In the last 48 hours, CMS released the final rules governing the first stage of MU and CCHIT launched its oncology workgroup. Things are heating up this July. The ARRA regulations for the incentive program for implementation of meaningful use of HIT were released as 3 documents. The one of greatest interest to oncologists is the Final Rule providing guidance to providers on what they neeed to do to qualfy for the incentive dollars ($44,000 over 5 years per eligible provider participating in Medicare). The other two regulatory documents address the requirements that EHR's will need to meet to be deemed certified for ARRA, and the process of testing and certifying such EHR systems.

Most of the 864 page document provides detailed responses to the thousands of public comments that were submited. Compared to my past experiences reading CMS responses, these are unusually clear, thoughtful and transparent (it helped that I spent 10 out of the last 36 hours in airplanes). In numerous situations, the CMS assessment has lead to CMS accepting the validity of the public comment, reversing itself and making it much easier for providers to qualify for the incentives offered. The ARRA program is unlike any other that CMS has taken on and CMS has approached this with an open vision. I see this as a sign that CMS and ONC realize that a transformative event such as this will only occur if there is buy in on the part of providers and that a cultural change like this cannot be regulated into existance with a blunt instrument.

For example, CMS has removed any requirements that would require a provider to manually go through paper records. Instead, the certified EHR must be able to generate the numerators, denominators and percentages, greatly easing the administrative burdens on practices to participate. The overall number of requirements has been greatly reduced. CMS accepted that the previous requirements were too rigid and self defeating in that too few providers would qualify. Consequently, the requirements have been split into 15 core measures that all must meet and 10 measures in a menu set where the provider may eliminate any 5 (as long as one remains that falls into the population and public health domain).

Another feature of ARRA is the requirement that providers report on quality measures chosen from a list of National Quality Forum (NQF) endorsed measures. This reporting feature is one of the more novel features of ARRA and will require much development before it becomes robust and meaningful. It has been a sore point for me that the NQF endorsed measures have no measures that are relevant to oncology practice. CMS indicates that given the short time line and the manner in which ARRA legislation was written, priority was given to NQF measures, but that in the future stages of MU, speciality organizations will be consulted. I hope this means ASCO!

However, CMS did reduce the required quality measures to six; three core measures and three discretionary measures. Furthermore, they eliminated the proposed requirement that an oncologist must use the three oncology NQF measures, one of which was not likely to apply to most medical oncologists (not ordering bone scans in favorable prognosis prostate cancer patients folowing up after surgical or radiation therapy of early stage disease). More important, CMS clarified that the only objective is demonstration that providers and systems report on these measure, not that they exceed a performance threshold. "Thus, the clinical quality measure requirement for 2011 and beginning in 2012 is a reporting requirement and not a requirement to meet any particular performance standard for the clinical quality measure, or to in all cases have patients that fall within the denominator of the measure". In other words, even if no such patients exist in a practice, the act of reporting that qualifies.

The second big event of the week involves the Commission for Certification of HIT (CCHIT), which has two roles to play in this. First, CCHIT has submitted its application (500 pages!) to become a certifying body of EHRs under the temporary program that was set up for the first year of ARRA. Earlier this year CCHIT performed a gap analysis for several dozen systems that had previously been certified by CCHIT under its original comprehensive certification program that predates ARRA. It is thought that those systems will be among the first to achieve ARRA certification once CMS determines the certifying bodies, which CMS expects to occur later this summer. The bad news for oncologists is that none of the oncology specific EHR systems have prior CCHIT comprehensive certification since that certification program was designed for large, complex enterprise systems used by hospitals and large medical groups.

The second CCHIT news was the launch of an oncology certification workgroup that met yesterday in Chicago. This group includes four medical oncologists, all members of the ASCO EHR WG; Drs. Larry Shulman, Nancy Sklarin and Robert Miller. I co-chair this WG with Dr. Pawan Goyal of Hewlet-Packard. The other 9 members represent radiation oncology, survivorship, the American Cancer Society, vendors, oncology nursing and the NCCCP program. Initially focusing on adult ambulatory oncology systems that are a part of enterprise EHRs, this group will also lay the groundwork to potentially develop certification for the stand alone ambulatory systems more commonly in use by oncologists.

Finally, later this month the Institute of Medicine and ONC will co host the first of a series of workshops to help lay a groundwork for a national electonic health infrastucture that will go far beyond EHRs and encompass all of the elements needed to support health care reform that achieves improved quality and affordability. More on that in a couple of weeks.

		Peter Yu 2 Aug 2010 5:56 PM
		That is certainly true for oncology. A provider could easily implement a system that qualifies for the MU incentives and yet have a system that does little to improve oncology related office functions. The short term gain of the incentive dollars will be insufficient compensation for the misery of acquiring a system that was not designed for medical oncology.

		vishal swamy 2 Aug 2010 5:26 PM
		Nice post. Seem true on most accounts but I also think that today medical practitioners are looking to avail of this federal incentive by trying to comply with the definition of meaningful use but at the same time EHR providers are looking at their own set of profits. This misunderstanding is mostly I believe as a result of wrong interpretation of the federal guidelines. The EHR providers need to look at these guidelines from the prospective of the practitioners who deal with different specialties. Each specialty EHR has its own set of challenges or requirements which I believe is overlooked by in most EHR vendors in an effort to merely follows federal guidelines. This is resulting in low usability to the practitioners, thus less ROI, finally redundancy of the EHR solution in place. I think ROI is very important factor that should be duly considered when look achieve a 'meaning use' out of a EHR solution. Though one may get vendors providing 'meaning use' at a lower cost, their ROI / savings through the use of their EHR might be pretty low when compared to costlier initial investment. Found a pretty useful ROI tool that is pretty customizable and easy to use. It also accounts for the different specialty EHR's too. Also the introduction of REC’s through the HITECH act. is a great way to avail of quality EHR solutions at competitive prices. The stiff competition among not only these REC’s but also among EHR vendors ( to become a preferred vendor of a given REC) will result in lot of positives to medical practioners. Looking the funding provided to the REC’s, the staggered grant allocation system also promises to be an unbiased way of allocating funds. It will also help in the concept of REC’s helping out each with their own unique business models. It can be one of the possible answers to the 'safe vendor challenge' as discussed by many critics.