As we generally do with proposed regulations that impact EHR developers and their customers, the Electronic Health Record Association (EHRA) carefully reviewed and collectively commented on CMS’s proposed rule on the Hospital Outpatient Prospective Payment Systems (HOPPS) and EHR Incentive Program on September 1. Our comments, submitted on September 1 and available here, are based on the collective experiences of more than 30 EHRA member companies who service the vast majority of hospitals and ambulatory care providers using EHRs across the United States.

We put forth two key positions. The first centers around advocating for program alignment across Medicare and Medicaid requirements, as well as the EHR incentive programs with the Merit-Based Incentive Payment System (MIPS). The second states strongly that changes to the EHR incentive program at this late date relative to the current or next reporting period lead to costly and negative repercussions. We strongly recommend that CMS make every effort to incorporate the comments received up to and including this comment cycle in future rulemaking, in order to set appropriate and achievable requirements and deadlines to reduce the need for mid-year revisions.

These two important positions are referenced throughout the comments through examples such as the proposed 90-day reporting period in 2016 and the modifications to measure calculations to actions outside of the EHR reporting period.  With regard to the variety of changes to Medicare meaningful use criteria, the EHRA views each of these proposals through the lens of the effect such a change would have on program harmonization. We see the elimination of measures and adjustment of thresholds as a good, although incomplete, start toward what we hope will become a more complete conversion between the EHR Incentive Program and the Advancing Care Information (ACI) components of MIPS.  We leave most comments on individual measures to provider groups, with notable exceptions where clarifications are necessary, such as the Patient Access Measure.

In summarizing our comments, the EHRA recommends against updating measure thresholds each year, and offers a discussion of how to make measures more stringent in future years, as is required by the Social Security Act.  We believe that changes to the program should meet the goals of the Act, including improving patient care and effectively managing costs.  If the individual measures are more focused on that goal, and performance on such precise measures improves, then the bar for achievement rises and stringency is place in an effective and meaningful way.

We look forward to continuing our work with provider organizations, CMS, and other stakeholders in order to create programs that improve patient care and reduce unnecessary costs.  As always, the EHR Association and its members are committed to supporting safe healthcare delivery, fostering continued innovation, and operations with high integrity in the market for our users and their patients and families.

Recognizing the complexity of the MACRA legislation, the Association expressed appreciation that CMS considered a variety of comments from a diverse set of stakeholders in developing the proposed rule.  In their detailed comments, they emphasize that some of the complexities in the proposed rule will lead to many significant changes and implications for eligible clinicians.  EHRA urged CMS to take every possible step to dramatically simplify requirements in the final rule and to develop provider-focused communications to reduce complexity.

On June 7, 2016, the EHR Association sponsored a briefing for Congressional staff engaged in crafting proposed legislation that addresses interoperability.  EHRA member company, Allscripts, invited their client Stephen Nuckolls, CEO of Coastal Carolina Health Care (New Bern, North Carolina, U.S.A.), to participate as a panelist, along with four other healthcare provider organization executives. Their blog post shares some of his comments at the briefing, which covered successes and areas for improvement with health information technology.

With the accelerated adoption of electronic health records (EHRs), there is growing recognition of the benefits associated with the use of these technologies – reduced medical errors, faster access to complete information, more efficient communications among busy clinicians, and increasing patient engagement in their healthcare decisions.  At the same time, there is a dialog taking place among all stakeholders on the issues related to busy clinicians taking advantage of data re-use capabilities to avoid re-entering identical information as they create their encounter documentation.

The EHR Association strongly believes that data re-use tools are critically important for clinicians, provide clear benefit for patients and, when used appropriately, enable accurate legal and financial recording workflows for providers.

Before delving into the pros and cons of data re-use, it is important to recognize that there are many facets to what is generally referred to as “copy/paste” (sources noted):

• Copy functionality:  reproducing text or other data from a source to a destination (American Health Information Management Association (AHIMA). Appropriate use of the copy and paste functionality in electronic health records [online]. 2014 [cited 2015 Aug 26], http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050621.pdf).
• Copy and paste:  action performed either by keyboard command (e.g., Ctrl + C to copy and Ctrl + V to paste) or with a mouse; selecting data from an original or previous source to reproduce in another location (Association of American Medical Colleges (AAMC) compliance officers’ forum: electronic health records in academic medical centers [online]. 2011 Jul 11 [cited 2015 Aug 26]. https://www.aamc.org/download/253812/data/appropriatedocumentationinanehr.pdf).
• Cut and paste:  removing or deleting the original source text or data to place it in another location (e.g., Ctrl + X to cut and Ctrl + V to paste) (AAMC, as above).  (NOTE:  We believe that deleting any portion of a patient’s electronic record should never occur so will not address this capability here.)
• Cloning:  duplication of a note (Weis JM, Levy PC. Copy, paste, and cloned notes in electronic health records: prevalence, benefits, risks, and best practice recommendations. Chest Mar 2014;145(3):632-8. PubMed, http://www.ncbi.nlm.nih.gov/pubmed/24590024).
• “Whole note cloning”:  copying patient notes from one visit to the next; copying a note from one patient encounter to the next with little or no editing (Terry K. Redesign EHRs to fit clinical workflows, ACP says [online]. 2015 Jan 12 [cited 2015 Aug 26], http://www.medscape.com/viewarticle/838019).
• Carry/copy forward:  bringing forward a portion of a note or an entire old note (Weis and Levy, as above).
• Auto-fill:  automatically draws data from another part of the record and inserts it upon a specific command
• Auto-complete:  automatically matches text and provides one or more options

We recognize that there are competing viewpoints regarding the use of these capabilities. On the positive side, the ability to reuse text saves time for clinicians in documenting care, and potentially improves data quality by eliminating the need to re-key text.  These contributions to improved clinicians’ satisfaction with use of their EHRs cannot be undervalued.  On the other hand, there are risks associated with inadvertently copying information that is not relevant or accidentally copying into the wrong record, and the patient safety component of this conversation deserves further exploration.

One additional question raised is whether and how to indicate data provenance – i.e., when was the original data entered into the patient’s record, by whom, and/or at what care delivery site?  Some EHRs may have space limitations such that including information on data provenance forces users to go through additional pages in the clinical workflow.  Further research is required to better understand what will work most effectively for both end-users and health information management professionals to indicate, store, and assess the provenance of copied/pasted content.

The Association believes that this topic is most appropriately considered in the broader discussion of usability, as EHR developers, provider organizations, and regulators seek to address perceived obstacles to effective, efficient workflows and better end-user satisfaction with their EHRs.  Of value to clinicians are speed, accuracy, and completeness of the record to properly document their interaction with the patient.   Proper documentation includes the ability to provide a summary to the patient, comply with various third-party billing requirements (e.g., Medicare), and to persist a legal record of what was and was not done.

Organizations like the ECRI Institute (https://www.ecri.org/Resources/HIT/CP_Toolkit/Toolkit_CopyPaste_final.pdf) and the American Health Information Management Association (AHIMA,  http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050621.pdf) have published their guidelines in attempts to give providers parameters around which to make implementation decisions and set organizational policies relative to data reuse features.  While the Association supports these efforts to advance the conversation regarding safe practices related to such functions as they are implemented in EHRs and other health IT, we believe that further analysis is needed to better understand how these features are being used today, whether there are any specific patient safety implications, and what best practices can be applied across different healthcare environments using different EHRs.

Accordingly, EHR Association members have been working with provider organizations, as well as their own customers, to better understand the issues that are perceived to impede usability, and to develop best practices related to implementation decisions, end-user training, and organizational policies that can impact workflows and clinicians’ perceptions of their EHRs and other health IT.  We believe that these collaborative efforts are important in understanding potential patient safety risks, as well as identifying user-centered design best practices.

Frequently overriding these considerations, however, are organizational policies that are put in place to guide clinicians on how to both take advantage of the efficiency of data reuse features and ensure that they are used appropriately to create accurate and clearly understood clinical notes.  Given the variations and implications of how these functions can be implemented and used, we suggest that recommendations for adoption are best promulgated by the industry more broadly, with EHR Association member companies and other health IT suppliers determining how best to implement them in their products, in consultation with and based on their experiences with their customers.

The EHR Association will continue its collaboration with provider groups, standards development organizations (SDOs), regulatory bodies such as the National Institute for Standards and Technology (NIST), and experts in human factors engineering to better understand the broader challenges and opportunities to improve workflows and end-user experiences.  It would be a mistake to ban the use of features that are important to clinicians, as we clearly need more time and experience to develop best practices in the area of data re-use.

MACRA and Alternative Payment Models – What You Need to Know

When it comes to alternative payment models (APMs), organizations often ask “is it better to be a Medicare Shared Savings Program (MSSP) Track 1 Accountable Care Organization (ACO) or a Patient-Centered Medical Home (PCMH)?”  Typically, the answer depends on a few factors:  organizational goals, level of readiness to adopt new delivery models, and the mix of public and private payer incentive programs.  Going forward, however, the newest factor that organizations must consider is how they want to be scored under the incentive programs created by the Medicare Access and CHIP Reauthorization Act (MACRA).  As the Centers for Medicare and Medicaid Services (CMS) prepares to release the proposed rule for MACRA, the agency has made it clear that not all organizations participating in APMs will be considered “eligible” for purposes of the law’s APM incentive program.  The statute requires that eligible APMs, those which qualify for the APM bonus payment, have the following characteristics:

1. Receive payment based on quality measures comparable to those in the Merit-based Incentive Payment System (MIPS) program.
2. Require use of certified electronic health record EHR technology (CEHRT).
3. Either (1) bear more than nominal financial risk for monetary losses or (2) be a medical home model expanded under the Center for Medicare and Medicaid Innovation (CMMI) authority.

Implications for MSSP ACOs

The requirement regarding nominal financial risk is particularly important for MSSP Track 1 ACOs. Because these ACOs share in the savings from their arrangement, but not the losses, it is highly unlikely they will be eligible for the incentive payment.  Excluding them from receiving the payment is another way policymakers hope to increase participation in APMs that entail “more than nominal financial risk,” such as Track 2 or Track 3 ACOs.

Track 1 ACO participants, however, still have an advantage under MACRA.  CMS has emphasized that APMs which do not meet the eligible APM criteria will still receive “favorable scoring” under the MIPS program, specifically within the clinical practice improvement activities category.  The law states that APM participants will receive a minimum score of half of the highest potential MIPS score for clinical practice improvement activities.  Because this is a new performance category for providers, it is encouraging to see that MSSP Track 1 ACO participants will receive at least 50% credit for it under the MIPS program.

Implications for Patient-Centered Medical Homes

The same requirement that excludes MSSP Track 1 ACO participants from MACRA’s APM incentive payments may allow patient-centered medical homes (PCMH) to be eligible without bearing financial risk.  Rather than define what a medical home is, the legislation specifies that “a medical home expanded under CMMI authority” may be eligible for incentive payments.  Since the CMMI has yet to expand the patient-centered medical home model, however, it is uncertain whether such an expansion will align with the existing PCMH certification programs and whether that will occur prior to 2019.  Organizations that have yet to commit to either an ACO or a PCMH model should keep a close eye on how medical homes are defined in the proposed rule.  Although they will still have to meet the first two requirements listed above, as well as the patient or revenue volume thresholds for the APM bonus payment, the medical home option may be more attractive than the risk-bearing ACO for some organizations.

The MIPS program also gives favorable treatment to medical homes.  A practice that is certified as a patient-centered medical home (or a comparable specialty practice), as defined by the Secretary, will receive the highest potential score for the clinical practice improvement activities performance category.  By contrast, as mentioned previously, non-eligible APM participants are guaranteed only 50% of the highest potential score for this category.  Despite the ambiguity in the phrase “as defined by the Secretary”, the reference to certification seems to allow for CMS to leverage existing certified PCMH programs.

While the proposed rule will provide more specifics around eligible APMs and corresponding incentive payments, one thing was made increasingly clear in the MACRA legislation ‒ fee-for-service is on its way out and alternative payment models are here to stay.  If your organization isn’t ready to embrace the ACO model, becoming a medical home is something to consider, given the favorable treatment in the MACRA incentive programs.  EHR Association members are invited to join the Delivery System Reform Workgroup to learn more about this trend, MACRA, and other related topics. Contact Emily LaMonica, staff to the Association, at elamonica@himss.org to be added to our list.

Suzanne Travis, Chair, Delivery System Reform Workgroup (and VP, Regulatory Strategy, McKesson)

Amanda Adams, Vice Chair, Delivery System Reform Workgroup (and Strategist, Government and Policy, Cerner)