January 11, 2010

IN THIS ISSUE

AMA Details Reasons For HR 3590 Support
Dr. Gray Appointed To Federal Payment And Access Commission
Detroit Congressional Hearing Looks At NFL Concussions, Dementia
WSU Med School Develops Less Invasive Skin Cancer Detection Technique
Oakwood Acquires Cardiac Monitors That Transmit Findings From Field
Feds Seek Feedback For Proposed EHR 'Meaningful Use' Definition
Nine Health Care Executives Respond To 'Meaningful Use' Definition
2009 Children's Holiday Party Contributors

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AMA Details Reasons For HR 3590 Support

(Editor’s note: the following is an open letter from the AMA to physicians explaining the organization’s support for the health reform bill currently being debated in congressional conference committee)

Health System Reform Bulletin - Dec. 23, 2009

Open letter/memo to physicians

From: J. James Rohack, MD, AMA president

Cecil B. Wilson, MD, AMA president-elect

Nancy H. Nielsen, MD, PhD, AMA immediate past president

Subject: AMA support for amended Senate health system reform bill

AMA decision to support H.R. 3590 as amended
After carefully evaluating the changes contained in the manager’s amendment filed by Senate Majority Leader Harry Reid (D-Nev.), the AMA Board of Trustees voted to support passage of H.R. 3590. In a letter of support to Sen. Reid, the AMA noted the need for additional changes in the final conference committee agreement that reconciles the differences between the House and Senate bills.

The AMA Board’s decision to support passage of the amended version of HR 3590 is consistent with the recommendation from the AMA Council on Legislation that the AMA support HR 3590 while seeking additional changes in the House-Senate conference committee agreement.

AMA success on previous changes in the Senate bill
Before Sen. Reid’s manager’s amendment was filed, the AMA succeeded in:

Blocking a proposed Medicare buy-in. The AMA mobilized media, grassroots and lobbying efforts that were a key factor in preventing the Medicare buy-in proposal for individuals ages 55-64.

Eliminating a proposal to impose a 5 percent cut in Medicare payments to physicians in the top tenth percentile of resource utilization. This provision was in the Senate Finance Committee package but not included in HR 3590 as a result of AMA advocacy.

Key modifications the AMA secured in the manager’s amendment
During the past few weeks, the AMA has been working seven days a week, around the clock, to modify provisions in the Senate health system reform bill. As a result of AMA lobbying, the manager’s amendment filed by Sen. Reid included the following changes:

Eliminating the budget neutrality adjustment for the primary care and rural surgery bonuses. Other physician services will not be cut to pay for these bonuses as result of this change.

Eliminating the proposed tax on elective cosmetic surgery and medical procedures. The concept of federal taxation of medical services must be nipped in the bud. Once started, federal taxes could easily expand to cover other elective medical services that are labeled “noncovered” or “not medically necessary.”

Eliminating the proposed Medicare/Medicaid enrollment fee for physicians. We did not want to allow a new physician tax or user fee to be authorized that could be ratcheted up in the future to pay for new government initiatives.

Modifying provisions to establish an independent comparative effectiveness research entity to secure greater representation for physicians on its governing board and to clarify that this entity cannot issue practice guidelines or make coverage, payment or policy recommendations

Further, by being engaged in the negotiation process, the AMA was able to review other proposals while the manager’s amendment was being drafted and successfully modified or prevented legislative language that would have been harmful to physician practices.

Key elements in H.R. 3590 that the AMA supports
Health insurance reforms to provide more choice and access to affordable coverage for individuals and small businesses (e.g. eliminate denials based on pre-existing conditions, discrimination based on health status and gender, annual and lifetime limits)

Advanceable, refundable tax credits, inversely related to income, for low-income individuals to purchase health insurance

Creation of health insurance exchanges to stimulate competition and offer more affordable choice

Additional federal funding to improve the Medicaid safety net

Coverage for prevention and wellness initiatives without co-payments or deductibles

Administrative simplification provisions to streamline, standardize and lower the cost of processing health insurance claims

No public plan option
The revised bill does not contain a public plan option and, as noted earlier, the AMA played a key role in blocking the Medicare buy-in proposal.

Medicare physician payment
The AMA urged the removal of a one-year patch to the Medicare physician payment formula in HR 3590 that would have provided a 0.5 percent increase in 2010 but would also have led to a 23 percent cut in 2011. Eliminating the one-year patch freed up funds to offset the cost of removing the provisions dealing with budget neutrality, the cosmetic surgery tax and the enrollment fee.

A separate Department of Defense (DOD) appropriations bill passed by the House and Senate averts a Jan. 1 cut of 21 percent. The DOD bill provides for a 60-day extension of the 2009 conversion factor.

Permanent repeal of the sustainable growth rate (SGR) formula is essential to the stability of the Medicare program and to the success of any health reform initiative. The Obama administration, the House leadership and the Senate leadership are committed to passage of a permanent repeal of the SGR before the current two-month extension of the 2009 conversion factor expires on March 1.

On Dec. 19, Sen. Reid stated that after the holidays he will renew efforts to pass a permanent repeal of the SGR. Sen. Max Baucus (D-Mont.) also recently reaffirmed his support for a permanent repeal of the SGR on the Senate floor.

Medical liability reform
The manager’s amendment included a provision offered by Sen. Tom Carper (D-Del.) that authorizes $50 million over five years for state demonstration programs for alternative medical liability reforms. This provision would allow for a broader array of demonstration projects than the provision in the House bill. It is similar in nature to the $25 million initiative that President Obama directed the Agency for Healthcare Research and Quality to implement. The grant application process for that initiative closes in late January.

The amended bill also includes a Government Accountability Office study to determine if quality and payment policies create potential new causes of action or legal liabilities for physicians.

During conference committee negotiations, the AMA will be working to maximize the opportunity for alternative medical liability reforms while protecting current state tort reform laws that are effective. The AMA will work to block potential new causes of action that may arise as a result of new federal health policies.

Outstanding concerns with HR 3590
The AMA was not able to solve all of its concerns with the manager’s amendment and will work vigorously during the House-Senate conference committee negotiations on the following issues:

Independent Payment Advisory Board
The AMA expressed opposition to the proposed Independent Payment Advisory Board in HR 3590. Physicians are already subject to a spending target under the Medicare physician payment formula. The proposed board would establish a new spending target that could subject physicians to multiple cuts in a given year. In addition, the Senate bill exempts hospitals and other providers from potential cuts in the first four years the board is in operation. The manager’s amendment also expanded the scope of the board and authorized it to make advisory, nonbinding recommendations for private payers.

Additional changes are needed to allow adjustments for legitimate increases in Medicare spending as well as to assure that there is adequate accountability, transparency and physician input for this new body.

Legislation passed by the House does not include an Independent Payment Advisory Board, and several key House members recently signed a letter opposing the creation of such a board.

Cost/quality adjuster
The AMA has been working to modify a proposal authored by Sen. Maria Cantwell (D-Wash.) that proposes to adjust and redistribute individual physician payments based on cost and quality outcomes beginning in 2015.

The AMA supports the concept of value-based payments. The challenge is that some policymakers want to implement new payment programs before proper measures and tools have been developed and tested. New payment methodologies must be based on scientific data that is accurate, valid and verifiable. The Cantwell proposal goes well beyond the existing state of the art. At this time, we do not have good cost and outcomes measures, and current risk adjustment and attribution methods at the individual physician level are woefully inadequate.

The Senate leadership has committed to working with the AMA during conference committee negotiations to modify the legislation to reflect the need for accurate, valid and verifiable data as the basis for any policy changes.

Medicare data release and quality improvement initiatives
The AMA was able to insert some important safeguards into a provision that would authorize the release of Medicare data that would be aggregated with private payment information to create public provider performance reports.

The AMA pressed Senate offices to be sure that the measures and data are accurate, valid and verifiable. In addition, physicians must be provided advance copies of information before it is publicly released and be given an opportunity to correct inaccurate information prior to the release of public reports.

HR 3590 as amended retains the provision that would impose penalties beginning in 2015 for physicians who do not participate in the Medicare physician quality reporting initiative (PQRI) program. The House bill would not impose any penalties on physicians for not participating in the PQRI program.

Physician-owned hospitals
For the past several years, the AMA has led the fight to block legislation to restrict physician ownership of hospitals. Physician-owned hospitals have received some of the highest quality ratings.

Unfortunately, provisions to ban new physician-owned hospitals are in both the House and Senate health reform bills. The Reid manger’s amendment does provide a modest time extension, from Feb. 1 to Aug. 1, 2010. The AMA will continue to advocate for legislative modifications in the conference agreement to protect existing physician-owned hospitals.

House-Senate conference negotiations
The AMA has made it clear to senior White House staff, the Senate leadership and the House leadership that its support for a House-Senate conference agreement is contingent upon:

Movement on a clear pathway for passage of legislation to permanently repeal the SGR by the end of February

Modifications of the proposed Independent Payment Advisory Board

Refinements of the quality improvement and Medicare data release provisions

No new major problematic provisions surfacing in conference
While there were some earlier reports about efforts to circumvent the House-Senate conference committee process, recent statements from the House leadership indicate that the House will not take the Senate bill as is or with minor changes. As noted earlier, the House bill does not include an Independent Payment Advisory Board, and 53 House members signed a letter objecting to that concept.

The AMA’s strategy of constructively working for changes at each stage of the process has put it in a position to have significant influence in the House-Senate conference committee negotiations. The AMA retains the ability to withhold support for a conference committee agreement if it fails to achieve our priority objectives.

We still have not seen the final bill that the president hopes to sign into law. The AMA will be actively engaged throughout the conference committee negotiations to positively influence the key issues for medicine.

Conclusion
The Senate bill is not perfect. But the current health care system isn’t perfect either. The pending health system reform legislation will achieve several of the essential elements for health system reform that we outlined last summer. We recognize there are some problems with pending provisions that must be corrected.

We are closer than ever to realizing a number of AMA goals, but we still have important work to do to secure additional changes in the final bill. With your help, input and support we can continue to advance health system reform policies that will benefit patients and physicians.

The AMA will provide you with regular updates on the House-Senate conference negotiations through the Health System Reform Bulletin, physician and patient grassroots alerts, the www.hsreform.org website and periodic conference calls.

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Dr. Gray Appointed To Federal Payment And Access Commission

The federal Government Accountability Office (GAO), today announced the appointment of 17 members to the new Medicaid and CHIP Payment and Access Commission (MACPAC), including Herman Gray, MD, MBA, president of Children’s Hospital of Michigan (CHM) and senior vice president of the Detroit Medical Center.

The official announcement will be published in the Federal Register.

“Many highly qualified individuals sought to serve on the Commission,” Dodaro said. “Those selected bring to MACPAC an impressive range of professional expertise and experience as well as geographic diversity and meet the specific requirements of the legislation.”

The Children’s Health Insurance Program Reauthorization Act of 2009 established MACPAC to review Medicaid and CHIP access and payment policies and to advise Congress on issues affecting Medicaid and CHIP. The Act directs the Comptroller General to appoint MACPAC’s members, with initial appointments to be made no later than January 1, 2010.

The terms of MACPAC commissioners are intended to be staggered, with the first set of appointments for terms of one, two, or three years. Commissioners may be appointed for subsequent three-year terms.

At CHM Dr. Gray served previously as pediatrics vice chief for education, pediatric residency program director, chief of staff and then chief operating officer. He also served as associate dean for graduate medical education (GME) and Vice President for GME at Wayne State University School of Medicine and the Detroit Medical Center, respectively. Dr. Gray has also served as the chief medical consultant for the Michigan Department of Public Health – Children’s Special Health Care Services and as Vice President and Medical Director of Clinical Affairs for Blue Care Network. During the 1980s he pursued private medical practice in Detroit. Dr. Gray serves on the Board of Trustees of the National Association of Children’s Hospitals and Related Institutions, the Board of Directors of the Child Health Corporation of America, and the American Hospital Association Section for Maternal and Child Health Governing Council. He received his medical degree from the University of Michigan in Ann Arbor, and an executive Master of Business Administration from the University of Tennessee.

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Detroit Congressional Hearing Looks At NFL Concussions, Dementia

Detroit and Congressman John Conyers played host to a congressional hearing on NFL football and dementia resulting from the repeated head trauma associated with the sport.

The hearing was attended by two members of Congress other than Conyers (Steve Cohen, D-Tenn., and Linda Sanchez, D-Cal.) and was a follow-up to a Oct. 28 hearing on the subject in Washington, DC.

The New York Times reported that Dr. Ira Carson, a Forest Hills, NY, neurologist and former co-chairman of the league’s committee on concussions, continued his insistence that there is insufficient evidence connecting concussions with dementia.

 “My position is that there is not enough valid, reliable or objective scientific evidence at present to determine whether or not repeat head impacts in professional football result in long-term brain damage,” Casson stated in a written statement before his appearance, reported the Times.

Other witnesses included the retired NFL player Kyle Turley, executives from two helmet manufacturers and representatives of the NCAA and youth football organizations, reported the Times.

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WSU Med School Develops Less Invasive Skin Cancer Detection Technique

When a patient with a suspicious skin growth visits a dermatologist, the physician has little choice but to perform a biopsy to determine whether the lesion is indeed malignant. That entails numbing the area, discomfort when the physician shaves off a portion of the lesion for testing and 10 to 14 days of anxiety while the patient awaits the test results.

Two researchers, one a dermatologist with the Wayne State University School of Medicine, have tested a method that shows promise in bypassing the current biopsy practice and providing immediate results. Their study indicated that high-frequency ultrasound with elastography measurement of skin can determine cancerous skin growths.

"Dermatologists tend to biopsy any lesions that seem visually suspicious for disease," said co-investigator Bahar Dasgeb, MD, a resident in the Department of Dermatology at the Wayne State University School of Medicine and the Pinkus Dermatopathology Lab in Monroe, Mich. "Consequently, many benign lesions are needlessly biopsied in order to avoid the risk of missing a potentially deadly melanoma."

According to the American Cancer Society, physicians diagnose more than 1 million cases of skin cancer annually in the United States. The most serious form of skin cancer – melanoma – is responsible for 68,720 of those cases, and killed approximately 11,590 people in 2009.

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Oakwood Acquires Cardiac Monitors That Transmit Findings From Field

Oakwood Hospital and Medical Center (OHMC) recently bought a number of cardiac monitors to assist emergency medical services (EMS) technicians in the field. These monitors enable EMS to transmit 12-lead electrocardiograms from a patient’s house, park, mall, or any other area, to the hospital.

If signs of a heart attack are visible, the 12-lead will be sent via e-mail to the emergency department and the catheterization (cath) lab from the field. This allows doctors to activate the cath lab much earlier. When the emergency department doctor confirms that the 12-lead in fact shows a heart attack, they will meet the ambulance, ensure patient stability and the patient will by-pass the emergency department and go directly to the cath lab with EMS.

“This is a great development for OHMC,” said Michael Gehab, MD, division president of OHMC. “The monitors reduce the door-to-balloon time of heart attack patients, saving more heart muscle and potentially saving the lives of many patients with significant blockages. We are proud to be working collaboratively with fire department providers and provide this much needed service to the community.”

The Dearborn Fire Department has already begun to use these monitors.

For more information, visit www.oakwood.org.  

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Feds Seek Feedback For Federal EHR 'Meaningful Use' Definition

The Centers for Medicare & Medicaid Services (CMS) last month announced a proposed rule to implement provisions of the American Recovery and Reinvestment Act of 2009 (Recovery Act) that provide incentive payments for the meaningful use of certified EHR technology. The Medicare EHR incentive program will provide incentive payments to eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) that are meaningful users of certified EHR technology. The Medicaid EHR incentive program will provide incentive payments to eligible professionals and hospitals for efforts to adopt, implement, or upgrade certified EHR technology or for meaningful use in the first year of their participation in the program and for demonstrating meaningful use during each of five subsequent years.

This fact sheet summarizes CMS’ proposed definition of meaningful use.

Meaningful Use – Policy Goals and Definition
Through the Medicare and Medicaid EHR incentive programs, CMS hopes to expand the meaningful use of certified EHR technology.  Certified EHR technology used in a meaningful way is one piece of a broader Health Information Technology infrastructure needed to reform the health care system and improve health care quality, efficiency, and patient safety. The Office of the National Coordinator for Health Information Technology (ONC) will be issuing a closely related interim final rule with comment period that specifies the Secretary’s adoption of an initial set of standards, implementation specifications, and certification criteria for EHRs. ONC will also issue a notice of proposed rulemaking related to the certification of health information technology.

CMS’ goal is for the definition of meaningful use to be consistent with applicable provisions of Medicare and Medicaid law while continually advancing the contributions certified EHR technology can make to improving health care quality, efficiency, and patient safety. To accomplish this, CMS’ proposed rule would phase in more robust criteria for demonstrating meaningful use in three stages.

Stage 1 Criteria for Meaningful Use
The proposed Stage 1 criteria for meaningful use focus on electronically capturing health information in a coded format, using that information to track key clinical conditions, communicating that information for care coordination purposes, and initiating the reporting of clinical quality measures and public health information.

The proposed criteria for meaningful use are based on a series of specific objectives, each of which is tied to a proposed measure that all EPs and hospitals must meet in order to demonstrate that they are meaningful users of certified EHR technology.

For Stage 1, which begins in 2011, CMS proposes 25 objectives/measures for EPs and 23 objectives/measures for eligible hospitals that must be met to be deemed a meaningful EHR user.

In 2011, all of the results for all objectives/measures, including clinical quality measures would be reported by EPs and hospitals to CMS, or for Medicaid EPs and hospitals to the states, through attestation.

In 2012, CMS proposes requiring the direct submission of clinical quality measures to CMS (or to the states for Medicaid EPs and hospitals) through certified EHR technology. CMS recognizes that for clinical quality reporting to become routine, the administrative burden of reporting must be reduced. By using certified EHR technology to report information on clinical quality measures electronically to a health information network, a state, CMS, or a registry, the burden on providers that are gathering the data and transmitting them will be greatly reduced. The burden of generating the necessary information for the provider to then use the information to improve health care quality, efficiency, and patient safety will also be reduced.

Development of Stage 1 Criteria for Meaningful Use
The Recovery Act created two new federal advisory committees, the Health Information Technology Policy Committee and the Health Information Technology Standards Committee. In addition to advising the National Coordinator on developing the standards and certification criteria for certified EHR technology, these committees provided recommendations on the criteria for defining and demonstrating meaningful use of certified EHR technology. On August 10, 2009, the HIT Policy Committee submitted to the National Coordinator its recommendations on the criteria for meaningful use, including a matrix of priorities, goals, objectives, and measures. This matrix served as the foundation from which CMS, in partnership with ONC, worked to develop its specific proposal for the Stage 1 criteria for meaningful use found in the proposed rule. The HIT Standards Committee focused its efforts on specific measures tied to meaningful use and on identifying the standards necessary to implement them.

Additional information on the federal advisory committees and their impact on meaningful use can be found at http://www.cms.hhs.gov/Recovery/11_HealthIT.asp.

Beyond the Stage 1 Criteria for Meaningful Use
The policy goals of meaningful use will be most fully realized by building on findings from Stage 1 and by making full use of the greater proliferation of certified EHR technology and supporting HIT infrastructure that will take place under Stage 1. CMS intends to propose through future rulemaking two additional stages of the criteria for meaningful use.

Stage 2 would expand upon the Stage 1 criteria in the areas of disease management, clinical decision support, medication management, support for patient access to their health information, transitions in care, quality measurement and research, and bi-directional communication with public health agencies. CMS may consider applying the criteria more broadly to both the inpatient and outpatient hospital settings.

Consistent with other provisions of Medicare and Medicaid, Stage 3 would focus on achieving improvements in quality, safety and efficiency, focusing on decision support for national high priority conditions, patient access to self management tools, access to comprehensive patient data, and improving population health outcomes.

Additional information can be found at www.cms.hhs.gov/Recovery.

CMS provides a 60-day comment period on the proposed rule.  The proposed rule may be viewed at http://www.cms.hhs.gov/Recovery/11_HealthIT.asp.

Source: CMS website

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Nine Health Care Leaders Respond To 'Meaningful Use' Definition

(Editor’s note: The following reaction to the ‘meaningful use’ announcement from CMS is published below with permission from HealthLeaders Media IT, a free weekly e-newsletter that features news, commentary and trends about healthcare technology. To view the original article on the HealthLeaders website, please link to: http://www.healthleadersmedia.com/content/TEC-244439/Nine-Healthcare-Executives-Respond-to-the-Meaningful-Use-Definition.html.)

CARRIE VAUGHAN, for HealthLeaders Media, January 5, 2010

The long-awaited definition of meaningful use is finally here. Just before the New Year, the Centers for Medicare & Medicaid Services and the Office of the National Coordinator released both the definition of "meaningful use" for electronic health records and the standards to improve the efficiency of health information technology.

Hospital and provider group organizations have already offered their criticism of the proposed regulations. Yesterday, my colleague Janice Simmons offered a good evaluation of the American Hospital Association, Medical Group Management Association, and the American Medical Association concerns.

I was curious what individual providers thought of the definition, so I asked physicians, chief information officers, and other industry leaders whether they thought the meaningful use bar was set too high or low, and what they thought was the most significant change to the HIT Policy Committee's recommendations, if any. Many executives are still delving into the 700+ page document, but here are their initial reactions.

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The ONC and CMS have set the bar at an appropriate level. While everyone does not agree with everything they are doing, it is very clear that the health IT agenda in the United States will be driven by the ONC agenda. There is considerably more health "reform" in the HITECH legislation than is likely to come out of the current healthcare reform debate going on in Washington. This legislation will likely prove to be the biggest and most transformational quality and safety initiative ever launched in this country. A huge national experiment is about to take place, and I am looking forward to being involved in it!

John L. Haughom, MD
Senior vice president, clinical and patient safety
PeaceHealth
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CMS and ONC have admitted they won't be ready to enforce the rules for 2011 and that answered the biggest question I had regarding how will I report and qualify for the first year. Other items that make the first year easier include relaxed quality measure reporting and the requirement to be ready for a health information exchange but not actually exchanging information. The cost calculation is somewhat low. It states that it should cost a hospital $5 million to meet the requirements, which is really low for most hospitals. The five clinical decision support rules were a surprise and need more definition. Overall, I think the document lifts a good deal of fog that blocked organizations from moving forward.

Jack Kowitt
Chief Information Officer
Parkland Hospital and Health System
Dallas
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Overall, the criteria are thoughtful and fair. I like that we are not stretching for the stars—100% compliance for [CPOE] for instance—which indicates that the ONC is listening to sites that are live with an EHR and still having problems getting everything working perfectly. Where we might struggle is in creating accurate denominators that include paper or non-EHR processes, because these are notoriously difficult to collect. For example, the denominator for order entry or ePrescribing seems to require that you keep track of all paper orders. This was never done in the past and is not tracked in our EHR. Therefore, it is a new process and we will have to figure out who/how/when this will be done.

Some providers will think the bar is too low. But when you examine the measures, it becomes clear that the low threshold will almost be immediately exceeded by the mere implementation of the functionality. If an organization is going to all the trouble of CPOE, it is hard to envision that they would stop at 10%.

Naturally, the requirements around HIE are the most daunting. I think the ONC is doing the right thing by including them in the requirements, if for no other reason than to continue to put pressure on communities to develop functioning HIEs that will meet the criteria. I don't think HIE would occur naturally otherwise as it is quite laborious and lacks an immediate ROI to make it attractive.

Richard Vaughn, MD
Corporate Vice President Clinical Decision Support and Medical Director, Project Beacon
SSM Health Care
St. Louis, MO
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We are extremely disappointed that CMS has decided to exclude critical access hospitals from the Medicaid (as opposed to Medicare) portion of the incentives. We are concerned that CAHs still don't have the all the information they need to understand what constitutes an "eligible EHR expense." The objectives have not significantly changed from the HIT Policy Committee's recommendations. The bar has been set much too high for small and rural facilities. The key question for all to consider is how one can set the same bar for providers at early stages of adoption and at advanced stages of adoption. The result of this single-bar strategy is that providers who already have EHRs—and therefore don't need assistance—will get the lion's share of the incentives. Disadvantaged providers at low stages of adoption who especially need the assistance will be much less likely to get help. CMS and ONC have structured the incentive program in a way that will dramatically expand the digital divide between our country's EHR haves and have-nots, large proportions of which are small and rural providers.

Louis Wenzlow
Director of Health Information Technology
Rural Wisconsin Health Cooperative
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This is the initial analysis of "meaningful use" by the National Rural HIT Coalition's rural hospital user group. This proposed rule builds on concerns we have about how CAHs are rewarded for EHR implementation under ARRA. Although CAHs are significantly behind other general hospitals, their EHR financial incentives are significantly lower than prospective payment system hospitals. CAH incentives require that they purchase rather than lease, meaning CAHs have less flexibility than the other hospitals. In developing their ARRA compliance strategies, CAHs (unlike PPS hospitals) depend on rule makers to articulate exactly what costs are eligible. This delay and resulting uncertainty will prevent many CAHs from reaching meaningful use. CAHs are extremely dependent on the speed with which the certification process takes place, but many applications don't have certification processes in place.

These barriers mean that CAHs must rely on CMS and ONC to issue instructions that are sensitive to the realities of community hospital EHR vendor models, the numerous systems that generally fall outside of the certified EHR vendor offerings, certification organization capabilities, and how all of this impacts CAHs' costs incurred.

Terry J. Hill
Executive Director
Rural Health Resource Center
Duluth, MN
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The proposed definition of "meaningful use" will result in the fulfillment of the policy priority of "improving quality, safety, efficiency and reducing health disparities." The proposed definition will also meet the five care goals of the HIT Policy Committee. The objectives in the Stage I criteria of meaningful use are reasonable and appropriate and should not represent a significant challenge for users of Certified EHRs. Southeast Texas Medical Associates is performing all of the measures of Stage I, II and III.

Even though there is a great deal of overlap in national quality measures, the Physician Quality Reporting Initiative and National Quality Forum clinical quality measure sets are too robust for a beginning effort. The extensive quality measure tracking and reporting requirements will result in many excellent groups either not participating, or not succeeding in their participation in the CMS program. A more circumscribed measurement group would be appropriate with gradual increasing of the breath of the requirement.

Caution must be used in the requirement for being able to report patient information electronically between practices, some with different EHRs and some without EHR capability. This interoperability is in development. The rules for participation in the CMS HIT incentive program must not discourage participation, but encourage it.

The promise of EHR and actually of "electronic patient management," is within our reach. The meaningful use requirement is a step in the right direction; it must proceed steadily but not so rapidly as to discourage participation.

James L. Holly, MD
CEO
Southeast Texas Medical Associates
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The issue of whether CMS is reaching too high really depends on the situation each organization faces. It would have been nice, if the standards addressed the different situations that organizations face rather than a one approach for all. It is also noteworthy that these tight standards are being issued at a time when hospitals face major cutbacks in funding at both the state and federal levels and therefore have little available funds to implement the changes these regulations were intended to achieve. This is particularly true for rural hospitals that will have to decide if they can really take on the risk of taking out loans to pay for system implementations when there is a high risk they will still not achieve "meaningful use".

Marc Gibbs
Chief Information Officer

Crouse Hospital
Syracuse, NY
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CMS wishes to use the same "meaningful use" definitions for both Medicare and Medicaid. However, each state must create its own administrative program (subject to approval) and can add other "meaningful use" measures. We think these two points will add challenges to reconciling both programs.

Hospitals may participate in both the Medicaid and Medicare programs if they qualify for each. In addition, those hospitals participating in both will not have to meet additional state (Medicaid) meaningful use measures if they meet Medicare's. Physicians, on the other hand, cannot participate in both, and instead would have a onetime option of switching from one program to another. At the very least, these disparities will cause confusion.

CMS did modify some of the objectives recommended by ONC's Policy Committee. Most notably, CMS rejected recording advanced directives. They also rejected the suggestion that providers report quality improvement and public reporting to patient registries.

CMS has chosen a three-stage approach: Stage I (2011-2012) emphasizing "electronically capturing health information in a coded format; using that information to track key clinical conditions and communicating that information for care coordination purposes"; Stage II (2013-2014) encouraging "the use of health IT for continuous quality improvement at the point of care and the exchange of information in the most structured format possible"; Stage III (2015) on "promoting improvements in quality, safety and efficiency, focusing on decision support for national high priority conditions, patient access to self management tools, access to comprehensive patient data and improving population health." Using this staged approach, CMS is proposing a flexible system that allows hospitals and physicians to start adopting over time, where those starting in later years would have to accelerate through the stages to catch up with earlier adopters in order to collect incentives. It's hard to know at this juncture how providers will navigate the many different potential paths to qualifying for incentives or which paths are the most efficient and effective.

Bruce Taffel, MD
Chief Medical Officer
Shared Health
Chattanooga, TN
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Carrie Vaughan is a senior editor with HealthLeaders magazine. She can be reached at cvaughan@healthleadersmedia.com.

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2009 Children's Holiday Party Contributors

The following is a list of contributors to the WCMS Foundation’s 24^th Annual Holiday Party for underprivileged children that took place Dec. 5 at the New Detroit Science Center. For more information, or to contribute, call (313) 874-1360 or visit www.wcmssm.org

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