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The strongest objections are related not to the specifics of the proposal, but to the whole idea of laying out the stage 3 objectives before stage 2 has commenced and while many providers are still struggling to get through stage 1.
The American Medical Association (AMA), for example, said in its letter to Farzad Mostashari, MD, national coordinator of health IT, "We are extremely concerned with the recommended approach to move full speed ahead [with stage 3] without a comprehensive evaluation of the program and resolving existing barriers, including Health IT infrastructure flaws."
Similarly, the American Hospital Association (AHA) letter to Mostashari said, "The AHA believes it is too soon to define the meaningful use requirements for stage 3." The AHA noted that as of last September, fewer than a third of hospitals had met the stage 1 requirements and received incentive payments. Moreover, the AHA noted, hospitals had not yet had any experience with meeting stage 2 requirements.
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The College of Health Information Management Executives (CHIME), which represents chief information officers, did not go as far as the AHA. But CHIME did note that it was difficult to comment on the stage 3 proposals without knowing what was going to happen in stage 2. "Suffice it to say that it will be important to re-assess the reasonableness of proposed Stage 3 objectives and measures in light of actual experience under prior stages," the organization said in its letter.
"In this regard," the letter added, "CHIME's strongly held view is that every desirable EHR-related objective cannot feasibly be met by 2016." Instead, it said, HITPC and the Department of Health and Human Services should be "guided by thorough evaluations and reasonable expectations of what hospitals, health professionals and EHR vendors are capable of accomplishing over time."
Both AMA and AHA called for an independent review of the Meaningful Use program before HITPC proceeded any further. Said AHA, "Rather than rushing ahead to set Stage 3 requirements, the HITPC should recommend that the Department of Health and Human Services (HHS) fund a comprehensive, external evaluation that highlights progress to date, but also seeks to understand why, more than two years into the program, the large majority of hospitals and physicians have yet to attest to Meaningful Use." AHA asked HITPC not to finalize stage 3 recommendations until such a review had been completed.
Another thread running through the comments was the lack of progress to date on making EHRs interoperable. The organizations noted that this deficiency will make it difficult for providers to meet some objectives in stage 2, as well as some of the criteria proposed for stage 3. "Addressing the current limits to interoperability will bring far greater benefits than rushing into a definition for Stage 3 that is not built on lessons learned from Stage 1, let alone Stage 2," said the AHA.
The AMA cited several concerns and made recommendations on all of them. Besides calling for external program review and interoperability, the organization said that physicians should not have to meet every Meaningful Use requirement completely to receive incentives and avoid penalties; that program requirements should be flexible enough to accommodate the situations of all physicians, regardless of specialty; and that the usability of certified EHRs should be more fully addressed.
Noting that the ONC has certified over 2,000 EHR products, AMA said it was very difficult for physicians to differentiate among them. Primary care physicians get some help with that from regional extension centers, the letter pointed out, but specialists are on their own. Also, AMA noted, it's very likely that not all of these products will be around for a long time and that some vendors will not upgrade their EHRs in later stages of Meaningful Use. Therefore, it asked ONC to "consider requiring vendors of certified EHR products to commit to support subsequent stages of the meaningful use program."
The Association of American Medical Colleges also weighed in with these recommendations:
-- Make Meaningful Use measures flexible enough to fit all specialties.
-- Allow physicians and hospitals to sidestep Medicare penalties as long as they meet most of the Meaningful Use objectives
-- HITPC shouldn't increase the number of criteria that depend on the actions of others, such as patients.
-- Place all newly proposed stage 3 measures in the optional menu, not in the core set of requirements.
-- Don't increase the thresholds for stage 2 core measures for stage 3 until evidence exists that all types of providers can meet the current thresholds for stage 1 and stage 2.
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