Hospital, physician group, and health system IT leaders have been busy the past few days analyzing the Notice of Proposed Rulemaking (NPRM, or “proposed rule”) on Stage 2 of meaningful use, which was released by the federal Office of the National Coordinator for Health IT (ONC) and announced publicly by Farzad Mostashari, M.D., the national coordinator for health IT, on Thursday, Feb. 23, during the waning hours of the HIMSS Conference, being held last week at the Venetian Sands Expo in Las Vegas. With 455 pages to scan, many are finding that just reading through the text of the proposed rule is taking numerous hours.
Not surprisingly, some organizations are taking their time to perform a comprehensive analysis of the Stage 2 proposed rule, in order to make sure that they understand what’s facing them in the next phase of federal mandates coming out of the American Recovery and Reinvestment Act/Health Information Technology for Economic and Clinical Health (ARRA-HITECH) Act.
For example, Thomas Smith, CIO at the four-hospital NorthShore University HealthSystem in Evanston, Ill., says his meaningful use team, which meets once a week, has broken down responsibility for analyzing specific aspects of the NPRM to different team members. At first glance, he says, it appears that the Centers for Medicare and Medicaid Services (CMS) has changed some of the reporting definitions in terms of numerators and denominators, which will require working with EHR vendors to rejigger how measurements are done to make sure the reporting is correct.
“The best thing about Stage 2 is that vendors and providers now have at least 18 months to make the changes,” Smith says. “If they had left the timeline where it was originally, that would have been a tough assignment.” Otherwise, Smith says, he sees no real surprises in the core and menu framework and threshold changes.
One change that did surprise him involved using EHRs to send summary-of-care information with referrals. Initially, providers had been expecting in Stage 2 to use health information exchange to send data to three major referral partners. To meet that requirement, NorthShore assumed it would use technology made available by its vendor, the Verona, Wis.-based Epic Systems, to share data with other Epic customer hospitals in the Chicago area. But the Stage 2 NPRM requires that a hospital “that transitions or refers their patient to another setting of care or provider of care electronically transmits a summary of care record using Certified EHR Technology to a recipient with no organizational affiliation and using a different Certified EHR Technology vendor than the sender for more than 10 percent of transitions of care and referrals.”
Smith says that he understands that CMS wants to get away from vendor-based systems, but it means NorthShore won’t be able to rely on its Epic connection and will have to depend on regional and statewide HIE projects, neither of which are up and running yet. It will also depend on nursing homes that get referrals from NorthShore adopting EHRs and participating in HIEs, which may be a tall order for them.
While perhaps a difficult set of requirements to meet for some patient care organizations, some industry analysts see the information exchange requirements in the proposed rule as a bold, positive move on the part of ONC. One of these is Richard Temple, an executive consultant with the Weymouth, Mass.-based Beacon Partners consulting firm. “One of the things I really like about Stage 2 is the emphasis on health information exchange and transitions of care,” Temple says. “The notion that they’re mandating what they call a summary of care record, while allowing some latitude around it—that’s going to be huge, because it’s really going to plant a seed, and the fact that they’re mandating that 10 percent of those documents have to be conveyed electronically is laying a foundation there as well.”
Temple, who overall says he is very positive about the shape of the proposed rule, adds that “That kind of a common summary of care record, coupled with the certification requirement that systems be able to use the DIRECT protocol, that is going to allow for secure exchange of data without point-to-point proprietary interfaces, is huge, because it makes electronic data exchange something that is a lot more affordable and a lot more doable.”
Metrics requirements seen as challenging to some
Russ Branzell, vice president and CIO of Poudre Valley Health, in Ft. Collins, Colo., says that “My concerns now about Stage 2—the positiveness and the concerns—are actually identical to those around Stage 1.” Branzell, who has been a member of the metrics work group at ONC, says, “I think the standards are appropriate for some organizations, though way too weak for others. For others still, the standards are still going to be too fast. The metrics are what are going to be challenging again in Stage 2 as in Stage 1, for some organizations.” Still, he adds, “ONC is trying to honor the original intent of the law, and that is to say that Stage 2 should be about actually tracking and improving clinical outcomes.”
With regard to the complexity around metrics, Branzell cites the example of working with MU’s requirements around VTE (venous thromboembolism) prophylaxis: “It gets down to tracking a specific clinical environment around how something like how VTE prophylaxis is tracked and measured in an organization; when it’s appropriate, not appropriate, and when exceptions take place, how you analyze them—all of those elements will all be difficult.”
On a broader level, Branzell says that one of the underlying challenges in the entire MU process is one of balance. “The question,” he says, “is, where’s the line between the government saying you should do this, and to be honest, I absolutely agree with that; and the ability to make it appropriate and work for their organization and environment?—because I don’t think the government’s intent was to standardize everybody’s workflow. But to do this, you almost have to standardize everybody’s workflow to make it work out.” In other words, he says, whatever level of data mandate emerges in any particular area out of meaningful use, it will force some standardization of process to meet that requirement or set of requirements.”
Speaking of balance, Robin Raiford, director, research and insights, at the Washington, D.C.-based Advisory Board Company, says, “The requirements discussed by Dr. Mostashari and his team closely parallel the recommendations provided by the Health IT Standards Committee and Health IT Policy Committee. They appear to be more aggressive, but that’s not surprising given that everything that’s ultimately included in the final rule must first appear in the proposed rule first and go through the required 60 day public comment period required in rule making which is likely to soften the requirements. In Stage 2 proposed criteria,” she adds, “the major challenges for providers are likely to revolve around the increasing need for real time data capture, the active use of information exchange between care providers, an increased push for patient engagement, care coordination, and quality improvement as well incorporation of a transport standard which was not part of Stage 1.”
A mosaic of details
Meanwhile, in a memo just published by the Waltham, Mass.-based Global Institute for Emerging Health Care Practices at the Falls Church, Va.-based CSC, Erica Drazen, Sc.D., senior partner in that division, made note of numerous detailed elements in the proposed rule. In the memo, she wrote that “The proposed rule generally makes Stage 1 optional (menu) items required (core) in Stage 2. Stage 2 does retain the concept of core and menu requirements for new requirements; for example use, of e-MAR [the electronic medication administration record] is now a core requirement for hospitals and the ability to view images is a new menu requirement. Many of the thresholds from Stage 1 have been raised—some to a higher level that those recommended by the HIT Policy Committee. For example,” Drazen notes, “the requirement for CPOE for medications is 30 percent in Stage 1, the Policy Committee recommended it be raised to 50 percent and the proposed rule raises it to 60 percent.
“Other new requirements,” Drazen went on to say in her group’s memo, “include CPOE for laboratory and radiology orders, the ability of patients to view, download and transmit their health information, and public health reporting to cancer registries and other specialized registries. The CPOE measurement was changed from being based on one order per patient to a percentage of all orders—which will raise the bar considerably. The only major recommendation from the policy committee that was not included in the NPRM,” she wrote, “was for an electronic physician note for 30 percent of office visits and 30 percent of hospital days. While no longer required for meaningful use, physician notes are a major source of data that will be required for electronic reporting of quality requirements.”
Given the full range of requirements facing providers under Stage 2 of meaningful use, Beacon Partners’ Rich Temple advises healthcare IT leaders to “Start building those relationships with the outside world now, because this is going to catalyze a real push towards exchanging information either through an HIE or some other method. And I would always recommend that CIOs and other IS leaders do this anyway,” he emphasizes. “But in any case, they need to think strategically, and think about the business drivers. And do everything out there to make sure that this new technology is supported. Don’t think of yourself as a bits-and-bytes geek,” he urges. “Instead, think of yourself as a strategic change leader; I recommend that anyway, but with Stage 2, it’s absolutely vital, because there’s no turning back at this point.”
As industry leaders continue to share their reactions to the Stage 2 proposed rule, we at Healthcare Informatics will continue to share their comments with our readers this week and in the coming week. Please continue to return to our website for further information and insights.