15 ways MACRA causes seismic shifts in healthcare IT

Final rule includes tough stands on interoperability, blocking and EHR certification.

IT takes a leading role in the final MACRA rule

Healthcare information technology is a common theme running throughout the 2,400 pages of the final rule published by the Department of Health and Human Services has published the final rule for the Medicare Access and CHIP Reauthorization Act (MACRA) Quality Payment Program. The new rules, which revamp physician reimbursement to reflect quality and efficiency of care, will significantly impact providers’ use of IT. Here are some highlights of provisions that will have the biggest impact on HIT for providers.

Where HIT fits into the final rule

MACRA consolidates components of three existing programs—the Physician Quality Reporting System, the Physician Value-based Payment Modifier and the Medicare Electronic Health Record Incentive program for eligible professionals. Regarding the EHR program, the focus will shift away from just completing objectives to supporting interoperability and advanced quality objectives. The overall goal is for the new reimbursement program to “be cohesive and avoid redundancies.”

The most important changes are in the areas of interoperability; information blocking; the use of certified health information technology; and the use of EHRs to improve care.

The HITECH Act won’t be cast aside under MACRA

The final rule notes that HITECH requires the Secretary improve the use of EHRs and healthcare quality over time by requiring more stringent measures of meaningful use. The Merit-Based Incentive Payment System (MIPS) and the advancing care information performance category seeks to continue the direction of the EHR Incentive Payment Program, but to do so “by adopting a new, more flexible scoring methodology…that would more effectively allow MIPS-eligible clinicians to use EHR technology in a manner more relevant to their practice.” The new methodology emphasizes patient electronic access, coordination of care through patient engagement and health information exchange—“objectives we believe are essential to leveraging (certified EHR technology) to improve care by engaging patients and furthering interoperability.”

The new approach would de-emphasize the use of objectives, which “will reduce burden, encourage greater participation and direction attention to other objectives and measures (that) have significant room for continued improvement.”

“Through this flexibility, MIPS-eligible clinicians would be incentivized to focus on those aspects of CEHRT that are most relevant to their practice, which we believe would lead to improvements in healthcare quality.”

MACRA offers flexibility and a 90-day reporting period in 2017

In 2017, a MIPS eligible clinician who has technology certified to a combination of 2015 Edition and 2014 Edition may choose to report on either the Advancing Care Information objectives and measures specified for the advancing care information performance category “of this final rule or the 2017 Advancing Care Information Transition objectives and measures.”

In response to comments it received, rule writers decided to “accept a minimum of 90 consecutive days of data from the CY 2017 performance period. MIPS-eligible clinicians who have EHR technology certified to the 2014 Edition and then transition to EHR technology certified to the 2015 Edition in 2017 have flexibility and may select which measures they want to report on for the 2017 performance period.”

Scoring for the Advancing Care Information Transition objectives and measures

The final rule sunsets payment adjustments under the current Medicare EHR Incentive Program for eligible professionals.

CMS contends that “MIPS eligible clinicians reporting the 2017 Advancing Care Information Transition will not be disadvantaged.” These clinicians will have the ability to earn as many as 155 percentage points for the advancing care information performance category. “In order to make up the difference in the number of measures included in the performance score for the two measure sets, we have increased the number of percentage points available for the performance weight of the Provide Patient Access and Health Information Exchange measures (up 20 percent for each measure), as these measures are critical to our goals of patient engagement and interoperability.”

Despite the challenges, health information exchange is crucial

The proposed rule that the health information exchange requirements force eligible professionals to be responsible for the actions of patients and other physicians over which they have no control, or over technology that “overestimate the interoperability of EHR technology.” The rule notes that while there are a bevy of issues hampering exchange, “we believe the electronic exchange of health information between providers and clinicians would encourage the sharing of the patient care summary from one provider or clinician to another and important information that the patient may not have been able to provide.”

MACRA will be used to target information blocking

ONC is ramping up efforts to stop efforts to block the flow of information. Here’s the background and rationale included in the final rule for MACRA:

“On December 16, 2014, in an explanatory statement accompanying the Consolidated and Further Continuing Appropriations Act, the Congress advised ONC to take steps to ‘decertify products that proactively block the sharing of information because those practices frustrate congressional intent, devalue taxpayer investments in certified EHR technology, and make certified EHR technology less valuable and more burdensome for eligible hospitals and eligible providers to use.’ The Congress also requested a detailed report on health information blocking (referred to in this final rule with comment period as the Information Blocking Report). In the report, which was submitted to the Congress on April 10, 2015, ONC concluded from its experience and available evidence that some persons and entities—including some healthcare providers—are knowingly and unreasonably interfering with the exchange or use of electronic health information in ways that limit its availability and use to improve health and healthcare.”

What MACRA will require providers to attest regarding information blocking

The information blocking attestation consists of three statements related to health information exchange and the prevention of health information blocking. The statements, are also being finalizing in other rules for eligible hospitals and critical access hospitals, just as they are in MACRA for eligible professionals. “We believe that these statements, taken together, communicate with appropriate specificity, the actions healthcare providers must attest to in order to demonstrate that they have complied with the requirements.”

The statements are:
Statement 1: A healthcare provider must attest that it did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.
Statement 2: A healthcare provider must attest that it implemented technologies, standards, policies, practices and agreements.
Statement 3: A healthcare provider must attest that it responded in good faith and in a timely manner to requests to retrieve or exchange electronic health information, including from patients, health care providers.

MACRA won’t hold providers accountable if blocking isn’t their fault

The final rule notes that certain types of practices are inherently likely to interfere with the exchange or use of electronic health information:

• Contract terms, policies or other business or organizational practices.

• Prices or fees “that make exchanging and using electronic health information cost-prohibitive.”

• EHR technology that is implemented “in non-standard ways that are likely to substantially increase the costs, complexity or burden of sharing electronic health information.”

• Certified EHR technology implemented in ways that are “likely to lock in users or electronic health information.”

The rule states the requirement regarding information blocking “ensures that healthcare providers are not penalized for actions that are inadvertent or beyond their control.”

MACRA does not let vendors off the hook for blocking

Groups that offered comments on the proposed rule noted that information blocking also could be caused by EHR vendors, “with some commenters alleging that EHR vendors are routinely engaging in these practices,” CMS noted in the final rule. “Commenters alleged that EHR vendors are unwilling to share data in certain circumstances or charge fees that make such sharing cost prohibitive for most physicians, which poses a significant barrier to interoperability and the efficient exchange of electronic health information.”

Requirements for EHR vendors or other health IT developers, however, lie beyond the scope of MACRA. However, “we note a series of legislative proposals included in the President’s Fiscal Year 2017 Budget would prohibit information blocking by health IT developers and others to provide civil monetary penalties to deter this behavior.” ONC also has taken action to expose and discourage information blocking, and recent ONC guidance on contracts “can assist healthcare providers to compare EHR vendors and products and negotiate appropriate contract terms that do not block access to data or otherwise impair the use of certified EHR technology.”

MACRA foresees technology development in the future

Writers of the final rule understand that not all the technology is in place yet to achieve interoperability, and that there are challenges yet to be solved with the bi-directional exchange of information. But that capability is already in use by “a significant number of healthcare providers...We expect those trends to increase as standards and technologies improve, and as healthcare providers, especially those participating in Advanced APMs, seek to obtain more complete and accurate information about their patients with which to coordinate care, manage population health and engage in other efforts to improve quality and value.”

Associated certification rule expands ONC’s role

On October 19, ONC published the ONC Enhanced Oversight and Accountability final rule, which enhances oversight under the ONC Health IT Certification Program by establishing processes to facilitate ONC’s direct review and evaluation of the performance of certified health IT in certain circumstances, including in response to problems or issues that could pose serious risks to public health or safety. ONC’s direct review of certified health IT may require ONC to review and evaluate the performance of health IT in the production environment in which it has been implemented.

The rule anticipates provider support and involvement. “We stressed in the proposed rule…that such surveillance and direct review will not be effective unless healthcare providers are actively engaged and cooperate with these activities, including by granting access to and assisting ONC-ACBs and ONC to observe the performance of production systems.”

Other means to exchange information

The MACRA rule encourages the use of other kinds of IT to achieve the “widespread exchange of health information.” For example, one way to do so could involve telehealth, included under the care coordination subcategory of the rule. “Ensuring that there is bilateral exchange of necessary patient information to guide patient care…could include participating in a health information exchange—this would require interoperable communications.”

Surveillance of Certified EHR Technology

The Office of the National Coordinator for Health Information Technology is taking on expanded roles in observing certified healthcare IT in the field. As part of MACRA, providers will be asked to attest that they are cooperating with the ONC’s efforts. It requires “EPs, eligible hospitals and critical access hospitals (as part of their demonstration of meaningful use under the EHR incentive programs) that they have cooperated with the surveillance and direct review of certified EHR technology under the ONC Health IT Certification Program,” the rule states. “ONC has established ‘certain safeguards that can minimize potential burden on healthcare providers in the event that they are asked to cooperate with the surveillance of their certified EHR technology.”

Two parts to provider attestation

CMS sets up a two-part attestation for providers’ activities to support certification (for which it uses the acronym “Supporting Providers with the Performance of Certified EHR technology activities,” or SPPC activities. Through these, providers “cooperate in good faith with ONC-ACB authorized surveillance and, separately or collectively as the context requires, a healthcare provider’s actions in cooperating in good faith with ONC direct review.”

Healthcare providers must attest that they engaged in good faith in SPPC activities related to ONC direct review—acknowledging both the requirement and that, if a request is received, that they cooperated in good faith.

Optionally, healthcare providers may attest to the same two statements in their dealings with ONC-ACB surveillance of health IT under the certification program.

Protection for providers assisting in the review process

In comments CMS received, some groups asked that the agencies soften the impact on providers that are offering access to those reviewing the technology on site. CMS agreed. “We believe that several safeguards established by ONC will minimize the burden of these activities,” the MACRA rule explained. “We expect that, in most cases, ONC and ONC-ACBs will accommodate providers’ schedules and other circumstances, and that, in most cases, providers will be given ample notice of and time to respond to requests from ONC and ONC-ACBs.”

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