The new year marks the start of the “meaningful use” era of health IT. The bold attempt to transform the U.S. healthcare delivery system comes with a staggering investment: $30 billion- plus in funding set aside in last year’s American Recovery and Reinvestment Act (ARRA) to encourage providers and provider organizations to go digital.
The funds, in the form of Medicare and Medicaid incentive payments, will flow to providers who can “demonstrate” a significant EHR deployment. Therein lies the rub. With so much money in play, how will doctors’ offices and hospitals account for how they put their new EHRs to use—and how will government program managers authenticate those claims?
The Centers for Medicare and Medicaid Services (CMS), which will administer the incentive program, last month issued its much-anticipated plan for meaningful use. The policy clarifies what specific electronic services providers must offer to qualify for ARRA incentives.
But the actual means through which CMS will track whether providers meet the agency’s objectives remain vague. Health IT experts believe CMS is likely to use multiple electronic reporting systems to document how providers use EHRs.
These systems will act as flight data recorders for the project, plotting the path of meaningful use and documenting what Dr. David Blumenthal, the national coordinator for health IT, has called a “vast social project of change management.”
Ultimately, the data will yield important clues as to whether IT can help meet the primary goals of health reform: to reduce costs and improve quality of care. The systems also will largely determine whether the $30 billion project rates as a good investment or a costly miscue.
Those questions are drawing interest from members of Congress. In an October 2009 letter to electronic health record system developers, Sen. Charles E. Grassley (R-Iowa), the ranking member of the Senate Finance Committee, said, “Every accountability measure ought to be used to track stimulus money invested in health information technology.”
CMS lists the development of “systems to monitor and evaluate incentive payments” among its 2010 objectives. These systems— the practical plumbing of meaningful use—could involve repurposing existing mechanisms or creating new ones. Additionally, myriad third-party organizations might be called on to help account for meaningful use, including health information exchanges and value-added networks (see sidebar, page 20).
“I have a feeling that meaningful use is going to be well defined and the types of data that need to be reported are going to be well-defined, but the [reporting] processes are going to be open enough that multiple structures can fulfill those objectives,” said John Feikema, the chief information officer of VisionShare, which provides software that transmits Medicare transaction data.
State and federal paths
The electronic channels through which providers will report their EHR progress to the government will need to rollout concurrently with the multi-year meaningful use incentive plan. By and large, CMS will manage incentive payments to Medicare providers, while state Medicaid offices will oversee the program for practices that qualify for Medicaid incentives.
To give states an incentive of their own, CMS said it would reward those states which devise oversight systems. In a September 2009 letter to state Medicaid directors, CMS said it will cover 90 percent of a state’s administrative costs if they conduct “adequate oversight of the incentive program, including routine tracking of meaningful use attestations and reporting mechanisms.” Those dollars are entirely separate from the EHR incentive funding.
On the Medicare side, CMS has developed and is developing reporting systems that allow providers to submit clinical data to health policy researchers tracking the quality and outcomes of certain programs and treatments. Existing data channels could influence the development of meaningful use systems, according to health IT analysts.
Kerry Weems, the former administrator of CMS and now senior vice president for health strategy at IT services firm Vangent Inc., said CMS will likely use at least three different reporting mechanisms for meaningful use. Those include CMS’s Physicians Quality Reporting Initiative (PQRI), clinical registries and EHR systems themselves, he said.
PQRI, established in 2007, provides incentive payments to physicians who report data on quality measures for services provided to Medicare patients. Providers may report PQRI data through the regular claims process to a Medicare administrative contractor, which in turn provides the data to CMS.
This approach requires providers to insert a G-code (Healthcare Common Procedural Coding System codes) that adds clinical data—say, a patient with A1c blood sugar levels in a specific range—to the usual administrative diagnosis and procedure codes used in billing. A practice’s accounts receivable enters the G-code on the patient’s bill before sending it to Medicare.
Weems said PQRI could be pressed into service for meaningful use reporting, which also will deal with clinical and quality data. But there are some drawbacks with this approach. CMS compiled a study on PQRI’s 2007 reporting year, Weems said, and found that only 109,000 out of the 700,000 eligible physicians participated and about half of those successfully reported data and received payment.
“If, in fact, they use [PQRI] it will need significant improvement to demonstrate meaningful use,” Weems said.
The program saw some improvement during the 2008 reporting year. CMS in November reported a one-third increase in physician participation in PQRI that year compared with 2007. Still, Weems said he had hoped for a better result. The G-code is another difficulty with PQRI, since it compels providers to alter the billing process by throwing clinical data into the mix.
The role of registries
CMS, however, has an alternative reporting channel for PQRI: designated clinical registries.
A registry is a database that collects health information on particular patient populations. A mix of organizations operate registries, including hospitals, health IT vendors and health associations. Today, online registries enable providers to post quality data through a Web interface, which can then be submitted to CMS.
A registry makes quality reporting part of the clinical workflow, which eases the burden for providers. “I think the PQRI program is not only going to be transferable to meaningful use, it will be initially one of the core reporting mechanisms,” said Dr. John Haughton, chairman and chief medical officer of DocSite, a company that provides a CMS-designated PQRI registry.
CMS has anointed more than 70 registries to submit PQRI data on behalf of providers. The registries go through a vetting process that examines their ability to provide the needed data elements, according to CMS.
CMS may permit registry reporting for meaningful use authentication, according to Weems, but it is not yet clear which registries will be qualified to do so. Though CMS has used registries for quality measures and clinical guidelines in the past, the approach is a “bridge” to a long-term solution, he said.
Standardized electronic reporting via an EHR—outside of the claims system— will ultimately become the long-term solution that verifies meaningful use, according to health IT experts.
Weems said he envisions EHR vendors tweaking their existing reporting tools to comply with a yet-to-be-created federal reporting tool specification. The resulting interoperable interface would replace numerous vendor-specific EHR interfaces for reporting to CMS.
Trust, but verify
In the meantime, EHR systems’ proprietary reporting methods may provide a temporary solution. CMS perhaps foreshadowed that development in October, when it announced that providers would be able to use their EHR systems to report PQRI quality measures. At the time, CMS said the move would “provide both eligible professionals and CMS with experience on EHR-based reporting.”
“We have seen the beginning of that interim approach” with CMS’s announcement, according to Weems.
Not all EHR systems deployed today possess reporting features, and still might not by 2011, the first year providers are eligible to receive the incentives. Jana Skewes, chief executive officer at Shared Health, a Tennessee-based health information exchange, said meaningful use reporting might rely on an honor system of sorts while EHR reporting is ironed out.
One interim option: an electronic survey, in which physicians could answer questions regarding EHR. This approach would ask providers to essentially vouch for their meaningful EHR usage, as opposed to reporting data directly from the EHR. Although a “less elegant report,” Skewes said, it could stand-in for the more hard-wired approach.
Dr. Bruce Taffel, chief medical officer at Shared Health, said surveys could address meaningful use requirements such as participating in health information exchange or e-prescribing. Random audits could then help authenticate the survey results.
“Trust, but verify—that is going to be part of the initial systems,” he said. Micky Tripathi, president and chief executive officer of the
Massachusetts
eHealth Collaborative, a non-profit group that works to advance EHR adoption in the state, agreed that self-reporting may be the direction meaningful use reporting initially takes. But he emphasized the importance of audits in that scenario. “Self attestation is meaningless without a periodic audit to support it,” he said.
e-Prescribing model
While Medicare providers await CMS developments, Medicaid providers will watch as states rollout reporting struc-tures of their own.“States will need to engage in planning to ensure that they are able to track such use, consistent with the federal rules,” CMS acknowledged in a letter to state program operators last fall.
Few states have a blueprint for such tracking, but some may adapt existing systems designed for other types of reporting.
New York
State
’s Department of Health is rolling out an e-prescribing incentive program—unrelated to meaningful use— through which it will offer Medicaid providers 80 cents for every e-prescription they write. The state’s experience accounting for e-prescriptions under the program may prove useful when it addresses the thornier requirements of meaningful use.
E-prescribing, part of the foundation for meaningful use, will be one of the simpler requirements to authenticate, since a network infrastructure to carry out the service already exists.
New York
plans to track the prescriptions by capturing the CMS-issued, 10-digit National Provider Identifier (NPI) number providers use to make pharmacy claims. Data authenticating the transaction will travel from providers to the state via electronic e-prescribing networks, such as SureScripts, or other intermediaries.
This approach has a dual purpose, according to Dr. James Figge, medical director of the department’s Office of Health Insurance Programs. It will help manage the state’s e-prescribing program, but it also positions the state for managing meaningful use. “When we get to the meaningful use requirement, we can credit that prescription for meaningful use,” he said.
To authenticate participants, NPI numbers may be linked to cryptographic keys, according to Figge. Keys could be assigned to authorized providers who pass security audits. Figge said the proposed approach is intended to stimulate discussion, noting that it is not known what techniques CMS will ultimately require. The use of NPI numbers could apply to not only the meaningful use’s e-prescribing requirement, but to other potential aspects of the program, including the use of HIEs and the quality metrics reporting, Figge added.
Medicaid systems
Medicaid reporting will also likely involve state Medicaid Management Information Systems, which process and pay claims. Integrators and consultants who work on Medicaid systems believe states will add to current systems, rather than build new ones to deal with meaningful use.
“Medicaid administrators are thinking about the implementation of systems to accept and use these new measures in time for (fiscal year) 2011 implementation,” said David Nelson, director of planning and strategy at Thomson Reuters, which works with 28 state Medicaid agencies to provide systems and consulting on data, data systems, and quality and cost analysis.
“Our customers are asking us how we can enhance their existing data systems with the addition of meaningful use data.”
Dr. Kit Gorton, vice president of medical management at HP Enterprise Services, a leading manager of MMIS systems, said every one of the 22 states where the company provides claims administration services, “is talking to us about how to leverage the MMIS infrastructure to collect data and administer the meaningful use incentives.”
Gorton said he believes states plan to use either their emerging HIE infrastructures, if sufficiently advanced, or their MMIS systems to collect data and administer incentives. As for MMIS, Gorton said current vendor systems already “have the core functionality” that will enable them to flag providers who are doing meaningful use and push out payments.
A head start on meaningful use reporting can’t hurt. Policy makers will need any edge they can find to manage the largest ever investment in health IT.
