From the perspective of the business I work in—Medicare Advantage and commercial health plans—interoperability is truly a business imperative if you are trying to holistically approach both quality and risk adjustment for your clients. This involves the stakeholders from the plan and the provider working together to streamline processes related to data collection and analysis. The holistic approach goes nowhere if plan and provider data can’t “talk” to one another.
In the previous article in this series I spent some time on how the December 2016 passage of the 21st Century Cures Act and its focus on interoperability in electronic health records (EHRs) could create the impetus for nationwide progress. The business imperative is another story—where another piece of legislation, which went into full effect on January 1, 2017, comes into play.
The Medicare Access and CHIP Reauthorization Act (MACRA) and its Quality Payment Program (QPP) are helping to drive the business imperative for interoperability. Those eligible clinicians participating in the Merit-Based Incentive Payment System (MIPS) are seeing this in their reporting requirements under Advancing Care information, which this year is weighted at 25 percent of their score for Medicare payment incentives under the QPP.
The information sought in the Advancing Care Information category shows the pressing need (and business case) for interoperability in healthcare informatics. All of the reporting measures below will require a growing degree of interoperability.
In this category, to potentially earn a positive payment adjustment beginning on Jan. 1, 2019 under MIPS, clinicians must send in data to MIPS about how their practices used technology in 2017 by the deadline of March 31, 2018. (Those who are using an Advanced Alternative Payment Model, or APM, will report through that model by the same date and may earn a 5% incentive payment in 2019.) There may be some crossover in reporting on this category for the Clinical Practice Improvement Activities category, and bonus credit may be available for reporting in both.
For full participation in the advancing care information performance category, MIPS eligible clinicians will report on five required measures:
Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified EHR technology in accordance with requirements in 45 CFR164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the MIPS eligible clinician’s risk management process.
At least one permissible prescription written by the MIPS eligible clinician is queried for a drug formulary and transmitted electronically using certified EHR technology.
For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient’s health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician’s certified EHR technology.
For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) creates a summary of care record using certified EHR technology; and (2) electronically exchanges the summary of care record.
- Request/Accept Summary of Care
For at least one transition of care or referral received or patient encounter in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician receives or retrieves and incorporates into the patient’s record an electronic summary of care document.
Eligible clinicians can choose to submit up to 9 measures for a minimum of 90 days for additional credit. For bonus credit, they can report public health and clinical data registry reporting measures, and/or use certified EHR technology to complete certain improvement activities in the improvement activities performance category.
Other measures under Advancing Care Information (Option 1) include:
- Clinical Data Registry Reporting
- Clinical Information Reconciliation
- Electronic Case Reporting
- Immunization Registry Reporting
- Patient-Generated Health Data
- Patient-Specific Education
- Provide Patient Access
- Public Health Registry Reporting
- Secure Messaging
- Syndromic Surveillance Reporting
- View, Download and Transmit (VDT)
Moving Forward in Interoperability
As stated in the Interoperability Roadmap, “Movement to alternative payment models will naturally stimulate demand for interoperability.” At the same time, it urges that, “a supportive payment and regulatory environment must lower real and perceived costs of interoperability.”
As efforts to achieve interoperability move forward, many challenges and obstacles lie in the way, and a lot of them are people-related rather than technological. These include reluctance to share information for many reasons, including competitive advantage for both providers and developers, costs and liability. We hope the carrots will outweigh the sticks in achieving these goals.
In the next article, we will explore the problem with EHRs.
