The 132,000-member ACP presented its comments in a letter to Dr. Farzad Mostashari, head of the Office of the National Coordinator for Health Information Technology at HHS, from Dr. Michael Zaroukian, chairman of the ACP's Medical Informatics Committee. Zaroukian is the chief medical information officer at Sparrow Health System, Lansing, Mich, and made Modern Healthcare's Top 25 Clinical Informaticists.
The ACP's “primary concern,” Zaroukian wrote, is that the policy committee's proposed Stage 3 requirements are “too ambitious for a single stage” and “may be overwhelming for vendors and resulting product may be unaffordable for providers.”
The ACP also called for changing what so far has been the simultaneous development of meaningful-use requirements by the CMS and the development of companion EHR testing and certification criteria by the ONC.
“As a general rule,” Zaroukian wrote, physicians and other so-called “eligible professionals” under the programs “should not be expected to demonstrate use of new functions until those functions have been implemented in systems and successfully tested in real-world settings.” Instead, EHR functions should be tested and certified through the ONC process “at least two years ahead of CMS incorporating them into 'core' measures for meaningful use,” he said.
The 47,000-member Texas Medical Society, as well as the ACP, asked Mostashari to consider adding flexibility to the EHR incentive program to accommodate those physicians whose vendors go out of business or stop supporting EHR systems that the physicians have already purchased.
Its comments and objections came in a letter to Mostashari from Dr. Joseph Schneider, chairman of the state society's ad hoc Committee on Health Information Technology. Schneider is chief medical information officer and medical director of clinical information at Baylor Health Care System.
“With over 1,200 certified EHRs, this will be a likely issue as the criteria become more difficult for smaller EHR companies, forcing them to either close or be sold to a larger company,” Schneider wrote on behalf of the Texans. His letter recommends that physicians stuck in this situation “should be permitted to meet only 90 days of meaningful use during two transitional years, with appropriate documentation of making the transition to a new, certified EHR.”
The society cited the case of a Texas physician recently forced to switch EHRs “because a major vendor was sunsetting the product this physician had purchased only nine months before.” That developer's replacement “cost twice as much as the product initially purchased. Because of the price difference, the physician shopped around and decided to switch to another company. The cost for the physician to migrate only nine months of patient data was $12,000.”
The Texans said one way around the problem was to require vendors to apply XML tags to key data elements, those likely to be moved when a user switches from one EHR system to another.
“Vendors would also need to be able to receive and process data feeds with this standardized XML, storing it in their native tables,” the Texas letter said. This tagging process, already in limited use in the federally endorsed Continuity of Care Document/Continuity of Care Record electronic document transfer formats, could also assist with transfers to health information exchanges of meaningful-use data that are not part of the current CCD/CCR, such as data on smoking cessation counseling.
The ONC began pilot testing a meta-data tagging scheme in 2011 following a recommendation by the President's Council of Advisors on Science and Technology in late 2010 calling for the use of such tags to improve interoperability.
The data tags also could technologically enable patients to provide or withhold consent for the sharing of the more sensitive elements of their healthcare information as a means to protect their privacy.
In a telephone interview, Schneider said he is asking the ONC to carve out a category of healthcare data—medications or allergies for starters—and require as a condition of testing and certification for the meaningful-use program that EHR developers affix meta-data tags those targeted elements.
“We've got it in the CCD now,” Schneider said. “Let's consciously develop a program, and it's going to take Farzad to do this, in the next two years we're going to work on the transfer of medication administration, so we throw all our energies into that. Then, when two years are up, we're going to focus on family history and we do that.”
Schneider said tagging all healthcare data, as recommended by the PCAST, is a “monumental” task, “so, piece by piece you do it. It's going to take a decade at least.” For Stage 3, “we are closest, probably say, with meds and allergies, where the CCD has made us closer to being able to do this. So, let's start with meds and allergies.”
HIMSS proposed a major shift in rule making for Stage 3, asking Mostashari to move “toward a less prescriptive model that focuses on encouraging and assisting providers to take advantage of the substantial capabilities established … particularly in Stage 2.”
HIMSS also called for a slowing of the tempo of change. Specifically, it asked that CMS and ONC rulemakers schedule “at least 18 months” between the publication of the Stage 3 final rule and its implementation date.