Stage 2 Meaningful Use: What Do You Think?

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.


Meaningful Use Stage 2–Physicians’ Opinions Count Most

The HIT Policy Committee’s Meaningful Use Workgroup met this week to begin discussing the question that I posed at the end of my EMR Straight Talk post last week, i.e., how to reconcile the various stakeholders’ positions regarding Stage 2 meaningful use. Most of the feedback received by the workgroup in response to its request for comments relate to issues surrounding timing, with providers and vendors urging restraint, and consumer groups (representing patients and payers) pushing for more aggressive timelines.

Given the statutory constraints (i.e., changes to the law itself would require Congressional action, a path the workgroup will not pursue), the options are limited—and each carries consequences for the program’s long-term goals. The workgroup acknowledged the concerns of vendors regarding the time needed to adequately and safely develop and deploy any new required functionality. They also appreciated the impact on providers of the implementation and training demands associated with upgrading technology, particularly at a time when providers are facing other IT challenges such as ICD-10 and HIPAA 5010. The workgroup considered the following options:

  • Option 1: Slow down the program’s pace by not adding any new measures and functionalities to Stage 2, but merely increasing the thresholds related to Stage 1 measures.
  • Option 2: Delay the start of Stage 2 by allowing each provider more time at Stage 1 or by basing the initiation of Stage 2 on the overall level of provider compliance/success in Stage 1.
  • Option 3: Shorten the first year’s reporting period to 90 days when providers progress to Stage 2.

The workgroup identified the following as the problems associated with each of the above proposals:

  • Option 1 (no new measures) will not get the program where it needs to be rapidly enough. It does not advance the program past data capture and towards the program’s goals: interoperability; “advancing clinical processes” (the goal of Stage 2); or improving outcomes (the goal of Stage 3).
  • Option 2 (delay Stage 2) raised the concern that extending Stage 2 will set a precedent for delaying Stage 3. The dwindling financial incentives and the lack of positive incentives after 2016 could reduce interest in Stage 2 or make it difficult for the program as a whole to ever progress past Stage 2, given that there are no positive incentives available after 2016.
  • Option 3 (90-day reporting period) does nothing to resolve the vendors’ concerns about the timeline for development.

Another critical issue to be addressed is how to increase the relevance of the EHR program to specialists, which will be the subject of a special hearing on May 13—similar to the hearing that solicited their input for Stage 1. Of all of the stakeholders, physicians are the most critical to the attainment of the EHR program’s goals. Physicians—primary care and specialists alike—are the cornerstone of the program, and their participation beyond Stage 1 will depend on the development of a set of reasonable and achievable requirements.

Meaningful Use Stage 2—So Many Opinions

While providers are still struggling with the details of meaningful use Stage 1—and as of yet, no one has actually demonstrated meaningful use of their EHR—plans for defining Stage 2 requirements are moving ahead at full speed. A preliminary set of recommendations was released by the Meaningful Use Workgroup of the HIT Policy Committee in January, along with a Request for Comment by February 25. And comment they did!

Major organizations representing the various stakeholders submitted lengthy letters detailing their recommendations. While the specific concerns they express differ slightly, a clear consensus is emerging:

  • Rushing providers to do too much too quickly in the next stage will be counterproductive to the end goal of successful and widespread EHR adoption, as well as have a negative effect on patient care.
  • The proposed timelines are too aggressive in several areas.
  • Expectations should not exceed the existence of a sufficient information-exchange infrastructure, e.g., syndromic surveillance is identified as unrealistic.
  • Stage 2 requirements should be based on an objective evaluation of the experience in Stage 1 and the value of individual measures.

The last point above reveals a sense of frustration over the fact that the existing timetables create pressures that do not allow for this approach. Without taking into consideration the successes, failures, and physician participation rate in Stage 1—including, I would add, the rate of participation by specialists—Stage 2 could lay the groundwork for failure.

The AMA’s letter on behalf of 39 medical societies reiterates those societies’ initial concern about the excessive burden being placed on physicians. The letter argues for increasing flexibility, expanding the ability to opt out of measures that are not relevant to a physician’s routine practice, retaining a menu set rather than making all measures core and therefore required, and limiting physicians’ responsibility to what is within their control and not subject to compliance by other parties (e.g., patients’ use of portals for access to health information).

MGMA identified many of the same concerns, adding a request for harmonization of government programs to eliminate duplication of effort. (See discussion of this topic in my last EMR Straight Talk post.) Premier, Inc., a provider alliance, urged that new no clinical quality measures should be added until Stage 1 performance can be evaluated.

From the IT industry, AHIMA (an organization of healthcare IT professionals) cautioned about the impact of the overwhelming number of complex initiatives that practices will have to incorporate at the same time—ICD-10, Healthcare Reform, and meaningful use. EHRA, the EHR vendor trade organization, not surprisingly expressed its concern about the time needed to develop the software updates that will be required, particularly in light of the impending regulations identified by AHIMA. It therefore recommended that Stage 2 be limited to increased thresholds for Stage 1 measures with no addition of new measures. EHRA specifically identified clinical decision support as an area in which the government’s expectations go well beyond the scope of an EHR. As an overarching recommendation, EHRA urged a delay in the start of Stage 2 and the extension of certification to three years instead of two.

A somewhat different perspective comes from consumer organizations. The Consumer Partnership for eHealth and the Campaign for Better Care, on behalf of a number of other groups such as AARP and several unions, argue for a significant raising of the bar and accelerating of the program. For example, they ask that all menu measures become core measures, patient and family engagement via use of portals be emphasized, and clinical decision support rules be defined and adherence required. Deborah C. Peel, MD, Founder and Chair of Patient Privacy Rights, submitted a letter expressing her disappointment that “the current MU Stage 2 criteria and schedule for MU Stage 3 criteria completely ignore/omit privacy rights and protections in existing privacy law . . .“ It is not surprising that these groups would take a more aggressive stance and have higher expectations—these are the people who are paying for this program.

How will all of the above positions be reconciled? Based on the experience of Stage 1, in which the HIT Policy Committee and CMS revised the initial requirements to make meaningful use more achievable, I believe that they will do the same for Stage 2 and create a set of rules that are beneficial to the overall healthcare system and patients, while not overly burdening physicians.

Meaningful Use Stage 2: Speak Now or Forever Hold Your Peace

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!