At this week’s HIT Policy Committee meeting, the Meaningful Use Workgroup presented its Stage 2 thinking to date, based on the 422 comments they received on their initial proposal. As discussed in a previous EMR Straight Talk post, the issue at the forefront is timing—with providers and vendors expressing significant practical concerns, and consumer groups pushing for rapid advancement.

The workgroup presented the following options for consideration by the Policy Committee. (I invite you to voice your opinion by responding to the poll below.)

1. Maintain current timeline. Stage 2 would begin in 2013 for providers who demonstrate meaningful use in 2011. Providers who first demonstrate meaningful use in 2012 would have until 2014 to meet the Stage 2 requirements.
2. Maintain the current timeline (as above), but allow a 90-day reporting period, instead of a full year, when providers are first governed by Stage 2 requirements. This would give providers until October 1 to begin their first year at Stage 2, instead of January 1—a nine-month delay.
3. Delay Stage 2 by one year, allowing providers 3 years instead of 2 years at Stage 1. This means that the earliest any provider would have to meet Stage 2 expectations would be 2014.
4. Phased-in approach separating existing from new functionalities:
   - Stage 2a (2013) would increase thresholds for measures for which the functionality already exists, (required to meet Stage 1), adding only new clinical quality measures.
   - Stage 2b (2014) would add new measures that require new EHR functionalities .

The responses from various HIT Policy Committee members covered the gamut.

• Some were in favor of moving aggressively at all costs, presenting various arguments such as: (a) If we don’t pressure providers now, we will face the exact same issues at the next stage; (b) More extensive data capture does nothing to move us towards Stage 3 goals; and (c) We cannot just address the physicians’ workflow problems and ignore the challenges patients face in dealing with the current, difficult-to-navigate healthcare system.
• Other Committee members, like Gayle Harrell, cautioned against trying to do too much too quickly—as she has from the outset—and stressed the long-term value to the program of setting providers up for success. Pushing them too hard could cause them to drop out after they earn the bulk of the incentives associated with Stage 1.
• The phased-in approach was perceived as creative, but I was surprised that there was not much discussion about the administrative complexities this plan creates—to say nothing of the challenge of conveying it to providers.

Related posts:

1. Meaningful Use Stage 2: Speak Now or Forever Hold Your Peace
2. A preliminary set of recommendations for defining Stage 2 meaningful...
3. Meaningful Use Stage 2–Physicians’ Opinions Count Most
4. The HIT Policy Committee’s Meaningful Use Workgroup met this week...
5. Stage 2 Meaningful Use Delayed to 2014: What’s It Really About?
6. HHS has made it official—Stage 2 of meaningful use will...

Yesterday morning, in a podcast interview with Neil Versel, a respected HIT journalist, I was asked to compare the mood at last year’s HIMSS meeting with my expectations for this year’s assembly. In 2010, I listened as David Blumenthal, head of ONC, spoke to a standing-room-only crowd, whipping up a frenzy of excitement about ARRA and its EHR incentives in what I can only describe as a pep rally. I told Neil that I anticipate a more subdued and somewhat anxious atmosphere at this year’s meeting, since the practical realities and challenges associated with the complexities of meaningful use have set in. A recent survey of hospital CIOs, for example, revealed reduced confidence in the ability of their respective institutions to successfully meet the requirements within the allotted timeframes, and a resulting skepticism about whether they would earn the incentives. Similarly, at the recent 2-day hearings conducted by the Adoption and Certification Workgroup, the generally positive sentiment was tempered by concerns about operational issues, timing, IT workforce challenges, and the multitude of government programs on the plates of practices.

Then, yesterday afternoon, the news broke that David Blumenthal is stepping down from his post as the national leader of the EHR adoption and incentives program. Although we all know that no single individual is ever indispensible, the timing of his departure struck me as quite odd. The program is at the precipice—its launch is just underway and the first attestations of meaningful use are expected in April. Initial success or failure will be evidenced imminently. One would think that this would be the time to demonstrate stability and unwavering commitment from the top down—a time to rally all of the forces to ensure the program’s success.

I cannot help wondering the following:

• Why is Blumenthal stepping down now, when the program is at such a critical juncture?
• Why is HHS Secretary Sebelius just now “conducting a national search for the right successor” even though she reports that it was always the plan that Dr. Blumenthal would end his term at this point?
• What are the implications for the EHR incentives program?
• Will his departure affect the likelihood of its success?
• How will provider confidence in the program be impacted?
• Should we expect changes in the program? What kind of changes?

Please share your thoughts on David Blumenthal’s departure by commenting below.

Related posts:

1. Blumenthal and EHR Program: Time Will Tell
2. In the aftermath of Dr. Blumenthal’s departure announcement, he has...
3. It’s An Outrage!
4. “One thing we haven’t done is apply the scientific method...
5. Finally Talking About What Matters!
6. Finally, the EHR conversation has shifted to the products. Questions...

A preliminary set of recommendations for defining Stage 2 meaningful use was released by the Meaningful Use Workgroup of the HIT Policy Committee earlier this month in the form of a Request for Comment—the deadline for comments is February 25. The decision-makers in Washington clearly realize the value of securing buy-in from providers, having received over 2,000 comments to the proposed Stage 1 rule when it was issued last year. As a result of those lobbying efforts, which included the Voice of the Physician Petition that we circulated on EMR Straight Talk, CMS made changes that accommodated the specialists and made participation realistic for them.

This is the opportunity for physicians to have a voice in Stage 2 before the final recommendations are submitted to CMS this summer. This request comes very early in the process of developing and finalizing the requirements—the workgroup will consider the comments and then present its recommendations to the HIT Policy Committee, which will review and revise and then forward them to CMS, which will issue the final rule. So for this stage, providers have the chance to provide input well before recommendations become set in stone.

Since most providers haven’t even embarked on Stage 1, and many are not yet conversant in the rules and requirements for that stage (as evidenced by the results of the Meaningful Use IQ Test), the following are highlights of the proposed recommendations. Note that clinical quality measures are not discussed—they will be the subject of a separate set of recommendations.

• The proposal does not address the excludability of non-relevant measures. I assume its retention is implied, but it is important to comment on the need to keep these options in place. This was a very valuable modification added to Stage 1, particularly for specialists.
• Disappointingly, Stage 2 still does not define meaningful use in a way that adds value for many specialists, and a way that will keep them engaged once the significant portion of the incentives have been collected.
• Menu measures will become core measures, so the measures physicians choose to defer in Stage 1 will be mandatory in Stage 2. Some of these measures pose challenges for specialists, e.g. sending reminders to 20% of patients may not be reasonable for certain specialists such as orthopaedists or ENT physicians, because they provide episodic care.
• Most of the changes involve increased thresholds for satisfying the measures, e.g., CPOE increases from 30% to 60%, ePrescribing from 40% to 60%, etc. These changes should not present a challenge since the software and relevant workflows will already be in place from Stage 1.
• There are several new measures, such as adding lab or radiology to CPOE and including online secure patient messaging.

To voice your thoughts on this initial set of recommendations, go to www.regulations.gov and click “Submit a Comment”. Don’t say they didn’t ask!

Related posts:

1. Meaningful Use Stage 2–Physicians’ Opinions Count Most
2. The HIT Policy Committee’s Meaningful Use Workgroup met this week...
3. Meaningful Use Stage 2—So Many Opinions
4. While providers are still struggling with the details of meaningful...
5. Stage 2 Meaningful Use: What Do You Think?
6. At this week’s HIT Policy Committee meeting, the Meaningful Use...

Physicians practice evidence-based medicine. They base clinical decisions on evidence gained from scientific research and experience. As patients, this is the source of our confidence in their diagnoses and treatment plans for us. Unfortunately, an alarming number of physicians do not apply evidence-based decision-making to their EMR purchases. This explains the 50–80% EMR failure rate documented in the Milbank Quarterly and cited by the AMA.

Recently, I’ve spoken with several ophthalmology practices that are struggling under the weight of unsuccessful EMR implementations—many of these situations would have been averted by asking the right people the right questions at the right time—before signing the EMR contract. Let me share a few examples of how aggressive due diligence uncovers important facts:

An ophthalmology practice purchased an EMR from [Vendor 1] based on its ad stating that nearly 500 ophthalmology practices use a [Vendor 1] product. Had the physicians asked for the names of 10 ophthalmology practices of their size that use this vendor’s EMR, they would have learned—by the lack of response—that most of the 500 practices use the vendor’s practice-management system, not its EMR. Don’t fall prey to deceptive marketing.

Beware of references with vested interests. For example, a physician would never know that the reference for [Vendor 2] has an ownership interest in the vendor’s company. Not surprisingly, the reference physician described the EMR as “excellent.” It was only a subsequent blog comment from another physician in the practice that revealed that, after 3 years, she still schedules 6 fewer patients each day and has hired a skilled technician to assist her, adding $37,500 per year in costs.

Another practice made a visit to [Vendor 3’s] reference site and learned that the physicians in the practice are, in fact, using the EMR. If they had probed further and asked about staffing, however, they would have learned that instead of 8 scribes, this practice now employs 24 scribes to handle the necessary data entry—two for each ophthalmologist (instead of one before the EMR adoption), and one for each optometrist (when the optometrists had never needed any scribes at all before the EMR).

It’s equally important to randomly select physicians to call. Do not limit your conversations to those physicians hand-picked by the vendor—other physicians in the practice will always take calls from colleagues. Ask each physician how many patients he or she sees each day now as opposed to before EMR implementation. Within the same practice that purchased [Vendor 4’s] EMR, physicians using the EMR successfully are those who see only 25 patients per day, while the ones who see 60 patients daily do not use it because of its effect on their productivity.

If you apply the same due diligence and evidence-based decision-making to your EMR search that you do to treating your patients, you will have the information you need to ensure that the EMR you select will be the right EMR for your practice.

Related posts:

1. EMR References: Cast a Wider Net
2. Client references and site visits can be a rich source...
3. 100% EHR Success – A Clinical Approach
4. Last week’s EMR Straight Talk post, “Are EHRs Being Oversold,”...
5. Readers Respond: The Exorbitant Cost of Meaningful Use
6. As anticipated, the release of the proposed rules on “meaningful...