Forward Movement, with Balance

That’s right. And a few other things: there’s more flexibility in the approach to certification. So in Stage 1—and this is something that sort of evolved through various FAQs—a provider has to ‘possess certified technology’ covering applicable areas; but in many cases, that meant you had to possess technology for items you were deferring. So ONC created a very nice framework and said, there’s a base EHR, and everyone has to have that capability, whether or not they’ve claimed exclusion for some of those items; but beyond that, you only have to have certification for items you have, and you only have to have those items if you are using those elements for meaningful use; so it provides an element of flexibility.

They also added more flexibility for specialists, in a few areas. So they continued with the general approach of having some menu items, which gives some flexibility relative to what your particular practice is. There’s an exclusion for vital signs, where there are three elements of vital signs (height, weight, and blood pressure)—and for a physician to claim an exemption, you’d have to attest that none of those were relevant in your practice—but they’ve made each element separate. And this is looking ahead to what they’re calling payment adjustments (penalties)—they’ve proposed several categories of exemptions, such as not having broadband, or being a new doctor, or if a tornado hits your town; but they’ve also asked for specialty-based exemptions. For example, the meaningful use framework really doesn’t fit with how pathologists actually work. So it wouldn’t make it easier to get the payments, but it would prevent you from incurring the penalties.

Were you surprised at all, or was it essentially what you had expected?

In the main, it was what I had expected. I was surprised that they had added imaging in Stage 2, not because it didn’t make sense, but because the HIT Policy Committee had been having discussions more about including imaging in Stage 3. Other than that, nothing really surprised me; they proceeded in a fairly logical way.

Others have said they think the Stage 2 proposed rule is reasonable, equitable, and fair. Would you agree?

Yes. Now, we have to look carefully; some of the thresholds may be too high as you look at new people coming in; but in the main, it was a positive reaction to the rule.

What would your advice to CIOs, CMIOs and other IT and clinical informaticist leaders be at this point?

They should certainly be reviewing the rule carefully, and engaging as an active participant or listener in various discussions about the rule. Number one, because it’s really important that the actual final rule reflect the experiences of those in the provider community. And second, they should really be assessing what will almost certainly survive, even if certain specifics change. So in addition to the CMS meaningful use rule, it’s important, particularly for a CIO, to look at the ONC rule, which looks at standards and certification, so that they can anticipate the kinds of technology changes and upgrades that may be coming, as well as the implications of particularly vocabulary proposals, like the sole use of SNOMED for problem lists.

And there are a couple of areas here around patient engagement: providers will be responsible for whether patients use the view-and-download capability; for whether patients actually use secure messaging. So, anticipating patient engagement and the specifics around it, will very much be a part of Stage 2. I think it would definitely make sense for hospitals, medical groups, and other providers, to take steps now in terms of patient engagement, with regard to patient portals and secure messaging, so that they’re well-positioned to hit those ten-percent thresholds; and that’s more of a business process/change management issue than it is a technology issue.

Overall, we are looking very carefully at both the CMS and ONC rules, to determine what comments to make, and to identify those steps that we need to be taking in the next few months, in advance of the final rule, to be well-prepared.