On CMS 's Promoting Interoperability Program (the program formerly known as the EHR Incentive Program)

A while back I read through CMS's recent rule changing the EHR Incentive program to the Promoting Interoperability program.  I promised a blog update but for some reason (work), didn't get around to writing it.  I decided to take action and finally sit down and finish it.

The published rule is something like 1800 pages, 36 reams of paper when printed double-spaced (as preprints are).  You can find it at the link above.  It goes by the precise but lengthy title of:

Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Proposed Policy Changes and Fiscal Year 2019 Rates; Proposed Quality Reporting Requirements for Specific Providers; Proposed Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs (Promoting Interoperability Programs) Requirements for Eligible Hospitals, Critical Access Hospitals, and Eligible Professionals; Medicare Cost Reporting Requirements; and Physician Certification and Recertification of Claims

I will only cover two parts: Quality Reporting Requirements, and the Promoting Interoperability Programs.  The first part is interesting because everyone who cares about the second part also has to deal with the quality reporting part.  You can find my raw read-through comments on Twitter.

Quality Reporting Requirements

If you haven't been paying attention to CQL, you really need to be.  The first publication of reporting requirements technical specifications will be this spring (coming REAL soon) for use in 2019 (coming sooner than you think).  According to CMS (and me) "We believe that compared to CQL, QDM logic is more complex and difficult to compute".  CMS will be using a sub-regulatory process to make technical corrections to the measure specifications.  This is good because it means that the quality measure specifications will be able to have more quality without going through a heavyweight process to fix mistakes.  But it also means you have to pay attention.

Hospital measure data will join the myriad of other public data out there, as it will .  Soon we'll be able to compare not just meaningful users and their EHR systems, but also the quality results they'll be able to get from the use of them.  That should be an interesting mashup.  Hey ONC! Are you listening?

A lot of measures are going to be eliminated, either because they are topped out (hospitals are doing so well its not worth measuring any more), duplicative, or cost too much to produce for value received or ...  There's are lists of the measures that CMS is proposing to remove in the rule.  While everyone is happy about measures being removed, just remember that also means that there are fewer choices to succeed with...

Promoting Interoperability Programs

Why did they change the name?  Well, they remind us in the rule that the EHR Incentive part of the program is about over for anyone participating (we're now in the penalty stage).  So that part makes sense.  One significant change is that the singular program became the plural programs. 

They are planning to require 2015 Certified EHRs for these programs because, in part, ONC has confirmed that at least 66 percent of eligible clinicians and 90 percent of eligible hospitals and CAHs have 2015 Edition available (see the link above at meaningful users and their EHR systems).  Also, the evaluation period is a minimum of any continuous 90-day period within each of the calendar years 2019 and 2020, as you all probably hoped and expect.  The rationale for this change was that health care providers may need extra time to fully implement and test workflows with the 2015 Edition of CEHRT.

Miscellaneous

Security Risk analysis is simply required, you don't get any extra points for doing what you are required by law and regulation to already do.

For ONC and CMS, it's pretty routine to ensure that whatever the latest and greatest healthcare crisis is, there needs to be something to in the regulations about it.  So new measures have been added to address opioid abuse, including Queries of prescription drug monitoring programs (PDMPs), and verification of opioid treament.

Closing the referral loop also gets some love with a new quality measure supporting that buzz phrase.

A number of exclusions (loopholes) are being removed, few are using them or they aren't warranted according to CMS.

Puerto Rico hospitals become eligible for the program, something that wasn't available to them previously.

Some capabilities will no longer be required to be used (though they will still exist in the certification requirement): Secure Messaging, View/Download/Transmit.

So, there you have it, my summary of about 10% of the rule.

For what it's worth

The section on Future Directions is worth reading for those of you who are worried about what is next, but that is merely non-binding self-promotion for the most part.  The really important part related to that is where CMS asks you to tell them where they should go.

ICD-10-CM Delay… Prolonging the Distraction

I ran into John Carter at HIMSS, he's a former colleague and a standards buddy in a number of different places. John's a vocabulary geek, a place I tend to avoid in standards conversations ... well ... because there are experts like John who cover it much better than I could.  We chatted, and while he doesn't usually blog, I asked him to write a guest post on the topic, because I think his insights would be valuable.  Without further ado, here's John...

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By John Carter, Vice President, Apelon, Inc.

On February 16, 2012, HHS Secretary Kathleen Sebelius announced an unspecified delay in the U.S. implementation of ICD-10. Reaction to that announcement has ranged from self-satisfied to frustrated. We should ask ourselves what all the fuss is about, and reconsider our priorities.

My company specializes in helping its clients achieve semantic interoperability, with a special focus on terminologies. A few years ago, we considered what to do about the ICD-10 problem. Customers were asking about it, some of our competitors were marketing 9-to-10 transition services, and a host of new companies and products were springing up to help with the transition. In the end, we decided that it wasn’t really our gig. My colleagues and I have spent more than two decades working on data interoperability. Our core interest and focus are on enabling decision support, because we see that as the only significant opportunity to moderate cost increases and address quality variances. We’re not billing specialists, and ICD-10 is (just) another billing system. Sure, it’s got more codes, more detailed granularity than ICD-9, but it’s mostly used to summarize care in order to get paid. We repurposed some  software to assist do-it-yourselfers with mappings, and we hope that some of those new customers will become interested in exploring reference terminologies and decision support. We held steady with our long-term mission, and we didn’t bet the firm on the 9-to-10 gold rush.

Instead, we’re focused on semantic interoperability using every tool available. That means that while we are happy to wring every ounce of meaning out of ICD-9 and ICD-10, we’re even more interested in highly expressive clinical terminologies like SNOMED CT and LOINC. ICD-11 will incorporate the ontological framework currently used in SNOMED CT, the largest and most formally structured clinical terminology out there. For all its many flaws and gaps and hiccups, SNOMED CT relentlessly gets better every six months, and the list of governments providing their support also keeps growing. Applying SNOMED CT in one’s daily practice is still rare, but that doesn’t mean it can’t or shouldn’t be done. The recipe is straightforward: start with a well-defined set of documentation and analysis tasks, add in the right set of structured and semi-structured documents, serve in an EMR that provides good usability, perhaps adding a dash of NLP to taste.

There’s still a divide between two models of healthcare documentation and delivery, with ICD-10 (and below) on one side ICD-11 / SNOMED CT on the other. Today, you provide and document care and then, separately, you assign some codes and hope to get paid. With ICD-11, there’s the idea that your clinical documentation is sufficiently structured and comprehensive to get you paid without extra steps or coding gamesmanship. For any provider who can move beyond meeting HHS’s evolving requirements, that’s where the action is: high-quality computable documentation leads to clinical decision support, statistically comparative quality measurement, and the possibility of population-based health improvement.

Tom Sullivan wrote about the pros and cons of skipping ICD-10 and going to ICD-11, and he concludes that it’s probably too big a step to take, like Keith does elsewhere on this blog. I regretfully agree… if ICD-10 is such a burden, there’s no way for the system to even contemplate ICD-11 (since it’s not even available for contemplation at this point). That means the distractions will continue.

The good news is that more and more enterprises are going ahead and implementing better, more structured, more computable documentation systems today, while still supporting whatever billing codes are needed. Systems like Kaiser Permanente, Intermountain Healthcare and Mayo Clinic, among others, have long recognized that good documentation leads to good measurement leads to better care and lower costs. At the same time, health information exchanges are more popular than ever, because even though the business model isn’t clear yet, the value of exchanging clinical information is simply too great to pass up.

The delay in implementing ICD-10 is probably unavoidable, and of course providers must fight to protect their revenue stream. Still, I hope as a nation we’ll continue to find ways to get past the all that and keep moving toward semantic interoperability. As the standards and the terminologies have improved, and as the deployment of electronic health records continues, we find ourselves at a time of momentous opportunity. We have a vision for a health care system that provides decision support, powered by computable documentation, available when and where it’s needed, and the sooner we can put the ICD-10 conversion behind us, the sooner we can get moving!

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Following up on John's comments, the only way to move to ICD-11 would be through regulatory action. CMS originally proposed a regulatory process for delaying ICD-10, and then went back to stating "a process" (e.g., sub-regulatory). I suspect they changed their stance after someone pointed out how long a regulatory process could take (just days before, or even after the current ICD-10 deadline). CMS could,  without changing the regulation, decide on what they do about enforcement on dates (just as they did for 5010). So, no regulation means no chance for ICD-11, only ICD-10.  So, ICD-10 it is no matter what, it's just a matter of when.