On Tuesday, May 20, the Health IT Policy Committee is holding the first of two listening sessions featuring testimony from physician practice and hospital IT leaders about their Stage 2 meaningful use concerns. In their written testimony, the health IT leaders highlighted the challenges around transitions of care and the patient engagement “view, download and transmit” (VDT) requirements. Some called for making Stage 2 the final stage of meaningful use or for delaying Stage 3 to allow the industry to optimize work already done.
In his written testimony, Michael Lee, M.D., M.B.A., director of clinical informatics at Atrius Health, a large multi-specialty ambulatory group practice in the greater Boston area, said the “complexities of the measures around transitions of care make this the largest challenge we have faced thus far.”
Among other things, he noted, Massachusetts is an “opt-in” state for its health information exchange (Mass HIWay). “The difficulty of implementing that and the Meaningful Use requirement that we send transactions has created an unusual dichotomy where everyone is preparing to send transactions but as of today no Massachusetts organization has published Direct standard addresses to receive our clinical summaries, so we cannot meet this measure at all as originally intended.”
On the in-bound side, Atrius receives automated ADT (admission, discharge, transfer) notification from some local medical centers. It then triggers messages to clinicians about those events and use our discharge nursing program to ensure patient follow-up, Lee wrote. “We then ask providers to document medication reconciliation at the next appointment.” However, many transitions of care do not have the above notification and the timing of the messaging and the most-appropriate time to perform medication reconciliation is a significant workflow challenge, he noted.
Lee said Atrius believes that it will begin to be able to attest for Stage 2 for some providers beginning in the third quarter of 2014, and is hopeful that the remainder will be successful following the fourth quarter. “However, to be in May 2014 and still so unsure about our success in Stage 2 should serve as a harbinger for you that most eligible providers nationally in 2014 will not meet this hurdle,” he added. “We are hoping that the above gives you significant pause about moving on to Stage 3. It is our view that it will take about five years before we can fully assess the impact of all of this work. Like you, we consistently want to demonstrate the importance of our work on patient outcomes. Simply raising the bar on technology may in fact reduce the success of Meaningful Use by focusing all the resources on meeting the needs of the program in the hopes it will improve outcome but without any real data.”
Lee recommended making Stage 2 the final “stage” of meaningful use, and every three to five years, ONC should add a small number of features as a minimum base for certification and then measure outcomes, not just processes, from clinician groups and hospitals to refine reporting and comparative metrics over time. “The current stage jumps are just too large to absorb and as you have seen from your thoughtful delays, are harder to achieve than anyone thought at the outset,” he wrote.
As we transition into the “penalty” phase of Meaningful Use, there will be many physicians and hospitals that cannot reach Stage 2, Lee noted. “Planning a Stage 3 right now will hinder your progress and program. Moving forward with a long-term designation that EHR use and reporting will be required for CMS payment makes sense. The goal of setting a successful and ongoing standard for technology availability and reporting on the outcomes supported by technology will go a long way toward helping all of us achieve the Triple Aim.”
In her written testimony, Pamela Arora, CIO of Children’s Medical Center Dallas, also discussed transitions of care. “One of the most significant challenges associated with meeting meaningful use Stage 2 requirements involves ensuring the market is ready to accept Continuity of Care Documents (CCDs),” she wrote. “With relatively few providers prepared to accept CCDs, the flow of information is not as robust as we would like.”
Stephen Stewart, chief information officer for Henry County Health Center, a small critical access hospital in Mt. Pleasant, Iowa, noted that many of its challenges related to public health and transitions of care have to do with referral sites not being ready to receive messages. In one case, the required Direct secure messaging method of delivery is a “quantum step backwards” from the HL7 automated messaging already running directly into an independent providers group’s EHR, he wrote.
Stewart also mentioned being held accountable for measures beyond HCHC’s control, especially the view, download and transmit capability. He admitted to mixed emotions about the measure: “Five percent actually use the VDT capability. This we have absolutely no direct control over, yet are subject to reimbursement penalties if we fail to meet it. I believe we are being held accountable and possibly punished for something we cannot control. We cannot force a patient to use our portal.” However, he noted that engaging the patient is a key to bending the cost curve. “This is a step in the right direction,” he wrote, adding that “with some creativity, it is doable.”
Stewart pleaded for a period of time following MU2 to allow the community as a whole (both the EHR partners and the providers) to optimize work already done. “We need to go back and fix processes to make them more efficient and time-sensitive for the providers.”
He added that the delay of ICD-10 punished those who responded to CMS direction in favor of those who did not. “My organization was well prepared and ready to move,” he wrote. “Many dollars had been spent on training, system upgrades and testing. Much of that may be wasted if CMS is not ready to take ICD-10 claims in October. I believe the industry would have been far better off to have stayed the course on ICD-10 and delayed the penalty date for MU2 by a year.”