Provider Backlash Threatens to Gut MU Public Health Objectives

The chorus of health care provider complaints about growing federal HIT requirements, from Meaningful Use (MU) to switching to ICD-10 diagnosis codes threatens to claim some public health victims.  On February 19 the Meaningful Use workgroup of the US HIT Policy Committee (HITPC) responded to the latter’s pressure to reduce the number of Stage 3 MU objectives by voting to delete electronic reporting of reportable lab results (ELR), syndromic surveillance (SS), and reducing requirements for reporting to public health registries.  They declined to endorse a new objective for clinical case reporting of reportable conditions, but appear posed to recommend continuing reporting to immunization information systems (IIS, often called immunization registries) and adding the capability for EHRs to upload immunization histories from an IIS.

Ironically, ELR and SS were common (but far from universal) even before Meaningful Use. An impediment to rapid expansion of ELR to new hospitals was the need to convert in-house lab codes to LOINC (but this is now MU-required for in-hospital lab reporting anyway).  Meanwhile, providers that had happily submitted HL7 Admission, Discharge and Transfer (ADT) messages for SS in the past were confronted by more complex message requirements in Meaningful Use rules.  Some providers questioned why they should spend time and money sending standardized data when many public health jurisdictions could not accept it electronically.   Thus these efforts resemble half-built bridges, with those on neither shore willing to invest enough to finally meet in the middle.

The MU Workgroup decisions reflect a narrowing of HITPC focus from simultaneously meeting five large social goals (one being improving public and population health) to enabling “transformation of care” as envisioned in medical homes and accountable care organizations.

Some providers might enjoy short-term savings by avoiding MU standardized reporting, but then face ongoing costs and retarded outbreak response associated with inefficient manual reporting.  Of course such cost-efficacy depends on health department adoption of standardized electronic reporting.  Progress was reported in 2013 with 95% of jurisdictions receiving some ELR, and the share of 20 million annual reports received electronically rising 62% from 54% in 2012. That represents 1,600,000 fewer manual reports yearly and 1,600,000 more communicable illnesses addressed more quickly and efficiently, just in the earliest stages of MU.

Public health advocates are typically best represented at the MU workgroup level, so greater effort is required to modify HITPC recommendations and proposed rules changes. The MU Workgroup will return to the discussion (unclear how final are the recommendations at this point) on  March 4 and it seems likely HITPC will take up the topic March 11.  Interested parties can tune in.  Health.e.volution has learned the Joint Public Health Informatics Task Force of public health associations is crafting a strategy, so concerned agencies and individuals can contact their association to get involved.

Stage 2 Meaningful Use begins this year. Is public health ready?

Thousands of eligible professionals and hospitals will have to meet Stage 2 requirements for the Electronic Health Record (EHR) Incentive Program (“Meaningful Use”) in the coming year.  Some hospitals may seek to attest to Stage 2 objectives as soon as 12 months from now.  For healthcare providers, failure to achieve objectives can put thousands or millions of dollars of incentive payments at risk.  Will health departments be ready to meet them half way in information exchange?  The answer depends on whether they are preparing now.  Absent a strong project plan in the next few months, the answer may be “no”.

Here is a checklist for health departments to consider:

1. Are you prepared for MORE DATA?  The standard for Stage 2 rises to on-going data submission, rather than just sending a test message.   Are you ready to receive, parse and use steady streams of data from many healthcare providers?  Health departments can still manage the pace of on-boarding new providers, but must do so in a way that does not put providers at risk (see points 6 and 7).

2. Are you ready to accept MORE TYPES of reporting from each provider?  In Stage 1 providers could select only one of several “menu” public health objectives.  Some menu options in Stage 1 are now required (“core”) in Stage 2.  For example, hospitals must submit ALL OF immunization data,  electronic laboratory reporting and syndromic surveillance reports to health departments ready to accept them.   Eligible professionals must submit immunization data AND  select from other menu objectives (including several public health options) to obtain their incentive.

3. Are you prepared to use HL7v2.5.1 messages for immunizations and syndromic surveillance?  Two standards to choose from in Stage 1 created confusion and frustration, so there is only one standard for each Stage 2 objective.   However…

4. Are you willing to GRANDFATHER providers that have achieved on-going submission of HL7v2.3.1 messages in Stage 1?  This option is up to the health department, and can help you avoid having to re-on-board those providers already successfully submitting data using HL7v2.3.1.  Any new data providers must use v2.5.1 however.

5. Will you accept CANCER REGISTRY data documents using the Clinical Document Architecture standard specified in Stage 2? Do you intend to sponsor any other SPECIALIZED REGISTRIES in 2014?   These are new “menu” options for Eligible Professionals.

6. Do you have a plan to publicly DECLARE READINESS of what public health reporting objectives you will offer for Eligible Professionals and Eligible Hospitals during each reporting period?  Because providers need timely and definitive information, Stage 2 rules now allow providers to claim EXEMPTION from public health meaningful use objectives if such a declaration is not publicly available for their jurisdiction.  (Public health departments need not receive data for any or all objectives, but if they wish providers to be motivated by Meaningful Use incentives to submit data, they must publicly state in advance of each reporting period which objectives will be accepted.)  A closely related issue: if more than one jurisdiction in a state receives Meaningful Use data submission (for example, if there are both local and state level syndromic surveillance or immunization information systems) are state and local departments planning to COMMUNICATE CLEARLY  which exchange opportunities and requirements apply to which jurisdictions?

7. How will you manage Eligible Professionals and Eligible Hospitals that intend to initiate data submission during each reporting period?  Stage 2 rules require providers to REGISTER their intent to submit data with the appropriate health department.   The health department need not then immediately on-board the provider, but has the option to later disqualify a registered provider from receiving incentives if it fails to respond within 30 days to two written requests to take action (i.e., to begin sending test data, or to adjust transmission, structure or vocabulary to the required standards).

8. Do you intend to DESIGNATE a Health Information Exchange to receive some public health data submissions?  To ensure good end-to-end transmission of reports, HIEs cannot claim to substitute for health departments unless they are designated to do so.

9. Is there CLOSE COORDINATION and a RESPONSIBLE OVERALL MANAGER linking planning with each of the affected surveillance programs (and jurisdictions), the state HIT coordinator, Medicaid director and HIT Extension Center?

[And 10. for health departments using EHRs and enrolled in the EHR Incentive Program: Will my EHR migrate to 2014 edition certification standards, and can we meet Stage 2 objectives to earn our incentive?]

Obviously, serious planning is needed.  Some health departments may be asking: is all this worth the effort?  It is critical to remember that:

1. Meaningful use is establishing the de facto standards that will be used for information exchange in the future.  The faster health departments adopt the new national standards and on-board data submitters, the faster they can be automating data management and the detection and management of critical events.   This can serve both effectiveness AND efficiency.  National data and exchange standards will foster the ability of vendors and development of systems to aid health departments with these tasks.

2. Before long, most providers will have electronic health records that are all certified to capture and transmit information in standardized ways.   Onerous reporting processes for providers, and incomplete reporting to health departments, can both be addressed to the benefit of both through automation.  

3. Health departments can decide the pace at which they enroll providers in Meaningful-Use-specified data exchange.  Health department participation is optional, but Meaningful Use incentives (and later, penalties) will induce providers to begin submission whenever the health department is ready.   What the new Stage 2 rules demand in return is that health departments communicate clear plans and requirements to providers.  It is the latter who then face financial loss if objectives aren’t met.

4. The new rules continue to support the idea of “queuing providers” and on-boarding them at the pace the health department can tolerate.  Once providers are registered, they are not at risk of losing their incentive UNLESS they fail to respond timely (30 days) to requests from the health department.  The health department can invite registered providers to initiate data exchange at whatever pace is practical, and neither party “gets hurt.”

5. Stage 3 will likely move beyond surveillance to improving preventive care delivery.  For example, immunization information systems (which by Stage 3 will be bulging with information submitted by hundreds of thousands of healthcare providers) will likely be able to alert professions to immunizations patients lack, using the EHR during the context of care.

It may be a tough slog now, but there’s much to gain at the far end!

Fortunately, a Stage 2 Task Force of affected public health associations has formed under the leadership of the Joint Public Health Informatics Task Force, the Centers for Disease Control and Prevention (CDC), and the Office of the National Coordinator for Health Information Technology (ONC).  It will soon be issuing fact sheets and other tools, which will likely be distributed at the NACCHO ePublic Health Blog among other modalities.



Dear NPR: There IS a treatment for that diagnosis: electronic health records and immunizations

NPR’s All Things Considered yesterday described “growing pains” in health information technology (HIT) by saying many doctors in Colorado had to enter immunization records twice: first into their Electronic Health Record (EHR) system, and then into the state’s immunization registry.   According to the story, many doctors fail to do both

In fact, immunization registries, the Centers for Disease Control and Prevention, the HHS Office of the National Coordinator for HIT, and the Centers for Medicare and Medicaid Services (CMS) have worked together to implement solutions for this problem.*  The federal EHR Incentive Program (better known as “Meaningful Use”) includes an objective for EHR systems to upload shot records into immunization registries, eliminating the “double entry” problem.  The Colorado registry has implemented the necessary standards, and instructions for doing so are published on the same website cited in the NPR story.

This process is still not simple.  But the needed standardization is further improved in Stage 2 of Meaningful Use, scheduled to begin in October 2013.  And in October 2015 federally-certified EHRs could be required to download immunization records and alerts for clinicians about which vaccines a patient lacks.   Such automated data and reminders are needed to accelerate the completeness of childhood immunization which remains subpar.

I appreciate NPR’s attention to this challenging issue.  But while various difficulties affect the transition to electronic health records, NPR inadvertently selected a success story to illustrate the problems.

*Full disclosure: I was among those involved in this collaboration.