The Three Ways That ONC Gets HIE Right in Stage 2
(Editor's note: This guest blog was written by Chris Giancola, principal consultant at CSC Global Healthcare Group, Falls Church, Va.)
This is an exciting time for health information exchange. The objectives for meeting Stage 2 of the meaningful use of electronic health records were shared with the public March 7, and the 60-day comment period on those objectives recently closed. If the current objectives remain intact, healthcare providers across the U.S. will for the first time have a mandate to electronically exchange clinical information with each other.
In Stage 1 of meaningful use, the "exchange of key clinical information" was part of the optional "menu" set of objectives. In Stage 2 - if it remains substantively in its current form - the Office of the National Coordinator (ONC) gets serious about health information exchange in three ways:
1. Health information exchange is now a part of the core (required) set of objectives.
2. The use case for health information exchange has been more clearly defined.
3. The measure for achieving the health information exchange objective has a twist that promotes the real premise underlying it.
HIE is No Longer Optional
Broadly speaking, the ONC's vision for the stages of meaningful use has been clear for quite some time: Stage 1 puts EHRs in the hands of healthcare professionals and gets a basic set of data into those EHRs in a structured format. Stage 2 gets a deeper and wider set of structured data into the EHRs and starts to leverage that data for improving quality at the point of care. Stage 3 gets even more data into the EHR and further broadens the uses of the data being collected and exchanged for the advancement of care quality and public health.
Keeping with that vision, the exchange of information between healthcare professionals was put into the optional "menu" set of objectives in Stage 1. This meant that those hospitals and EPs that attested to meaningful use of their EHR could choose to defer the exchange of clinical information to sometime in the future, and they did so in large numbers: 93 percent of hospitals and 85 percent of physicians did not attest to it in Stage 1. In fact, hospitals deferred health information exchange more than any other Stage 1 objective.
In the Stage 2 Notice of Public Rule Making (NPRM), health information exchange has been moved to the core set of objectives, meaning that it is no longer optional for hospitals and EPs to exchange clinical information when they attest to the meaningful use of their EHR. If meaningful users wish to receive their EHR adoption incentive payments for 2014 and beyond, they must provide a summary of care document for 65 percent of all their transitions of care and referrals, and 10 percent of all transitions of care documents must be sent electronically.
A More Clear Case
Stage 1's health information exchange objective was phrased as the "capability to exchange key clinical information," and it did not require the actual exchange of any clinical information. Furthermore, most EHR products were not capable of producing an electronic document with that key clinical information in it that was suitable for exchange. Doing so would have required purchasing either additional interfaces from EHR vendors or expensive custom programming services, both of which were difficult to justify for an optional objective.
Redefining the "capability to exchange key clinical information" objective in Stage 1 to "provides a summary care record for each transition of care or referral" in Stage 2, makes a much clearer case as to not only when the exchange of clinical information needs to take place, but also why it's important to do so.
First, there's more certainty for providers and vendors by clearly defining when the exchange of information needs to take place - the transition of care from one venue to another. Questions of where and how operational workflows need to change can now be answered, and appropriate changes to processes, forms, and software can be made by both providers and their EHR vendors. Additional rule making in both the Standards and Certification NPRM and the NHIN Governance RFI will contribute to defining the guidelines that will ensure responsible, secure, and successful health information exchange across the nation.
Second, both research and common sense suggest that better clinical information in the hands of providers leads to better decisions about a patient's treatment. Better treatment leads to fewer readmissions, and fewer readmissions preserves revenue and reduces uncompensated care costs.
Patients who follow up with their PCP within seven days of discharge decrease their chances of re-hospitalization, and that risk is further reduced when the PCP has received the patient's discharge summary. However, manual discharge coordination is fraught with error, frequently missing vital information such as the main diagnosis, discharge medications, test results, and pending tests, implying that electronic data capture and support of care transitions should be the preferred method of exchanging health information.
Further, consider the larger context of recent efforts at healthcare payment reform. Under payment reform, insurers make a single payment to a healthcare provider or Accountable Care Organization (ACO) based on a patient's diagnosis and not for each patient visit. Also under payment reform, insurers reduce or eliminate payments for readmitting patients into treatment for the same clinical episode; the quality of care, not quantity of care, is what counts most. For example, Medicare will not pay for preventable readmissions, and will impose an additional 1 to 3 percent payment penalty across all Medicare DRGs for those healthcare providers in the worst-performing quartile for readmissions as compared to their peers.
So by combining Stage 2's more specific requirement of supporting transitions of care with changes being made in the ways that health care is paid for by insurers, a clear line can now be drawn between meeting the health information exchange objective and avoiding real costs and revenue erosion.
The Measure and the Premise
The previous National Coordinator for Health Information Technology, Dr. David Blumenthal, was clear that the free-flow of patient data across settings of care, regardless of technical or business-imposed barriers, was a key premise of the HITECH Act. This premise is apparent in the specific transitions of care that are counted toward achieving the minimum measure of the health information exchange objective in Stage 2.
The measure of health information exchange in Stage 2 is a percentage, with the total number of transitions of care in the denominator, and the total number of those exchanges that were done electronically and done with external entities using disparate technology from that of the provider in the numerator. This quotient must exceed 10 percent in order for the hospital or EP to qualify for meaningful use incentive payments.
By insisting that patient data in support of care transitions moves outside the virtual "four walls" of the hospital or health system, the measure keeps the spirit of data liquidity alive and the vision of ubiquitous transmission of patient data moving forward.