Delays and more delays

Originally, the 10th revision of the International Statistical Classification of Disease and Related Health Problems–aka ICD-10–was slated for adoption here in the United States on October 1, 2011 by all “covered entities” under HIPAA.

As early as January 2009, the deadline was pushed out to October 1, 2013 and with it, migration to ANSI 5010 moved to January 1, 2012 in order to support ICD-10 codification. If, like me, you have become so immersed in the politics of such timing, just remember that the ANSI 5010 standard and ICD-10 code set updates are intended to be helpful, streamlining and improving transactions and improving diagnosis reporting and analysis.

Anyway, the “best-laid schemes of mice and men oft go awry”… unless you’re living in France, or one of the Nordic countries…circa 1997.

The industry transition to ANSI 5010 has been less than smooth and the Centers for Medicare and Medicaid Services (CMS) recently extended the enforcement start date to July 1, 2012. In response to feedback from organizations like the American Medical Association (AMA) regarding the administrative burden and cost of the ICD-10 transition, CMS announced in February that the agency would also consider postponement of ICD-10 implementation.

No lack of points of view

Finally, on April 17, the Department of Health and Human Services (HHS) published a Notice of Proposed Rulemaking (NPRM) in the Federal Register to propose a one-year delay to the implementation of ICD-10 until October 1, 2014. Prior to the release of the NPRM, policymakers and thought leaders weighed in with a wide range of opinions as varied as: “Don’t delay!”, “Make it a 2 or 3 year delay”, “Let’s just move on to ICD-11”, “Do we even need ICD-10 or can SNOMED suffice?” (While this last idea may seem a bit radical and unlikely, we tend to agree with its potential to simplify—removing the administrative burden on providers and avoiding redundancy.)

But at this point, the length of a delay doesn’t really matter. What does matter is that delays continue for everything—ANSI 5010, Meaningful Use, ICD-10, the Sustainable Growth Rate resolution. And with each delay, the innovative doctors, vendors, patients, health systems and payers aren’t rewarded for their speed and efficiency.

I understand the thoughtful arguments of advocates on all sides and I know we’re collectively tackling monstrous issues. But, the culture of delay is really beginning to keep our industry stuck in a rut. The discussion seems to be increasingly focused on “When will we?” rather than “How can we?”

As always, we’d love to hear your thoughts and, more importantly, encourage you to share them with the feds, who take the comment process very seriously.

You can review the NPRM at the Federal Register. The rule also includes proposals for the adoption of a standard for a unique health plan identifier (HPID), a data element that would serve as an “other entity” identifier (OEID) and a National Provider Identifier (NPI) requirement. Comments are due no later than 5 p.m. on May 17, 2012 and instructions regarding submission can be found on page 22950 of the rule.

There’s still time to weigh in on the Meaningful Use of EHR! We’re about a month away from the submission deadline for comments in response to two Notices of Proposed Rulemaking (NPRM): The Centers for Medicare and Medicaid Services (CMS) Meaningful Use Stage 2 NPRM; and the Office of the National Coordinator for Health Information Technology (ONC) 2014 Standards and Certification NPRM. And you can provide valuable feedback to the ONC and CMS. 

Why is your feedback so important?

Because officials in DC or other vendor headquarters simply do not have your clinical expertise and day-to-day insights on the use of an EHR. Yes, athenahealth is in the process of developing our own comments. And while we plan to represent the interests of our clients—primarily with respect to administrative requirements and the best utilization of health IT—we strongly encourage providers and administrators like you to submit your own comments, too. 

Luckily, CMS and the ONC have created a helpful site that tells you exactly how to submit comments. You’ll find the two proposed rules, a video overview of the Stage 2 requirements, fact sheets for both and links to where you can electronically submit your comments. 

If you don’t have time to read both rules, I recommend you focus on the CMS Rule—the Stage 2 NPRM—and that you register for our next Stage 2 webinar, scheduled for April 25th, to get an overview of what the rule entails. 

You can also zip through the rules by doing a search for “comment” using the “Ctrl+F” function on your keyboard. This isn’t an exact science, but that search should get you to all the places where CMS specifically wants feedback.

What do you think? If you have some thoughts you want to share with colleagues, comment right here.

The 2012 HIMSS Convention seems so long past, yet it was only last week. Or was it last month? Either way, one thing stands out through the fond memories of smoky blackjack tables, icy cocktails and bad food: the HIMSS Flavor of the Year was the federal government, with lots of Meaningful Use. 

Every time I turned around, it seemed there was a familiar face from ONC (Office of the National Coordinator of HIT) or CMS (Centers for Medicare and Medicaid Services) standing there: engaged, accessible and ready to explain something I should know. This massive health IT sales and marketing extravaganza (with its crazily lopsided ratio of sellers to buyers) felt like a rather large stage for the feds to explain how they plan to steer the HIT ship.

… Was this reality or were my DC visits just getting to me? Luckily, my inner nerd took home a few copies of the HIMSS12 Daily Insider newspaper. I dug them out, paged through and voila! Proof that I was not imagining things!  

February 22 headline, above the fold: Stage 2 announcement expected today

Then, for effect, February 23 headline, again above the fold: Meaningful Use Stage 2 READY FOR PRIMETIME

Indeed, the feds had arrived. And if the number of CMS calls I’ve eagerly awaited and ONC-proposed standards I’ve spent hours contemplating are an indicator, it appears they’re here to stay for a while. 

Among the post-HIMSS, government-related issues creating buzz in our world and on the Hill: the ICD-10 timeline re-examination, originally announced by Acting Administrator Marilyn Tavenner in February. Since then, industry stakeholders have weighed in with a variety of opinions, ranging from “Viva la delay!” and “Keep pushing forward, we’ve invested so much already” to “We might as well move to ICD-11”. There are even sites dedicated to stakeholder feedback on the implementation timeline. But CMS has remained quiet.    

The Recent EHR Kerfuffle

Another attention-getter is a recently released study featured in Health Affairs: “Giving Office-Based Physicians Electronic Access to Patients’ Prior to Imaging and Lab Results Did Not Deter Ordering of Tests.”

Here are a few references and responses I recommend:

• The Washington Post and New York Times featured the study
• National Coordinator for Health IT, Farzad Mostashari, provided a response to the study
• The researchers responded to Mostashari in a Health Affairs blog post
• The HIMSS Electronic Health Record Association release addressed the New York Times article
• Aaaaand… athenahealth’s own CMIO Todd Rothenhaus’ recent blog post discussed the study

My biggest takeaway from all this had nothing to do with the study or its conclusions: After my friends and family emailed me about the study, I realized that health IT may not be a household topic yet, but it’s finally entering the space of common knowledge. How ‘bout that? Maybe they will ask me about Meaningful Use at Thanksgiving dinner …

New Measures and Standards

Finally, the ONC and CMS gave us two notices of proposed rulemaking (NPRM) on EHR standards and certification criteria and the Stage 2 Meaningful Use measures, respectively. 

Since the notices were released in February and subsequent published in the Federal Register on March 7^th, my brain has been swimming with measures and standards. Here are a few takeaways at a glance:

• While there are some unexpected items, there aren’t too many surprises as the ONC and CMS consistently took direction from the HIT Policy and Standards Committees
• In the Meaningful Use Stage 2 NPRM, there is an increased focus on patient engagement, clinical decision-making tools (more Clinical Quality Measures and Clinical Decision Support requirements) and health information exchange
• We’ll no longer refer to certified versions of health IT by stage—instead we’ll have the “2011 Edition” and “2014 Edition”
• The implementation of Stage 2 Meaningful Use will be delayed to 2014.  This delay only affects providers who adopted Meaningful Use in 2011, as those providers will demonstrate Stage 1 criteria for 3 years (2011-2013) before moving to Stage 2 in 2014. The delay does not affect the incentive payment schedule.
• Except for 2011 MU adopters, providers will report on measures over a 90-day period in their first year and over a full year thereafter. Additionally, aside from 2011 adopters, eligible providers will always perform Stage 1 for two years, followed by two years of Stage 2 and then onto Stage 3. I hadn’t fully understood these adoption timelines, so I wanted to emphasize them.

Want a more in-depth review?  Then, please join me for a live webinar next Wednesday, March 21 at 12:15 p.m. ET. (Register here!) In the meantime, this Meaningful Use Stage 1 & 2 comparison from The Advisory Board Company is helpful and you can find the rules on the Federal Register— here’s the Stage 2 NPRM and Standards and Certification NPRM. 

We’ll continue to provide updates about the rules and our opinions. If you’re an athenahealth client, we can chat about all things government at our annual User Conference at the beginning of April. And, as always, we invite your thoughts right here on the blog.

The first half of January was quiet for the Government Affairs team with the nation’s capital having been closed for the holidays. OK, fine, and maybe I was being a lazy blogger as some of you have pointed out.

But last week, to the delight of idling cab drivers and bored policy wonks alike, lawmakers came back from their districts and DC was back in business! And it quickly became clear that the spotlight will continue to shine hot and bright on health care—and our HIT corner of it.

Here’s how 2012 started off inside the Beltway:

Monday, Jan. 23

The Senate returned, joining the House, to begin their longest combined work period of 2012. Because of the presidential election, this year will likely be light on legislation after a more permanent solution to the payroll tax holiday-UI- Sustainable Growth Rate (SGR) extension is passed. Fortunately, we can count on the Centers for Medicare and Medicaid (CMS) and the Office of the National Coordinator (ONC) to keep us busy with… Meaningful Use!

Tuesday, Jan. 24

The House and Senate Conference Committee for H.R. 3630, the “Temporary Payroll Tax Cut Continuation Act of 2011” held its first meeting, which fondly brought back divided Super Committee memories, with high level statements coming from both parties. You can check out the meeting and read statements from Sen. Max Baucus, D-Mont. and Rep. Dave Camp, R-Mich. We in health care are paying close attention to their decision-making because without a fix to the SGR, physicians face a 27.5% cut to Medicare reimbursement starting on March 1. Ultimately, the debate will come down to the funding source  for an extension of some sort. The committee met again on February 1^st and, right now, with so many details up in the air, many expect a decision to come down to the wire.

President Obama also gave the 2012 State of the Union address. He surprised many of us by leaving health care almost entirely off the agenda. He did reference Medicare and Medicaid, but mostly focused on job creation, education reform, energy and personal responsibility. We were, of course, happy to hear him call out the need for innovation. (Cloud! Cloud! Cloud! Just sayin’…)

Wednesday, Jan. 25

CMS sent Meaningful Use (MU) Stage 2 Notice of Proposed Rulemaking (NPRM) to the Office of Management and Budget (OMB) for regulatory review. CMS had previously sent the proposed rule for new and revised standards, implementation specs and certification criteria for electronic medical records (EHRs). In case you were wondering… the rules get sent to the OMB because they have an effect on our budget.

Besides the budget implications, the Stage 2 NPRM matters because it will define the Stage 2 criteria eligible providers must meet beginning in 2014, using a certified EHR, in order to meet Meaningful Use (MU). In contrast, the certification proposed rule will inform HIT vendors of standards that they must incorporate into their development for Stage 2 certification. Some items we expect to see include more specialty-specific measures, usability requirements, certification process details and interoperability and standards specifications.

The HIT Policy Committee met again on Feb. 1, though CMS informed the committee that, due to the timing, it would not be prepared with an updated analysis of MU performance results. You can refer to their January analysis for national trends and check out our Meaningful Use dashboard for athenahealth results.  Because of the February 29^th attestation deadline, we don’t expect final Year One numbers until March.

Thursday, Jan. 26

CMS and the ONC hosted The Care Innovations Summit, with over 1,000 attendees from across the health care spectrum. It’s always a treat to hear Atul Gawande speak and see Todd Park, Farzad Mostashari and Aneesh Chopra bring enthusiasm that I’m not accustomed to finding in health IT outside the walls of athenahealth. (As a side note, we’re sad to see Aneesh Chopra leave his federal role.) I’ll focus on the summit in a subsequent post, but the biggest highlight was a clear, broad consensus on the need for VALUE-based care.

Friday, Jan. 27

On Friday, the Bipartisan Policy Center released a report, “Transforming Health Care: The Role of Health IT,” at a morning event in DC. Whether you’re looking for good data, big ideas, or a good summary view of the status of HIT and its role in health care reform, I recommend reading the report. This one is right in our wheelhouse and we’ll circle back to it soon.

En fin

If you find your brain spinning (don’t worry, mine was too), stay tuned for deeper coverage of all these topics and events in the coming months. Think of this as a cheat sheet for what’s on deck in 2012. As always, we appreciate all your comments and questions, so send them in.

On Jan. 5^th, we issued a press release about the positive advisory opinion we received from the HHS Office of the Inspector General (OIG) on our athenaCoordinator service pricing. Insiders have observed that it is different from other OIG advisory opinions on referral management arrangements because it enables transaction-based pricing for value-added health information exchange. 

This is an opinion that was sent to athenahealth and only applies directly to athenahealth. However, it was made public, so many in the industry (mostly lawyers!) will look at it for guidance on other health information exchange (HIE) arrangements on which they may be advising clients.

There is a lot of legal language in the opinion, which can make it a little difficult to understand exactly what athenahealth plans to do with its athenaCoordinator service. Some commentary I’ve seen in the blogosphere and elsewhere has mistakenly referred to our service as a “private HIE.”

It’s not.

For starters, athenaCoordinator is cloud-based and it’s a service that provides order transmission, insurance pre-certification and patient registration among physicians, hospitals and other care nodes. It’s intended to eliminate the errors and redundancies that can impede the flow of care in our health system. When you travel through the care chain, you should be a known entity at each stop and not someone who has to re-establish your identity and health information with each iteration.

As for how athenaCoordinator is not a private HIE, let me try to cut through the legalese (as well as a General Counsel can reasonably do) and explain why athenahealth’s plans are innovative and different. 

1. Everybody is welcome – One of the big problems with the effectiveness of HIE is that HIE systems, both public and private, are typically open to only limited regions or markets. With public HIE, this is a result of governance and funding—they tend to be focused on specified regions and the administrative and technical barriers to sharing useful information limits their reach. Private HIE is typically and intentionally targeted within specified health systems or regions based on business considerations. The ultimate intent of athenaCoordinator is to make the data exchange services available to anyone in any market in the United States. We believe that widespread participation results in a stronger network, leading to better information quality and therefore better care coordination.

2. It’s sustainable – Rather than relying on the largesse of public or private grant funders or donors, the transaction-based pricing enables a sustainable market for health information exchange.

3. Information is “on demand” – The idea is that users will pay for valuable information, what they want, when they want it and that they will pay fair value for it. The model de-emphasizes complex legal or administrative structures. Subscription is simple. athenaNet will serve up the information in a usable format. If it’s not eminently usable, customers won’t pay for it!

I will be candid. Effective nationwide HIE is a tough nut to crack. A lot of smart people have been working on HIE for years under more traditional models and most such models have failed.

Many are skeptical these arrangements can succeed. Yet most in the industry acknowledge the immensely powerful benefits of nationwide HIE.

So what makes us think that the athenaCoordinator model will work? It already does work to a large extent through the services offered by athenaCoordinator, known as Proxsys, LLC prior to our acquisition—including care coordination services to hospitals, ambulatory surgery centers (ASCs), and imaging centers. The changes planned by athenahealth for the athenaCoordinator service will expand these services and multiply the value of HIE by leveraging the demographic and clinical data of clients who subscribe to our EMR service, athenaClinicals.

Leveraging the other athenahealth services will enable more streamlined workflows and powerful reporting. This supports care coordination and more effective participation in payment programs that provide incentives for demonstrating adherence to care protocols. Of course non-athenahealth clients will be able to send to subscribing receivers as well. They will realize many of the benefits and their participation will strengthen the network power that enables better coordination.

We are heartened by the OIG’s policy approach that’s reflected in the advisory opinion. It recognizes the potential of free market approaches to accelerate the development of sustainable HIE in conjunction with government programs to support HIE and the use of EMR.

Will it work? Here at athenahealth, we know we’re creating an offering that tackles key barriers to effective, widespread HIE. We are trying to eliminate the silo-ing of information and create an economically sustainable model to exchange only valuable information when and as demanded. We also hope that our continuing engagement in the dynamic health regulatory environment stimulates more innovative models to solve these and other problems.   

Do you have any thoughts on HIE and care coordination? If so, send in a comment and let’s start a discussion…