Striving for Meaningful Use Stage 2

This article appears in the August 2012 issue of HealthLeaders magazine.

The debate continues to rage: Are meaningful use requirements too specific or too vague? On target or wide of the mark? It still depends on who you ask.

"If these guidelines remain this rigid, this inflexible, this one-size-fits-all, there may well be a number of physicians who try in good faith and fail," says Steven J. Stack, MD, chair of the board of trustees of the American Medical Association and an emergency physician with Lexington, Ky.–based Saint Joseph Health System.

"It actually ends up creating a lot of unnecessary overhead to offer options," counters John D. Halamka, MD, MS, the CIO of the Beth Israel Deaconess Medical Center in Boston.

During the meaningful use rollout in 2011, allowable options in the specification diluted the interoperability between systems. The rules governing Stage 2, also now known as the 2014 edition of meaningful use, specify one way to implement content, domain vocabularies, and transport, Halamka says. "Every time you offer options," it's actually more work and less interoperability."

Attesting for meaningful use 2014 edition requires providers to interoperate, and with health information exchanges being in their infancy, providers may be hard-pressed to meet those interoperability requirements.

"We recognize that to really get meaningful meaningful use takes time," says Farzad Mostashari, MD, ScM, national coordinator for health information technology within the office of the U.S. Department of Health and Human Services secretary.

Previously, Mostashari said that meaningful use would be successful this year if CMS paid 100,000 providers in 2012 for attesting compliance with the 2011 meaningful use guidelines. "Now it looks like we're going to smash that 100,000 mark," he says. In a June 19 press release, HHS reported that more than 110,000 eligible professionals and over 2,400 eligible hospitals have been paid by the Medicare and Medicaid EHR Incentive Programs.

Some attestations have been more easily won, as institutions that have built their EMRs for years can fine-tune them to meaningful use requirements. Others are dramatic come-from-behind affairs occurring in recent months.

One example is the 722-licensed-bed University of Mississippi Medical Center in Jackson, Miss., which on June 1, went live with an implementation of the EpicCare EMR from Verona, Wis.–based Epic. In true 21st-century fashion, UMMC tweeted and issued posts to a public Facebook page before, during, and after go-live. Moving to meaningful use engaged the entire institution, says John Showalter, MD, MSIS, the CMIO at UMMC. "We have more than 900 people who signed up to be super-users on our training," Showalter says. "All those people had to be released from their regular clinical duties or administrative duties or lab duties to come and take extra training, and at go-live they were pulled out of their regular jobs just to be support staff."

Institutions take a financial and operational hit during the transition to meaningful use. UMMC has a $90 million implementation budget spread over five years, Showalter says. Because it is a state institution, the money came from a state-backed bond. "We whittled away a considerable portion of our cash while we were waiting for the bond to get through and get the money back from the bond. The bond has gone through and the money is coming in."

Other numbers tell their own story. In the past two and a half years, UMMC deployed more than 7,000 devices, counting barcode scanners and printers. In the end, UMMC brought up 15 applications in five hospitals and more than 20 clinic locations in a single day.

Staff had to pass a proficiency test or did not get access to the system. IT staff were able to learn valuable lessons by attending a similar go-live previously at Ochsner Medical Center in New Orleans, La., Showalter says.

Because approximately 35% of the UMMC patient population is eligible for Medicaid, the health system has already attested in 2012 and will receive more than $9 million in meaningful use reimbursement through the Medicaid Adopt program, Showalter says.

Those who attested in 2011 are breathing a sigh of relief over CMS' decision to allow them an extra year to achieve the Stage 2 thresholds.

"Common sense told us they were going to have to relax and push it out a year, so that was good news and I'm glad they did," says Ed Ricks, vice president of information systems and CIO at Beaufort (S.C.) Memorial Hospital. "We would have had to have been at Stage 2 by October 1 of this year, and now it's October 1, 2013. We can do that."

The American Hospital Association and the AMA came to at least one agreement on meaningful use. Commenting on the Notice of Proposed Rulemaking for Stage 2, they say the spirit of the law shouldn't allow CMS to peek back at 2012 data in order to get a full year's worth of data in each meaningful use attestation.

"It deprives providers of desperately needed time to comply," says the AMA's Stack.

As of this writing, it was unclear whether appeals for a 90-day recordkeeping period in 2013 would be substituted in the final rule for the 2014 edition of meaningful use.

The 197-licensed-bed Beaufort Memorial has done meaningful use in phases, Ricks notes. Three-quarters of its physicians are independent, and of those, not all are yet using computerized physician order entry. As of late May, Beaufort was about to bring its OB-GYN and pediatricians live on CPOE. So certain rollouts vary by specialty.

"The biggest challenge may be the quality measures and collecting the discrete data from areas that historically were not pieces of discrete data, that we abstracted out," Ricks says. "Luckily we were migrating to a new version of Meditech software over the past couple of years, and so we tried to build in the collection of that data in the work flows up front for the clinicians so that we didn't have to do any kind of double work as we went on."

Two requirements in the meaningful use 2014 edition loom large and pose bigger challenges for all providers: information exchange and patient engagement.

Mostashari says the 2014 edition moves from tests of data exchange to actual exchange of information across organizational and vendor boundaries. "Patients are certainly quite aware that their care is not as coordinated as it could be," he says. "They certainly know there are tests repeated unnecessarily."

Outweighing even the cost of repeated tests is the patient safety danger from those tests—for example, excessive ionizing radiation, Mostashari adds.

The 2014 edition as proposed requires discharges to be accompanied by a care summary for 65% of transitions of care or referrals, and for that to be done electronically 10% of the time across organizational and vendor boundaries.

Not all physicians agree that the data exchange requirements in the 2014 edition are a win-win.

"This is a great example of where the system potentially is going to shift the work toward the doctor," says Lyle Berkowitz, MD, medical director of IT and innovation at Northwestern Memorial Physicians Group, a Chicago-based multisite practice of 100-plus primary care physicians who are on the medical staff at Northwestern Memorial Hospital and faculty members of Northwestern University's Feinberg School of Medicine. "Meaningful use isn't saying exactly how it's going to be done from a work flow perspective. We actually need to train doctors how to run a team. It's not a skill that's traditionally taught."

As for patient engagement, many providers remain unsure how their organizations will achieve this goal of the 2014 edition.

"I don't know how a healthcare provider can be responsible for making sure that a patient that receives information is going to look at it and use it in a meaningful way," says Jackie Lucas, FACHE, vice president and CIO of Baptist Healthcare System, a seven-hospital system with approximately 2,000 licensed beds headquartered in Louisville, Ky.

In discussing these meaningful use requirements, one of her staff suggested that a provider could offer a nonmonetary incentive to patients to access their information electronically. "We've got to be very careful," Lucas says. "I suggested anything a provider did would have to meet HIPAA regulations.

"That's a lot to ask the provider, not only to ensure that the information is available to the patient electronically, but also to require the provider to meet a targeted percentage of patients who have actually accessed their information electronically," she adds.

On the health information exchange front, both NMPG and Baptist deployed McKesson's RelayHealth technology to provide a secure patient portal. This eliminated the need for time- and labor-consuming faxes and phone calls to affiliated physician practices, Lucas says.

"You improve quality, and it's also more secure," she says. "You don't have a fax lying around on a fax machine, curled up on the floor, or somebody punches the wrong number accidentally and sends that fax to the wrong location."

Other providers are still sorting out exchange strategies. "South Carolina has a statewide initiative, and we are participating with that," says Beaufort's Ricks. "But we're looking at building our own sort of health information exchange for the community, so a clinician can see a current picture of what's going on with that person across the community." For now, fax machine referrals will continue to some degree, he adds.

Ricks is determined to move ahead on patient engagement not just because of meaningful use regulations, but also because "we just know that somehow over the next five or seven years, there's going to be an evolution of the way we're reimbursed. It has to happen.

"We're looking at some solutions, very new in the marketplace, that are an adjunct to a patient portal. The intent is to engage patients with real-time monitoring of things," Ricks says. "I hate to use the word gamification, but that's the word I keep hearing, a social media aspect to some degree."

For example, to cut down on 30-day readmissions, discharged congestive heart patients might be sent home with a Bluetooth-enabled scale, Ricks says. The system would alert staff if measurements stopped or if the patient gained weight for two or three days in a row.

"Meaningful use is less about a technology implementation and more about policy and work flow implementation," says Beth Israel Deaconess' Halamka. "Think of the medical record as Wikipedia for each patient, where it's the collective editing of the entire institution that results in a record that's complete enough."

By eliminating those options that Halamka alluded to earlier, the cost of interfaces between the remaining disparate systems will drop from thousands of dollars per interface to hundreds of dollars. "There's still customization, but it's minor."

Although everyone speaks of meaningful use as a platform upon which to build tomorrow's innovations in medicine, there are complaints today about the lack of ease of use of EMRs.

"The cost to us in lost efficiency by implementing a health information system is somewhere between $300,000 and $750,000 in the first year," says Prentice Tom, MD, chief medical officer of CEP America, an Emeryville, Calif.–based provider of hospitalist services that sees 4.5 million patients annually.

To make up for the inefficiency, CEP hires scribes that cost about $27,000 per physician annually.

EMRs would be adopted more rapidly, and wouldn't require as many government incentives to acquire, if they included algorithms that present the useful information out of the record, Tom says.

"It's a fair indictment," Halamka says. "If it takes 47 clicks to write an e-prescription, as opposed to one click to order a CD on Amazon, something's wrong." Future meaningful use rules will require "some measure of usability" to address this, he says.

"The conversation has really got to be more about value for the money we are spending," Mostashari says. "Electronic health records are a necessary, though probably not sufficient part of that equation."

Reprint HLR0812-5

This article appears in the August 2012 issue of HealthLeaders magazine.