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US Digital Service Revamps CMS, QPP User Experience from the Inside Out

The US Digital Service is one of the driving forces behind the Quality Payment Program website, taking an "API-first" approach to overhauling the CMS user experience.

CMS, QPP user experience and APIs

Source: US Digital Service

By Jennifer Bresnick

- The notorious inefficiency of the federal government has long been a common complaint for citizens, businesses, and other entities attempting to acquire information, apply for programs, or receive acknowledgement for some achievement.

Healthcare professionals are certainly not alone in feeling that government services often fall short of the mark when it comes to user experience, transparency, and the ability to complete tasks quickly. 

Shannon Sartin, Executive Director of the HHS US Digital Service Team
Shannon Sartin, Executive Director of the HHS US Digital Service Team Source: Xtelligent Media

Since the advent of the EHR Incentive Programs, participating healthcare providers have ramped up their interactions with CMS, especially in the digital environment. 

CMS has made a concerted effort to shift reporting requirements to online portals and electronic data systems in order to streamline attestation and reduce paperwork burdens, and many of the activities involved in the new Quality Payment Program (QPP) for eligible physicians can now take place online.

READ MORE: Verma: CMS Will “Use Every Lever” for Promoting Interoperability, Data Access

Going digital is a big step forward for data analytics enthusiasts.

But the migration to online services also raises concerns about how the federal government will create user-friendly environments that further CMS’s oft-repeated goals of reducing administrative burdens and putting patients over paperwork.

Luckily for everyone involved, CMS has a relatively secret weapon in the battle against bureaucratic clutter. 

The US Digital Service, a 200-strong cadre of technical developers, designers, and user experience experts often drawn from the high-profile dreamscape of Silicon Valley, tends to fly somewhat under the radar. 

Formed by the Obama Administration in response to the very public failure of Healthcare.gov during the launch of the ACA health insurance marketplaces, the US Digital Service provides technical expertise to a number of federal stakeholders including the Department of Veterans Affairs, the Pentagon, and the Department of Health and Human Services.

READ MORE: EHR Users Want Their Time Back, and Artificial Intelligence Can Help

“We’re based in the White House to help solve problems ranging from software development to user-centered design to creating more impactful strategies for engaging with the American people,” explained Shannon Sartin, Executive Director of the team embedded in HHS. 

“When we were formed in 2014, it was because the White House recognized that there was a common theme across government when it came to technology projects.  There were too many failures, and there was a lack of technical talent that could help to deliver consistently good services to the public.”

The HHS team is primarily focused on enhancing digital experiences at CMS, Sartin told HealthITAnalytics.com

“Medicare has a huge impact on the entire healthcare industry, so we want to make sure that CMS is communicating clearly and that nothing is holding up its ability to improve care, expand access, or improve outcomes,” she said. 

“Technology is playing an increasingly important role in doing all of that, so we’re here to act as the firefighting squad when something comes up that needs to be addressed.”

READ MORE: The Difference Between Big Data and Smart Data in Healthcare

The launch of the Quality Payment Program brought plenty of opportunities for the Digital Service to prove its value. 

The program originated as a way to respond to provider complaints about cumbersome, duplicative, and confusing reporting requirements. 

“It’s time to modernize the Medicare physician payment system to be more streamlined and effective at supporting high-quality patient care,” former CMS Acting Administrator Andy Slavitt said in 2016 when announcing the refreshed version of meaningful use for physicians.  “To be successful, we must put patients and clinicians at the center of the Quality Payment Program.”

With such a bold mission statement underpinning the effort, CMS could not afford to create a digital user experience that didn’t deliver on its promises to make it easier and more intuitive to participate in quality measurement initiatives.

“Typically in government, policy writing happens behind closed doors without much conversation with industry about the impacts of implementation,” Sartin observed.  “That sometimes results in the government shooting itself in the foot a little bit, and the end users are the ones that suffer for it.”

“For the QPP, however, one of the first things we did was embed with the CMS policy team to have conversations about the problems we were trying to solve and how we could achieve those goals with user-centered design.”

One of the many challenges for the US Digital Service when designing the QPP website was creating an online interface that works equally well for providers across the entire industry spectrum, from solo practitioners in rural regions to academic medical centers with thousands of physicians on staff.

“Everyone has their own unique needs, and everyone is getting something different out of the QPP,” said Sartin.  “A rural clinic doesn’t necessarily care about exactly the same things as a large, urban hospital.  Their data is going to look different.  Their resources need to be tailored to what they’re trying to achieve.” 

In order to enable tailored data access that meets the needs of as many participants as possible, CMS and Sartin’s team committed to an “API first” strategy.

“You can’t solve all problems for all people, but you can develop a core set of features that can then be enhanced and customized through an application programming interface,” she said.

“APIs allow third parties to create submission tools or analytics tools to improve the experiences of specific subgroups of participants.  If someone wants to create an amazing application that fills a need in the market and goes beyond what the government is capable of doing right now, they should be able to.”

Homepage of the Quality Payment Program

Source: qpp.cms.gov

The API, released towards the end of 2016, plays a key role in submitting and interacting with QPP data.  Providers can submit their performance data electronically and receive real-time feedback on the information, including preliminary scoring and error reports.

The API also allows developers to create tools leveraging the “Explore Measures” section of the QPP website, which allows providers to select and save a set of measures that are a best fit for their practices. 

Third-party software engineers or EHR vendors can then create dashboards or other applications based on those customized measure sets that allow providers to interact with their data in a more workflow-friendly manner.    

The API-based data submission process has been well-received by the industry, Sartin said, and the ease of using the system has gone some way towards reducing frustration with the federal agency.

“We know that people complain about CMS all the time,” she acknowledged.  “A lot of providers still feel resentful about having EHRs forced on them, and we can understand why.  EHRs haven’t fulfilled the promises CMS made, and it’s easy to see why people still feel slighted by that.”

“That makes it even more gratifying that people were actually really excited and very vocal about how much they liked the submissions process through the new site.  That’s important for CMS to hear.  It shows that it’s possible for an agency to build great products and create tools that are – if not a joy to use, then at least painless to interact with.”

There may still be a long way to go before it becomes truly painless to work with the agency, but Sartin sees a bright future ahead for better user experiences, patient-centered design, and streamlined administration of quality reporting programs.

“I’m very encouraged by seeing CMS lean into some of the policies around Patients Over Paperwork and the reduction of physician burdens,” she said. 

“CMS is at the forefront of patient-centeredness and user-centered design.  I’ve never seen a federal agency adopt something so quickly when it was so foreign to them only a couple of years ago.  I believe it’s going to have a transformative impact on the way CMS writes policy and delivers programs.”

Recent suggestions for changes to the 2019 Medicare Physician Fee Schedule and Quality Payment Program may be proving Sartin correct rather quickly. 

Earlier in July, CMS proposed to reduce documentation requirements related to certain types of clinical visit, remove low-value process measures from MIPS reporting, and rewrite the “Promoting Interoperability” category of the QPP to encourage EHR data exchange and patient access to personal health information.

“Physicians tell us they continue to struggle with excessive regulatory requirements and unnecessary paperwork that steal time from patient care,” CMS Administrator Seema Verma stated.

“The proposed changes to the Physician Fee Schedule and Quality Payment Program address those problems head-on, by streamlining documentation requirements to focus on patient care and by modernizing payment policies so seniors and others covered by Medicare can take advantage of the latest technologies to get the quality care they need.”

The latest technologies aren’t just about bringing data into CMS through the QPP, Sartin explained.  The way data flows out of CMS to patients, providers, and other stakeholders is equally important.

The US Digital Service was also actively involved in the development and release of Blue Button 2.0, another application programming interface that is intended to expand patient access to data, improve care coordination, and foster more robust population health management.

Blue Button 2.0 logo

Source: CMS

“I know there’s a lot of debate about the value of claims data, but I truly believe claims can be unbelievably powerful if you combine them with the right analytics technology,” said Sartin. 

“We have data on about half of the population at any given time through Medicare and Medicaid.  There’s a lot we can do with what we have – we just need to make sure that we are developing a truly connective, interoperable system that works on open standards.”

Blue Button 2.0, announced at HIMSS18 as part of the MyHealthEData initiative, is an important step towards achieving that goal.  The API is built on healthcare’s most promising open standard, known as FHIR.

“With the Blue Button 2.0 API, we definitely doubled down on our commitment to FHIR,” Sartin asserted.  “For the past few years, FHIR has been this really interesting, revolutionary new idea, but no one wanted to be the first to commit to it.  Some people thought it was too complex, and some thought it was going to just be another flash in the pan like a lot of other standards.”

“CMS is trying to be in line with industry best practices as much as possible to make sure that we can get out of an environment where data lives in all these different formats,” she continued.  “Even if FHIR isn’t perfect, it’s the best we have right now.  If we want to make it even better, we have to embrace it and give input every step of the way about how to improve.”

The US Digital Service is always looking to recruit new team members to provide that input and guide the development of future healthcare data initiatives, Sartin said.  All types of software engineers are welcome to apply – technical product managers, designers, and ‘bureaucracy hackers’ with experience navigating government projects are also in short supply.

Healthcare-specific experience is a plus, but not required, Sartin said.  The main criteria are expertise in a given area and a willingness to solve complex problems during a limited “tour of duty.”

“The number of people frustrated with government right now feels pretty infinite,” she admitted.  “Everyone has something that they want to change, or improve, or eliminate.”

“The US Digital Service is your chance to make government better.  There are so many projects that can measurably impact the people the government serves.  If you know how to help a veteran get access to his or her benefits, or you know how to make healthcare better at the VA so those benefits contribute to making their lives better – come work for my team.”

The best place to influence policy is from the inside, Sartin stressed, and the US Digital Service offers the opportunity to marry technology, policy, and implementation in a unique way. 

“There’s nothing more powerful than being in the room when decisions are made,” she said.  “In healthcare, there’s no place more powerful than CMS.  If you want to see how policy is made from the bottom up, and understand the inner workings of government, you’ve got to be here to see it first-hand.” 

“Change filters down slowly.  Sometimes it takes ten or fifteen years for the industry to adopt a new principle or strategy.  And if you’re involved with the process at the beginning, you have a much stronger ability to take what you’ve learned and accelerate adoption when you get back to the private sector with the benefit of having been on both sides of the table.”

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