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A Clash of Coalitions Coming?

March 3, 2011
by Mark Hagland
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Medical, consumer groups see MU Stage 2 very differently

Even as providers struggle to fulfill Stage 1 meaningful use requirements, conflicting waves of interest are already rising around the potential Stage 2 requirements, with consumer groups and medical societies urging the federal government in different directions regarding the rigor of the Stage 2 requirements, as officials at the Office of the National Coordinator for Health Information Technology (ONC) receive comments from interested parties around Stage 2 issues.

On the healthcare professional side, a coalition representing the American Medical Association and 38 other national medical societies and associations (including the Medical Group Management Association, plus a broad range of medical specialty societies) sent a letter on Feb. 25 to Joshua Seidman, Ph.D., at ONC, urging ONC to take a number of steps. The coalition’s letter stated that “Inflexible, overly ambitious incentive program requirements will only hinder health IT transitions underway today. Promoting greater flexibility to meet meaningful use requirements will help us achieve the desired outcome for the Medicare/Medicaid EHR incentives—accelerating the widespread use of technology to improve our nation’s health care delivery system,” the letter urged.

Among the specific steps the coalition urged ONC to take were the following:

  • “The Centers for Medicare & Medicaid Services (CMS) and the ONC should survey physicians who elected to participate and those who elected NOT to participate during Stage 1 of the incentive program and identify barriers to and solutions for physician participation prior to moving to Stage 2.”
  • “Measures for meeting meaningful use should factor in appropriate use. Reasonable exclusions for many requirements should be included so that a physician can opt out of the measure if the measure has little relevance to the physician’s routine practice…”
  • ONC and CMS should “thoroughly assess” the impact on efficacy of any new measures in the core set of Stage 2 measures, and should assess the potential of administrative burden and costs that would be added to physicians’ efforts in order to achieve meaningful use.
  • “High thresholds should be avoided for objectives that cannot be met due to the lack of available, well-tested tools or bidirectional health information exchanges.”
  • And, “Measures that require adherence from a party other than the physician should be removed (e.g., patient’s accessing patient portal, labs reporting test results).”

One of the key issues that the coalition identified in its letter around what its members considered overly burdensome requirements were those that have been mainly primary care-focused, with little relevance or benefit to specialist physicians, yet without what the coalition considers appropriate exclusion categories. “Eight of the 15 Stage 1 core measures and three of the 10 Stage 1 menu options do not include an exclusion category,” the Feb. 25 letter noted, adding that “We strongly recommend that many of the measures for Stage 2 include an exclusion option so that a physician can opt out of the measure if the measure has little relevance to the physician’s routine practice.”

Meanwhile, also on Feb. 25, a coalition called the Consumer Partnership for eHealth sent an equally strongly-worded, detailed letter to Dr. Seidman at ONC, focusing on the benefits to healthcare consumers of a very rigorous process in Stage 2 and stating that “We strongly support the transition of all ‘menu’ (optional) criteria from Stage 1 to ‘core’ (required) in Stage 2.” The Consumer Partnership is an umbrella coalition of 25 national consumer, senior, and organized labor groups, including the American Association of Retired Persons (AARP), Families USA, the National Consumers League, the AFL-CIO, and the Service Employees International Union (SEIU).

Among the numerous recommendations of the Consumer Partnership for eHealth were the following:


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Hi Mark,
You did a great job of describing these contrasting viewpoints. Perhaps we'll see a repeat of Stage 1, when the proposed rule required more dramatic change, and the final rule backed off somewhat, and providers breathed a sigh of relief. Of course, it will also depend on other factors, including ONC's perception of how many providers are having success with Stage 1 and who replaces Dr. Blumenthal as ONC's leader.

Mark, I concur with David. This post really captures the essence of Stage 2 from the implementer's view and the consumer's view.

Apart from this current discussion, the broader issue is what should be the rules of goal setting? There are two wildly different general approaches, incremental and assumptive. For a good discussion of this topic, go here: http://www.manager-tools.com/2010/12/assumptive-goal-setting

The provider/implementers are arguing for well qualified incremental improvements, with vague and inertia-ladden caveats that sound like they would prefer to opt-out of the whole thing. On the other hand, given the high percentage of small practices with little or no infrastructure today (beyond nearly obsolete billing systems), they have a highly defensible and rational case.

Some providers would look to the consumer's agenda and jaundicely observe a demand for a higher level of service without a commensurate obligation to pay for it. That's often healthcare, isn't it?

When Dr. Blumenthal has spoken, he has clearly and consistently argued that the government has an obligation to strive for assumptive goal setting. If scope should be broadened and thresholds raised to these assumptive (consumer described) goals in Stage 2, what should be the reciprocal obligations on the government and consumers to address the very real implementers challenge?

David and Joe,
Thank you both for your excellent, thoughtful comments!
David, I agree completely, the degree of rigor of the stage 2 MU requirements will definitely depend to a significant degree on the perceptions of ONC officials with regard to progress in stage 1, and particular the perceptions of whoever the new National Coordinator is.
Joe, thank you for sending me background offline regarding assumptive goal-setting I think this is a fascinating situation, in which there are so many stakeholders and dynamics involved, there are quite a number of possible scenarios for how this could all play out in the next three or four years. There is certianly an argument for broadly assumptive goal-setting here in principle indeed, the whole concept of achieving meaningful use under the HITECH Act could be argued to be an exercise in assumptive goal-setting how ONC officials calibrate everything will determine what happens.
Thank you both for your very thoughtful comments!