Wednesday, December 31, 2014

[UPDATED] Unique Patient Identifiers and Congressional Appropriations

Unfortunately, I have discovered that the prohibition is still in effect. 

The language is slightly different than I am used to searching for but is included in the legislation HERE and copied below:
Sec. 510. None of the funds made available in this Act may be used to promulgate or adopt any final standard under section 1173(b) of the Social Security Act providing for, or providing for the assignment of, a unique health identifier for an individual (except in an individual's capacity as an employer or a health care provider), until legislation is enacted specifically approving the standard.
In March 2013 I submitted a petition to the White House suggesting that the President should ask Congress to no longer prohibit HHS from establishing standards for a unique patient identifier. Sadly, it did not get the required number of signatories (and could have been just ignored in any event) and is now removed from the WhiteHouse site, but the issue now suddenly seems to have been resolved, at least for the time being. 

In 1993 under President Clinton's health plan, the government would have issued "health security cards" to all Americans certifying their right to medical care, and the plans for a unique patient identifier were put in place. While the health reform did not make it into law at that time in 1996 Congress passed the Health Insurance Portability and Accountability Act of 1996 (HIPAA) [Public Law 104-191].  HIPAA included administrative simplification provisions that required HHS to “adopt national standards for electronic health care transactions” and “a standard unique health identifier for each individual, employer, health plan, and health care provider for use in the health care system” [PL 104-191]. HHS has since adopted unique identifiers for employers, health care providers, and is now in the process of adopting a unique health plan identifier, but has not adopted a standard unique identifier for individuals. 

On October 21, 1998, the 105th Congress passed Public Law 105-277 (an omnibus appropriations act for fiscal year 1999) that prohibited HHS from spending any funds to “promulgate or adopt any final standard…providing for, or providing for the assignment of, a unique health identifier for an individual…until legislation is enacted specifically approving the standard [Title V, Section 516 of PL 105-277].” 

For the past 15 years, despite calls from experts at RAND Corporation and the Healthcare Information and Management Systems Society (HIMSS), identifying the potential administrative cost savings and safety benefits associated with a unique patient identifier, Congress has maintained this prohibition. It appears there is no such prohibition in the Continuing Resolution Omnibus Appropriations Bill recently signed into law. (hat tip to Carl Bergman at EHRSelector)

While a unique patient identifier is no silver bullet it seems prudent for Congress to permit HHS to pursue its implementation, especially if such an identifier could increase administrative efficiencies and prevent medical errors due to incorrectly linked medical records. 

Wednesday, December 3, 2014

Health IT Sections in Proposed Rule to Update the Medicare Shared Savings Program

On December 1, 2014, CMS released an NPRM updating policies under the Medicare Shared Savings Program (MSSP). The proposed rule outlines proposed changes and seeks feedback in key program areas, including some health IT components. Comments are due February 6, 2015. The proposed rule is available here. The sections dealing with health IT are below.

8. Required Process to Coordinate Care

a. Overview

Section 1899(b)(2)(G) of the Act requires an ACO to "define processes to … coordinate care, such as through the use of telehealth, remote patient monitoring, and other such enabling technologies." In the November 2011 final rule (76 FR 67829 through 67830), we established requirements under § 425.112(b)(4) that ACOs define their care coordination processes across and among primary care physicians, specialists, and acute and postacute providers. As part of this requirement, an ACO must define its methods and processes to coordinate care throughout an episode of care and during its transitions. In its application to participate in the Shared Savings Program, the ACO must submit a description of its individualized care program, along with a sample care plan, and explain how this program is used to promote improved outcomes for, at a minimum, its high-risk and multiple chronic condition patients. In addition, an ACO’s application must describe target populations that would benefit from individualized care plans.

In developing these policies for the November 2011 final rule (76 FR 67819), we received comments acknowledging that requiring ACOs to define processes to promote coordination of care is vital to the success of the Shared Savings Program. Commenters stressed the importance of health information exchanges in coordination of care activities and recommended that CMS allow ACOs the flexibility to use any standards-based electronic care coordination tools that meet their needs. Other commenters suggested that the proposed rule anticipated a level of functional health information exchange and technology adoption that may be too aggressive.

As stated in § 425.204(c)(1)(ii), applicants to the Shared Savings Program must provide a description, or documents sufficient to describe, how the ACO will implement the required processes and patient-centeredness criteria under § 425.112, including descriptions of the remedial processes and penalties (including the potential for expulsion) that will apply if an ACO participant or an ACO provider/supplier fails to comply with and implement these processes. Under § 425.112(b), an ACO must establish processes to accomplish the following: promote evidence-based medicine; promote patient engagement; develop an infrastructure to internally report on quality and cost metrics required for monitoring and feedback; and coordinate care across and among primary care physicians, specialists and acute and postacute providers and suppliers.

In addition to the processes described previously, we believe it is important for applicants to explain how they will develop the health information technology tools and infrastructure to accomplish care coordination across and among physicians and providers Adoption of health information technology is important for supporting care coordination by ACO participants and other providers outside the ACO in the following ways: secure, private sharing of patient information; reporting on quality data and aggregating data across providers and sites to track quality measures; and deploying clinical decision support tools that provide access to alerts and evidence based-guidelines. As ACOs establish more mature processes for risk management, information technology infrastructure allows ACOs and providers to conduct robust financial management of beneficiary populations, deliver cost and quality feedback reporting to individual providers, and streamline the administration of risk based contracts across multiple payers. We believe that requiring ACOs to address health information technology infrastructure in their application to the Shared Savings program would support more careful planning and increased focus on this issue.

b. Accelerating Health Information Technology

HHS believes all patients, their families, and their healthcare providers should have consistent and timely access to their health information in a standardized format that can be securely exchanged between the patient, providers, and others involved in the patient’s care. (HHS August 2013 Statement, “Principles and Strategies for Accelerating Health Information Exchange”) HHS is committed to accelerating health information exchange (HIE) through the use of EHRs and other types of health information technology (HIT) across the broader care continuum through a number of initiatives including: (1) alignment of incentives and payment adjustments to encourage provider adoption and optimization of HIT and HIE services through Medicare and Medicaid payment policies; (2) adoption of common standards and certification requirements for interoperable HIT; (3) support for privacy and security of patient information across all HIE-focused initiatives; and (4) governance of health information networks. These initiatives are designed to encourage HIE among health care providers, including professionals and hospitals eligible for the Medicare and Medicaid EHR Incentive Programs and those who are not eligible for the EHR Incentive programs as well as those providers that are participating in the Medicare Shared Savings Program as an ACO and those that are not, and are designed to improve care delivery and coordination across the entire care continuum. For example, the Transition of Care Measure #2 in Stage 2 of the Medicare and Medicaid EHR Incentive Programs requires HIE to share summary records for at least 10 percent of care transitions.

We believe that HIE and the use of certified EHRs can effectively and efficiently help ACOs and participating providers improve internal care delivery practices, support management of patient care across the continuum, and support the reporting of electronically specified clinical quality measures (eCQMs).

c. Proposed Revisions

We continue to believe that ACOs should coordinate care between all types of providers and across all services, and that the secure, electronic exchange of health information across all providers in a community is of the utmost importance for both effective care coordination activities and the success of the Shared Savings Program. We understand that ACOs will differ in their ability to adopt the appropriate health information exchange technologies, but we continue to underscore the importance of robust health information exchange tools in effective care coordination.

ACOs have reported how important access to real time data is for providers to improve care coordination across all sites of care, including outpatient, acute, and postacute sites of care. We believe that providers across the continuum of care are essential partners to physicians in the management of patient care. ACOs participating in the program indicate that they are actively developing the necessary infrastructure and have been encouraging the use of technologies that enable real time data sharing among and between sites of care. We believe having a process and plan in place to coordinate a beneficiary’s care by electronically sharing health information improves care, and that this helps all clinicians involved in the care of a patient to securely access the necessary health information in a timely manner. It also can also be used to engage beneficiaries in their own care. We further believe that Shared Savings Program applicants should provide, as part of the application, their plans for improving care coordination by developing, encouraging, and using enabling technologies and electronic health records to make health information electronically available to all practitioners involved in a beneficiary’s care.

Therefore, we propose to add a new requirement to the eligibility requirements under §425.112(b)(4)(ii)(C) which would require an ACO to describe in its application how it will encourage and promote the use of enabling technologies for improving care coordination for beneficiaries. Such enabling technologies and services may include electronic health records and other health IT tools (such as population health management and data aggregation and analytic tools), telehealth services (including remote patient monitoring), health information exchange services, or other electronic tools to engage patients in their care. We also propose to add a new provision at § 425.112(b)(4)(ii)(D) to require the applicant to describe how the ACO intends to partner with long-term and postacute care providers to improve care coordination for the ACO’s assigned beneficiaries.

Finally, we propose to add a provision under § 425.112(b)(4)(ii)(E) to require that an ACO define and submit major milestones or performance targets it will use in each performance year to assess the progress of its ACO participants in implementing the elements required under § 425.112(b)(4). For instance, providers would be required to submit milestones and targets such as: projected dates for implementation of an electronic quality reporting infrastructure for participants; the number of providers expected to be connected to health information exchange services by year; or the projected dates for implementing elements of their care coordination approach, such as alert notifications on emergency department and hospital visits or e-care plan tools for virtual care teams. We believe this information would allow us to better understand and support ACOs’ plans to put into place the systems and processes needed to deliver high quality care to beneficiaries.

We also note that ACOs have flexibility to use telehealth services as they deem appropriate for their efforts to improve care and avoid unnecessary costs. Some ACOs have already reported that they are actively using telehealth services to improve care for their beneficiaries. We welcome information from ACOs and other stakeholders about the use of such technologies. We seek comment on the specific services and functions of this technology that might be appropriately adopted by ACOs. For example, does the use of telehealth services and other technologies necessitate any additional protections for beneficiaries? Are these technologies necessary for care coordination or could other methods be used for care coordination? If a particular technology is necessary, under what circumstances?