- As originally planned, eligible professionals and hospitals would to move from EHR adoption and data capture to advanced EHR use an health information exchange. While the meaningful use timeline has changed considerably with Stage 3 Meaningful Use beginning in 2018 (rather than 2016 as designed), the emphasis on health IT interoperability and health data exchange has not.
Since the publishing of the final rule for Stage 3 Meaningful Use and modifications to meaningful use requirements in previous stages, the Centers for Medicare & Medicaid Services issued a proposed rule for MACRA implementation that removes Medicare providers, known as eligible clinicians, from the EHR Incentive Programs. However, Medicare hospitals still remain subject to payment adjustments for failing to demonstrate meaningful use.
Additionally, the advancing care information performance category under the Merit-based Incentive Payment System requires eligible clinicians to meet meaningful requirements, albeit under a different name.
With that in mind, let's review the impact proposals for Stage 3 Meaningful Use will have directly on health IT interoperability.
Setting a course for HIT interoperability
The CMS final rule for Stage 3 Meaningful Use sets as its target the establishment of an interoperable health IT infrastructure across the country.
Across the eight categories of objectives, the federal agency has identified three activities that the final stage of the program will rely on to promote healthcare interoperability:
- Provider to provider exchange through the transmission of an electronic summary of care document;
- Provider to patient exchange through the provision of electronic access to view, download, or transmit health information; and
- Provider to public health agency exchange through the public health reporting objectives.
According to the final rule, CMS intends to rely heavily on the Office of the National Coordinator for Health Information Technology and its program for certified EHR and health IT systems.
"The program leverages the ONC HIT Certification Program and the associated editions of certification criteria to ensure that eligible providers possess health IT that conforms with standards and the requirements for the capture and exchange of certain data in a structured format," it states. "This improves interoperability by ensuring that data within one system can be received and used by the recipient system."
In describing the role of health IT interoperability in Stage 3 Meaningful Use, CMS notes that four of the eight requirements for this phase of the program "are clearly focused on the electronic exchange of health information through interoperable systems."
Here they are:
- Patient Electronic Access
- Coordination of Care through Patient Engagement
- Health Information Exchange
- Public Health and Clinical Data Registry Reporting
"Each of these objectives involves the capture of structured data using a standard and the transmission of that data in a standardized format that can be sent, received, and incorporated electronically," CMS explains in the final rule. "These objectives build on the transmission standards established in prior rules by incorporating receipt standards and consumption requirements for HIE. We also proposed to expand the technology functions that may be used for transmission including a wider range of options, such as application-program interface (API) functionality."
The emphasis is clearly on advanced EHR use and sharing rather than data capture and entry.
The federal agency also notes that two other Stage 3 Meaningful Use requirements — computerized physician order entry (CPOE) and electronic prescribing — have bearing on promoting "the interoperable exchange of health information through the process of creating and transmitting prescriptions, medication orders, laboratory order, and diagnostic imaging orders using standards established by CEHRT for that purpose."
A new role for API use in information sharing
As part of the Stage 3 Meaningful Use objective for patient access, CMS includes the use of application programming interfaces (APIs) as a means of enabling patients with the ability to view, download, or transmit their health information and patient-specific resources " using any application of their choice that is configured to meet the technical specifications of the API in the provider's CEHRT."
CMS makes clear that the onus is on providers to make health data accessible and not on provide to demonstrate that the patient has done so. "If this information is provided to the patient in a clear and actionable manner, the provider may count the patient for this objective," the rule states.
The Stage 3 rule also contains an explanation as to how APIs will differently impact providers and patients:
From the provider perspective, an API could complement a specific provider “branded” patient portal or could also potentially make one unnecessary if patients were able to use software applications designed to interact with an API that could support their ability to view, download, and transmit their health information to a third party.
From the patient perspective, an API enabled by a provider will empower the patient to receive information from their provider in the manner that is most valuable to the patient. Patients could collect their health information from multiple providers and potentially incorporate all of their health information into a single portal, application, program, or other software. Such a solution may be offered on a state, local, or regional basis, for instance, through a health information exchange, or through another commercial vendor. In addition, we recognize that a large number of patients consult with and rely on trusted family members and other caregivers to help coordinate care, understand health information, and make decisions. For this reason, we proposed the inclusion of patient-authorized representatives within the measures.
Here are specific measures for Patient Electronic Access to Health Information.
Under Coordination of Care Through Patient Engagement, meaningful users are required to use certified EHR technology (CEHRT) to engage 5 percent on patients and their care givers in 2017 and more than 10 percent in 2018, with an emphasis on moving information to a third party via API use supported by the provider's EHR system, as part of the first measure.
The second measure requires meaningful use participants to send and respond to secure messages for five percent of patients in 2017 and more than 25 percent in 2018.
The third measure is all about the incorporation of patient-generated health data into CEHRT for more than five percent of patients.
The remaining objectives for health information exchange and public health reporting build on previous efforts by CMS to support health data exchange between providers and third parties either directly or indirectly (e.g., via health information exchanges) and place the responsibility for enabling information sharing on certified EHR vendors. Yet none represent a paradigm shift comparable with increased API use for increasing the fluidity of health data.