted. In the meaningful use Stage 3 proposal, CMS advocates for an "open API" that would allow patients to view, download and transmit their own EHR data. Although FHIR is not mentioned, the Office of the National Coordinator for Health IT cited FHIR several times in its 2015 EHR certification proposal.

The FHIR standard was recently coupled with another innovation designed by researchers at Harvard Medical School and Boston Children's Hospital -- the Substitutable Medical Applications and Reusable Technology platform. SMART provides a Web-based graphical user interface to FHIR, using software written in HTML5 and Javascript. The combined programming is known as SMART on FHIR.

An app developer could write an app to SMART on FHIR specs and would be able to connect it to any FHIR-enabled EHR. What this means is that consumers could select SMART on FHIR apps from outside firms and plug them into their provider's EHR.

Clearly, this would be an enormous spur to innovation among the nation's app developers.

Former U.S. CTO Aneesh Chopra said, "If you lower barriers to entry, you make it easier for innovators. A FHIR-enabled world should result in hundreds, if not thousands of apps, competing for the right to make better health decisions, live healthier lives and lower costs."

But this is the only the beginning of what SMART on FHIR might be able to do, according to Chopra and McCallie.

CCDA Replacement?

Currently, the only way to exchange care summaries between disparate EHRs is to use the CCDA, a document that follows another HL7 standard. But some EHRs are unable to exchange these care summaries because the standard is complex and allows too much room for variations. FHIR could provide a way to escape this dilemma by allowing discrete data to be exchanged directly instead of as part of a document.

The Argonaut Project is now focusing on a subset of FHIR that consists of the 16 data elements in the CCDA. Chopra said these components have been trimmed to 12 FHIR profiles. The Argonauts are testing these profiles and creating open-source implementation guides for them. "What FHIR proposes to do is to make it much easier to exchange and use the individual data elements," he said.

McCallie agreed. Noting how much simpler FHIR is than the CCDA, he said, "My bet is that a wider variety of vendors will be able to properly form FHIR messages than is currently the case with CCDA."

Another advantage of FHIR, McCallie said, is that clinicians can query other EHRs for just the information they're looking for, rather than having to obtain a CCDA and search the entire document for that piece of data. "With FHIR, you say, 'Just send me the patient's current conditions,' and you get it back in a second."

When a certified EHR sends a CCDA to another certified EHR, certain elements of the care summary are supposed to be transportable into the data fields of the receiving EHR. There's usually a "data reconciliation" step where the provider who wants to import some of the data looks it over first. Then he or she can bring the data into the correct field. "But not all vendors do this well, and it's slow," McCallie said. "It can take four to five minutes to do this, and doctors don't have four to five minutes.

"With FHIR, the doctor can say, 'Is my allergy record complete? Show me what else is known about allergies on this patient.' And they can do it in a couple of seconds, so doctors are more likely to do it that way," he said.

Expanding EHR Capabilities

EHR developers provide the core capabilities of EHRs and associated financial systems, "but we can't build everything that users need or want," McCallie said. "So the [FHIR-enabled] apps will open that up for extensions in ways that go beyond what the vendor had focus or interest or time to provide."

These apps might add new functionality to the EHR or they might enable EHR users to import additional data from other sources. For example, an accountable care organization might be able to provide a "population view" to a physician who participates in the ACO through a specialized app, McCallie said.

Another example of how this might work is being pioneered at Geisinger. Through its xG Health Solutions spinoff, the Danville, Pa.-based health care system plans to transfer the best practices it has developed for treating multiple health conditions to other health care organizations. xG will use apps to extract data from FHIR-enabled EHRs, analyze them, reorganize them and present the information back to the organization in its workflows.

If providers used FHIR-enabled apps to extend the functions of their EHRs, Chopra said they might create a marketplace for those apps. "Imagine a 1,000-doctor network that could choose among FHIR-enabled apps, and each specialty had different EHR extensions through apps," he said. "Only the ones that were used would be paid for."

Future of Interoperability

In the long run, Chopra said, FHIR could solve the technical problems of EHR interoperability. But business, legal and policy issues will continue to impede the flow of information, he predicted. The key to effective data sharing, in his view, will be the right of the patient to his or her own data.

"Whether the government forces hospital A to share data with hospital B or not, if they can both speak FHIR to the patient, the data become liquid and can be exchanged safely and securely through the patient," Chopra said.

McCallie questioned, however, whether consumers will be as interested in ferrying information between their providers as they are in using mobile health apps plugged into EHRs. Moreover, he noted that providers might be wary of importing such data into their EHRs because they don't know the information's source or whether it has been tampered with.

A more likely scenario, he said, is that providers in a region will form a cloud-based network that can share data through apps plugged into their EHRs. While this isn't very different from a health information exchange, he observed that HIEs have to work with vendors to write interfaces to all of the EHRs in their networks. "It's the difference between doing it the hard way with a lot of custom engineering or doing it with a plug-in that doesn't require any custom engineering."

With SMART on FHIR apps, it would be much easier to share information, McCallie said. "The app model should make it more uniform and less expensive."

Meanwhile, the FHIR train continues to chug onward, gaining adherents as it goes. EHR vendor Greenway is not part of the planning for SMART on FHIR, but Greenway CEO Tee Green praised the initiative.

Noting that Greenway has had its own API platform for four years, with 80 companies now contributing apps, Green said, "FHIR and other technologies continue that evolution. No longer will we operate in the Hotel California model, where you come but you can't leave. Those days are coming to an end. It's exciting, because consumers are demanding it, and it's going to create a tremendous amount of efficiency and technology breakthroughs."

Several groups have offered recommendations for CMS' proposed rule for Stage 3 of the meaningful use program, Clinical Innovation & Technology reports (Walsh, Clinical Innovation & Technology, 5/29).

Background

Under the 2009 economic stimulus package, providers who demonstrate meaningful use of certified electronic health records can qualify for Medicaid and Medicare incentive payments.

The comment period for the Stage 3 proposed rule closed on Friday.

Under the proposed rule, all eligible professionals beginning in 2018 would report on Stage 3 of the meaningful use program regardless of their previous participation. Providers would have the option to move to Stage 3 starting in 2017 (iHealthBeat, 5/28).

AMA's Comments

In a letter, the American Medical Association called on CMS to address current program issues before moving on to the next stage.

The association made several recommendations should CMS choose to continue with the Stage 3 transition in 2018, including:

• Allowing quality measures that are reported to clinical registries to satisfy meaningful use reporting requirements;
• Establishing a reporting period that is less than one year;
• Seeking physician and vendor feedback before implementing or retracting measures; and
• Setting 2017 as a transitional year for providers and vendors to adapt to system and workflow changes (AMA release, 5/29).

AMIA's Comments

Meanwhile, the American Medical Informatics Association said that the transition to the Merit-based Incentive Payment System established by the repeal of Medicare's Sustainable Growth Rate formula would be "highly burdensome while offering only modest gains" under the proposed Stage 3 rule (Pittman et al., "Morning eHealth," Politico, 6/1).

HIMSS' Comments

In comments submitted last week, the Healthcare Information and Management Systems Society emphasized the importance of interoperability and the meaningful use program's role as a "critical tool for enabling health care transformation."

HIMSS also said that it supported CMS' efforts to align the meaningful use program with other CMS quality reporting programs that use certified EHR technology, citing the proposal's potential to ease the burden on providers.

However, HIMSS recommended that CMS:

• Allow 18 months between the finalization of relevant rules and the transition to Stage 3 for providers to prepare; and
• Lessen the "prescriptive nature" of the meaningful use program.

MGMA's Comments

In its own comments, the Medical Group Management Association also expressed concerns over the current state of the proposed rule.

MGMA said that the meaningful use "program has become a significant administrative burden and is proving to be counterproductive."

The group recommended that the proposed rule be "substantially modified" and urged CMS to delay finalizing the Stage 3 rule until:

• The effect of the Medicare Access and Children's Health Insurance Program Reauthorization Act of 2015 and its meaningful use provisions are determined; and
• Useful data on eligible professionals' participation in Stage 2 is made available.

MGMA also encouraged CMS to:

• Create additional categories for qualifying for hardship exceptions;
• Establish a 90-day reporting period for the entire program; and
• Set objectives and measures that are reasonable and do not discourage EPs from participating (Clinical Innovation & Technology, 5/29).

AHA's 2015 Health IT Certification Criteria Comments

Meanwhile, the American Hospital Association in a letter to National Coordinator for Health IT Karen DeSalvo applauded the 2015 Edition Health IT Certification Criteria proposed rule for its provisions to:

• Create a health information exchange infrastructure; and
• Improve interoperability.

However, AHA also urged the Office of the National Coordinator for Health IT to increase transparency and the reliability of certified health IT through:

• Surveillance of products being used "in the field";
• More disclosure requirements for vendors; and
• Testing (Dvorak, FierceHealthIT, 5/29).

Linda Fishman, senior vice president of public policy analysis and development at AHA, wrote, "While this may narrow the scope of a final 2015 Edition rule," it also could "improve both the ability of vendors to develop technology in conformance with certification requirements and the ability of providers to successfully implement technology to meet regulatory requirements" (AHA News, 5/29).