During a July 23 hearing held by the Office of the National Coordinator for Health IT’s (ONC) federal advisory committees, chief information officer and chief medical information officers shared their concerns about the challenges they see ahead in Stage 2 of meaningful use.

Pamela McNutt, senior vice president and CIO of Methodist Health System in Dallas, said her biggest concern is that Methodist doesn’t have enough time to implement the 2014 certified software. “We were an early adopter of our vendor’s certified 2014 release, yet we just upgraded last week. We are in the queue to have the patient portal delivered in August,” she said.

“Since every vendor’s approach to the measures will be different, we must exercise the system to understand how the measures work in our upgraded software. We know that there will be many workflow and screen changes needed that will yield heavy training and education needs for our staff.”

She listed five Stage 2 objectives that will be most difficult for Methodist:

1. Patients actually access their records in the patient portal.

2. Data exchange at transitions of care.

3. Fully automated medication reconciliation for 100 percent of patients.

4. Summary of care electronically exchanged 10 percent of the time.

5. Creating completely accurate quality metric data directly from the EMR remains a challenge.

McNutt said she is concerned Methodist will experience unintended consequences due to a hasty implementation if it rushes to start its 90-day Stage 2 reporting period by July 1, 2014. She suggested that while Stage 2 should start in October 2013 for those that are ready, providers should be given an extension well beyond Sept. 30, 2014, and there should also be allowances for phasing in the more difficult measures.

Randy McCleese, CIO of St. Claire Regional Medical Center in Morehead, Ky., noted that small, rural hospitals such as his are dealing with razor-thin margins and rounds of staff layoffs as they try to pay for new features such as public health interfaces and patient portals. A patient portal to access the patient’s continuum of care record that is housed in multiple systems is a significant capital outlay, he noted. In his written testimony, McCleese added that quality measure reporting is also a challenge. “The multitude of state and federal agencies and organizations that require reporting is significant and there seems to be little in the way of standardization of how they want and need their data. Substantial resources (human and systems) are being focused on the required reporting. Synchronizing several of these report requirements would substantially reduce the provider efforts and allow more resources for direct patient care.”

In both his written testimony and five-minute oral report, Craig Bradley, M.D., chief medical information officer of Texas Tech Physicians of Lubbock, offered some blunt observations.

In response to a question about why eligible providers may be electing not to participate in meaningful use, Bradley said that in smaller physician groups, the $44,000 total incentive split up over five years simply isn’t enough to convince physicians to invest the amount of work required.

In his written testimony, Bradley said that it is only two months until Stage 2 attestation could/should begin for eligible hospitals (and only five months for eligible providers) and Texas Tech Physicians’ vendor has, as yet, not even finalized functionality or workflow suggestions. “So, without a dedicated EHR adoption team at the ready, how could a small group be ready to roll out new workflows on very short timelines?”

Bradley also noted that some providers might be meeting the letter of the law, but not necessarily the spirit of the law in regard to meaningful use. As an example, he recently polled about 15 colleagues at other institutions or large practices with this question: What percentage of the patients in their EHR have a fully populated and completely accurate problem list, past medical history, family history, and surgical history? The consensus was that as a group, they settled on only 25 percent. “That ought to scare the bejesus out of you,” he told the hearing attendees. In his testimony, he said he believes the most important measures for Stage 3 are the ones that allow patients to interact with their own medical records. “Patients are the key pieces in building accuracy. Pushing more clinical decision support on data that is not pristine is going to result in disappointment.”

In his written testimony, Bradley added that he would like to see a Stage 3 measure that requires reporting of clinical decision support statistics. “Having eligible providers review the number of alerts they override compared to the ones which result in a modification of behavior is a vitally important tool for two reasons,” he noted. “First, it helps to reinforce the importance of said measures. Second, it is important to review and prune the clinical decision support alerts. As we all know, alert fatigue is a real problem and reviewing the signal to noise ratio of these alerts should be required.”

He also suggested that vendors should be required for certification to allow for the recording of genetic information in some way.“There are DNA snips that we know with a fair amount of certainty could be useful for clinical decision support in terms of prescribing, treating, or screening. There is no time like the present to require EHR vendors to start grappling with this.”