June 18, 2012

Stage 2: Meaningful Use Branches Out
By Mike Bassett
For The Record
Vol. 24 No. 12 P. 20

With the final rule expected soon, healthcare entities ready themselves for an expanded list of requirements.

The buzz was palpable at this year’s HIMSS conference in Las Vegas, and it had nothing to do with any Hangover-style shenanigans. Instead, the commotion centered on the much-anticipated release of the notice of proposed rulemaking (NPRM) for stage 2 meaningful use. Overflowing crowds digested information and asked a plethora of questions as federal officials laid out the requirements.

Between the February release of the NPRM and the May 7 deadline for comments, healthcare leaders formed an array of opinions on the hurdles they faced to meet the guidelines. Numerous healthcare constituents took the opportunity to respond to the proposed regulations, with the American Medical Association (AMA), 98 state and medical specialty societies, the College of Healthcare Information Management Executives (CHIME), and AHIMA among those chiming in.

Now that the comment period has lapsed, many healthcare groups are urging the Centers for Medicare & Medicaid Services (CMS) to act quickly. In its comment letter, the Premier Health Alliance, which represents more than 2,600 hospitals, called on the CMS to publish the final rule no later than August to give EHR vendors and providers enough time to prepare for a 2014 start date.

For the most part, industry experts view stage 2 as a direct extension of its predecessor. “[Stage 1] set the foundation by focusing on the capturing of data,” says Michelle Knighton, program manager for healthcare testing at ICSA Labs, an ONC-ATCB. “Stage 2 takes that to the next level by focusing on the exchange of that data.”

Patient Engagement
The stage 2 requirements that provide some of the biggest challenges and are among the most controversial relate to patient engagement, Knighton says. These provisions requiring hospitals to provide patients with access to their electronic health information won’t be easy to implement. For example, the CMS proposes a new objective that would allow patients to view online, download, and transmit information about their hospital admission. This proposed objective features the following two measures:

• More than 50% of all patients who are discharged from the inpatient or emergency department of an eligible hospital or critical access hospital must have their information available online within 36 hours of discharge.

• More than 10% of all patients who are discharged from the inpatient or emergency department of an eligible hospital or critical access hospital should view, download, or transmit to a third party their information during the reporting period.

 “That’s frontier type of information, and there’s definitely going to be some reservations from some folks,” says Amit Trivedi, healthcare programs manager for ICSA Labs.

In its 68-page comment letter submitted to the CMS on April 30, American Hospital Association (AHA) Executive Vice President Rick Pollack wrote, “Taken as a whole, the proposed requirements for meeting Stage 2 raise the bar too high and are not feasible for the majority of hospitals to achieve.” He added that AHA members were specifically “concerned with the proposed objective to provide patients with the ability to view, download and transmit large volumes of protected health information via the Internet (a patient portal). The AHA believes that this objective is not feasible as proposed, raises significant security issues, and goes well beyond current technical capacity.”

Fauzia Khan, MD, FCAP, chief medical officer of DiagnosisOne, a provider of clinical decision-support solutions, says enabling patients to access their healthcare information electronically is problematic but “very much needed.” Still, there are significant barriers. For example, how do providers incentivize patients to be part of the paradigm?

Khan suggests providers could selectively communicate with patients, offer financial incentives, or even use gaming techniques to encourage them to access electronic records. “But it’s certainly an area the medical community is not well prepared to handle right now,” she concedes.

Shortly after the NPRM was released, HIMSS presented a virtual briefing on the proposed rules with Pat Wise, RN, MS, vice president of health information systems, examining how the regulations would affect eligible hospitals. Wise says the briefing was dominated by questions and comments about patient access to electronic records, including the following:

• How do we do this?

• How are we going to be measured on patient responses?

• Getting patients to access the Internet to review their records is beyond our control.

While it’s apparent there is some concern and resistance out there—as demonstrated by the comments from the AHA and other organizations—Wise says that in conversations with and among providers, she hears strategies starting to emerge. For example, some organizations are looking at workflow patterns to see how they might have to change to handle stage 2 patient engagement requirements. “At some point, providers might have to have physicians or nurses engage the patient,” Wise says. “So they can literally show the patient, ‘This is how you do it; this is how you access your information.’”

The increased focus on patient engagement is “going to be interesting in the sense that it’s going to require more automation if healthcare organizations didn’t implement this as part of their overall EMR package,” says Karen Knecht, RN, a partner at Encore Health Resources. “Things like having an electronic medication administration record in at least one unit, e-prescribing on discharge, as well as the online access to health information by the patients” will all provide challenges.

Quality Care
Clinical quality care measures are among the core objectives hospitals must meet in stage 2. Under the proposed rule, they must satisfy 24 of 49 clinical quality measures. The qualifying data can be submitted through the Hospital Inpatient Quality Reporting System.

“It’s clear there is going to be this continued focus not only in getting data into the electronic health record but in the ability to aggregate, calculate, and record for quality measures as well as share and exchange information securely,” says Knecht, who adds that achieving the required number of quality measures is one of the most difficult aspects of meaningful use. In fact, a 2011 survey of chief information officers conducted by CHIME revealed that capturing and submitting data for quality measures was the biggest concern for meeting stage 1 requirements. That trepidation is only likely to grow with stage 2.

“So we are continuing to encourage our clients and to work with them around getting the quality measures right,” Knecht says. “One of the things we have learned from stage 1 is if you get the quality measures right, you really meet most of the objectives.” But automating clinical processes to demonstrate quality is “pretty far reaching,” she notes, adding that organizations need “to have the ends in mind and then work backward.”

Demonstrating quality is much more than capturing a data element on a computer screen, Knecht says. “Each of these measures has multiple components, including multiple data elements and associated code sets. It’s much more complicated than building an order set and building clinical documentation,” she says.

Knecht recommends hospitals not focus solely on meeting minimum requirements but also look to the future. For example, Tenet Healthcare, an Encore client and one of the largest for-profit healthcare systems in the country with 50 hospitals in 11 states, recently had six hospitals attest to stage 1 meaningful use. “And this is an organization that had no electronic health record,” she says.

In working with Tenet, Encore focused on building and designing around quality. “We had them thinking about how this data was going to be reported, not only for stage 2, but for all of the other kinds of healthcare changes on the horizon,” Knecht says.

Take stroke measures, for example. Instead of viewing them in terms of meaningful use, take into account other quality programs as well. “Ask yourself, ‘Can we use these stroke measures as a foundation for looking at future programs like value-based purchasing?’” Knecht says. “These data elements and quality measures will all be components of these other programs, including accountable care organizations.”

Such thinking can drive a strategy involving more than just how to install an EHR; it also has organizations thinking about how they can reuse and repurpose data beyond meaningful use, Knecht says. “This should not just be about meaningful use as an IT initiative,” she says. “It also needs to be looked at as a stepping-stone and building block for your larger organizational strategy concerning how you are going to respond and be ready for all the other upcoming initiatives that are value or performance based and will be driving change in our reimbursement.”

Imminent Storm of Regulations
Another major concern cited by those who would like a speedy resolution to the question of stage 2 target dates centers on the juggling act being performed by many providers faced with tackling other initiatives—such as the implementation of ICD-10 codes—on top of meaningful use. The AMA recently sent a letter to the CMS expressing “serious concern about an onslaught of overlapping regulations that affect physicians.”

“Facing all of these deadlines at once is overwhelming to physicians whose top priority is patients,” says AMA President-Elect Jeremy Lazarus, MD. “We have asked CMS to develop solutions for implementing these regulations in a way that reduces the burden on physicians and allows them to keep their focus where it should be: caring for patients.”

There is a sense of urgency about meeting the requirements, Wise says. “Stage 2 will quickly be upon us and a lot of hospitals still have to move through stage 1, so you take all these regulatory changes, along with what may or may not be happening with ICD-10, and you have to feel for these physicians and hospitals,” she says.
Seasoned veteran or relative newcomer, the atmosphere can get chaotic. “There is so much change happening,” Wise says. “Even for those of us who work in the space on a daily basis, it’s a tremendous amount to take in.”

Be Prepared
For those providers still trying to make sense of the proposed stage 2 requirements, Knighton advises them to take matters into their own hands—literally—by reading the entire document, which numbers several hundred pages. For those with neither the time nor inclination to digest all that material, there are shortcuts available.

“Depending on the size of the facility, they may or may not be in tune with what’s happening with these regulations,” Trivedi says. “The NPRM came out during the HIMSS12 annual conference, and it was interesting to see what was happening when the regulations were dropped. People were doing real-time analysis over Twitter and in blogs and various social media. So there are plenty of different avenues where folks can learn about the regulations.”

Knighton says smart providers will monitor workflow issues and develop best practices as part of a comprehensive transition plan to meet stage 2 requirements. “And then you should be talking to your EHR vendors,” she notes. “Vendors certainly won’t know what changes they should be making until they get that final rule, but you should be thinking about questions you want addressed.”

Knighton suggests asking vendors the following questions:

• When do you anticipate entering the testing and certification process?

• What’s the timeline for finishing the process?

• Once the process is finished, when do you expect to roll out the certified system?

• When it’s rolled out, how much will it cost?

For hospitals that have yet to implement an EHR, stage 2 can provide the impetus to push them into an electronic environment.

“In many ways, stage 2 should provide better assurance to providers that these EHRs are being tested and certified in a way that makes it more likely they are going to want to use them,” Knighton says. “And that will be key if they are on the fence about EHRs.”

A cost-benefit decision needs to be made, she says. “How much is it going to cost to implement an EHR vs. how much am I going to get for these incentives with the understanding that, down the line, the reality is they are going to receive less from Medicare and Medicaid if they aren’t complying.”

While stage 1 focused primarily on HIT adoption, stage 2 addresses more complex uses of technology, Trivedi says, adding that the issue isn’t whether an organization needs an EHR but rather understanding that it’s actually a cost of doing business.

“The question instead will be how well are you using your EHR and how can you leverage this technology to improve the quality of care you are providing,” he says “And that’s what you are going to see in stage 3.”

— Mike Bassett is a freelance writer based in Holliston, Massachusetts.