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Has ONC Assumed Too Much about Interoperability for MACRA?

Responses to an ONC RFI on measuring interoperability for MACRA poke holes in the federal agency's understanding of data exchange and use.

By Kyle Murphy, PhD

- The closing date for responding to an Office of the National Coordinator for Health Information Technology (ONC) request for information on measuring health IT interoperability for MACRA implementation came and went a week ago with several industry groups having weighed in on the pros and cons of its proposed methodology.

ONC interoperability for MACRA

Here's a recap of the main issues raised by these handful of responses.

To set the table, ONC published the RFI in April seeking feedback across three areas: measurement population and key component of interoperability to be measured; current data sources and potential metrics; and others sources of data and metrics for consideration to broaden interoperability measurement.

The importance of meaningful exchange

In its response to the RFI, the American Medical Association was joined by 36 medical societies in expressing doubts over the influence of meaningful use requirements on MACRA implementation under the Merit-based Incentive Payment System and Alternative Payment Models.

READ MORE: Slavitt: CMS Already Mulling Changes to MACRA Start Date

"Despite claims by many health IT vendors that their products are interoperable, the vast majority only exchange static documents in a manner that satisfies minimum Meaningful Use (MU) requirements," the letter stated.

"Many in health care view this level of exchange as little more than digital faxing," they continued. "We are therefore concerned that both the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator (ONC) are misinterpreting the current use of health IT as a benchmark for successful interoperability."

The 37 organizations were particularly adamant that meaningful use has demonstrated a preference for the number of documents exchanged rather than the usefulness of the data shared.

"These measures are a poor metric for interoperability, being too focused on the quantity of information moved and not the relevance of these exchanges or the underlying business case for transmitting data," they argued. "Greater exchange of patient data does not mean that we are achieving interoperability and better coordinated care. For medical professionals and patients alike, interoperability means the usefulness, timeliness, correctness, and completeness of data, as well as the ease and cost of information access."

Understanding the capabilities of current health IT

READ MORE: Health IT Interoperability in Stage 3 Meaningful Use

For its part, the American Hospital Association worried that ONC was jumping in the gun in not calling for an assessment of current health IT infrastructure and its ability to support widespread interoperability.

"The AHA recommends that ONC expand its scope of measurement beyond just the exchange and use of electronic health information to include whether we have the standards, technology and infrastructure needed to support these goals," argued Ashley Thompson, Senior Vice President of Public Policy Analysis and Development.

"In the RFI, ONC proposes to measure 'exchange' and 'use' of electronic health information," she explained. "It does not, however, seek input on how to assess whether we have the correct infrastructure to support exchange."

The recommendation suggests that that assessment will reveal limitations in health IT infrastructure that could prove to be stumbling blocks moving forward if not addressed straightaway.

Connecting interoperability, health information exchange

READ MORE: ONC Addresses MACRA Health Data Interoperability, HIE Measures

For DirectTrust, the main problem with the ONC plan for measuring interoperability for MACRA hinged on the federal agency's lack of acknowledgment of how interoperability is replacing outdated methods of data exchange.

 “The interoperability of electronic exchange of clinical information is a relatively new and highly innovative phenomenon in an industry historically dependent on fax, mail and courier services for transports of most clinical information,” President & CEO David Kibbe said in a letter to ONC. “Additionally, the infrastructure standards that make it possible for the electronic exchange are also relatively new and are unfamiliar to many providers.”

Without a baseline for understanding interoperability and health information exchange, ONC won't be able to adequately measure interoperability for MACRA, the DirectTrust letter stated. Additionally, the organization called on the federal agency to consider interoperability from the perspective of non-meaningful users.

“It is important to measure activity by any and all exchange partners, notwithstanding that ONC plans to assess interoperability primarily among ‘meaningful EHR users,’” Kibbe noted. “The reason for our preference is that there are significant numbers of exchange partners outside the population of providers using certified EHR technology, for example, home health agencies and social service agencies.”

Patient access to health data

Both the Healthcare Information and Management System Society (HIMSS) and the Personal Connected Health Alliance (PCHA) have voiced concerns about the lack of patient-centric interoperability measurement in ONC's proposed methodology.

“We observed that the patient perspective, and their ability to access their health information, is missed in this definition and should be considered in any metrics that assess interoperability,” they said in joint letter to ONC. “In our healthcare system’s continued shift to a value-based payment system, patients and the care they receive should be at the forefront and fully considered in assessing overall interoperability and health information exchange.”

Additionally, the pair requested ONC to consider the volumes of patient data maintained by health information exchanges (HIEs) and the lessons learned by these organizations in working to move clinical health data between providers and patients.

Care coordination as a top priority

For family practitioners, the value of interoperability depends on whether it improves care coordination between providers. This according to the American Academy of Family Physicians.

"The AAFP recommends that measuring actual progress toward interoperability across disparate systems and across clinicians for the purpose of care coordination should receive highest prioritization among measures," AAFP Board Chair Robert Wergin, MD, stated in a comment letter. "Again, administrative burden must be avoided to allow clinicians to focus their time on coordinating care rather than measuring the level of progress toward interoperability in care coordination."

Similar to the other responses to the ONC RFI, AAFP found the proposed reliance on meaningful use requirements and data as providing too limited a view of interoperability across the care continuum.

"For the purpose of continuity of care, care coordination, and the standard of care for any given care encounter, physicians and healthcare providers who are meaningful EHR attesters must exchange information with non-meaningful users who have not yet attested to Meaningful Use, MACRA, the Merit-based Incentive Payment System (MIPS) or an Alternative Payment Model (APM)," added Wergin.

"For this reason, it does not make sense to limit the focus of measurement to only those who are meaningful EHR users," he continued. "A calculated measurement of the achieved percentage of interoperability across the U.S. which does not include many long-term care facilities that are not yet meaningful EHR users does not reflect an accurate view of the status of interoperability within the health care ecosystem."

Now the entire healthcare industry must wait on ONC to consider and respond to their complaints and recommendations.



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