Can MACRA's 'entice and goad' approach bring EHR vendors on board?

Marla Hirsch

The new final rule implementing the Medicare Access and CHIP Reauthorization Act (MACRA) expands the use of electronic health records and health IT even farther than before.

But it’s particularly noteworthy how the government is attempting to get EHR vendors to improve their products and conform to the rule, even though technically they’re not subject to it. 

Let’s call it “entice and goad.”

The Quality Payment Program (QPP) created by MACRA includes many components that relate to or require the use of certified EHRs. For instance, both aspects of MACRA’s QPP--the advanced alternative payment models and the Merit-Based Incentive Payment System (MIPS)--require the use of certified EHRs. The measurements in the Meaningful Use of EHRs category of MIPS, now known as the “advancing care information” performance category, have been reduced from 18 in Meaningful Use Stage 3 and 11 in the proposed rule to only five--but they all pertain to interoperability. And some of those requirements go beyond the basics. They now include items such as incorporating received information into the EHR, sharing and obtaining information from more than one setting and incorporating patient-generated information. 

But none of this is going to work if the EHRs can’t support the clinicians. And this is where it gets interesting.

Although the rule does not address it--since, as it applies to providers, not vendors, it really can’t--Centers for Medicare & Medicaid Services Acting Administrator Andy Slavitt used the press call announcing the final rule to send his message that the vendors must step up to the plate to make this rule work.

Slavitt said that the rule relies on health IT and EHRs and that EHR vendors must start innovating and providing systems that help physicians meet their goals. He stated that “now the burden needs to shift to technology companies to get this done,” calling this is a “vital role and vital opportunity” for health IT. Technology companies are “encouraged” to support physicians, he continued, adding that the shift is moving away from government regulation, meaning customer needs must take over.

He even went so far as to say that MACRA is the “next shift” and “arguably a much richer opportunity” than the HITECH Act was for vendors.

That’s the “enticement.” C’mon vendors! Grab the brass ring!

Then we have “goad.” CMS can’t--at least in this rule--put the squeeze on vendors to improve their products. But it can do so indirectly by putting the pressure on providers to turn and pressure the vendors.

For instance, the final rule adopts the proposed rule’s requirement that all eligible clinicians and hospitals must attest that they’re not engaged in information blocking. It’s an involved, three-part attestation, which includes statements that the provider didn’t take action to limit or restrict interoperability, that it implemented steps to ensure it is connected and provides access to patients and other providers and has responded in good faith to requests for information.

But commenters in the proposed rule were concerned that they’d be to blame if their EHRs didn’t meet the standards in the attestation. CMS responded, saying, among other things: 

“We reiterate that a healthcare provider will not be held accountable for factors that it cannot reasonably influence or control, including the actions of EHR vendors. ... We do expect, however, that a healthcare provider will take reasonable steps to verify that the certified EHR technology is connected [that is, implemented and configured] in accordance with applicable standards and law and in a manner that will allow the healthcare provider to attest to having satisfied the conditions described in the information blocking attestation. In this respect, a healthcare provider’s obligations include communicating these requirements to health IT developers, implementers and other persons who are responsible for implementing and configuring the healthcare provider’s certified EHR technology. In addition, the healthcare provider should obtain adequate assurances from these persons to satisfy itself that its certified EHR technology was connected in accordance with applicable standards and law and in a manner that will enable the healthcare provider to demonstrate that it has not knowingly and willfully take action to limit or restrict the compatibility or interoperability of certified EHR technology.”

It’s good news that CMS recognized that the vendors play a powerful role, and that providers aren’t the only ones accountable.

But will entice and goad work? Is it good enough? How much pressure can providers put on vendors to meet the rule’s requirements, especially if the provider already has an EHR and isn’t in the market for a new one?

And if they work, how well? How innovative and supportive will vendors be? Or, will vendors update their products to meet the rule, as they did with the HITECH Act, but not much further, so that EHRs will still have usability and functionality design flaws? Then EHRs may be able to exchange information and provide access, but not necessarily easily. And providers may still struggle to use EHRs to improve the quality of care.

Will the rule's entice and goad approach bring the vendors on board the way CMS wants? I hope so, but that remains to be seen. - Marla (@MarlaHirsch and @FierceHealthIT)