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Stage 2: New Challenges Emerge as CMS Raises the Bar

August 28, 2012
by John DeGaspari
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Patient engagement, interoperability, and governance issues top list of concerns
Initial reactions to the meaningful use Stage 2 final rule released last week by the Centers of Medicare and Medicaid Services (CMS) have overall been fairly positive, but also point to significant challenges. While CMS has raised the bar in several important areas, it also showed some flexibility by lowering the thresholds and moderating reporting periods. Yet experts interviewed this week also note that the new mandates may pose special challenges for small, critical access hospitals and large medical groups.

Charles E. Christian, CIO of Good Samaritan Hospital, Vincennes, Ind., said that CMS responded thoughtfully to concerns of providers in the Stage 2 final rule. “They moderated the things they could and took everything into consideration,” he says. “They identified the significant stumbling blocks for most of healthcare and they moderated those.” Nonetheless, he said the Stage 2 rule will be challenging for smaller, rural and critical access hospitals that have fewer resources and may have more catch-up work to do in meeting the requirements.

Regarding the requirement that 5 percent of patients download and transmit their health information, it is the only mandate that is outside the direct control of the provider, Christian says. “CMS is making us accountable for the actions of our patients,” he says, adding that exclusions are based on broadband access of the provider, not the patients. He is also concerned about being able to track the patients’ activity. “Whatever portal activity we put in place, there has got to be metrics involved that will allow us to track the patients’ activity, so we can record that,” he says.

Christian also sees an issue with access by the patient. Samaritan, for example, is a multi-entity organization with three separate EMRs, each for a center of care, and each with its own portal. The issue is that patients who see their primary care physician and also use care from another setting such as the community health or outpatient diagnostic services can use more than one portal, “and we don’t want to do that. We want to one portal in which they can do everything—appointments regardless of the care setting, results, studies, secure messages to the provider, all in one place. We will continue down that road,” he says.

He adds that in Indiana, which has a robust health information exchange, some of that interaction can be done at the HIE level. The question is, how is going to be funded and who is going to pay for it,” he says.

Christian says that the Stage 2 rule raises the bar for interoperability and the exchange of health data. He notes that Samaritan is in an area with a strong HIE, but meeting the interoperability requirement will be difficult for small critical care access hospitals in areas of the state with no HIE. “The smaller the organizations the more difficult it is going to be, because they don’t have the talent and the resources, so they lean on the vendors and the vendors will charge them money to do that.”

Christian was not surprised that CMS raised the requirements for quality measures. “That’s one of the things we are tracking internally—a lot,” he says. “Quality measures for me have always been the most difficult thing to do, because it depends a great deal on how items are documented in the electronic chart,” he says. “That type of clinical information doesn’t lend itself most of the time to discrete data elements.”

He says that it is interesting that the imaging mandate was kept in the Stage 2 rule, and having the images accessible from the electronic medical record. “I’m looking for the definition of what ‘accessible’ is. Does it mean you have to be linked so it takes you right to the studies, or does it mean that you have to get to it from within the certified health technology,” he said. He adds that it is not a problem for Samaritan hospital, but it could be for a physician practice that uses multiple imaging locations.

Laura Kreofsky, a principal with Naperville, Ill.,-based Impact Advisors LLC, says CMS did a good job laying out the Stage 2 requirements, and showed some flexibility in the mandates. She says provider organizations need to start preparing for greater patient engagement through the use of patient portals. Also, although CMS has lowered the summary of care documents from 65 percent in the proposed rule to 50 percent in the final rule, provider organizations will need to revise their workflows and documentation now to meet that requirement.

Governance and management of the Stage 2 mandates are going to be very challenging for large medical groups, she says. Large physician practices with providers joining over a period of time are going to have a “compendium of providers to track with different requirements and different reporting time periods. It’s going to be a challenge,” she says.

There is a tremendous amount of decision making that goes into each of the elements of setting up a program of meaningful use, Kreofsky says. CPOE, for example, involves granular decisions about moving to the new denominator or continuing to adopt the old one, or whether or not to include standing orders, she says. That magnifies itself when you are in a large organization, because there are different practices with different geographical and practice variations that have to be worked out, she says.

Kreofsky says she is concerned that large organizations have the pushing power to administer programs like this, because of other demands such as accountable care, ICD-10, value-based purchasing and hospital readmissions. “It’s an onslaught of programmatic changes,” she says.