Schreiber, Basch on pros, cons of Stage 3

Calling the Meaningful Use Stage 3 proposed rule “disappointing overall,” Richard Schreiber, CMIO of Holy Spirit Hospital in Camp Hill, Penn., said what sounds like simplification might just be “restructuring of the outline form to make it look simpler.”

Schreiber spoke with Clinical Innovation + Technology, making sure to note his thoughts are based on a preliminary read-through of the prosed rule.

Because everyone will be held to the same requirements under the rule, there will be one data collection. That simplifies things from the government’s point of view, he said. And, despite claims over the past few months that the government plans to offer more flexibility in the incentive program, Schreiber said, “I don’t see much flexibility when everybody has to answer to the same things.” “The only objective that offers choice involves public health reporting for which hospitals already are doing three of them, leaving a choice of one out of three. That’s not very flexible.”

Despite the ongoing focus in Washington on interoperability, “there is nothing in this that promotes that interoperability,” he said. While he said APIs are a great idea and there are lots of available apps, “there’s nothing out there that allows me to safely incorporate that information into the EHR and be able to see it before I can download and vet it.  And what if the provider does not want to ‘incorporate’ the data for some reason?  Does a provider get credit for reviewing it?”

Speaking of Direct messaging, Schreiber said he’s confused by some numbers. The threshold for use of Direct messaging in the Stage 3 proposed rule is 25 percent. “I’m shocked that the number is that high. We are struggling to get to 15 percent. Other places I’ve talked to are just barely above the 10 percent threshold for hospitals.” The same goes for the view, download and transmit requirement. “We’re struggling to get above the 5% threshold percent. Others have done much better but it’s a big struggle.”

Regarding the optional year to attest in 2017, Schreiber said that is helpful. However, the original plan was to go into Stage 3 no later than fall of 2016 so the additional year is really only pushing the timeframe back by three months. “That helps the user a little bit but doesn’t help the vendor one bit. They still need to come up with functionality for users who want to go live in 2017.” Few vendors will be ready for those providers who want to get started on the early side and everyone will be scrambling. “If it doesn’t help the vendor, it doesn’t help us.”

Peter Basch, MD, director of EHR and HIT policy for MedStar Health, based in Columbia, Md., agreed that 2017 as a “buffer year” is a good idea. Some people might be ready to embrace Stage 3 because it is more consistent with their workflow and might be easier to do than some of the more complex measures in Stage 2. They have the option to move ahead earlier. “That was smart to do,” Basch said.

Schreiber also noted mention in the rule that says incentive payments will end before 2017. If that is indeed the case, “why are we bothering? That’s a big open-ended question.”

Basch said the proposed rule also addresses penalties. Despite the low rate of successful attestation for Stage 2, the proposed rule only plans for a 5 percent failure rate. “How do we get from where we are now in 2015 with 51-52 percent of EPs getting a penalty to 95 percent success? I would love to think they have a secret they haven’t shared with us. It concerns me that there are things in there that might be based on that assumption.”

This proposed Stage 3 rule does not offer a “transition away from process measurement to outcomes measurement-guided health IT that we expect to really be focused on as we shift to pay-for-value,” said Basch. The proposed rule, “instead of talking about transitioning away from process measures actually codifies itself into a forever rule.” In the past, problems with one stage had the potential to be changed in a subsequent stage but “unless I’m reading it wrong, what is written here doesn’t expire. It doesn’t go away if it’s irrelevant. It’s a little frightening.”

Given the pace of innovation, no one can predict the future in healthcare beyond 18-36 months. “At some point we have to stop thinking about the details and focus on the traffic,” said Basch, comparing the situation to those learning to drive. Good drivers have to move away from all the conscious checkboxes and focus instead on driving safely. Not enough time has been spent on looking at the potential for care improvement from the vantage of other specialties, he said. A single set of process measures for all providers means people could perform excellently on some but not others, then they fail. It will appear to patients, payers and the Medicare compare website as less than ideal. That’s a problem.  It’s disheartening because it doesn’t encourage what I thought we’d be seeing now in our providers – gone through basics now time to step up and have an environment with which you can specialty-specific customize. Here’s a set of tools, do great things. Tackle a problem. Work with your colleagues. I think that this leads to focus in the wrong direction. That’s problematic.

Basch said if various aspects of healthcare performance can reliably on their own, then we should try to avoid a process measure because that causes undue expense. And, the “very fact that we spend lots of time trying to figure out exactly what the measure means is time away from focusing on healthcare goals that are more specific to our specialty.”

For example, the proposed rule did a pretty good job of explaining the rational for top-down measures. Things that may or may not have been done well before—once it seems they’re done reliably past the 80 percent mark, it’s considered ingrained the provider workflow and we no longer need a process measure. Electronic prescribing (eRx) occurs at a rate of low 90s percent. That’s certainly a numeric threshold of success.

eRx is mentioned in legislation as an area of special concern and something that needs to be focused on as part of MU, he noted. However, while there are things that can be done to improve eRx, we’ll just ratchet up the threshold. “If indeed we really are in the low 90s, you could say I’m just being picky. Most people will pass it anyway. The big deal is that the assumption of what physicians do has any bearing on eRx changing or improving are uninformed.” Basch would like to see lots happen to improve eRx to make it better, easier to do, easier for doctors and patients to figure out preferred pharmacies and more. MU doesn’t allow for that; rather it’s just one tool that’s like a hammer hitting over providers’ heads. “That’s an overall principle in MU that I’m sorry to see. I don’t see evidence of it going away. When something isn’t working as well as it should, the onus is put on providers.” One could argue that customers create a market force, but Basch said if he’s unhappy with his eRx vendor, he can’t create his own network. This unfinished improvements in eRx are going to remain unfinished no matter the threshold, he pointed out.

The final Stage 3 will have some lower thresholds, said Schreiber, particularly for Direct messaging, view, download and transmit and perhaps medication reconciliation, which is at 80 percent in the proposed rule. “It’s a good goal. I personally think it’s attainable but there will be push back because it’s hard work. Nobody is going to ask for more things to be put into the rule. But, if you want to see outcomes as part of MU you’re not going to get it.”

Basch agreed. “As long as there are process measures, we don’t really fix the problem.”