Wednesday, November 20, 2013

Fine Tuning the National Healthcare IT Timeline

I've recently written about healthcare.gov and the lesson that going live too soon creates a very unpleasant memory.

As I work with healthcare leaders in Boston, in New England, and throughout the country, I'm seeing signs that well resourced medical centers will struggle with Meaningful Use stage 2 attestation, ICD-10 go live, HIPAA Omnibus Rule readiness, and Accountable Care Act implementation, all of which have 2013-2014 deadlines.

People are working hard.   Priority setting is appropriate.   Funding is available.

The problem is that the scope is too big and the timeline is too short.

What are the risks?

Because of the complexity of the Meaningful Use stage 2 certification process, many stage 1 certified products have not yet been certified for stage 2.   Those that are stage 2 certified have only been recently introduced into the marketplace, making upgrades, training, testing, and full implementation before July 1, 2014 (the beginning of the last reporting period for hospitals which attested to stage 1 in 2011 and 2012) very challenging.   I believe that we could see hundreds of hospitals fail to attest to Meaningful Use stage 2 by the current deadline, despite their best efforts.

We learned from healthcare.gov that end to end testing with a full user load and complete data set is important to validate the robustness of an application.   ICD-10 go live for every provider and most payers (other than Workman's Comp) is 11 months away.    Does CMS have time for a full end to end test of all functionality with its trading partners?   I am concerned that not enough time is available.    Will most payers and providers be ready to process transactions on October 1, 2014?  Maybe.   Will new documentation systems, clinical documentation improvement applications, and computer assisted coding to ensure auditable linkage between the clinical record and the highly granular ICD-10 billing data be in place?  Doubtful.    Will RAC audits discover that not enough time was available for training, education, testing, innovation, and workflow redesign?  Certainly.    The risk of a premature ICD-10 go live will be the disruption of the entire healthcare revenue cycle in the US.   The consequences of a delay in enforcing ICD-10 use are minimal.

ONC federal advisory committees are taking testimony from multiple stakeholders regarding the technology and policy readiness of provisions in the HIPAA Omnibus rule such as the Accounting of Disclosures and private pay redaction requirements.    It's very clear that more time and more research is needed before these elements of the law can be enforced.

The Affordable Care Act has many provisions including a move from fee for service to reimbursement based on quality. Quality measures were to be automatically submitted using the QRDA standard.  On November 5, CMS backtracked and announced that they would not accept the QRDA formats and all reporting for January 2014 would revert back to a manual web upload process called GPRO.   It is clear that CMS is not ready to move forward with ACA implementation on the original planned timelines.

So what should we do to fine tune the national healthcare IT timeline?

Meaningful Use Stage 2 attestation timelines should be extended by 6 months to enable recently certified products to be fully implemented in a safe and thoughtful way.    90 day reporting periods for hospitals begin October 1, 2013 and for eligible professionals begin on January 1, 2014.  Attestation must be completed within one year.  Extending attestation to 18 months will give us time to implement new software upgrades properly.

ICD-10 enforcement deadlines should be extended by 6 months to enable additional testing and workflow redesign.  The October 1, 2014 deadline may work for some providers and payers. Transaction flow can begin if systems are functional.   However, a 6 month extension will enable providers and payers to revise and improve systems before a mandatory full cutover.   We need to do this to avoid another healthcare.gov situation.

The Accounting of Disclosures and private pay redaction aspects of the HIPAA Omnibus rule should be delayed until pilot implementations can be studied and lessons learned broadly shared, likely a year.

Affordable Care Act implementation should await for maturity in the tools needed to support care management and quality reporting, likely another year.

All of these projects can be done and are reasonable components of national efforts to improve quality, safety, and efficiency.

However, the well meaning people who devised the policy principles did not take into account the operational requirements to do all this work simultaneously.   We should keep moving forward on these goals, but need to adjust the pace.    We all want to finish the race and not collapse before the finish line.

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