As more healthcare leaders begin to pore over the Stage 2 Notice of Proposed Rule-Marking (NPRM), also referred to as the “proposed rule,” for the meaningful use process coming out of the American Recovery and Reinvestment Act/Health Information Technology for Economic and Clinical Health (ARRA-HITECH) Act, they are adding their voices to the wide-ranging discussion emerging across the industry.

Specifically, healthcare CIOs and consultants are citing a variety of health information exchange (HIE), e-prescribing, clinical decision support (CDS) infrastructure, and patient engagement requirements described in the proposed rule, as issues that their colleagues should be thinking about.

Randy McCleese, vice president for information services and CIO of 159-bed St. Claire Regional Medical Center in Morehead, Ky., says that although he hasn’t had the time yet to review the Stage 2 NPRM in detail, the one area that stands out to him as most challenging is patient engagement. A Meditech customer, McCleese had a chance to see the vendor’s patient portal offering in beta form at the HIMSS12 Conference last week in Las Vegas. “The earliest we will get it is in early 2013 for the hospital, and then we will have to start working with clinics and physician offices,” McCleese says. “Getting the patient portal and secure messaging in place is going to be a reach for us,” he says, adding that, “The requirement that you have to demonstrate that 10 percent of the patient population actually uses the portal ‘threw us for a loop.’ That wasn’t expected. A lot of people here in Northeast Kentucky have never used a computer.”

St. Claire doesn’t expect to meet and report on Stage 1 requirements until early in 2013, but McCleese says that by the time the hospital has to meet Stage 2 requirements, it should be in good shape concerning most of basic requirements concerning electronic medication administration record, (eMAR) care coordination through HIE, and CPOE (computerized physician order entry).

Positive in Vermont

Chuck Podesta, CIO of Fletcher Allen Health Care, Burlington, Vt., had a positive initial reaction to the proposed Stage 2 rules. “Overall, I think they were very thoughtful,” he told Healthcare Informatics via e-mail. “I believe that meeting Stage 2 will actually do something for the quality of patient care versus an incentive check for providers,” he says.

Among the points Podesta sees as most important in stage 2 are the following:

> The rule confirms a one-year delay for the onset of Stage 2 implementation.

> It aligns clinical quality measures with those of National Council for Quality Assurance (NCQA), the Physician Quality Reporting System (PQRS), the Centers for Medicare and Medicaid Services (CMS) Shared Savings Program, the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), the Hospital Inpatient Quality Reporting (HIQR), and the Joint Commission (TJC). “This will allow us to build inputs once to satisfy all requirements,” he says.

> Twelve CQMs for eligible professionals and 24 CQMs for hospitals don’t seem too onerous, especially given the alignment with the above programs, Podesta says.

> The Stage 2 rules take a menu approach rather an “all-or-nothing” approach.

> The proposed rule also clarifies the certification process for vendors.

> The Stage 2 rule clarifies the health information exchange (HIE) criteria, so that it is based on transitions of care, he says. Rather than having just a test or a successful test, they identified the information that should be sent electronically with the patient as the patient moves from one care setting to another. This makes more sense than just sensing a continuity of care (CCD) document to an HIE upon discharge or visit,” Podesta says.

In addition, Podesta notes that the Stage 2 proposed rule clarifies the numerators and denominators for some of the stage 1 items. “You can either the use the new ones or keep the old ones for future attestations,” he says, adding that the flexibility makes sense.

CIOs urged to pay close attention to quality measures

Judy Hanover, research director at IDC Health Insights in Framingham, Mass., says that the NPRM follows pretty closely the recommendations of the federal HIT Policy Committee and Standards Committee. “I think the increase in requirements for e-prescribing and decision support infrastructure is great,” she says. Hanover also thinks it makes sense to allow physicians in the same practice to report together. (CMS is proposing a group reporting option to allow Medicare providers within a single group practice to report core and menu objective data through a batch file process in lieu of individual Medicare EP attestation through the CMS Attestation website.) “I like the cross-tabulation in clinical quality measures with other CMS programs such as PQRS,” she adds. “If they can simplify submission, it would be good, but it remains to be seen how it will be implemented.”

Bob Schwyn, a principal with the Pittsburgh-based consulting firm Aspen Advisors LLC, says CIOs should pay close attention to the clinical quality measures section of the NPRM, which he believes raises the bar pretty significantly. He said that with Stage 1, some clients manually tabulated results while others were content to rest on their laurels that they were using a certified EHR to meet the measure. “But there should be an increased focus on the quality of data being gathered through the EHR and how that information is incorporated into quality improvement programs,” Schwyn says.

Both Hanover and Schwyn note that the language in the patient engagement section clarifies what is required of patient portals. In Stage 1, Schwyn says, providers tried lots of different ways to provide “electronic copies” of health records to patients, including handing them thumb drives, CDs, etc., rather than thinking about what made most sense from a business perspective.

Healthcare Informatics will continue to share the perspectives of industry leaders on the release of the Stage 2 NPRM in the coming days and weeks.