Even before the rules for Stage 1 of meaningful use were finalized, health IT policymakers were already turning their attention to Stage 2 to determine which criteria would best enhance patient engagement, care coordination, and public health initiatives. As with the first stage, the question is how specific they will be in terms of requirements and timelines.
When the Centers for Medicare and Medicaid Services (CMS) unveiled the meaningful use Stage 1 final rule on July 13, health system CIOs breathed a collective sigh of relief that the agency had scaled back some requirements and deferred others. And many expressed an eagerness to pore over the 864-page document explaining the final rule, then roll up their sleeves and get to work.
CMS is giving providers the benefit of the doubt,” says Daniel Barchi, CIO of eight-hospital Carilion Clinic health system in Roanoke, Va. “If they have invested in infrastructure, this will give them time to continue working on clinical pathways and processes so that what might have seemed unachievable is now achievable.”
While CMS did not offer many specifics on Stage 2 in its Stage 1 final document, the agency did make clear that it will expect more robust use of health information exchange (HIE) and that all the optional objectives will become mandatory.
But if there is one thing CIOs, analysts, and policymakers seem to agree on, it is that people shouldn't focus too narrowly on Stage 1. Instead, they should keep their eye on where they need to be in 2015.
The meaningful use incentives were created to help offset costs and to be a guidepost, so it would be a mistake to look too narrowly at Stage 1 incentives without a broader sense of the overall vision, says Paul Tang, M.D., vice president and chief medical information officer with the Palo Alto Medical Foundation in California. “It is better if you are not chasing rules or incentives,” he adds. “Those may help you along the path, but a more long-term, strategic approach with a vision of improving outcomes for patients is best.”
Indeed, some analysts say too narrow a focus could be detrimental. “Health reform is going to intervene with its own set of requirements, so it will pay dividends to take a bigger picture view of where you need to be in 2015,” says Erica Drazen, managing director of CSC's Waltham, Mass.-based Emerging Practices Group. She also believes it is a mistake to wait for Stage 2 to do electronic medicine administration with bar coding. “It will definitely be there in Stage 2,” she says, “so you might as well plan now and implement it if you can.”
While it is difficult to speculate about what will be in Stages 2 and 3 specifically, Mitch Morris, M.D., a principal in Deloitte Consulting's Life Sciences and Health Care practice in New York, says you don't have to look much further than what CMS is doing with accountable care organizations, alternative payment mechanisms, and pay for performance to see that it has implications for CIOs, because EHRs are central to those efforts.
Morris, former CIO at the University of Texas MD Anderson Cancer Center in Houston, suggests that CIOs have a visual picture of health reform and meaningful use in overlapping circles. “Have a plan that addresses both generally and fine-tune it as you move forward,” he says. “Ask yourself what type of technology you need to meet the broad elements.”
Stage 2 will also see a ramp-up in the expectations regarding clinical quality measures derived from electronic health records (EHRs) rather than claims data.
Janet Corrigan, president and CEO of the National Quality Forum (NQF), Washington, D.C., says her nonprofit performance improvement organization is working on recommendations to present in September to the federal advisory committees of quality measures that can feasibly be accomplished for 2013.
YOU MIGHT THINK THAT JUST GETTING PHYSICIANS ON ANY EHR SYSTEM IS OK, BUT IF YOU HAVE SIX DIFFERENT SYSTEMS BEING USED BY PHYSICIANS IN YOUR ORGANIZATION, YOU'LL PROBABLY HAVE TO ADOPT A SEVENTH JUST TO DO CARE COORDINATION.-ERICA DRAZEN
“We are trying to quickly identify what types of measures can be developed or modified for 2013 to move toward collecting data over the full breadth of care across patient-focused episodes,” Corrigan explains. For instance, providers might be asked to gather data on readmissions across the community rather than just within their own health systems, she says.
Collecting data on those measures across organizational boundaries is a big step for providers, but it is a step in the right direction, Corrigan stresses. Today, patients often fall through the cracks and there is no hand-off of relevant information between providers. “If we are going to get to the real potential of health IT, it has to involve connectivity across the community, and we need to take incremental steps to get there.”
Tang, who co-chairs the meaningful use work group of the federal Health IT Policy Committee, is just gearing up to begin consideration of recommendations to the Office of the National Coordinator for Health Information Technology (ONC) for Stage 2. His work group has held or scheduled hearings on patient engagement, health disparities, public health reporting, and care coordination. Although he doesn't know yet the level of specificity his work group will recommend on these topics, he and other experts and CIOs shared their thoughts on the directions ONC is likely to go.
Highlights of the Stage 1 Rule
CMS’ final rule for the first stage of meaningful use made several modifications of the rule as initially proposed. The changes are widely seen as offering providers more flexibility in their efforts to win incentive payments. Here are some key essentials of the program:
The proposed rule had laid out 23 objectives for hospitals and 25 for clinicians. The final rule is composed of two groups of objectives: a set of 15 core objectives for eligible providers and 14 for hospitals for implementing EHRs, and a separate à la carte menu of 10 additional objectives from which providers and hospitals must choose five to implement in 2011 and 2012.
The core menu consists of essential functions, including: entering basic data such as patients’ vital signs and demographics; maintaining an active medication allergy list; creating up-to-date problem lists of current and active diagnoses; and capturing smoking status. The optional menu items include performing drug-formulary checks, incorporating clinical laboratory results into EHRs, and providing patient-specific health education resources.
In 2011 and 2012 clinicians will have to report data on three core quality measures: blood-pressure level, tobacco status, and adult weight screening and follow-up. The clinicians in addition have to choose three other measures from metrics lists to incorporate into their EHR.
The proposed rule called for computerized physician order entry (CPOE) use for 10 percent of all hospital orders and 80 percent of all orders by eligible providers. The final rule calls for 30 percent of all patients seen in both settings having at least one medication order placed using CPOE. The requirement for e-prescribing using an EHR also was reduced from 75 percent to 40 percent.
Stage 1 was fairly aggressive in pushing for patients to have electronic access to their own information, and Stage 2 will build upon that foundation. Patient engagement measures may be changed to look at things from the patient's perspective, rather than traditional provider-based quality measures. No doubt, that would require both technological and cultural changes to accommodate the new requirements.
Tang notes that there are placeholders in the meaningful use matrix designed to get data from places other than traditional care settings. “There is a clear value in direct input from patients and families,” he stresses. “One of my favorite components of meaningful use is helping patients get access to their own data, and the next step may be developing tools to help them make use of it.” Providers may also need to incorporate more information from patients into the health record, he adds, and to upload data from electronic medical devices in the home.
David Muntz, senior vice president and CIO at 14-hospital Baylor Health Care System, based in Dallas, Texas, says it would be relatively easy for his organization to include patient information from personal health records (PHRs). “It could speed up registration and provide significant benefits in helping track chronic conditions,” he says. “My preference would be PHRs from outside vendors such as Google and Microsoft that we tap into with the patients’ permission.”
But Harry Greenspun, M.D., chief medical officer for Dell Health Services, Dallas, says he would be surprised if CMS pushes PHR rules very far in Stage 2, if only because the current usage levels are so low. “Consumer engagement is a tough nut to crack,” he says. “Consumers haven't felt a compelling need to use PHRs yet. But accountable care organizations, more transparency and payment reform may have an impact.”
“Accountable care organization” and “patient-centered medical home” are two of the hottest buzzwords in healthcare because they tie IT improvements to payment reform. Both involve changes to care coordination that must be IT-enabled.
Tang says it's clear that better tools are needed to share information within an organization and across organizational boundaries. Stage 1 recognized that the HIE infrastructure was not in place, but signaled to vendors that they should have the functionality to exchange data. “It is not clear yet whether in Stage 2 we can ramp up requirements unless the infrastructure is in place,” he adds.
Care coordination requires a central repository so that you can search a common data source. “This is one of the traps you can fall into if you don't look ahead,” CSC's Drazen says. “You might think that just getting physicians on any EHR system is OK, but if you have six different systems being used by physicians in your organization, you'll probably have to adopt a seventh just to do care coordination.”
The situation at Baylor Health perfectly illustrates one of the challenges of improving public health reporting. “We report to two different health systems in Dallas and Fort Worth and we have to present the data in different formats for each,” says Muntz.
Public health agencies at the local and state level often use antiquated systems and to date there has been little standardization of data formats. “It is true that the public-sector infrastructure has to coordinate federal, state, and county, come up with standards and get their systems up to date,” Tang says. “And we have to get more physician offices with EHRs gathering data. It is not either/or; it is both.”
Although Health and Human Services is determined to invest in public health, several analysts say this is an area in which the extent of the challenge is so great that ONC is unlikely to make a lot of progress in either Stage 2 or Stage 3.
Deloitte's Morris says there is potential for HIEs to collect data and public health agencies to extract it from them. “But public health agencies are conservative and have to follow many laws and regulations,” he says. Change does not happen quickly in those agencies, and states are facing severe fiscal problems. “I would be surprised to see much happen here by 2015,” he says. “There is an opportunity for change, but it won't come quickly.”
Meaningful Use Work Group's Tentative Timeline
September: Meaningful use work group discusses preliminary Stage 2 and Stage 3 criteria.
October: Meaningful use work group presents proposed Stage 2 and Stage 3 criteria to Health IT Policy Committee.
November: Health IT Policy Committee issues Request For Information (RFI) on preliminary Stage 2 and Stage 3 criteria.
Second Quarter of 2011: Health IT Policy Committee finalizes recommendations to ONC.
Source: Office of the National Coordinator for Health Information Technology
Among the first 15 Beacon Community grant winners were several organizations focused on using health IT to fight disparities in health outcomes between socio-economic groups through coordination of care and improved access for disadvantaged populations dealing with diabetes, obesity, and other chronic conditions. Tang says one of the biggest developments in Stage 1 was the collection of demographic data, and getting even deeper levels of demographic detail may be part of Stage 2.
“The IOM [Institute of Medicine] recently came out with a study showing how important collecting that data at even a more granular level could be,” he says. “Because not all Asians or all Latinos are the same in response to treatments, for instance. Once we start collecting that data in a standard way and aggregating it, it will help us see trends about risks for cancer and cardiovascular disease, for instance.”
Muntz says Baylor Health already has a chief equity officer to study disparities. “The data we collect in Stage 1 will be very valuable, but we have a natural inclination to go beyond that information to gather more on language, ancestry, and belief system,” he says. “We would be doing it anyway, but I think it would be great if everyone did it.”
CIOS LOOK AHEAD
On the whole, CIOs tend to express satisfaction that the meaningful use matrix offers clear enough direction, although some would like more specificity about later stages now.
“We'd all like to know where Stage 3 is going to be,” Muntz says. “It's like in construction; you need to know how heavy the third floor is going to be before building the first floor.”
Chuck Podesta, CIO at Fletcher Allen Health Care, a 562-bed hospital in Burlington, Vt., believes the specifics of what CIOs need to do in 2011 is enough detail for now. “I know that the five items I choose not to do from the menu will be expected next time,” he says, and all the requirements that were deferred will be expected as well as other new ones.
“One thing I am concerned about is the electronic submission of reports,” Podesta adds. “One of the most challenging things about all of this may be putting together the electronic system to prove you're actually complying.”
Carilion Clinic's Barchi says health IT community members have a good sense of what will be expected in years three and five of the program. “We have to put ourselves on a pathway to be ready to achieve those goals,” he says. “But it is incumbent on CMS to define them as early as possible in the process so we are not scrambling around to meet standards.”
Healthcare Informatics 2010 September;27(9):8-13