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The Least Popular Thing About Stage 2 MU So Far

March 19, 2012
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Providers question requirement that 10 percent of patients access their data

I attended a HIMSS Virtual Briefing on Stage 2 of meaningful use last week. Kenneth Ong, M.D., chief medical informatics officer of New York Hospital Queens, gave a valuable presentation summarizing what is new about Stage 2 and the areas in which CMS has specifically asked for public comment. But it didn’t take long for the audience to zero in on the new proposal that isn’t sitting well with providers: the patient engagement measure that requires that not only do more than 50 percent of patients have the ability to view, download, or transmit their data, but that 10 percent of patients actually have to look at their data, download it, or transmit it to others.

One HIMSS briefing participant wrote in the online discussion: “I think that the requirement to enforce a threshold involving 10 percent of patients in the access, downloading, or viewing of their health record is completely unrealistic. The hospital/EP requirement should end with the availability of the data via an online portal. Also, an EH/EP has absolutely no control over the transfer facility EHR vendor! How can we be held accountable for the choices made by other facilities? Also, this will need to be accomplished via a Health Information Exchange Network. How can the hospital possibly track the EHR vendor of the recipient? The requirement should end with the actual submission of patient summaries of care to the HIE.”

When Dr. Ong was asked how providers could be held accountable for making sure patients use a portal, he said, “I don’t have a good answer. I have that same question myself.”

He added that the question has come up many times in listservs and other forums where people are talking about meaningful use.

He added that there is good evidence from integrated health systems such as Kaiser Permanente to suggest that patients with chronic diseases make good use of portals to ask for appointments and get medications refilled. But the evidence is less clear so far about whether you get the same sort of benefit to patient care and efficiency in a stand-alone hospital.

There are also questions, Ong added, about whether the 10 percent threshold should apply to all specialties, or whether there should be different values for ambulatory care surgery vs. a pediatrician. “These are really important questions,” he added.

Others have noted the challenge this threshold presents. Asish Jha, M.D., an associate professor of health policy and management at Harvard University, wrote on the Health Affairs blog that “federal policymakers are trying to move the provider community from the ‘ability’ to do things electronically to actually demonstrating that they are doing it.  While this is a laudable move, I suspect that many providers are going to push back.  It is not clear that 10 percent of patients will want to view, download or transmit their data to others.  It is hard to imagine that we are going to punish providers when their patients choose not to look at their own data.  Whether this part of the preliminary rule will make it into the final one is unclear.”

Louis Wenzlow of the Rural Wisconsin Health Cooperative wrote on cooperative’s Rural Health IT blog that the requirement introduces a new wrinkle that is likely to disproportionately negatively impact rural providers. He notes that there are exclusions available to rural providers in areas where broadband Internet access is limited. But Wenzlow suggests that, “even with the 4-Mbps broadband availability exclusion provision, it’s likely that rural providers (who disproportionately serve older patients) will have significant challenges meeting a core requirement that is not reasonably within their control. My experience of the ‘provide patient with an electronic copy of health information’ Stage 1 objective is that many rural providers had zero patients make the request. In this context, a 10 percent access core requirement seems unjustified.”

Based on these and other comments, my nominee for “Measure Most Likely to be Scaled Back After the 60-Day Comment Period” goes to the 10 percent rule.

Anyone in the Healthcare Informatics community disagree? Or do you have any other measures you would nominate for Most Likely to Be Scaled Back?



Hi! I'm Amanda Vandervoort from Pratt Regional Medical Center and am actually the "one HIMSS briefing participant" from the second paragraph! It is gratifying to see that the Healthcare Informatics community may be considering the same questions that have emerged upon my own first reading of the MU Stage 2 proposed rule.

I am reading the Steve jobs book so excuse me for including this Apple marketing theme. However it does apply in this case. Not all practices will be able to meet this requirement but certainly all PCPs, Internal Medicine and several specialties will. If you haven't noticed the Internet is big and lots of people use it. I would guess that at least 90% of most patients have access or have a family member or parent who does. So what doctors are balking at is that they have no control over this. But they do. They can influence the required behavior by selling this to their patient. Another way would be to offer patients an incentive (sound familiar docs?). If the patient (or proxy) uses the portal to perform a particular service (review labs, make an appt, send your records to another treating provider) the doc waives the co-pay. Docs might say they will lose money on this but I don't think that is true. I think a service like this can cut overhead (taking phone calls, calling patients with results, faxing over records to another provider) so I am guessing that this will be a "wash" over time. Research also shows that engaged patients come back for follow up visits. They probably make their money back right there. @MikeLGagnon

And your reply is an interesting approach. Incentives are good, and once patients are educated, many want to access their medical records. There was a recent survey completed a couple of months ago, indicating majority of consumers want to be able to access their medical records. As an MU SME and HIT consultant, I have seen the benefit and value and also attest to the fact that patients are interested. The 10 % goal is not too difficult to achieve once education is in place.

Jim Borda
MU SME and HIT Consultant

I agree that having an online portal and encouraging patient engagement is a great idea! However,the premise of the above article is that it is unfair to attach a percentage to that goal when many rural hospitals may be disproportionately affected. The issues compound when one considers that the patient population includes a great number of elderly, coupled with the connectivity problems still faced in rural America. The requirement to provide a portal should not be tied to a specific percentage in the first year of Stage 2. Should not vendors crawl before attempting to walk? For some, creating a portal and rolling out to healthcare facilities will be challenging enough.

I completely agree, the very first thought I had upon reading the Stage 2 proposed rules was that patients accessing their records online is completely out of our control. Personally, I'm not even sure that I would access them online--I won't even go into my concerns with respect to that.

Seems to me that the percentage that access their info would be inverse to the quality of care. As an example if I take good care of the patient, give them all the info they need, provide them a wallet card with the written info they need, make sure they understand, answer all their questions and follow up with them they will not need to access the data. If I do the opposite, rush them through, glance over the problems, fail to give them their results and forget to follow up then they will access the data to find answers to their questions. Maybe the quality measure should be at least 80% given access but less than 50% of those with access actually access it.

Patient Engagement is one of the biggest drivers of positive outcomes so the ONC should be lauded for using Stage 2 Meaningful Use as a catalyst to increase engagement. Consider that 75% of healthcare spend is spent on chronic disease and patients' (in)actions are the biggest determinant of outcomes (e.g., do they fill Rx's, take meds, exercise, diet, etc.). It's going to be virtually impossible for providers to succeed in a value/outcome based model w/o patient engagement.

Also consider that the 3rd most searched category on Google is health-related and that is across the entire population (not just sick people). It's predictable that vendors that have focused on getting bills out as big and fast as possible (their logical focus given historic reimbursement) are pushing back as driving patient engagement in a fundamentally different skillset. The good news is there are hundreds of new companies focused on patient engagement that providers can work with that don't charge a king's ransom. If one was to gather them in a room, I bet they could come up with 101 ways to far exceed the 10% threshold in less than an hour. This would assume that a proxy (e.g., adult child of an elderly person) using the system could also count towards the threshold. My nearly 80 year old, non-techy father can manage to buy and check-in for flights. In a heartbeat, he'd login to info about his conditions if it was as easy as buying a plane ticket. It's a failure of imagination to not think there are many ways to exceed a low, low 10% threshold.

If you are interested in efforts to increase the requirements, you can follow this link.