The way John Halamka, M.D., CIO at Beth Israel Deaconess Hospital (Boston, Mass.) says it, the federal Centers for Medicare & Medicaid Services (CMS)’ recently issued final rule for Stage 2 meaningful use under the American Recovery and Reinvestment Act/Health Information Technology for Economic and Clinical Health (ARRA-HITECH) Act was the “very definition of a compromise.”
“My sense is the ONC (Office for the National Coordinator of Health IT) are compulsive and they read every comment and considered it carefully,” Dr. Halamka said. “As I read the final rule, 474 pages of it, it seemed like they had done the Solomonic thing, and they weighed the pros and cons and came up with a reasonable compromise. The definition of compromise is everyone is that is equally unhappy. When I look at the reactions, and some say it didn’t go far enough, some say it went too far – I think, oh good, everyone is equally upset. They must have gotten it right.”
John Halamka, M.D.
Randy Thomas, vice president of portfolio strategy & design, at the Charlotte, N.C.-based Premier healthcare alliance, said the final rule of Stage 2 underscores the overall objectives the implementations of EHRs, which is not to get a system, but to improve the liquidity of data flow. This, she said, is important as healthcare transitions from a transaction-based business to integrated, accountable care.
In the eyes of CIOs like Halamka and Chuck Podesta, of Fletcher Allen Health Care (Burlington, Vt.), the changes from the proposed rule of Stage 2 to the final rule were few and far between. Podesta noted the core measure requirements and menu items were kept fairly intact.
“I think it’s pretty much the same,” Podesta said. “The core requirements are still there, and all the menu requirements are there, as they were back in February. We started preparing back then, nothing has changed.”
However, the small changes were overall positive the CIOs said, and remaining thresholds for interoperability and patient engagement were well received. Halamka says the rule that patients must view, download and transmit their health information, lowering the threshold from 10 percent to five percent, eases the requirements, while still keeping them in place to ensure providers move forward and get a portal.
“As a CIO, whether it’s one, five, or 10 percent, the functionality that you have to make available is the same. I think what this does, it’s a nice forcing function that ensures every hospital and ambulatory care site implements a fully functional patient portal,” Halamka said. “It allows gradual adoption for those that haven’t implemented the technology, recognizing in some ways the transmission of data is a novel concept.”
The exchange of information burden was lessened as well. For sending summary of care documents, the requirement went down from 65 to 50 percent when engaging in a transition of care. In addition, the threshold in the proposed rule required a provider to electronically transmit a summary of care for more than 10 percent of transitions of care and referrals, was lessened as well. The intent of that proposed rule, the CMS said, was to foster electronic exchange outside established vendor and organization networks. In the final rule, it’s only requiring at least one demonstration of this cross-vendor, organizational capability.
Halamka says these requirements will mark the end of “closed and proprietary thinking.”
‘Loud and Clear’
The refined timing was one of the biggest stories of the Stage 2 final rule. In it, CMS ruled that providers beyond the first year of demonstrating meaningful use would have a three-month, one-quarter reporting period to allow an additional up to nine months to upgrade certified EHR technology to the 2014 edition. This was well received across the board. It also ruled that providers who attested to Stage 1 of meaningful use in 2011 would attest to Stage 2 in 2014, instead of in 2013, as required previously.
“We thought that was a good call,” Premier’s Thomas said. “Giving organizations who are working really hard to push this forward the recognition that this hard work to appropriately and effectively implement an EHR with all the process changes to do it.”
Podesta said this change, with the extra nine months to get the upgrade, will be a big help for his organization. With it, he noted, “They heard some of the comments loud and clear.” However, he suggests while it will also be a help for vendors, there is still quite a bit required of them. “They kept a lot of criteria in certification that will cause vendors to spend money to get that 2014 certification. There’s quite a bit of technology in there, that doesn’t exist in the vendors’ product.”
According to Podesta, some of the large vendors, especially those with more than one thousand customers, will have a hard time getting all those upgrades in by 2014. “I don’t see logistically, how they could do it,” he said.
Even with the changes, Halamka said CIOs must begin to educate clinicians early. Software, he noted, still has to be implemented in 2013. Also, other regulatory burdens, such as the Accountable Care Organization (ACO) initiative and the transition to the ICD-10 code-set, will keep organizations pressed for time.
Achieving the Right Thing
The overarching theme when it came to reactions for the Stage 2 final rule was the idea that the requirements were doable. While some may say the requirements are still too stringent, Halamka argues while the requirements are not easy, they stretch providers to achieve the right thing.
“In the words of David Blumenthal several years ago, he said, ‘The escalator needs to be set at a speed where everyone gets to the top, but no one falls off,’” Halamka said.