CMS Eyes Payment Incentives To Drive E-Health Information Exchange

An agency white paper on how HHS, CMS and the Office of the National Coordinator for Health Information Technology plan to accelerate health information exchange acknowledges a current lack of financial incentives to encourage exchange of data.

CMS is evaluating ways to provide payment incentives to promote health information exchange through greater interoperability of providers’ electronic health record systems, according to a white paper released Aug. 7.

The agency already rewards providers with higher Medicare or Medicaid payments for adopting electronic health records and demonstrating that they are using them in a meaningful way. However, one criticism of the program is that while providers may be adopting EHRs, the individual EHR systems in use often are not able to interact with each other to exchange patient information.

The white paper, titled “Principles and Strategy for Accelerating Health Information Exchange (HIE),” was co-issued by HHS, CMS and the Office of the National Coordinator for Health Information Technology (ONC). It notes that “gaps and challenges still remain for the widespread use of interoperable systems and HIE across providers, settings of care, consumers and patients, and payers. Both providers and their vendors do not yet have a business imperative to electronically share person-level health information across providers and settings of care that exceeds the cost of doing so.” Indeed, a recent report on the state of health IT identified financial concerns as a barrier to HIE (Also see "Questions On Financing Electronic Health Info Exchange Obscure Its Future, Report Says" - Pink Sheet, 11 Jul, 2013.). ONC also has previously identified cost as an ongoing issue (Also see "E-health Record Interoperability “Remains A Challenge” – HHS Report" - Pink Sheet, 28 Jun, 2013.).

Robust information exchange is seen as a cornerstone to overall health care reform efforts (Also see "Health IT The Linchpin To Health Care Reform – Bipartisan Policy Center" - Pink Sheet, 13 Jun, 2011.). And with that in place, it is expected to have the secondary benefit of aiding in drug development and other medical research by improving efficiency and lowering costs. Efforts already are underway to develop methods to use EHRs within clinical research (Also see "EHR4CR Building Protocol Assessment And Patient Recruitment Tools That Leverage EHRs" - Pink Sheet, 27 May, 2013.).

The white paper was released in part as a way to consolidate responses to a request for information on how interoperability and HIE can be accelerated (Also see "HHS Seeks Suggestions On Hastening E-Health Record Interoperability, Data Exchange" - Pink Sheet, 7 Mar, 2013.). It notes that a “significant” number of respondents to the request for information looked to CMS to be a catalyst through reimbursement policy.

During a same-day conference call to discuss the white paper, Farzad Mostashari, head of ONC, summed up the comments by describing them as “a signal that we understand that the Medicare and Medicaid EHR Incentive Programs and Health IT Certification Program are necessary but they are not sufficient to achieve the widespread interoperability and health information exchange needed for delivery and payment reform. We intend to look at all programs, policies [and] authorities. We recognize that on the business side that the traditional fee-for-service reimbursement and business practices are strong influences of provider behavior and we do not yet have a strong enough business imperative for health information exchange. To put it another way, we cannot have it be profitable to hoard patient information and unprofitable to share patient information.”

The EHR Incentive Program provides reimbursement bonuses to eligible providers and hospitals that demonstrate adoption of EHRs and adherence to meaningful use criteria established by ONC and codified in regulation by CMS. The program has recently come under fire by Republican members of Congress, who have called for a pause until interoperability and other issues are sorted out, most recently by a group of six senators (Also see "GOP Senators Call For “Reboot” Of E-Health Records Incentive Program" - Pink Sheet, 19 Apr, 2013.).

Mostashari recently testified against any delays before the Senate Finance Committee (Also see "Pausing E-Health Record Meaningful Use Incentives Would Stall Progress, HHS Official Says" - Pink Sheet, 17 Jul, 2013.). Representatives from the vendor and physician communities at a separate hearing suggested a pause could help allow for the government to get interoperability standards right (Also see "Vendors, Physicians Call For Delay In E-Health Record Meaningful Use Regs To Get Interoperability Right" - Pink Sheet, 24 Jul, 2013.). On Aug. 6, he announced that he would be stepping down as head of ONC in the fall.

Combine HIE With New Payment Models

“Many commenters recommended adding specific requirements for HIE in the new payment models” such as within regulations governing accountable care organizations, the white paper states. “The Health IT Policy Committee recommended in their comments that CMS require HIE in all advanced payment programs and Medicaid waivers.” The white paper also suggested that payment adjustments under the current fee-for-service model be incorporated to drive the business case for HIE and the overall use of EHRs.

“CMS is evaluating strategies that begin with incentives or rewards through value-based payment programs and with defining well-established types of HIE as part of quality standards related to reimbursement under Medicare and Medicaid,” the report states. “CMS is also leveraging its e-health strategic planning to align health care administrative and clinical standards across HHS in support of interoperability.” An example given is current coordination efforts to implement the ICD-10 reimbursement coding system across various HHS agencies, including the Health Resources and Services Administration, the Centers for Disease Control and Prevention, the Indian Health Service and the National Institutes of Health.

Another common theme among commenters was the need for a “clear definition of what information must be exchanged from provider to provider and a standard to support the electronic exchange of information (e.g. a longitudinal care summary record),” the white paper states. “Commenters recommended that HHS address standardization of data elements, including the alignment of clinical quality measurements and reporting requirements.”

Commenters also “raised concerns about barriers to using standardized electronic laboratory results including the cost of interfaces and the current trend toward creating preferred laboratories,” the report continued.

Strategies For Accelerating HIE

In the white paper, HHS said it is “committed to an incremental, yet comprehensive and strategic approach to accelerating different types of HIE in support of care coordination, quality improvement and value-based payment.”

It identified that a “critical part of enabling the secure flow of information across the system is advancing the adoption of HIT standards through voluntary certification of HIT and HIE products and services. CMS will consider various ways in which the voluntary certification of HIT and HIE products and services under the ONC HIT Certification Program could be aligned with Medicare and Medicaid payment policy, to the extent feasible and within the scope of applicable law.”

Other strategies HHS offered include the implementation of policies that encourage HIE incrementally and could evolve from incentive and reward structures to ultimately consider HIE a standard business practice; where possible, support state-led health care delivery and payment reform; accelerate the alignment and implementation of electronic clinical quality measures, electronic decision support interventions and electronic reporting mechanisms; and develop standards and policies to enable electronic management of consent and HIE among providers treating patients with sensitive health data, such as those with behavioral health conditions or HIV.