The Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs—commonly known as meaningful use—have been credited with increasing adoption of EHRs among hospitals and ambulatory care providers. Long-term care, public health, mental and behavioral health, and ancillary service providers are not eligible for meaningful use incentives. Given finite public dollars, these exclusions were likely needed to enable sufficiently large incentives to motivate adoption in the selected groups.

Unfortunately, because these stakeholders were left out, they now lag substantially behind in adoption of EHRs and other clinical information technology (IT) systems. This is problematic because the sickest patients regularly bounce between eligible and ineligible providers, and their information therefore has to bounce between the electronic and paper worlds. The oft-used metaphor is a national road system in which only some of the roads are paved, creating a bumpy ride. When care transitions involve a patchwork of paper and electronic systems, a myriad of errors emerges, and there are limited opportunities for efficiency gains. The result is substantially less than optimal value from the public investment in EHRs under meaningful use.

The Office of the National Coordinator for Health IT (ONC) and the Centers for Medicare and Medicaid Services (CMS) have long recognized this challenge but understood that Congress was unlikely to authorize new funding to extend incentives to ineligible providers. Therefore, in late February 2016, CMS and ONC took action by making federal funding available at a 90 percent matching rate for state expenditures to promote health information exchange for providers ineligible for meaningful use incentives.

Although the funding had to fall within current regulatory goals that only include eligible providers, ineligible providers were targeted through a creative twist. A subset of meaningful use criteria involve electronic exchange of information between eligible and ineligible providers. Eligible providers that serve Medicaid recipients, and therefore participate in the Medicaid meaningful use program, can more easily meet meaningful use requirements if states fund efforts that enable ineligible providers to engage with them in electronic health information exchange (HIE). This approach falls squarely within current regulatory goals while making new money available to help ineligible providers avoid getting left behind in a paper world.

Challenges to Health Information Exchange between Eligible and Ineligible Providers

As states decide how to pursue this opportunity, there are some key challenges. First, adoption of clinical IT systems among ineligible providers is low, and existing systems have not undergone certification to ensure that they meet a minimum capability threshold and can create or receive standards-based care summaries. If ineligible providers do not have good core IT systems, there isn’t much to connect. Workarounds involve sending information to provider portals and making it available to view or download, but this approach falls well short of seamless bi-directional data exchange that would make information readily accessible and usable across the care continuum.

Second, not all states have a solid HIE foundation on which to build. Health information exchange capabilities vary greatly by state, and some have little in the way of infrastructure or services to which to connect ineligible providers.

Third, we do not know exactly how much money will be available, but it is unlikely to be enough to get the whole job done. States will need to target their investment to get the most value from the match funding and increase the flow of data across the care continuum in ways that improve outcomes. Here, it is particularly critical to avoid worsening a digital divide in which the ineligible providers that have already invested in EHRs get resources to allow them to get connected, while those that have not yet invested in EHRs get nothing.

Finally, state decisions are taking place in a rapidly changing policy and payment landscape. Meaningful use criteria for eligible Medicare providers are changing under the Medicare Access and CHIP Reauthorization Act (MACRA); recent proposed rules suggest that the new structure will be quite different from the current one, and that there will be future efforts to align Medicaid meaningful use with the changes in the Medicare program. It does not therefore make sense to invest heavily in paving certain roads if the traffic patterns are about to change.

What Costs Will (and Will Not) be Matched?

The new CMS guidance around ineligible providers, issued in a February 29 letter to State Medicaid Directors, provides specifics about the types of costs that do or do not qualify for match funding. For example, funding can be used for HIE start-up and onboarding, but not ongoing operations and maintenance. Funding also cannot be used to connect ineligible providers to an HIE that doesn’t in some way connect them to eligible providers, nor to purchase EHR technology for providers, nor to supplement the functionality of existing EHR systems. Given the focus on establishing electronic connectivity, the guidance encourages states to pursue models that are open, scalable, and standards-based, to avoid the need for costly custom interfaces.

To receive the funding, states are required to describe how they will use it to enable eligible providers who participate in Medicaid meaningful use to meet modified Stage 2 and Stage 3 meaningful use criteria. Two types of uses meet this requirement. The first is to directly fund onboarding of ineligible providers to HIEs or interoperable systems. As described in the guidance:

  • onboarding of pharmacies could help eligible providers meet ePrescribing or medication reconciliation criteria;
  • onboarding of clinical laboratories could help eligible providers meet the public health criterion for electronic reportable lab results or the criterion to use computerized provider order entry for laboratory orders;
  • onboarding of mental and behavioral health providers as well as long-term care providers could help eligible providers meet the criterion for electronically transmitting a summary of care record during a care transition; and,
  • onboarding of public health providers could help eligible providers meet the criteria for public health reporting and exchange of public health data.

The second use that would justify funding is to develop HIE and interoperability infrastructure and services that facilitate exchange between eligible and ineligible providers. For example, states could create provider directories that include long-term care, mental and behavioral health, and substance abuse providers that would help facilitate HIE between these providers and eligible providers. States could also invest in HIE infrastructure that allows secure messaging, query exchange, encounter alerting (such as notification of admissions, discharges, or transfers), or care plan exchange between eligible and ineligible providers.

Key Considerations for States Decisions

States face hard decisions about how best to use this newly available match funding. In an ideal scenario, funding could bolster other efforts to promote adoption of clinical IT systems among ineligible providers and ensure that the connectivity piece is in place. For example, some states are using CMS funding under State Innovation Model (SIM) awards to promote health IT adoption to improve care coordination and population health. Maine, for one, is funding the adoption of health IT in twenty behavioral health organizations.

State decisions about how to use match funding should also be guided by which types of exchange are likely to generate the most value for Medicaid. By focusing resources on connectivity with long-term care and other post-acute care providers, states can improve transitions for patients who move back and forth between acute and post-acute care, potentially reducing unnecessary re-hospitalizations (a significant source of savings).

However, to achieve this, states may need to engage a broader range of providers, such as mental and behavioral health providers. Community service providers would also be an important partner in reducing re-hospitalizations, but it is not clear whether onboarding them would fulfill the requirement of helping eligible providers meet meaningful use criteria. In the February 29 letter to Medicaid Directors, community service providers are not listed as a class of ineligible provider that could be onboarded in the context of specific meaningful use criteria, but they are mentioned as a stakeholder that would be valuable to include in care plan exchange and encounter alerting.

Connectivity that emphasizes medication management is also likely to be valuable, particularly to improve medication safety and target inappropriate drug-seeking. While the benefits may not be as large as those gained from reducing re-hospitalizations, they may be easier to achieve since exchange and reconciliation of medications is a simpler use case, involving a well-defined set of stakeholders and types of data.

Public health connectivity is another potential big-ticket item. While onboarding clinical laboratories to improve the exchange of reportable lab results (as well as electronic transmission of lab orders) could help with surveillance, benefits in the Medicaid population are likely to be substantially greater if public health providers can bolster their ability to receive immunization data and then transmit information back to providers about gaps.

States’ decisions should also be informed by insight about which HIE-related meaningful use criteria providers are most struggling to achieve. Recent data on eligible provider attestation levels from the Medicare program reveal varying patterns of achievement, depending on the criterion. Specifically, for computerized provider order-entry for lab orders and for medication reconciliation, the majority of eligible providers already far exceed the required thresholds of 30 percent and 50 percent, respectively (Exhibits 1 and 2). Similarly, for electronic prescribing, the majority of providers are well above the 50 percent threshold (Exhibit 3).

Exhibit 1. Criteria Achievement among Eligible Providers in the Medicare Meaningful Use Program: CPOE for Lab Orders Criterion

Julia_Adler_Milstein_Exhibit1

Source: Author’s analysis of Medicare Eligible Provider Stage 2 Attestation data through Q4 2015 

Exhibit 2. Criteria Achievement among Eligible Providers in the Medicare Meaningful Use Program: Medication Reconciliation Criterion

Julia_Adler_Milstein_Exhibit2

Source: Author’s analysis of Medicare Eligible Provider Stage 2 Attestation data through Q4 2015

Exhibit 3. Criteria Achievement among Eligible Providers in the Medicare Meaningful Use Program: Electronic Prescribing Criterion

Julia_Adler_Milstein-Adler_Exhibit3

Source: Author’s analysis of Medicare Eligible Provider Stage 2 Attestation data through Q4 2015

The picture looks quite different, however, for sending electronic summary-of-care documents during transitions of care. For this criterion, the threshold is only 10 percent, and the majority of eligible providers are close to that level (Exhibit 4). While these trends need to be confirmed among Medicaid providers (for which data are not publicly available), if they hold, it would suggest that states would be well-served to focus on connectivity that allows eligible providers to transmit a summary-of-care record to subsequent providers. This is likely to involve some effort to onboard mental and behavioral health providers, as well as long-term care providers, but likely more effort would need to be devoted to enabling infrastructure for sharing summary-of-care records, such as provider directories and secure messaging.

Exhibit 4. Criteria Achievement among Eligible Providers in the Medicare Meaningful Use Program: Electronic Transmission of Care Summary during Transition of Care Criterion

Julia_Adler_Milstein_Exhibit4

Source: Author’s analysis of Medicare Eligible Provider Stage 2 Attestation data through Q4 2015

Should a state choose to focus on bolstering summary-of-care record exchange, the match funding appears to allow for an exciting set of activities that is long overdue. A care-plan field within a summary-of-care record is intended to communicate care goals and instructions. Sharing information simply about historical care is not sufficient to ensure that care is well coordinated moving forward.

Currently, we have little insight into how best to create a cohesive care plan across a patient care team that can include multiple specialists, hospital(s), long-term care facilities, rehabilitation centers, home health care providers, and other Medicaid community-based providers. Indeed, there is little agreement among physicians about how to structure and use a problem list, which is a seemingly more straightforward information set. The new match funding specifically allows for the “design, development, and implementation of interoperable systems and HIE that facilitate the exchange of electronic care plans.” Hopefully CMS will apply a liberal definition to allow states to go beyond technical execution and pursue the far harder work of forging agreement on how to structure and implement a multi-disciplinary, patient-centric care plan.

Closing Thoughts

The new match funding offers an important and exciting opportunity to convert rocky byways into paved frontage roads merging onto our growing health information highway infrastructure. Importantly, it targets providers ineligible for meaningful use incentives, who have struggled to digitize at the same rate as eligible providers. Under regulatory constraints, however, funding is only available to establish connectivity between eligible and ineligible providers, but not to fund adoption of core clinical IT systems among ineligible providers.

Promoting adoption of clinical IT systems among ineligible providers should be a top priority for both federal and state policymakers. Indeed, putting new money into connectivity solutions, and not into fostering adoption of core systems, risks worsening the digital divide in which a subset of providers have robust systems and connectivity, while the remaining providers have neither. This is not simply an issue of equity, but of diminishing the effectiveness of the overall system. Translating new match funding into seamless flow of data across the full care continuum will therefore require complementary efforts to fulfill the vision of a fully digitized health information infrastructure.