John Halamka, M.D., chief information officer of Boston’s Beth Israel Deaconess Medical Center, was a critic of the Stage 3 electronic health records Meaningful Use program, even before it was finalized. Now with the final rule out, he would like to see Stage 3 eliminated altogether.

Speaking as a healthcare CIO and not as co-chair of the Health IT Standards Committee that advises the government, Halamka contends that Stage 3 is not only generally unhelpful but downright counterproductive.

“Walk inside a hospital, talk to the IT people and the providers. Everyone has the Meaningful Use hangover. We’ve been drinking Meaningful Use and boy do we have a headache,” he exclaims. “Stage 2 hasn’t even been optimized and now layering on the requirements for Stage 3 is too much, too fast. It’s not that I oppose the further adoption of IT and innovation but only 12 percent of doctors have made it over the Stage 2 finish line and now we’re going to make it even harder. Does that make sense?”

Also See: John Halamka’s Case to Delay Stage 3

Halamka says he would ideally eliminate Stage 3 and instead use merit-based pay to offer in effect rewards for innovation and outcomes achieved. This kind of incentive program for providers, he argues, would provide the latitude for success instead of the current highly prescriptive “regulation stack telling you exactly how you must do everything.”      

Providers would welcome the end of Meaningful Use in favor of merit-based payment “because at this point it is more effective and efficient for them to focus on achieving better outcomes for value-based care than being told exactly how they should get there,” according to Halamka.

Recognizing that the likelihood of delaying—let alone abolishing—the Meaningful Use program is not politically realistic, he would use the CMS 60-day comment period for the Stage 3 rule to modify some of the criteria and try to align the Meaningful Use program and the Merit-based Incentive Payment System (MIPS), as required under the Medicare Access and CHIP Reauthorization Act of 2015.

In particular, Halamka advocates removing the application programming interface (API) requirement for patient electronic access to their health information from Stage 3 and moving it to MIPS, enabling the marketplace to evolve innovative technologies after there is increased consumer and provider demand for such a technology.

Halamka calls the API requirement the most controversial part of the final Stage 3 rule. While he is a strong supporter of the use of APIs as a means to enhance interoperability, such as HL7’s FHIR, he argues that currently there are few patient-facing apps that use APIs and questions whether regulation is the best approach to accelerate the move to consumer-facing mobile apps and APIs for downloading of EHR data and uploading of patient generated data.

“To put it in regulation that there needs to be this API available to patient apps—in fact, any patient app—is just too early,” Halamka remarks. “I would have waited until we actually have experienced products and services and an ecosystem for which the API would actually be useful to patients.”    

Nonetheless, Stage 3 requires that providers meet the “Coordination of Care through Patient Engagement” measure by: viewing, downloading or transmitting to a third party their health information; or accessing their health information through the use of an API that can be used by applications chosen by the patient and configured to the API in the provider’s certified EHR technology; or a combination of both.

The Stage 3 requirements are optional in 2017 but all providers will be required to comply with the regulations beginning in 2018. Under this schedule, EHR vendors realistically would have only one year to make software changes and get certified, which could be very difficult—especially for the API requirements, Halamka says.

“In effect, this criteria says ‘you must drive a car but we haven’t built any roads.’ So, it’s kind of hard to drive,” exclaims Halamka. “I love the idea of patient and family engagement but to believe at this point in history that we’re going to have patients being the stewards of their own data, downloading x amount of payloads and transmitting them to third parties is just too early.”    

He makes the case that patient access to their medical records is one of the most difficult aspects of Meaningful Use for providers to achieve. In Meaningful Use Stage 2, only 5 percent of patients were initially required to access their information, but in Stage 3 the bar will be raised to 10 percent, according to Halamka. And, as he observes, Stage 2 was modified to move the 5 percent to just one patient.

“Regulation alone cannot change consumer behavior since APIs are not so much a technology but a market ecosystem to support the technology,” concludes Halamka. “Meaningful Use Stage 2 attempted to use regulation to accelerate patient view/download/transmit of data and there were few places to transmit consumer data and few compelling reasons for consumers to do it, so few tried. The reason that no one has done view/download/transmit is because there isn’t the value proposition to do it yet.”

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