Rethinking MACRA Part II

John HalamkaIn my blog posts, I speak from the heart without a specific political or economic motivation. Although I’ve not written about highly controversial subjects such as religion, gun control, or reproductive policy, some of the topics in my posts can be polarizing.   Such as was the case with MACRA.

Some agreed with my initial analysis that clinicians will have a hard time translating complex MACRA payment processes into altered clinical behavior.   Others felt I was overharsh, negative and inappropriate.  It’s never my intent to criticize people, instead I want encourage dialog about ideas.  In that spirit, here’s my opinion on how we should evolve from fee for service to pay for value/outcomes.

1.  Humans can never really focus on more than 3 things at a time.  Although we sometimes believe multi-tasking is efficient, in reality we do work faster with less quality.    Instead of 6 or 8 dimensions of Meaningful Use performance combined with a large number of quality indicators, why not delegate each medical specialty the task of choosing 3 highly desirable outcomes to focus on each year, then reward those outcomes?  For example, I have glaucoma.   Asking my opthalmologist to record my smoking status or engage in secure messaging with me is probably less important than ensuring my intraocular pressures are measured, appropriate medications are given, and my visual field does not significantly worsen.    The cost to society of my blindness would be significant.    Keeping my sight intact represents value.   Care Management software could ensure I’m scheduled for pressure check appointments, given medications, and have my visual field checked once per year.   Some percentage of reimbursement could be withheld until those outcomes are achieved. How  software does that is not important and innovative workflow would be left to the marketplace where clinicians will choose applications based on usability, cost, and time savings instead of regulatory oversight.

2.  Care coordination is important and there is a role for government to drive consensus around standards selection.   Certification could be limited to an application’s ability to perform a few key interoperability functions such as

a.  Look up a recipient address from a national provider directory and send a clinical summary of care (transition, referral request, consult note) to that address securely

b.  Query a record locator service/master patient index and retrieve a list of electronic addresses where patient data is stored, then be able to retrieve a small common data set from those locations (problems, meds, allergies, labs, notes)

c.  Be able to send a clinical summary of care to a patient provided electronic address.

d.  Be able to send a small number of data elements to a relevant registry

e.  Be able to participate in a prescription drug monitoring program

Each of these functions would use a single standards implementation guide without significant optionality,  tested in the marketplace and deemed mature enough for use.  How these transactions are implemented in workflow would be up to each vendor.    Certification would test nothing more than successful transactions against a publicly available test bed.

3.  All other Meaningful Use criteria and quality measures would be eliminated so that clinicians can focus on just the three goals per year relevant to their specialty while  working in an environment that thrives on the simple information exchanges listed above.

We need to avoid unnecessary burden for clinicians, hospitals and software developers.   Think about all the effort (and dollars) spent during the Meaningful Use Stage 1 and 2 processes to report quality measurements, which were never used for anything.   Think about all the certification done that was not related to health policy goals or outcomes.  Think of all the data entry required which resulted in clinicians  spending time practicing below the top of their licenses.

Focusing on 3 outcomes per specialty which are easily measurable, while radically focusing certfication on a few key interoperability transactions is likely to be acceptable to provider and developer stakeholders.   The big question – would it satisfy CMS goals for MACRA based on Congressional mandates?  I hope to have that dialog in several forums over the next few weeks.

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10 replies »

  1. Re: “I believe the entire EHR certification and MACRA process should be abandoned”
    Yes! This is the only way to ensure the technology will evolve to actually add value…..improve quality and reduce costs. Alas, no organized group seems to be championing this….and as long as that is the case the powers that be will ensure the continuation of the costly and corrosive mandates, incentives and subsidies.

  2. A decade+ of experience with the failure of mandated interoperability and certification standards allows me some perspective on John’s point #2. To achieve #2 we have to set aggressive _outcomes_ measures for interoperability (or inverse data blocking) instead of pretending we can make incremental progress by continuing to micromanage modest tech goals such as 2a-e through technology certification.

    The sad reality is that $35 B of silo incentives has made the standards process entirely captive to the large EHR vendors and a small handful of massive integrated provider networks. The standards makers can now pretty much ignore whatever MU or MACRA or the next ONC FACA throws at them along the 10-year interoperability road map.

    In a May 13 post https://thehealthcareblog.com/blog/2016/05/13/independent-decision-support-at-the-point-of-care-for-both-patients-and-physicians/ I describe one easy to understand outcome measure that would cover all five of the #2 goals and beyond:

    2a – “independent” means that directory lookup would no longer be controlled by the EHR silo and could be provided by medical societies eager to serve their members.
    2b – The “notification” on changes component of the proposal would be able to keep patient relationship locator services up to date.
    2c – The “patient digital signature” of the proposal requirement would ensure that no patient-provided PHR, medical home, or caregiver address could be blocked.
    2d – This is the same as 2b. Registries and Relationship Locator Services are cousins. They are separate from the EHR and subject to query outside the control of the EHR.
    2e – A PDMP is simply an example of “decision support at the point of care for a physician”.

    For any host EHR installation with a patient’s data, the question of whether a physician or a patient can:
    – use a different EHR,
    – query a registry,
    – access cognitive computing decision support like IBM Watson,
    – update the Precision Medicine Initiative, or
    – add data into their Apple HealthKit database,
    without any blocking by the host EHR has a single simple YES or NO answer.

    We expect all technology labeled WiFi or Bluetooth or USB to work with any other technology with the same label. We need to give a name to the ability to support independent decision support at the point of care and then measure data blocking progress by how many hospitals, health plans, and registries label themselves with that word.

  3. Again John is hitting the mark. Physicians are desperate for real IT solutions, not from counting smokers, or useless numerators/denominators/attestation, but actual innovative, custom, workflow improving, usable, safe and secure systems. Right now we have very large vendors that are putting all resources in measures and meeting gov regs, instead of working with actual front line providers that want to improve the care they are giving. Sorry CMS/ONC, we know what we want and need from our IT standpoint, we don’t need to be told, and we know what interop looks like, and CMS/ONC obviously does not. Its high time to abandon the ‘kinda more or less’ of the same MACRA, and let innovation come back in. Dr Zwerling is a perfect example, he has talents beyond being a physician, that includes what actual front line providers want and need for exceptional patient care. Seems silly to get him out of the process. And he is yet another good example of someone that CMS and ONC should utilize to fix the mess they are in…but they won’t. The ones are the panels have never really practiced front line medicine, or medicine at all (Farzad ONC chair that setup MU, did one year of residency, he doesnt even call himself MD anymore), and made this ‘doesn’t this sound good’ program that is awful. If MU was so great, why has it been clobbered year in and out, restruck, revised, changed names, all but abandoned by most providers, now 6 years into it. MACRA is just more of the same, with some puffery words like “flexible, simpler” and new names for the same programs. I suggest CMS lets REAL innovation come into the game. Let some providers go off the reservation without penalty, let us actually use customized, noncert EHR, that we make work for our patients. CMS can look at our costs, complications, patient satisfaction and see how we do? I bet we would knock CMS and ONC’s socks off. Its a bit disingenuous of me because we actually already do that, we are the top in quality and lowest in cost in all of Ohio for hip and knee replacements (thank you CMS data) and tops in the entire hospital system in patient sat, and we use a customized EHR, noncert, take penalties because we actually feel we are doing better by our patients, than any cert EHR can do, we can track what we need to track and give better care, without having to click 70 times to get something done and get the information we need immediately. There is no EHR company left that is willing to customize workflow, make things efficient, and remove unwanted and unnecessary annoyances that just get in our way. Why not test that CMS? CMS can keep penalizing me, but I stand by our work, we decided to take penalties over worse patient care, and sure I’ll take lumps for awhile, but not forever. And you will miss our group when we are gone, and so will our community and hospital. Dr H has it right, its time to let innovation back in the game.

  4. As a person who created a highly rated Stage I MU EHR (and tried to add the features needed for Stage II) I was furious how much money and time I spent adding features to my EHR that I knew were useless to my users and would have no salutary impact on either the quality or cost of healthcare. In the end, MU squashed my ability to innovate and ultimately killed the EHR I created and my user base enjoyed.

    Personally, I believe the entire EHR certification and MACRA process should be abandoned as it is a drag on innovative healthcare solutions while it distorts the priorities of the healthcare system.

    After we have objective data which demonstrates that a particular health information technology solution clearly improves the quality and or reduces the costs, physicians will eagerly adopt the new solutions without requiring any “incentives.”

  5. It’s likely a done deal that MACRA will require docs to report fewer measures and give them choices and more flexibility. I like John’s focus on 3 OUTCOME measures. But I wouldn’t necessarily hamstring the reporting of some simple (but not topped out) process measures since automation is going to get better in coming years and could facilitate reporting of those. I also like the idea of focusing on the interop transactions. Per previous THCB posts and discussions, clinical summary and communications to patients must be the priority there….and involve more than one patient. John’s participation in this dialogue on THCB is great since he’s been deep in the trenches on this issue for many years.

  6. Reasonable approach by @jhalamka. Imho, less is more on this front.

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  7. totally agree with a simplified approach–Fewer Measures as @donberwick suggested!

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  8. “Think about all the effort (and dollars) spent during the Meaningful Use Stage 1 and 2 processes to report quality measurements, which were never used for anything. Think about all the certification done that was not related to health policy goals or outcomes. Think of all the data entry required which resulted in clinicians spending time practicing below the top of their licenses.”

    Thank you for this. Yes, someone please think for “next time”.

  9. ” Humans can never really focus on more than 3 things at a time. Although we sometimes believe multi-tasking is efficient, in reality we do work faster with less quality. ”

    Indeed, could this be a factor in increasing medical errors?
    Secondly, how much does any of this have to do with the care of the patient at hand?