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Want to Fail? Approach Stage 2 Like Stage 1 (Part 2)

September 28, 2012
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Can You Achieve Meaningful Use Stage 2 Using Your Current Methods?


In Part 1 of this blog, we discussed the fact that the approaches we used to achieve Stage 1 of Meaningful Use may not be sufficient to move forward to achieve Stage 2.  The fact is, we all must be flexible as the various MU stages become more complex.  This means everyone involved in MU at your hospital needs to honestly accept the need for change when necessary, and then be willing member of the team dedicated to reaching your goals.


The following chart lists the four specific examples I’ll be using in this post to show you where change will be necessary.  As in Part 1, Approach 1 represents what we used for Stage 1, while Approach 2 is what we’ll likely need to achieve Stage 2.



Specific MU Stage 2 Examples


1.   Governance – We have seen that most organizations are discovering misplaced decision rights, as well as policy decision times that usually span weeks or months related to HCIT.  The results are false starts and delays, always with project-eroding frustration.  Given the October 2013 deadline, many organizations need to examine and refresh their governance.   See “Secrets of EMR Governance.”  Note the 10 DOs and DON’Ts.


2.   CPOE – Here, a pragmatic and exquisite focus on how order sets are used for common conditions is essential.


a.   How broadly are order sets being used and how much time is required when they are used? 

b.   Do they ensure the clinical quality standards, especially those specified by your Stage 2 deployment, that are relatively automatic and appropriate?  

c.   Do you have a physician-specific method to monitor that these order sets are being used when they represent the fastest and safest way to use the EHR? 

d.   Getting back to governance, how is utilization being tracked post go-live?  Can you detect an Approach 1 “wall” or bottleneck and deploy an Approach 2 solution if necessary?


3.   Problem Lists – Problem lists (§170.302b) are both important and very new (as a requirement) in terms of capturing them and evolving them with finite vocabularies.


a.   Along with commenting collaborators, I have provided extensive guidance on problem lists here and here.

b.   Next, integration with your organizations CDI strategy is essential; see “Getting the Diagnosis Correct: What's the Impact of HCIT? (Part 2).”  What percentage of your physicians document common conditions like “Chronic Renal Insufficiency” in a manner that is clinically compliant with outside auditors? 


If your hospital is like most, you have a double digit prevalence of renal insufficiency in your Medicare population.  Is it effortless for your providers to document this problem in appropriate patients?

c.   For another terrific resource, see Jeffrey Held’s HIMSS 2012 presentation, “The Problem List: Problems & Strategies to Solve it.  As with most HIMSS presentations, the candor contained in a good one is always worth the conference fee.  Dr. Held’s presentation is outstanding, and the PDF version (AC12-EHR-117) is freely available to all HIMSS conference attendees.


4.   Medication Reconciliation – This process has classic Approach 1 issues, as spelled out in detail in our Med Rec post.  Medication Reconciliation is “universally broken” as elaborated by Kamataris-Novaces, along with a detailed Approach 2 path to change “How” you approach Med Rec, “Who” should perform it, and “Where” it touches other critical processes. 


Asking every care provider to equally divide and conquer the challenge has a well-known and well-described wall that impacts several major MU and related indicators including CHF Core Measure Failures, Discharge/Continuity clinical summarization, and simply attainment of Med Rec, itself a Stage 1 and 2 objective.  If Med Rec is challenging with our current Approach 1 methods, what does this portend for the broader Clinical Reconciliation that instantly appears with clinical summary exchange?


5.   Other Stage 2 Measures – There are two dozen or so additional measures you’ll find have issues similar to those discussed in this blog. 


Closing Thoughts


This entire post has been about performance considerations in moving to Stage 2 Meaningful Use.  As many of you have personally experienced in recent years, our PCs can slow down to crawl speed if we open too many taxing Web pages at the same time.  When the iPad was released, Apple eliminated this, the single, largest performance killer of PCs, ensuring a responsive, “Approach 2 scalability” experience on the iPad.  It was described explicitly by Steve Jobs in an April 2010 open letter ─ see “Third … performance” and “Conclusions.” 


It’s clear to many of us that process scalability will be a key to success in Stage 2.  Exposing Approach 1 scalability walls will be painful.  Although the current state of affairs is generally well known, proven and popular, we will need to replace non-scalable practices, where necessary, by Approach 2 practices.  The most important factors will be understanding and communicating your own local practice experience.


What do you think?


Joseph I. Bormel, MD, MPH

Chief Medical Officer and VP

QuadraMed Corporation

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