I don’t know about you, but there’s nothing I like better than reading a 455-page federal regulation before going to bed. I’ve never slept so well in my life!

There’s a lot to digest in the CMS Notice of Proposed Rulemaking for Stage 2 of the Electronic Health Record Incentive Program — from which items moved from menu to core to the way CMS is proposing to deal with clinical quality measures. And over the next several days, the Healthcare Informatics editorial team will be dissecting the proposal and seeking out opinions of CIOs and analysts. But sometimes first impressions are worth recording, so what follows are a few of mine:

First, even though we knew that patient engagement would be a key focus of Stage 2, I was impressed with how strong the objectives are, given that regulators have heard a lot of pushback about these proposals in the past. Using secure electronic messaging to communicate with patients will be a core objective for physicians. And CMS followed the Health IT Policy Committee’s recommendations here. Just as meaningful use has become part of the lexicon, I think we are all going to get used to saying, “view online, download, and transmit.”

Basically, more than 50 percent of all patients seen by an eligible physician must get online access to their health information timely within four business days. And more than 10 percent of all patients (or their authorized representatives) must view, download or transmit to a third party their health information. For hospitals, more than 50 percent of all patients who are discharged from the inpatient or emergency department must have their information available online within 36 hours of discharge. And more than 10 percent of all patients who are discharged from the inpatient or emergency department must view, download or transmit to a third party their information during the EHR reporting period.

And here is the information that must be available as part of the hospital objective:
● Admit and discharge date and location.
● Reason for hospitalization.
● Providers of care during hospitalization.
● Problem list maintained by the hospital on the patient.
• Relevant past diagnoses known by the hospital.
● Medication list maintained by the hospital on the patient (both current admission and historical).
● Medication allergy list maintained by the hospital on the patient (both current admission and historical).
● Vital signs at discharge.
● Laboratory test results (available at time of discharge).
● Care transition summary and plan for next provider of care (for transitions other than home).
● Discharge instructions for patient, and
● Demographics maintained by hospital (gender, race, ethnicity, date of birth, preferred language, smoking status).

I have just had personal experience at two leading academic medical centers on the East Coast, and neither of them offered secure messaging or patient portals. If they are struggling with providing these patient-facing services, you can imagine that small community hospitals will have an even harder time with it.

Even though organizations have known that patient portals were going to be required, this ups the ante quite a bit. I think providers are gong to be unhappy with the requirement that makes them responsible for making sure that 10 percent of patients view or download health information. They’ll argue patient behavior is out of their hands. Of course, in Stage 1, the proposed rule sounded tough to achieve, but after feedback from vendors and providers, the final rule pulled back quite a bit on requirements. It’s sort of a good- cop, bad-cop approach that leaves the industry relieved with the final rule. We’ll see if that happens again.

Another impression I have is that the Health IT Policy Committee members have to be pretty happy with the CMS proposal because it largely follows their recommendations, and in some cases increases the thresholds they asked for.

For instance, it raises the threshold for e-prescribing by physicians from 40 percent to 65 percent, even though the Policy Committee had only asked that it be raised to 50 percent. CMS says it believes “that providers participating in Stage 2 will already have significant experience with this objective and can meet an even higher threshold.”

It seems to me CMS chose to skip only a few HIT Policy Committee recommendations. It is not proposing that hospitals provide structured electronic lab results to eligible professionals. It chose to leave recording advanced directives for patients 65 years old or older as a menu item rather than moving it to core. It chose not to make recording health care team members a separate measure; CMS said this information is better incorporated with other objectives that require summary of care documents and is not necessary as a standalone objective.

There’s a lot more to consider! I’ll be interested to hear CIOs’ response to the new approach to clinical quality measures, among other things.