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The Stage 2 Meaningful Use Of EHRs Proposed Rules: No Surprises

February 24th, 2012

Editor’s note: For more on the Stage 2 proposed rules defining meaningful use of electronic health records, see Larry Wolf’s Health Affairs Blog post.

Late in the day on February 23, 2012, the Centers for Medicare and Medicaid Services (CMS) released the preliminary rules for Stage 2 Meaningful Use.  For those not deep in the weeds of Health Information Technology policy jargon, “Meaningful Use” is the federal standard for eligible physicians and hospitals to receive incentives through Medicare and Medicaid for adopting and using an Electronic Health Record.

So why is this important?  Well, first, a little bit of background.  Just about three years ago, Congress passed the Health Information Technology for Economic and Clinical Health (HITECH) Act and set aside nearly $30 billion for direct incentives for providers to start using EHRs.  Over the last three years, we have seen a lot of activity in Health IT policy, with the Obama Administration laying out that the incentives would be given out over three stages.  Stage 1, finalized about two years ago, was meant to start getting providers to move key clinical data into electronic format.  Much of the U.S. healthcare system was (and arguably still is) being delivered on paper, and Stage 1 was simply meant to transition providers to electronic systems.  The early read says that about 10-15 percent of providers (both physicians and hospitals) have received payments for Stage 1 through January, 2012.  Some proportion of both physicians and hospitals are likely to come on board over the remainder of this year.

Now, what’s the big deal about Stage 2?  Stage 2 was supposed to raise the bar, tie HIT adoption more closely to driving improvements in care, and to show that EHRs are beginning to make a difference.  Now that it’s here, though, the biggest news about Stage 2 is that there is no big news.

The Office of the National Coordinator (ONC) that oversaw the process of creating the stage 2 rules played it safe.  Skimming through the 455 pages of the Notice of Preliminary Rule Making, one sees a careful, incremental approach.  No sudden moves.  No surprises.  Some people who have clamored for more aggressive rules for Meaningful Use, including requiring that providers demonstrate actual improvements in care as a result of their use of the EHR, will be disappointed.  Those that have argued that MU rules are too hard and that we should just provide incentives for acquiring the technology may not be fully satisfied either.  The incremental approach of Stage 2 feels like the right balance.

What The Stage 2 Proposed Rules Say

Let’s talk about what is in here.  In Stage 1, eligible outpatient providers (essentially, physicians and nurse practitioners) had to meet 15 “core” requirements and 5 of 10 “menu” items.  Eligible hospitals had to meet 14 “core” requirements and 5 out of 10 “menu” items.  In Stage 2, CMS proposes that eligible providers now meet 17 core objectives and 3 of 5 menu items;  hospitals must now meet 16 core objectives and 2 of 4 menu items.  Additionally, the timelines have been extended, giving providers more time to get into Stage 1 and a longer ramp-up into Stage 2.  CMS makes a series of other smaller changes as well.  There were things in the Stage 1 rule that were cumbersome and unclear and have gotten streamlined.

However, beyond the details, here are three highlights that seem particularly important:

  1. The bar for meeting use requirements for computerized provider order entry (CPOE), arguably the most difficult but potentially the most important EHR functionality, has been raised:  now a majority of the orders that providers write will have to be done electronically.
  2. There is a major move to tie quality reporting to Meaningful Use.  We knew this was coming, but CMS has laid out a host of quality measures that may become requirements for reporting through the EHR.
  3. Health Information Exchange moves from the “can do it” to the “did do it” phase.  In Stage 1, providers had to show that they were capable of electronically exchanging clinical data.  As expected, in Stage 2, providers have to demonstrate that they have done it.

All of these substantive changes were completely predictable.  Congress, in passing HITECH, signaled that the three most critical components of Meaningful Use had to be 1) computerized prescribing with decision support, 2) automated quality reporting, and 3) health information exchange.  These three “functionalities” of the EHR are the hardest to achieve, and arguably the most important to drive improvements in care.  It is heartening to see federal policymakers continue to move forward on these three areas.

What Might Change In The Final Rules

Of these three priorities, the final rule for CPOE and HIE will likely remain similar to the preliminary ones; they are the logical follow-on to the Stage 1 criteria.  One area in which there will likely be significant trimming between the preliminary and final rule, though, will be the quality measures.  There are a lot of measures, and CMS has made an attempt to align them with broader healthcare delivery reform initiatives, such as patient-centered medical homes and better transitions of care.  Which measures will make the final cut, and whether they will be the ones that are most clinically important, is unclear.  The value of EHRs would be significantly enhanced if CMS could identify the most important of its myriad of delivery reform initiatives and align the Stage 2 rules with quality measures that support those initiatives.  It is unclear if CMS will be able to do it.

One final area that received a lot of attention at the HIMSS Meeting on the day of the release, when Farzad Mostashari (the National Coordinator for Health IT) previewed the Stage 2 rules, was the requirement to give patients greater access to their own data.  Again, the changes feel more incremental than radical.  In Stage 1, patients just had to be given an electronic copy of their data.  In the revised rules for Stage 1 and the proposed rules for Stage 2, more than 50 percent of patients need to have the ability to view, download, or transmit their data.  Further, 10 percent of patients actually have to do it – look at their data, download it, or transmit it to others.

Much like the change with Health Information Exchange, federal policymakers are trying to move the provider community from the “ability” to do things electronically to actually demonstrating that they are doing it.  While this is a laudable move, I suspect that many providers are going to push back.  It is not clear that 10 percent of patients will want to view, download or transmit their data to others.  It is hard to imagine that we are going to punish providers when their patients choose not to look at their own data.  Whether this part of the preliminary rule will make it into the final one is unclear.

So, what’s next?  The Notice of Preliminary Rule Making opens up a 60 day comment period for the entire medical community to weigh in on the stage 2 rules.  There will surely be plenty of feedback.  CMS has given itself plenty of room to scale back some of the measures and be responsive to those comments, but fundamentally, the final rules for Stage 2 will look a lot like the preliminary rules.

This is a good thing.  Stage 2 is an incremental step forward, emphasizing the right points and slowing down the train so everyone can get on board.  If we are going to fix our broken healthcare system, health IT will need to be a fundamental part of the solution.  However, it can’t and won’t be the primary driver.  Payment and delivery reform efforts from major payers, along with innovative business models from the private sector, will be needed to improve the delivery of the healthcare system. We just need to ensure that health IT is effectively and meaningfully deployed as widely as possible.  The preliminary rules from Stage 2 Meaningful Use are the right next step.

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4 Responses to “The Stage 2 Meaningful Use Of EHRs Proposed Rules: No Surprises”

  1. chasedave Says:

    I feel for EMims. My advice to him/her would be to look at Direct Primary Care (I removed the link as I think it triggered a spam filter). The happiest MDs I know are all in Direct Primary Care as they are practicing medicine the way they were trained and earning a nice living doing it. Patients are happy to. The annual “go faster on the hamster wheel” story has to be frustrating.

    Having said that, I think we should put more emphasis on the patient engagement portion while the fundamental delivery model is rethought. In other words, if anything, we should increase the requirements. It’s really the only hope to improve outcomes (and slay the healthcare cost beast) for 3/4 of U.S. healthcare spend — chronic conditions.

    It’s a failure of imagination of the vendor community if we can’t come up with dozens of ways for providers to surpass the 10% engagement threshold. Any # of companies could help them. It will be a catalyst to finally bring in the most important member of the care team into the care process — the patient. It can be done. The winning EMRs will do this.

    Google “Patients are More Than a Vessel for Billing Codes” (I removed the link as I think it triggered a spam filter).

  2. Carol Flagg Says:

    For those of you who may be interested HITECH Answers will be interviewing one of the CMS authors of the NPRM on our internet radio show MU Live! this Tues. at 2 pm Eastern:

  3. EMims Says:

    I’m on the front line of this. I’m one of the soldiers. Alot of people…ALOT of people are touting how overwhelmingly important heath care IT is and how important it is for the advancement of health care in this country. Well, I hate to be the bearer of bad news and the reality check here, but the truth is, this very same IT is crippling us as PCP’s. There is NOT any time-saving. My office uses NextGen, along with 140 other PCP’s and specialists in our group. Across the board, we all agree, the entire system is bogging us down. I can reliably report that the subtle, unspoken truth of what is really going on in America is occurring….we are systematically being forced to either ration care to mid-level providers or slowly sink in the ever-increasing burden of IT entry. We’ve had 4 physicians in our comunity in primary care retire this year, mostly because they were not interested in tolerating the ongoing, perpetually worsening sacrifice of patient care time and attention as we sit in the room and keep our eyes glued to the monitor while patients get more and more frustrated at our “mandate for medical entry”. As hard as I try, its is the TRUTH that you simply cannot take care of complicated Medicare patients and simultaneously click 50 buttons as you wade thru as sea of data entry. Yet we are expected to…..or become evermore burdened with more costs for scribes, NP’s, PA’s, ect. I find it a sad time we live in when i’m told every 6-12 months by my practice consultant that we’ll “need to see a few more” each day to cover these costs and time sinks created wasting our training on imputing data, or sacrifice quality application of complicated medical expertise by delegating these same patients to mid-level providers. Wake up, America – we are losing our health care to the common denominator of who can click the “yes” or “no” button the best and the fastest. Health care is certainly NOT benefitting from this travesty of common denominator mentality. There’s a damn good reason we’re below 20th in the world in health care despite our technology and training. Its because we, as physicians, are overwhlemingly distracted to the point of despair at the administrative glut of data entry BS we are being forced to perform.

  4. Kim Slocum Says:

    I was also at HIMSS in Las Vegas and attended nearly all of the CMS or ONC sessions that dealt with Stage 2 of Meaningful Use. I agree with author’s general comment catheterizing the NPRM as incremental change from Stage 1, although there are some modest surprises. I’ve reviewed most of the document at this point and some of the most interesting parts are not necessarily the measures themselves but the commentary provided by the CMS/ONC authors regarding the rational for inclusion/exclusion and the thresholds selected. The first 200 pages or so are very much worth reading for people interested in improving medical quality through the use of health care information technology.

    The big questions of course are how much change will we see from the NPRM to the Final Rule–and when will the Final Rule actually be issued? My personal hope is that CMS does not back off from these proposed requirements, and perhaps even pushes a few of them more aggressively.

    Given the pressure on health care spending (particularly for public sector program) and the increasing perceived need to “do something” about it in Congress, it is time for the health care IT community to begin to show at least some tangible return on the significant investment that has been made in the space over the past several years. Many of us (including me) believe that the benefits are there, but so far what we’ve mostly seen are flashes of what could be provided by centers of excellence. If we’re ever going to get to a “value-based” health care system, this technology simply has to work, and work well in average practice settings. More to the point, it has to do so sooner rather than later.

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