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Digging Deeper Into Transitions of Care With an MU Expert

February 5, 2015
by Rajiv Leventhal
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Naomi Levinthal

When it comes to the transitions of care (TOC) requirement for Stage 2 of meaningful use, providers have had their share of difficulties. In fact, a study published last year in Health Affairs that looked at the adoption of electronic health record (EHR) systems in hospitals since the enactment of the Health Information Technology for Economic and Clinical Health (HITECH) Act found this measure to be a major pain point for healthcare organizations trying to attest to Stage 2. Researchers came to the conclusion that “Functions related to electronic data exchange, both with other providers and with patients (in particular, providing summaries of care during transitions and giving patients the ability to view online, download, and transmit their health information) are critical gaps.”

While the transitions of care objective in Stage 1 is optional, the Stage 2 requirement includes three measures, two of which rely solely on the use of Certified EHR Technology (CEHRT) to electronically transmit summary care records for transitions of care and referrals. Naomi Levinthal, consultant, research and insights at Washington, D.C.-based The Advisory Board Company, is an expert when it comes to meaningful use and care transitions, and was a valued source of information for Healthcare InformaticsTop Tech Trend on transitions of care. While parts of HCI’s interview with Levinthal were in that trend piece, this interview represents a more comprehensive look at the discussion between Levinthal and HCI’s Associate Editor Rajiv Leventhal on meaningful use and transitions of care.

How are policymakers closing the gaps when it comes to transitions of care?

The best example is around meaningful use, which is where I spend all of my time. You can see where there is a meeting of the two groups, the vendors and the regulators, coming together trying to figure this out from a meaningful use perspective. It’s a toe in the water right now. What’s happening right now with meaningful use, in relation to transitions of care, is that there is an optional requirement in Stage 1, for which a very high percentage of providers and hospitals did not take the government up on.

Now, everyone has to meet three measures in Stage 2 around transitions of care. It’s a rudimentary functionality that you see happening and what’s required for meaningful use, that’s what I mean by toe in the water. What a doctor’s office or hospital has to do is collect information about what happened to a patient and send it off in form of a Consolidated-Clinical Document Architecture (C-CDA) or summary of care record to the next provider of care. How it gets there isn’t a concern to the Centers for Medicare & Medicaid Services (CMS) for one of the measures, but it is for the other two. That’s where we see people struggling, and we have seen some relief from CMS in terms of the flexible reporting options that they have afforded to providers for 2014 if they’ve had a hard time getting their hands on the certified upgrades that everyone needed in order to do meaningful use in 2014.

There are three measures [related to transitions of care in Stage 2]. An example from a hospital perspective is that for all of the patients you see, things happen to them, and then they get discharged. For every one of those discharges, you have to send out a summary of care record whichever way you like for the first measure, and you have to do that for 50 percent of the patients you see. For the second measure, you have to send all those summaries out electronically. But the parameter by which that has to happen have become troublesome. In 2012, when the rule first came out, the options were Direct secure messaging, or you could hop onto eHealth Exchange to send it outbound. But people couldn’t get their hands on the Direct messaging functionality of their systems, and they still have that problem today. Also, the latter option wasn’t even available until pretty recently when CMS made it clear that you could basically use any uncertified mechanism to get that summary record outbound as long as you have sent it out using the Direct messaging that is native to your system that your vendor certified. CMS has since cleared up the ways to get that message outbound.  It kind of depended where you were getting that information from as to what your viable options were. Now that has relaxed some in terms of technical considerations.

The third measure is a yes or no. One option is to take an exchange you did to meet measure two, and show that you had the transmission be successful, and it went to someone who was using a different vendor system than your own. Cerner to Epic works, for example, but different versions of Epic would not work. The other option is, if you operate in area of country where there is a closed-loop environment, and most people are on the same system, you can also do a test of an exchange with an Office of the National Coordinator for Health IT (ONC) test EHR system. I have been surprised by the amount of people that have opted for that route. That’s been a good thing.

Since two of the three TOC Stage 2 measures require CEHRT, CMS has provided some recent relief as of September 2014. CMS said that as it was gauging folks’ readiness for Stage 2, it was finding that people were unable to get their hands on the certified upgrade that everyone needed to be up and running on in 2014. For some providers, their vendors weren’t certified in the first place for these new criteria that they needed to satisfy; others couldn’t get the technology fully implemented. So CMS has said that if you find yourself in one of those buckets, it will let you roll back the clock and report on earlier versions of meaningful use measures and objectives from Stage 1 even if you’re supposed to be in Stage 2 in 2014.

CMS also created the option for providers who couldn’t meet the second measure of the TOC objective. If no one was able to accept your summary of care records electronically—and you can prove that—you can roll back to the Stage 1 objective. It provided another way someone could still meet meaningful use in 2014, but report on a different set of objectives and measures, essentially taking out the TOC objective for Stage 2.

How about the other group? What are vendors doing to help close these gaps?

Vendors are doing what needs to get done in order to meet meaningful use in and of itself. What is required to be built into these systems is pretty rudimentary. For example, I don’t have to prove that you looked at the summary of care record if I’m the hospital sending it out to the specialist. But I think we will see some evolution as we move towards Stage 3, how we will have to encourage the market to be more actionable with information that is ported from one source to the next. I do see that they are rising to the challenges that providers need to meet in terms of meaningful use purposes, but most do not do much else with what they have to do other than meeting MU alone. It’s such a huge leap forward meeting the Stage 2 demands from Stage 1. So much else is going on, it’s taxing just getting ready for meaningful use alone.

How do you see this requirement playing out in Stage 3?

It will be interesting to see what happens with Stage 3 proposals, where the government will push folks. If we look at what the Health IT Policy Committee has finalized with their recommendations, we think that they require some sense of this actionability, if you will—“I’m going to send you something and make sure you look at it,” such as orders that need to get completed, what the progress rate is, and the completion rate on those. Seeing that order management lifecycle is something that might be on the docket.

There are also interesting recommendations around care notifications. If you are a patient from a specific specialist, and they need to admit you to the hospital, that specialist might be required to alert a primary care provider for that patient—a notification happens when a significant health event occurs. We see on the surface that the Health IT Policy Committee is pushing CMS and ONC to think of it not as a huge leap forward from Stage 1 to Stage 2, but instead more of a lighter lift from Stage 2 to 3. But we will have to wait and see.

Has MU become too “checklist-y” for providers? Isn’t it supposed to be so much more?

We’re just scratching the surface with this, as there are just huge demands on all organizations to get ready for the much more challenging objectives to meet for Stage 2. We advise folks to think strategically about meaningful use, because there will be a day when it’s not there anymore but you have put all this effort in creating the IT systems that support all of these processes. There’s no point in putting everything together without having an end game, so you need to think about alignment opportunities.

 If you are working on population health management and you want to get better at care coordination, why not leverage what you’re doing for meaningful use for those initiatives as well? Find ways to connect those inputs with outputs for other strategic inactivates. People are maxed out right now, trying to make sure things will get done. It is checklist-y. I think that people are still trying to think about that end game. We don’t know when [this program] will sunset, but nobody wins in meaningful use if you don’t figure out ways to make it more meaningful to you and the patient.

How does this all tie into readmissions?

We look at reports for our members’ meaningful use metrics, and we look at discharges and unique discharges. I can tell if they have huge readmission rates or not just by looking at those denominators. It’s important to look at meaningful use performance over your reporting period to get an idea of what your readmissions rate might be. The TOC objective will look at a true count of all your discharges, and the view/download/transmit measure will look at the unique discharges that you have. That will give you an idea of where your pain points might be and figure out where you can help your readmissions rates.


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