EHR Incentive Programs: Where We Go From Here

Screen Shot 2016-01-19 at 8.34.45 AMAs we mentioned in a speech last week, the Administration is working on an important transition for the Electronic Health Record (EHR) Incentive Program. We have been working side by side with physician organizations and have listened to the needs and concerns of many about how we can make improvements that will allow technology to best support clinicians and their patients. While we will be putting out additional details in the next few months, we wanted to provide an update today.

In 2009, the country embarked on an effort to bring technology that benefits us in the rest of our lives into the health care system. The great promise of technology is to bring information to our fingertips, connect us to one another, improve our productivity, and create a platform for a next generation of innovations that we can’t imagine today.

Not long ago, emergency rooms, doctor’s offices, and other facilities were sparsely wired. Even investing in technology seemed daunting. There was no common infrastructure. Physician offices often didn’t have the capital to get started and it was hard for many to see the benefit of automating silos when patient care was so dispersed. We’ve come a long way since then with more than 97 percent of hospitals and three quarters of physician offices now wired.

It’s taken a tremendous commitment by physicians, hospitals, technologists, patient groups and experts from all over the country to make the progress we’ve made together in a few short years. The EHR Incentive Programs were designed in the initial years to encourage the adoption of new technology and measure the benefits for patients. And while it helped us make progress, it has also created real concerns about placing too much of a burden on physicians and pulling their time away from caring for patients.

Transitioning From Measuring Clicks to Focusing on Care

Last year, the Administration and Congress took two extraordinary steps to put patients at the center of how we pay for care and support physicians. First, the Administration set a goal that 30 percent in 2016 and 50 percent in 2018 of Medicare payments will be linked to getting better results for patients, providing better care, spending healthcare dollars more wisely, and keeping people healthy. And, second, Congress advanced this goal through the passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which considers quality, cost, and clinical practice improvement activities in calculating how Medicare physician payments are determined. While MACRA also continues to require that physicians be measured on their meaningful use of certified EHR technology for purposes of determining their Medicare payments, it provides a significant opportunity to transition the Medicare EHR Incentive Program for physicians towards the reality of where we want to go next.

What Comes Next

We have been working side by side with physician and consumer communities and have listened to their needs and concerns. As we move forward under MACRA, we will be sharing details and inviting comment as we roll out our proposed regulations this spring. All of this work will be guided by several critical principles:

  1. Rewarding providers for the outcomes technology helps them achieve with their patients.
  2. Allowing providers the flexibility to customize health IT to their individual practice needs. Technology must be user-centered and support physicians.
  3. Leveling the technology playing field to promote innovation, including for start-ups and new entrants, by unlocking electronic health information through open APIs – technology tools that underpin many consumer applications. This way, new apps, analytic tools and plug-ins can be easily connected to so that data can be securely accessed and directed where and when it is needed in order to support patient care.
  4. Prioritizing interoperability by implementing federally recognized, national interoperability standards and focusing on real-world uses of technology, like ensuring continuity of care during referrals or finding ways for patients to engage in their own care. We will not tolerate business models that prevent or inhibit the data from flowing around the needs of the patient.

What This Means for Doctors and Hospitals 

As we work through a transition from the staged meaningful use phase to the new program as it will look under MACRA, it is important for physicians and other clinicians to keep in mind several important things:

  1. The current law requires that we continue to measure the meaningful use of ONC Certified Health Information Technology under the existing set of standards. While MACRA provides an opportunity to adjust payment incentives associated with EHR incentives in concert with the principles we outlined here, it does not eliminate it, nor will it instantly eliminate all the tensions of the current system. But we will continue to listen and learn and make improvements based on what happens on the front line.
  2. The MACRA legislation only addresses Medicare physician and clinician payment adjustments. The EHR incentive programs for Medicaid and Medicare hospitals have a different set of statutory requirements. We will continue to explore ways to align with principles we outlined above as much as possible for hospitals and the Medicaid program.
  3. The approach to meaningful use under MACRA won’t happen overnight. Our goal in communicating our principles now is to give everyone time to plan for what’s next and to continue to give us input. We encourage you to look for the MACRA regulations this year; in the meantime, our existing regulations – including meaningful use Stage 3 – are still in effect.
  4. In December, Congress gave us new authority to streamline the process for granting hardship exception’s under meaningful use. This will allow groups of health care providers to apply for a hardship exception instead of each doctor applying individually. This should make the process much simpler for physicians and their practice managers in the future. We will be releasing guidance on this new process soon.

These principles we’ve outlined here reflect the constructive and clear articulation of issues and open sharing of views and data by stakeholders across the health care system, but they also promote our highest priority – better care for the beneficiaries of the Medicare and Medicaid program and patients everywhere.

The challenge with any change is moving from principles to reality. The process will be ongoing, not an instant fix and we must all commit to learning and improving and collaborating on the best solutions. Ultimately, we believe this is a process that will be most successful when physicians and innovators can work together directly to create the best tools to care for patients. We look forward to working collaboratively with stakeholders on advancing this change in the months ahead.

Andy Slavitt is the acting administrator for CMS.

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16 replies »

  1. Its a good article on highlighting the keypoints of EHR incentive programs. I would also like to add a note that the historical data stored in the old EHR/EMR should not be forgotten. Many states require 5 to 7 years of data retention. Data management companies can help transition all the historical clinical and clinical data into the new EHR or archive them. There are some companies which specializes in such services – even without the cooperation of the old EHR vendor like https://www.triyam.com/data-conversion.html

  2. Thank you for these highlights! At the first view, it might seem that the healthcare heads to a wrong direction when focusing on CRM, revenue cycle and analytics areas since these tools mainly serve marketing and sales. But to deliver effective patient engagement, caregivers need to step forward, enter the post-EHR era, so to say. And this means to broaden the scope of influence tools.
    In my opinion, in the post-EHR era healthcare will offer patients an even more individual approach, not throwing the health records away, of course, but extending the range of communication techniques. For example, caregivers can provide visitors with the content backed by personalized medical website design elements, as it delivers relevant messages and targeted promotions, showing patients care and dedication: https://www.scnsoft.com/medical-website-design

  3. A slightly different perspective to most of the previous comments: yes, the EHR incentive/MU program went off the rails for reasons that are now well known. BUT, the impetus to “meaningful use” was always sound, and the physician community should keep that in mind. Namely, giving hospitals and docs large sums of money just to go out a buy hardware and software was a non-starter. Compelling them to use it in a way that benefited patients was a no-brainer. Hey, it’s the government’s money. It’s taxpayer dollars. It’s for the public’s benefit. We give you money. If you take it, you have to do X, Y, and Z. If you are a libertarian or similar (or just anti-government) then don’t take the money. The EHR program as passed in the stimulus bill was always going to be tough to implement. We all knew that in 2009, even as we cheered the lavish amount of money. As economic stimulus, the program worked pretty well. As inducement to adopt EHRs, the program was also a huge success. As a framework to compel interop and quality improvement, it’s still very much a work in progress 7 years down the road. Nothing surprising about that; the difficulty of the tech part was compounded by the human component. I understand docs’ anger but better to work with government to get this right over the next decade than complain, harp, be cynical, and knee-jerk anti-government.

  4. “We will not tolerate business models that prevent or inhibit the data from flowing around the needs of the patient.”

    But it is being so well tolerated now. Why would it change?

  5. Indeed. Huge walk-back.
    So CMS builds a failure machine and it can’t be stopped? Really?
    This is red meat for the “government is the problem” crowd. How would it be possible to legislate at all in an emergent world? This type of stagnation and incompetence should never touch technology or healthcare.
    I wish these kind of things were publicized better. The public should be disgusted that CMS and ONC are eviscerating what should be “the best health care system in the world”. No problem with wasting tax money, distracting physicians, raising health care costs and planting the seeds of interoperability in a toxic landfill…as long as it is “legal”.
    The physicians are going to go treat patients now. Let us know when your broken Pac-Man machine works. I would suggest a congressional hearing, but I don’t know how much good it would do.

  6. Incentive:
    1.a thing that motivates or encourages one to do something:

    One would think that if EHRs were so great and helpful to doctors and patients as well as being easy to use and not overly expensive, and would be a great ROI, incentives would not be needed, no?
    Do you think doctors needed incentives to use the stethoscope or anesthetics?

  7. But… but… but… 🙂
    Prior to the heavy handed regulation of EMRs, a doctor could buy a top-shelf EMR for $399 per month, including practice management system, and get one thrown in for free if he/she purchased billing services. There were cheaper options for bare bones packages too. Once the regulation regime commenced, hundreds of fly by night products entered the market and prices started climbing steadily, while utility (to the user) and quality decreased. Companies used to throw in patient portals, for example, for free. Now that they are “required”, these things either cost a lot of money, or are ad supported. When you have to buy something to stay in business, that something is going to naturally become more expensive. Someone should graph EMR prices over the last 5 years…. Regulation, and superfluous regulation in particular, rarely causes prices to drop.

    In addition, the short sighted use of “levers” to force the creation of monetizable data is actually hurting patient care, and here is an example. For physicians to get the measly chronic care management fees from Medicare, they must share care plans with other clinicians. Sounds great! However, they are not allowed (not allowed!!) to share information on paper or by fax (in person or phone conversation is not even mentioned). So the options now are, share structured data “electronically” or don’t share any information at all. How is this conducive to better care, better coordination, patient centered stuff, and all the professed goals of benefiting patients? Why not just say “share the darn information by any means necessary, just do it”? Seems like some surreal petty game…..

    So here is my suggestion: quit telling software developers how to build software products and stop micromanaging physicians with prescribed data sets and transport protocols. Want information (not data) to be shared? Ask that it be shared. Don’t presume you know what should be shared and how it should be shared, because you really don’t. If you must verify, ask people to describe and show you how they share.

    Basically, let people do the work they were trained to do. And maybe HHS/CMS should concentrate on the work it should do, like say, increasing the efficiency of its financial operations, or website development, which seems to be a challenge for some reason….

  8. How does the author believe that he can obtain cooperation from physicians that his office has abused for years?

  9. I think physicians understand more than you give them credit for. They probably best recognize how this program negatively affects the patient.

  10. While, we’re thinking out loud here, I would like to hear some ideas about how we make health information technology systems more affordable and open the field to new players

  11. It’s the cost of healthcare stupid! (not you, just paraphrasing an old Clinton campaign slogan). That’s really the big elephant in the room. While outcomes are important, and they should be measured, it is hard to realistically measure outcomes on a per physician basis. Too many variables and extenuating circumstances. And you will get no buy-in from docs on this. Furthermore, the system needs to be simple. I’ve worked with hundreds of physicians and very few understood MU. Do you really think they will understand MIPS? No way. You are setting yourself up for failure. Just focus on using HIT to keep care at the same level it is today and reduce costs at the same time. Do patients complain about the care their physicians are giving them? No. They complain about the cost. They can’t afford to pay their medical bills. Just focus on reducing cost. That is more than enough to keep you busy for the next 10 years.

  12. Enlightening and interesting article, but I still have a few questions regarding the points made in the “What Comes Next” section.

    1) How do we know which “outcomes” are being helped by technology? Certainly, the MU measures cannot be classified as “outcomes”. Perhaps these are processes or activities that some people believe could possibly lead to outcomes, but none are pure “outcomes” as far as patients are concerned. Are we referring to “outcomes” that can be easily measured by technology, such as mammography rates? As opposed to meaningful outcomes, such as survival rates, accurate diagnoses, effective therapies, etc.? Or are we referring to “outcomes” such as reducing the amount of money Medicare spends on people?

    2) What does “flexibility to customize health IT” mean? Does it mean that physicians are free to purchase whatever they want, or nothing at all, for their practices? Or is this a reference to an ONC sanctioned app store type of thing, where physicians can pick and choose little pieces of Certified software that are, hopefully, but not likely, able to work with their EHR? If the latter, is it realistic to expect individual doctors to engage in this type of exercise, or are we planning on having only larger systems with savvy IT folks? Considering that EHRs are not iPhones, nor should they be, is it realistic to assume that such an app store will be in existence sometime in the next couple of years?

    I understand that #3 and #4 are intended to create some ideal modular ecosystem (among other things), but I think we are grossly underestimating the difficulties, just like we grossly overestimated the power/usefulness of certification, the wisdom of micromanaging practice tool & die, and the willingness of people to conform to a singular vision of how things should be working.

    Just out of sheer curiosity, and I most certainly don’t expect answers, is there anybody up there who considered even for one fleeting moment that maybe, just maybe, we should gather some hard evidence to guide our next steps, if any?

  13. Pitiful. Karen and Andy are backtracking on any MU changes. From the sounds of it, Andy misspoke and now is on a full retreat. If they think they have lost the hearts and minds of physicians before this, boy have they lost them forever now. Good luck with getting us to participate in anything. I am amazed at the level of incompetence at the highest levels of our government, ONC and CMS. If those 2 were paid for performance and quality they would be getting penalized or fired. Am i angry? Yes. Why wouldn’t we be? They created a monster, which they now say, cannot be undone. What’s probably worse? Their next idea for a MU program. So we are damned either way.

  14. I work for a company that largely ignored MU for the past two years while developing our problem oriented EHR from scratch, and went for the concierge/direct pay market instead. Judging from the reactions of our current mature customers, it’s a breath of fresh air. When you don’t have a bunch of arcane seemingly arbitrary design rules for your EMR/Health IT, then its pretty easy creating something efficient and useful by just listening to the user needs of the Provider.

  15. As part of this rethink I hope there will be some effort at scientifically measuring and objectively assessing the impact of specific measurement attempts. (For the back story on this see Robert Wachter’s excellent NYT opinion piece this weekend.). At this point, it is clear that there are useful metrics and some that are less useful. And that is being nice about it.

    In many ways, metrics seem to lead lives that are a little bit like government programs and for many of the same reasons. Once they are willed into existence, it turns out they are almost impossible to kill. A healthcare system flooded with zombie metrics mindlessly consuming resources, tax payer dollars and eating the brains of healthcare professionals isn’t going to be much help to anybody….

    The answer is probably something that looks a little like the comparative effectiveness research program for the quantification movement. We need to be asking real questions. We may not like some of the answers. But that’s okay.

    What impact do measurement programs have? What are the trade-offs? (Everything has a trade off, remember?) What is the process by which they are approved? When and how do we get rid of them when it becomes clear that they fall into the “non-useful” category?

  16. You said CMS has lost the hearts and minds of physicians. How can we even begin to trust that after years of wasted money, time, and effort, and loss of patient-physician relationship that anything in the future will be better?
    You should read comments on Medscape to understand just how defeated physicians feel by all this wasted effort. You should read comments on KevinMD and the AAFP website.
    The perfect storm of MU and all its attendant irrelevancies, ICD-10, and mass confusion and shakeup from the ACA has given most physicians, but most importantly Primary Care total frustration and anger at the Medical Industrial Government Complex.
    If we wanted to win the hearts and minds of the Iraqi people, it certainly wouldn’t be by bombing the Heck out of them.