Experts: Stage 2 rule provides 'compromise and complexity'
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Although the one-year extension for implementation was expected, the new three-month reporting period “effectively extended it another nine months,” said Fortin. Because the Centers for Medicare & Medicaid Services (CMS) has been “very clear that it is intent on sticking with the schedule that calls for Stage 3 implementation in 2016, this is a way of providing some compromise and some flexibility without jeopardizing the timeline for Stage 3.”
Elizabeth Shinberg Holland, MPA, director of the Health IT Initiatives Group, Office of E-health Standards and Services at CMS, agreed that the final rule offers a scheduling compromise. “From our point of view, we were already proposing to delay the start of Stage 2 from 2013 to 2014. We were taken aback that people wanted us to delay even further. We were trying to find some neutral ground.”
CMS recognizes that it’s a big undertaking for all the EHR vendors to get all of their products upgraded and recertified, and then get the updates rolled out to all of their customers, she said. “We’re trying to be cognizant of that and stagger the dates in 2014. Everybody gets a shorter reporting period.”
Maureen Gaffney, MHS, RN, CMIO and senior vice president of patient care services at Winthrop University Hospital in Mineola, N.Y., said the extension accommodates the early adopters. She attested to Stage 1 in the 2011 federal fiscal year. “We made this decision when we heard that the HITPC [HIT Policy Committee] was going to recommend the extension. Otherwise, we would have changed our strategy and attested in 2012 fiscal year to provide us enough MU 2 implementation time.”
Gaffney also likes the additional nine months the three-month reporting period provides for MU Stage 2 in 2014. That will allow her facility to implement the technology needed for MU Stage 2. “It is apparent that CMS was sensitive to the providers’ dependence on the readiness of the vendors to have the upgrades available.”
Regarding quality objectives, some are much more complex, said Fortin. Almost all of the Stage 1 measures are mandatory in Stage 2, but several were combined which results in a lot of nuances. For example, the coordination of care measure contains four submeasures while in Stage 1 there was a single measure for each objective. How well facilities do with the changes will probably depend on how familiar they were with the proposed rule, he said. “The changes are consistent with what CMS proposed.”
Stage 1 required that 30 percent of patients have at least one order via computerized physician order entry (CPOE) while Stage 2 expands that 30 percent to radiology and laboratory orders. The final rule “expands the scope and is going to require a much more robust CPOE system. That was expected but still could pose challenges for some folks,” said Fortin.
The intention always was to move as many of the menu items in Stage 1 to the core list in Stage 2, said Holland. That plan is “one way of increasing what people need to do but have them do that through measures they’re already aware of. We believe that providers are comfortable with the concept” of core and menu items.
One of the most controversial elements of the proposed rule for Stage 2 was the requirement that patients have the ability to view online, download or transfer their records and eventually, providers were going to have to prove that at least 10 percent of their patients were actually doing so.
The move to more patient-centered care in the proposed rule was intentional, Farzad Mostashari, MD, ScM, the national coordinator of Health IT, said back in February when he introduced the proposed rule at the Health Information Management and Systems Society annual convention. In this final rule, the 10 percent threshold was reduced to 5 percent but “that’s not a trivial number at all, particularly on the hospital side,” said Fortin. While a few large organizations have been relatively successful with patient engagement efforts, "5 percent could be a challenge in some regions of the country.”
The action is “definitely a commendable push to embrace what this initiative is focused upon—patient access to their health information,” said Gaffney. “However, the measures are particularly challenging. Not only are the providers responsible for providing the functionality, we will be held accountable for something that is not in our control: the patients actually using it.”
Regardless, “we felt strongly about having this as a measure,” said Holland. The agency responded to the comments by cutting the threshold in half. “We believe it is achievable.”
The mandate for use of secure messaging could be a challenge for hospitals, depending on their vendor, said Fortin. “CMS did say they recognize that some vendors may struggle so if your vendor isn’t certified or can’t meet the requirements that could be grounds for exemption from penalties."
“I have some concerns about the feasibility for successful secure health messages to physicians from patients,” said Brian McDonough, MD, CMIO at St. Francis Hospital, Wilmington, Del. “It is necessary and important but there is an uncontrolled variable: patient participation. Remember, patients need to view downloaded or transmitted portions of health records as well. This should be achievable but there will definitely be a need for physician and patient to communicate verbally as well as electronically to explain the importance of this.”
Another requirement that could prove challenging is electronic exchange of summary of care documents, said Gaffney. “It’s interesting that one of the measures associated with this requires that providers will electronically transmit a summary of care for more than 10 percent of transitions of care and referrals and that summary of care be sent electronically to a provider with no organizational or vendor affiliation,” she said.
“This will be particularly challenging as more and more providers and hospitals form ACOs and other employment agreements to be ready for healthcare reform. I’m not sure that large healthcare systems that manage most of a patient’s care within the system, due to business model or geographic limitations, will be able to comply with this expectation.” Gaffney said the mandate “appears to be counterintuitive to the managed care model promoted by healthcare reform. This is also where our RHIO [regional health information organization] partners play a very important role. We need to ensure that there is oversight of the HIE vendors to standardize information exchange technology and cost.”
Everyone involved is going to need to understand all of the nuances and complexities of the final rule, said Fortin. Meanwhile, “CMS will have to address those that aren’t fully fleshed out. The frequently asked questions [FAQs] section of the website keeps growing and growing.”
“There will probably be more FAQs,” agreed Holland. The agency plans to repackage MU educational materials and “be really attentive to questions being asked so we can tweak answers and tip sheets so they address the questions we’re getting.”
Because the goal is to get as many people as possible to qualify for meaningful use, “it doesn’t help us to make the program too complicated,” said Holland. “We want it to be accessible to everybody.”
Most providers will have plenty to do to meet the Stage 2 requirements but CMS seems to doing everything it can to help them. “Overall, CMS appears to have listened to many of our concerns,” said McDonough. “MU is starting to more fully look at the clinical setting and helping to guide physicians to make changes that have a greater impact.”
Beth Walsh,
Editor
Editor Beth earned a bachelor’s degree in journalism and master’s in health communication. She has worked in hospital, academic and publishing settings over the past 20 years. Beth joined TriMed in 2005, as editor of CMIO and Clinical Innovation + Technology. When not covering all things related to health IT, she spends time with her husband and three children.