Meaningful use's directional shift

National Report-The federal government’s aggressive timeline for full Stage 3 implementation of meaningful use in 2018 seemed to derail on Jan. 11 when Acting Centers for Medicare & Medicaid Services Administrator Andy Slavitt declared that the program would come to an end this year.

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“The meaningful use program as it has existed will now be effectively over and replaced with something better,” Slavitt said in a speech he gave at the J.P. Morgan Healthcare Conference in San Francisco.

His words were interpreted by many reporters, bloggers, and Twitter users to mean meaningful use, like the wicked witch, was dead.

Now that the news has settled, urologists are among those who think meaningful use is very much alive, but evolving, and urologists and other physicians should not change electronic health record (EHR) course, just yet.

Dr. Dowling“I think that some of the quotes were possibly taken out of context by the sensationalism of it all,” said urologist Robert A. Dowling, MD, who is vice president of medical affairs and policy for IntrinsiQ Specialty Solutions (an AmerisourceBergen Specialty Group company). “When I read the transcripts, my initial reaction was that he hasn’t really made a lot of details about exactly what he meant, and we should anticipate clarification in the next couple of months.”

According to the AUA, Slavitt’s comments do not mean it’s time to abandon MU. In fact, it is essential that practices participate in meaningful use, as its requirements are only going to increase with each passing year.

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Rather, Slavitt’s comments could signal change that the focus of MU will move away from rewarding providers for technology use and toward patient outcomes.

“Providers will be able to customize their goals so tech companies can build around the individual practice needs, not the needs of the government. Technology must be user-centered and support physicians, not distract them,’” Slavitt said at the conference.

Next: Why the change?

Why the change?

CMS’s aim with meaningful use is to meet the government’s requirements under the larger framework of the Merit-Based Incentive Payment System (MIPS), which is part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), according to Steven M. Schlossberg, MD, MBA, the AUA’s treasurer as well as chief medical information officer at John Muir Health, Walnut Creek, CA. Where the initial meaningful use program was created to encourage EHR adoption, the focus of Stage 3 is on health information exchange, consumer engagement, and public health reporting.

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Dr. GonzalezThe biggest issue with the rollout of Stage 3 meaningful use was how the mandate would fit in with MACRA legislation-specifically, the MIPS reimbursement pathway, which starts in 2019 and will be based on 2017 data, according to AUA Health Policy Vice Chair Christopher Gonzalez, MD, MBA, who is professor and chair of urology at Case Western Reserve School of Medicine in Cleveland.

American Medical Association President Steven J. Stack, MD, said changes are necessary for the meaningful use program to succeed.

“As written, Stage 3 of the program is going to be extremely challenging for specialists, such as urologists, because of the one-size-fits-all approach. The program needs to be tailored to meet the needs of specialists; otherwise eligible physicians will choose not to participate,” Dr. Stack said. “The Stage 3 regulations also were published before Congress passed the MACRA law. As a result, it conflicts with goals of that legislation and fails to recognize the need to improve and better leverage electronic health records technology.”

Meaningful use Stage 3 was (and is) a big concern for the medical community. Many questioned whether physicians could reasonably comply with its complexity in order to avoid penalties, according to Dr. Gonzalez.

Reporting period comments to CMS reveal that many, if not all, physician organizations, including the AUA, wanted this mandate delayed. Among the demands, according to Dr. Gonzalez: simplify and validate the existing measures, eliminate the pass/fail aspect of attestation, establish a 90-day reporting period for at least the first year, and expand hardship exemptions.

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“On a positive note, Congress listened to the need to expand hardship exemptions. Legislation was passed to implement this on Jan. 4, 2016,” Dr. Gonzalez said.

Next: Urology, others "nowhere near onboard with meaningful use"

Urology and other medical practices are nowhere near onboard with meaningful use. According to the most recent statistics from the AMA, despite the fact that more than 80% of physicians are now using EHRs, 12% of eligible professionals were able to attest for Stage 2 meaningful use in 2014. Among urologists, just over 1,400 attested for Stage 1 in 2011, according to statistics provided by CMS. Close to 4,700 urologists attested for Stage 1 in 2012, about 4,400 attested in 2013, and 1,300 in 2014. Only 429 urologists attested for Stage 2 in 2014.

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Dr. KaufmanJeffrey Kaufman, MD, a urologist in Orange County, CA, a former AUA board member, and immediate past president of the AUA’s Western section, said he admits that he hates meaningful use.

“Phase 1 MU wasn’t too bad. There was pressure to simply begin, which was confirmed by reporting usage. Most who attempted qualified. Phase 2 is much more difficult and moves toward full integration-an impossible goal. But phase 3 is just ridiculous. The estimated success rate among those who attempt to comply, presumably the most sophisticated and computer literate among us, is no more than 18%,” Dr. Kaufman said.

The rules are too complex, patients are required to participate even when they are not willing, and there are too many criteria that are not clinically relevant, according to Dr. Kaufman.

“Electronic records are expensive and the bonus for participating-or avoiding the fine for failure-was meant as partial financial support for physician buy-in. Of course, even the most successful bonus does not begin to cover costs to participate,” Dr. Kaufman said. “And the fines applied are actually less than the cost of participation. Even forgetting all this for a moment, use of EHR slows performance and takes longer-another hidden cost.”

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Dr. Kaufman decided that Stage 3 attestation wasn’t worth it at this time.

“I give up. It’s human nature not to participate. I will disclose that I put my computers away,” Dr. Kaufman said. “For the last 4 years, I’ve been fully computerized with an EHR. We spent lots of money on hardware, software, licensing. I’ve gone back to paper charts. From a purely business standpoint, at the present, I believe it’s cheaper not to do it than to do it.”

Next: "...It now appears that the reports of [MU's] death may have been greatly exaggerated.”

Dr. StorkMuskegon, MI urologist Brian Stork, MD, was caught off guard by Slavitt’s statements and, at first, greatly relieved. His group, West Shore Urology, recently attested to meaningful use Stage 2, and the group’s members were talking about how to prepare for Stage 3 when Slavitt made the Jan. 11 announcement.

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“In its present form, MU has been extremely unpopular with physicians. It negatively affected our face-to-face time with patients and put an enormous financial strain on independent physician offices,” Dr. Stork said. “When I first heard the announcement that MU was dead, I immediately breathed a sigh of relief. But, like Mark Twain once said, it now appears that the reports of its death may have been greatly exaggerated.”

Prior to Slavitt’s declaration, HIT Consultant reported on the Stage 3 meaningful use requirements, which included that eligible providers would have to show more than a quarter of their patients had access to their own records, collect patient-generated health data for more than 15% of patients, offer secure messaging between patients and providers for more than 35% of patients, submit 60% of lab and imaging orders electronically, and create a summary of care and electronically exchange it with other providers for more than half of transitions of care and referrals.

Even physicians and physician groups that successfully attested through Stage 2 were weary.

Dr. SabaneghEdmund Sabanegh, MD, associate chief of staff, Cleveland Clinic Health System, and professor and chairman of urology at Cleveland Clinic Lerner College of Medicine, told Urology Times that the Cleveland Clinic Glickman Urological Institute has been participating with all meaningful use efforts since the program began in 2011. All Institute members were fully compliant with Stage 2 rules for 2015 and, while the Stage 3 rules have not been formally finalized and not due to be reported on until 2018, he said he anticipates that the physicians will successfully attest to Stage 3, too.

While Dr. Sabanegh said the institute’s physicians would rely on their certified technology and internal IT partners to help establish how to best be successful with these measures, he said Stage 3-specific rules could stretch providers and support staff, depending on how the information systems are developed.

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“Meaningful use Stage 3 is a stepping stone put before us,” Dr. Sabanegh said. “The original value of the program was to effectively digitize health care systems and facilitate the exchange of patient information. Again, this next phase seems increasingly difficult and, in doing so, we are concerned that it has departed from the original intent of the program.”

Next: Many unknowns

Many unknowns

Slavitt’s comments seem to acknowledge that there were significant challenges with the meaningful use program, that there were some unintended consequences, and that the anticipated transition to using the program in MACRA might be up for debate and discussion, Dr. Dowling said.

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But one thing is for sure: There are a lot of unknowns. The MU program is not going away; it’s evolving.

“This is just one more signal in a long line of developments in meaningful use in the last few years that seem to suggest the government recognizes there are major challenges and unintended consequences of their meaningful use rules as they were originally intended,” Dr. Dowling said. “An example of that would be that they modified Stage 2 earlier this year. Another example would be that they asked for comments on the Stage 3 final rule twice. Yet another: the pressure that has been brought through Congress and other avenues by societies like the AMA and even individual physicians to get relief from what is interpreted to be onerous.”

While it’s encouraging that CMS might have heard physicians’ concerns and is trying to devise a better plan, the extent to which physicians will have input on the plan remains to be seen, Dr. Stork said. “While there remain many unknowns, hopefully CMS’s recent announcement will mark the beginning of a fresh start,” he said.

Reports that meaningful use would end in 2016 seem inaccurate, according to the experts Urology Times interviewed.

When Slavitt said the meaningful use program, as it has existed, will now be effectively over, he also said it would be replaced with something better. The morsel of good news for physicians who struggled with or completely abandoned attesting is there’s hope the program will evolve into something more doctor-friendly.

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“I think the comments are encouraging and are in direct response to physician feedback on the final rule. Discussion and implementation of methods to improve interoperability are desperately needed,” Dr. Gonzalez said. “But I don’t think we can read much more into this until more concrete plans are announced this coming March.”

Next: Four new themes from CMS

Four new themes from CMS

Mr. SlavittIn the section of his speech about meaningful use, Slavitt said CMS has been “working side by side with physician organizations across many communities-including with great advocacy from the AMA-and have listened to the needs and concerns of many.” He indicated that details would be coming over the next few months, then provided four “themes guiding our implementation.”

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“For one, the focus will move away from rewarding providers for the use of technology and towards the outcome they achieve with their patients,” Slavitt said.

Second, providers will be able to customize their goals so tech companies can build around the individual practice needs, not the needs of the government. Technology must be user-centered and support physicians, not distract them.”

Third, the technology playing field will be leveled with open application program interfaces to allow apps, analytic tools, and plugins to get data in and out of an EHR securely; and reduce the EHR lock that early EHR decisions placed on physician groups.

“And finally,” Slavitt said, “we are deadly serious about interoperability. We will begin initiatives in collaboration with physicians and consumers toward pointing technology to fill critical use cases like closing referral loops and engaging a patient in their care.” Data blocking will not be tolerated, he said.

Dr. StackDr. Stack said the AMA strongly agrees with and applauds Slavitt’s comments.

“Administrator Slavitt acknowledged the frustration of physicians attempting to comply with the meaningful use regulations and pledged to work collaboratively with physicians to replace the program with a more effective alternative,” Dr. Stack said. “He listened to working physicians who said the meaningful use program made them choose between following byzantine technological requirements and spending more time with their patients.”

In December, the AMA released a set of recommendations to improve the meaningful use program to accommodate the real-world needs of physicians and patients while focusing on promoting the interoperability of EHRs.

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“Earlier this year, Administrator Slavitt established a collaborative approach to working with physicians when CMS adopted an ICD-10 grace period to help reduce the risk of disruptions to medical practices, so physicians could continue to provide high-quality patient care,” Dr. Stack said. “The AMA will continue to work with CMS and the Administration on moving to a new framework for electronic health records. Physicians are at the front lines of these programs, and their insights should guide how the regulations are written and implemented.”

Next: The message to urologists

Dr. SchlossbergDr. Schlossberg said the message to urologists is to monitor the news from CMS closely, don’t overreact, and try to understand timelines as they affect your practice.

“For example, whatever you do this year will usually affect your payment not the following year, but the year after. Meaningful use Stage 3 won’t come live until 2018 and be optional in 2017. Then there’s the modified meaningful use Stage 2 rule, which people are going to be living under this year and next year,” Dr. Schlossberg said. “The changes will be largely around the MIPS program in Stage 3. Personally, I think the best thing people can do is wait for the rule to come out, which should be in March or April.”

Stage 3 of meaningful use will be required in 2018, according to the AUA.

“Moving forward, physicians that do not participate in alternative payment models (APMs) will receive lower payment rates, as the traditional fee-for-service (FFS) offers no financial incentives,” according to an AUA statement to Urology Times. “The mandatory 0.5% FFS updates will conclude in 2019. Whatever the conversion factor is at that time, it will be frozen until 2026. At that point, the conversion factor will drop to 0.25% for physicians that do not participate in APMs.”

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