In today’s shifting health industry landscape, as more organizations are going at risk and accountable care organizations continue to proliferate, healthcare providers are searching for ways to improve value-based care metrics to improve their processes. An essential component is a local or regional health information exchange organization.
By aggregating data from across the community that are in disparate systems, these data are then parsed, patients are all properly identified in the system in real time, so the clinical data that are necessary to deliver improved care can provide a variety of tools for better managing populations and individual patients.
Value based care and alternative payment models are here to stay. MACRA—which repealed the flawed SGR payment mechanism for physicians and which was passed overwhelmingly in both houses of Congress and signed into law by President Obama—creates a framework for clinicians who are caring for Medicare beneficiaries to be to be reimbursed based on various levels of performance and improvement activities. The ultimate goal is to put all clinicians in value-based care arrangements, replacing fee-for-service reimbursement forever.
If we are going to move towards a system where we pay for quality of care rather than quantity, then quality data becomes as crucial as claims data in terms of payment. The quality reporting needed to meet reimbursement requirements can most readily be available via a health information exchange organizations. And as multiple provider organizations—which previously were in perhaps some friendly competition for market share—begin to find themselves at risk together in an ACO or other alternative model, the centralization of a regional health data repository and the sharing of these data will be an imperative.
It is possible to discover the benefits of utilizing a data foundation to intelligently integrate clinical information across an entire care community. Costal Connect Health Information Exchange (CCHIE) supports accountable care organizations and providers for exactly this purpose. Extracting and normalizing data from their HIE enables queries to be performed to better understand utilization, trends, readmission rates and other trends. These are all factors that contribute to successful value-based care. With data in a comparative analytics format, CCHIE ensures that their reporting needs are met.
Healthcare is facing increasing system integration pressure, from a regulatory, business needs and technical perspective. The proposed rule from CMS (just some light reading at 1058 pages) on the implementation of the MACRA law and the requirements for the Merit-based Incentive Payment System (MIPS) Advanced Alternative Payment Models (APMs), provides the mechanisms for how all physicians will now be paid for serving Medicare beneficiaries. It continues to highlight the critical importance of data sharing. Anyone going at risk in caring for patients should realize that interoperability is much more than just a buzzword—it is a key requirement for success.
As the regulatory framework for implementation of the law, and investigations by the Office of the Inspector General (OIG) get underway, we can expect to see robust enforcement of these provisions under this administration—violations of the law will be prosecuted. The recent settlement agreement of almost $155 million against an electronic health record (EHR) vendor (including personal liability for the CEO, CMO and COO) for violation of that False Claims Act and the Anti-Kickback statutes shows that the Department of Justice and the OIG are not playing around.
This is just the tip of the iceberg; the first (and only) study on information blocking found information blocking does in fact occur and that EHR vendors are primarily the culprits with increasing revenues as the main motivation. Vendors will say they are only doing what their customers want, but I'm not sure that will be an effective legal defense. John Halamka, MD, has called for EHR 2.0, and I agree—what I am calling for is Interoperability 2.0 as well (with sixteen letters I'll just call this #interop20).
With the business drivers in place and a strong legal reason to pay close attention to this area, interoperability would seem to be a huge area of focus for everyone involved in healthcare—providers, payers, patients and the government. Unfortunately, the level of effort has yet to tip the scales sufficiently.
Perhaps the government isn't pushing hard enough, or maybe providers don't really want to share patient information, or it could be that there is no faith that the move to pay for value over volume of care will win out in the end. While I don't hold to these views, there are many people who are making a lot of money under the current flawed system, and no one wants to see their particular sacred cash cow slaughtered. So as imperfect as it is, they desire to keep the golden spigot wide open and let the money flow; however, this will ultimately bankrupt the nation and serve patients very poorly.
The proposed rule from CMS, which was published in the Federal Register this summer and has a public comment period open until August 21, may help push us further along the path to interoperability—or because of added flexibility in the proposal, it may give some folks a sense that things are easing up and we don't have to work so hard. This would be a huge mistake.
In fact, we are at a critical juncture that, for many reasons, requires renewed focus on the secure exchange of health information all throughout the healthcare continuum, even incorporating environmental datasets, economic information and lifestyle factors. We must go beyond what had begun under the HITECH Act and the EHR Incentive Program with meaningful use, and into a broader approach that includes post-acute care providers and a deeper focus on the social determinants of health. Without this sustained effort, you won't survive in a transformed healthcare system.
The new approach under MACRA incorporates payments to reward providers for their use of information technology and data, and success for several of the measures will be dependent on interoperability capabilities. To be sure payment and delivery system reforms are moving ahead, while this administration also wants to reduce the regulatory burden of MACRA on providers. The flexibility granted to participants within MACRA's Quality Payment Program (QPP) under the previous administration has been proposed to be expanded in this new rule.
In fact this proposal reduces the low-volume threshold to half of last year's - this is certainly a good deal of flexibility and likely happy news for small practice and rural providers—so that two-thirds of eligible clinicians will not be subject to the program for the 2020 payment year. There was also introduced a popular measure last year called "pick your pace," which this administration is continuing for the current year. This basically enables clinicians to report a very minimal amount of data to avoid penalties and ease their way into the program.
CMS would also allow individual clinicians and groups to submit measures and activities through multiple submission mechanisms within a performance category to meet the requirements, moving away from the current requirement to use only one submission mechanism.
In terms of the advanced payment models mechanism, the rule also offers more detail on the All-Payer Combination Option for APMs that would begin in 2019. This option would allow clinicians to qualify as advanced APMs through a combination of Medicare and commercial payer APM participation. This opens the door for clinicians to meet the threshold based in part on payment amounts or patient counts associated with Medicare Advantage plans and other payers. This makes a lot of sense and will likely spur more private market cooperation in these efforts.
In a fee-for-service world, there was no need or incentive for scalable sharing and aggregation of patient data. But in a pay-for-performance world, its success is imperative. The business model for HIE organizations will only increase in value in a quality based payment world.
The lack of interoperability between competing EHR and related systems has become a challenge now that industry transformation from volume-based to value-based care delivery is accelerating. And without access to comprehensive patient data, clinicians cannot provide the best possible value-based care.
The ONC defines interoperability as “the ability of systems to exchange and use electronic health information from other systems without special effort on the part of the user.” (emphasis mine) Transactions are important as a baseline measure, but it is the use and usability of these data that are key. No one source system contains all of the relevant data as the current technology allows for a federated architecture that can access information across broad networks. It is connection that’s important.
To address the limitations inherent in a system that has evolved from paper silos to digital silos, then to first-generation facilitation of data exchange, what is needed is next-level data aggregation capabilities that ensure not only the exchange of data but the ability to use it without special effort or extra steps to improve outcomes. This is Interoperability 2.0—the future of health data exchange, analytics, and effective use of an individuals’ health data.
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