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As Proposed Rule Is Read, Initial Reactions Span the Spectrum

February 28, 2012
by David Raths, Jennifer Prestigiacomo, and Mark Hagland
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Healthcare IT leaders and industry analysts begin wading through 455 pages of details

Hospital, physician group, and health system IT leaders have been busy the past few days analyzing the Notice of Proposed Rulemaking (NPRM, or “proposed rule”) on Stage 2 of meaningful use, which was released by the federal Office of the National Coordinator for Health IT (ONC) and announced publicly by Farzad Mostashari, M.D., the national coordinator for health IT, on Thursday, Feb. 23, during the waning hours of the HIMSS Conference, being held last week at the Venetian Sands Expo in Las Vegas. With 455 pages to scan, many are finding that just reading through the text of the proposed rule is taking numerous hours.

Not surprisingly, some organizations are taking their time to perform a comprehensive analysis of the Stage 2 proposed rule, in order to make sure that they understand what’s facing them in the next phase of federal mandates coming out of the American Recovery and Reinvestment Act/Health Information Technology for Economic and Clinical Health (ARRA-HITECH) Act.

For example, Thomas Smith, CIO at the four-hospital NorthShore University HealthSystem in Evanston, Ill., says his meaningful use team, which meets once a week, has broken down responsibility for analyzing specific aspects of the NPRM to different team members. At first glance, he says, it appears that  the Centers for Medicare and Medicaid Services (CMS) has changed some of the reporting definitions in terms of numerators and denominators, which will require working with EHR vendors to rejigger how measurements are done to make sure the reporting is correct.

“The best thing about Stage 2 is that vendors and providers now have at least 18 months to make the changes,” Smith says. “If they had left the timeline where it was originally, that would have been a tough assignment.” Otherwise, Smith says, he sees no real surprises in the core and menu framework and threshold changes.

One change that did surprise him involved using EHRs to send summary-of-care information with referrals. Initially, providers had been expecting in Stage 2 to use health information exchange to send data to three major referral partners. To meet that requirement, NorthShore assumed it would use technology made available by its vendor, the Verona, Wis.-based Epic Systems, to share data with other Epic customer hospitals in the Chicago area. But the Stage 2 NPRM requires that a hospital “that transitions or refers their patient to another setting of care or provider of care electronically transmits a summary of care record using Certified EHR Technology to a recipient with no organizational affiliation and using a different Certified EHR Technology vendor than the sender for more than 10 percent of transitions of care and referrals.”

Smith says that he understands that CMS wants to get away from vendor-based systems, but it means NorthShore won’t be able to rely on its Epic connection and will have to depend on regional and statewide HIE projects, neither of which are up and running yet. It will also depend on nursing homes that get referrals from NorthShore adopting EHRs and participating in HIEs, which may be a tall order for them.

While perhaps a difficult set of requirements to meet for some patient care organizations, some industry analysts see the information exchange requirements in the proposed rule as a bold, positive move on the part of ONC. One of these is Richard Temple, an executive consultant with the Weymouth, Mass.-based Beacon Partners consulting firm. “One of the things I really like about Stage 2 is the emphasis on health information exchange and transitions of care,” Temple says. “The notion that they’re mandating what they call a summary of care record, while allowing some latitude around it—that’s going to be huge, because it’s really going to plant a seed, and the fact that they’re mandating that 10 percent of those documents have to be conveyed electronically is laying a foundation there as well.”

Temple, who overall says he is very positive about the shape of the proposed rule, adds that “That kind of a common summary of care record, coupled with the certification requirement that systems be able to use the DIRECT protocol, that is going to allow for secure exchange of data without point-to-point proprietary interfaces, is huge, because it makes electronic data exchange something that is a lot more affordable and a lot more doable.”

Metrics requirements seen as challenging to some
Russ Branzell, vice president and CIO of Poudre Valley Health, in Ft. Collins, Colo., says that “My concerns now about Stage 2—the positiveness and the concerns—are actually identical to those around Stage 1.” Branzell, who has been a member of the metrics work group at ONC, says, “I think the standards are appropriate for some organizations, though way too weak for others. For others still, the standards are still going to be too fast. The metrics are what are going to be challenging again in Stage 2 as in Stage 1, for some organizations.” Still, he adds, “ONC is trying to honor the original intent of the law, and that is to say that Stage 2 should be about actually tracking and improving clinical outcomes.”

With regard to the complexity around metrics, Branzell cites the example of working with MU’s requirements around VTE (venous thromboembolism) prophylaxis: “It gets down to tracking a specific clinical environment around how something like how VTE prophylaxis is tracked and measured in an organization; when it’s appropriate, not appropriate, and when exceptions take place, how you analyze them—all of those elements will all be difficult.”