Kelly Cronin, senior advisor, Centers for Medicare & Medicaid Services (CMS), provided the Keynote Address -- “Advancing RHIOs” -- during the RHIO Symposium yesterday on the opening day of the Healthcare Information Management Systems Society (HIMSS) meeting in San Diego.
Cronin said CMS has contracted with four consortia to create prototypes for a national healthcare information network (NHIN). The agency has set an aggressive agenda—the four are to present use cases in March, an operational plan is due in August, and revenue and certification models are due in October. “These contracts are the first attempt to make policy through market institutions rather than through regulations,” Cronin said.
The technology industry’s infrastructure is comprised of the following five components that must be addressed to advance RHIOs, Cronin said:
- Compliance certification
- National Healthcare Information Network
- Privacy and security
- Healthcare information technology (HIT) adoption
“RHIOS are a good first step to interoperability,” she said. They provide framework for a nongovernmental, multistakeholder organization and bring a business model to the forefront.
Cronin cited several key principles that CMS has for RHIOs. Those include establishing at least one in each state. States that have more than one RHIO should have an overarching RHIO responsible for connecting the other RHIOs in a state. Each RHIO should meet a minimum set of best practices and should follow the goals and recommendations of the American Health Information Community.
RHIOs offer several benefits, such as near real-time data, available data for quick response, infrastructure and data for quality measures, and the ability to provide consumers with information they need about their choices, Cronin said.
Other speakers during the symposium and audience members asking questions made it clear that there is significant skepticism regarding the RHIO timeframe Cronin set forth. However, she pointed out that 30 states have introduced or passed state HIT efforts, 40 states have at least one community-based HIT effort, and there are now 66 recognized RHIOs. She did admit that how those RHIOs “relate to the federal government is not well defined.”
Laws and ethics for RHIOs
The proposed federal budget was the first agenda item for Steven J. Fox, partner, Pepper Hamilton, LLP as he addressed legal issues of RHIOs and EHRs during the RHIO Symposium yesterday on the opening day of the annual Healthcare Information Management Systems Society meeting in San Diego. The budget allots $116 million for healthcare IT which might sound impressive, but Fox pointed out that it is less than the administration budgeted for its marriage initiative. Plus, the money isn’t even guaranteed.
“Until we solve the money problem, we’re not going to get too far” with RHIOs, Fox said.
Money isn’t the only obstacle to RHIOs. Fox discussed several governmental regulations that haven’t exactly moved the development of RHIOs forward. For example, the Community-Wide Health Information Systems (CWHIS) was issued by CMS as an interim final rule in March 2004 (effective July 2004) as a new exception under the Stark self-referral law. That was going to jumpstart RHIOs, Fox said. But, the rule generated widespread confusion. What does “community-wide” mean? To what extent does the CWHIS have to be “available” to residents of the community and all providers and practitioners? Plus, CMS has failed to revise the CWHIS rule since that time.
Another problematic regulation is the proposed rule for EHRs. CMS and the OIG took different approaches, Fox said. CMS proposed two Stark exceptions based upon when donation of items and services occur—prior to future HHS adoption of certification standards (pre-interoperability EHR exception), and after certification standards are adopted (post-interoperability EHR exception). The OIG only outlined proposed “pre-interoperability” safe harbor with similar elements to CMS’ exceptions.
The Stark exceptions are comparable to the e-prescribing requirements. Items and services must be “necessary” and used “solely” for the EHR. That is limited to software and direct training services, but not billing, scheduling, or general office management functions. “I think that’s too restrictive,” Fox said. “It doesn’t encourage computerization. It defeats the whole purpose of an EHR.”
Fox also sees problems with the proposed fraud and abuse rules. Group practices cannot donate to non-group member physicians. Hospitals can’t donate to physicians not on the medical staff. Donations do not permit costs of implementation and support/maintenance to be included. “Anyone who has been involved with an IT implementation knows that those costs often exceed the cost of the system itself,” Fox said.
James Dwyer, Ph.D., associate director of education, SUNY Upstate Medical University, Center for Bioethics and Humanities, discussed ethical issues that come up with RHIOs.
“There are always going to be conflicts of interest,” he said. Conflicts exist because it’s not a case of good intentions versus bad intentions—it’s hard because it’s good versus good.”
Good organization and preparation can help you prevent dilemmas to begin with, Dwyer said. You should also build in safeguards that are proportionate to what you’re trying to do, he said. “You don’t build your safeguards to create unintended consequences.”