Stage 2 Meaningful Use Prove Your Capabilities
To all physicians and informaticists treating the initial HITECH Act criteria for meaningful use as a checklist instead of a basic foundation of capabilities, it's time to stop and rethink as the demands of Stage 2 draw near. The likelihood of easing into that next stage, rather than face daunting obstacles, appears highly dependent on how comprehensively the organization approached Stage 1. Pain now, or pain later.
But that's all part of the plan hatched in the first stage, says Paul C. Tang, MD, chair of the workgroup within the federal Health IT Policy Committee responsible for recommending objectives to the Centers for Medicare & Medicaid Services (CMS). Setting intentionally low thresholds for meaningful use in Stage 1 was meant to avoid discouraging providers at the outset, but force them to build a technology capability that can intrinsically support much higher targets, he says.
For example, a recommendation in Stage 2 is for 60 percent of unique patients with at least one medication in their list to have at least one order entered using CPOE, up from 30 percent in Stage 1. Providers weren't going to stop once they hit 31 percent, says Tang. "We don't think it's much of a stretch to go from 30 to 60 because people are going to put [CPOE] in place." Stage 2 requirements add lab and radiology orders as well, which are typically part of the CPOE package.
"The premise is correct," says Ferdinand T. Velasco, MD, CMIO at Texas Health Resources, where 90 percent of all orders—for lab tests and radiology as well as medications—are entered electronically, all by physicians, at 11 hospitals owned and operated by the Arlington, Texas-based healthcare system. "If you have the functionality in place, and it's designed in such a way that you're already achieving some level of adoption to meet a 10-percent threshold, how much more difficult is it to achieve 80 or 90 percent?"
"We're not settling for meeting the Stage 1 requirements, we're projecting ourselves ahead," says Velasco. Texas Health's investment in its EHR, which it began implementing in 2006, exceeds $200 million. In May, the provider received $19.5 million in Medicare incentive payments for attesting to Stage 1 objectives, followed in July by $7.3 million in payments through Medicaid. "Stage 2 just happens to be aligned with where we were going anyway. We've invested a lot in the EHR, and it would be a shame not to take advantage of what value it gives us for enhancing the coordination of care."
But it will be the information officer's task to see not just that Stage 2 is reached, but that IT systems don't become a bigger burden on "time-bankrupt" physicians, says Michael J. McCoy, MD, CMIO of Catholic Health East, with 33 acute care and five long-term, acute care hospitals in 11 states. "There are substantial ramp-ups for Stage 2 compared with Stage 1, which not only creates problems for us, but also for the vendors that will have to undergo substantial work efforts to meet the requirements, particularly around interoperability and other reporting capabilities."
CMS projects that a notice of proposed rule making for Stage 2 objectives will be published in February, says Robert Tagalicod, director of the CMS' Office of E-Health Standards and Services. Tang says that the policy committee's recommendations in Stage 1 "tracked fairly closely" with the federal rule and that CMS and the Office of the National Coordinator for Health IT (ONC) "consider the HIT Policy [Committee] recommendations very seriously." However, in November 2011, the Stage 2 deadline was extended to 2014 for eligible hospitals and professionals that qualified as Stage 1 meaningful users in 2011.
Health information exchange in Stage 1 was a matter of requiring IT vendors to have that functionality, says Tang. In Stage 2, "we really need to start moving data around," with or without a formal HIE entity. "We're not specifying a technology, or requiring providers to find an HIE organization in which to exchange. We're just saying start exchanging with your clinical trading partners."
The technology is there for sending electronic documents to patients and other providers, says McCoy, but the bigger problem is having the actual information, as in getting hospital discharge summaries, compiled in timely fashion. Physicians using time-saving templates probably will meet expected transmission deadlines, but if practices are doing dictation now even with voice-recognition technology and 24-hour transcription services, "the turnaround is quick—but is it quick enough?"
It's also time for a systematic effort to get patients to join whatever web portal or secure email exchange their providers use in order to meet the 10 percent threshold, Tang says. "The patients are not directly under the control of providers, but the providers have huge influence over their [patients'] ability to access information electronically."
At Palo Alto Medical Foundation in California, where Tang is CMIO, medical assistants who show patients to rooms ask whether they have joined the online portal, and often they get signed up before the doctor walks in. Doctors bring up the subject again when they're about to order a test during an encounter. "We have two-thirds of our patients enrolled, and people who are very serious about it, who have these workflows, ramp up very quickly," he says. "That's why we thought 10 percent was not a high threshold."
The use of standards for capturing and sharing clinical information in a shareable format will increase in Stage 2—for example, the HIT Standards Committee is leaning toward specifying one standard, such as LOINC for lab tests, says Tang. "The more standards you have, the better for everybody, including doctors in small practices." Small groups don't have the leverage, for example, to ask labs for results in standard coded form, and their costs go up to accept multiple formats. "Not everybody uses [LOINC], but that's because they don't have to. If CMS and ONC decide to accept those [standards], then that starts to level the playing field."
Implementing standards will be a lot of work but yield a lot of upside benefit, and the pain will be felt by technical people much more than clinicians, says Velasco. "The impact on the physicians isn't going to be so much the standards. It's going to be the expectation of precise, descriptive documentation that will allow us to accurately code encounters for billing purposes or quality reporting," he says. "We have a federated model for managing patient information, and these standards are going to be critical for the exchange of those data in a way that can be absorbed, to be consumed by the various respective information systems residing in hospitals, physician offices and third-party centers."
Options include not only accelerating CDS implementation but also enabling physicians to breeze in and out of the computer system. At BJC HealthCare, with eight hospitals in and around St. Louis, a "virtual desktop infrastructure" ready for rollout allows a physician to go through the process of logging into all the applications he or she uses at the beginning of hospital duty and then use any computer thereafter like he or she is still sitting down at the first one," says Michael Kelly, who heads up IT for the system.
After a year-long pilot, he says it's been well received. "We are helping our doctors gain back some of the time that they could lose in having to navigate the electronic system."
BJC is at an early point even in Stage 1; its academic medical centers and community hospitals are on systems from two separate vendors, each with a different set of gaps in functionality to get in place. Kelly sees attesting to meaningful use no earlier than the second half of 2012. But just as important is preparing doctors for the necessity of making new tasks routine, says John Krettek, MD, VP of clinical improvement at BJC. "There's a whole cultural awareness that has to occur in the electronic world that physicians have not had to grapple with in the past," he says.
Healthcare organizations already have had to deal with significant new demands in Stage 1; problem lists being a standout example. Typically documented in a free-text progress note and later abstracted by health information professionals searching charts to code diagnoses, patient problems have been moved further forward in the patient-care progress by the Stage 1 requirement, requiring some structure to the content as well, says Velasco.
"Unlike order entry, a problem list is a novelty within the concept of medical documentation in the hospital environment," he says. Combined with an initial threshold of 80 percent, "it's a bit of a high bar early on in the program."
Despite the difficulty of implementing the objective, allowing such leeway with a problem list is "a significant flaw" that may have lasting consequences, says McCoy. "If it's put in electronically 30 days after the patient goes home by some coder, how much did that really help in the care of the patient?"
New directives
Stage 2's recommended objectives impose higher thresholds for systematically compiling lists, using computerized provider order entry (CPOE), incorporating clinical decision support (CDS) and supplying information to patients and outside partners. In many cases, clinicians will have to prove that they are actually doing some of the things they professed to be electronically able to accomplish in Stage 1.But that's all part of the plan hatched in the first stage, says Paul C. Tang, MD, chair of the workgroup within the federal Health IT Policy Committee responsible for recommending objectives to the Centers for Medicare & Medicaid Services (CMS). Setting intentionally low thresholds for meaningful use in Stage 1 was meant to avoid discouraging providers at the outset, but force them to build a technology capability that can intrinsically support much higher targets, he says.
For example, a recommendation in Stage 2 is for 60 percent of unique patients with at least one medication in their list to have at least one order entered using CPOE, up from 30 percent in Stage 1. Providers weren't going to stop once they hit 31 percent, says Tang. "We don't think it's much of a stretch to go from 30 to 60 because people are going to put [CPOE] in place." Stage 2 requirements add lab and radiology orders as well, which are typically part of the CPOE package.
"The premise is correct," says Ferdinand T. Velasco, MD, CMIO at Texas Health Resources, where 90 percent of all orders—for lab tests and radiology as well as medications—are entered electronically, all by physicians, at 11 hospitals owned and operated by the Arlington, Texas-based healthcare system. "If you have the functionality in place, and it's designed in such a way that you're already achieving some level of adoption to meet a 10-percent threshold, how much more difficult is it to achieve 80 or 90 percent?"
"We're not settling for meeting the Stage 1 requirements, we're projecting ourselves ahead," says Velasco. Texas Health's investment in its EHR, which it began implementing in 2006, exceeds $200 million. In May, the provider received $19.5 million in Medicare incentive payments for attesting to Stage 1 objectives, followed in July by $7.3 million in payments through Medicaid. "Stage 2 just happens to be aligned with where we were going anyway. We've invested a lot in the EHR, and it would be a shame not to take advantage of what value it gives us for enhancing the coordination of care."
But it will be the information officer's task to see not just that Stage 2 is reached, but that IT systems don't become a bigger burden on "time-bankrupt" physicians, says Michael J. McCoy, MD, CMIO of Catholic Health East, with 33 acute care and five long-term, acute care hospitals in 11 states. "There are substantial ramp-ups for Stage 2 compared with Stage 1, which not only creates problems for us, but also for the vendors that will have to undergo substantial work efforts to meet the requirements, particularly around interoperability and other reporting capabilities."
CMS projects that a notice of proposed rule making for Stage 2 objectives will be published in February, says Robert Tagalicod, director of the CMS' Office of E-Health Standards and Services. Tang says that the policy committee's recommendations in Stage 1 "tracked fairly closely" with the federal rule and that CMS and the Office of the National Coordinator for Health IT (ONC) "consider the HIT Policy [Committee] recommendations very seriously." However, in November 2011, the Stage 2 deadline was extended to 2014 for eligible hospitals and professionals that qualified as Stage 1 meaningful users in 2011.
Less capability, more action
Stage 2 recommendations call for clinicians to more fully use the power of computers to compose notes, track and present information once buried in file cabinets or charts, and make key clinical details such as care summaries expeditiously accessible outside the immediate work setting.Health information exchange in Stage 1 was a matter of requiring IT vendors to have that functionality, says Tang. In Stage 2, "we really need to start moving data around," with or without a formal HIE entity. "We're not specifying a technology, or requiring providers to find an HIE organization in which to exchange. We're just saying start exchanging with your clinical trading partners."
The technology is there for sending electronic documents to patients and other providers, says McCoy, but the bigger problem is having the actual information, as in getting hospital discharge summaries, compiled in timely fashion. Physicians using time-saving templates probably will meet expected transmission deadlines, but if practices are doing dictation now even with voice-recognition technology and 24-hour transcription services, "the turnaround is quick—but is it quick enough?"
It's also time for a systematic effort to get patients to join whatever web portal or secure email exchange their providers use in order to meet the 10 percent threshold, Tang says. "The patients are not directly under the control of providers, but the providers have huge influence over their [patients'] ability to access information electronically."
At Palo Alto Medical Foundation in California, where Tang is CMIO, medical assistants who show patients to rooms ask whether they have joined the online portal, and often they get signed up before the doctor walks in. Doctors bring up the subject again when they're about to order a test during an encounter. "We have two-thirds of our patients enrolled, and people who are very serious about it, who have these workflows, ramp up very quickly," he says. "That's why we thought 10 percent was not a high threshold."
The use of standards for capturing and sharing clinical information in a shareable format will increase in Stage 2—for example, the HIT Standards Committee is leaning toward specifying one standard, such as LOINC for lab tests, says Tang. "The more standards you have, the better for everybody, including doctors in small practices." Small groups don't have the leverage, for example, to ask labs for results in standard coded form, and their costs go up to accept multiple formats. "Not everybody uses [LOINC], but that's because they don't have to. If CMS and ONC decide to accept those [standards], then that starts to level the playing field."
Implementing standards will be a lot of work but yield a lot of upside benefit, and the pain will be felt by technical people much more than clinicians, says Velasco. "The impact on the physicians isn't going to be so much the standards. It's going to be the expectation of precise, descriptive documentation that will allow us to accurately code encounters for billing purposes or quality reporting," he says. "We have a federated model for managing patient information, and these standards are going to be critical for the exchange of those data in a way that can be absorbed, to be consumed by the various respective information systems residing in hospitals, physician offices and third-party centers."
Focus on the physician, not the checklist
The upshot is that CMIOs are on the spot to get their organizations as far away from the checklist mentality as can be, instead emphasizing workflow design that minimizes the burden of a proliferating information to-do list on doctors and nurses. We have to try to "make those things as automated as possible, so the physicians don't have to worry about remembering to do things," says Velasco.Options include not only accelerating CDS implementation but also enabling physicians to breeze in and out of the computer system. At BJC HealthCare, with eight hospitals in and around St. Louis, a "virtual desktop infrastructure" ready for rollout allows a physician to go through the process of logging into all the applications he or she uses at the beginning of hospital duty and then use any computer thereafter like he or she is still sitting down at the first one," says Michael Kelly, who heads up IT for the system.
After a year-long pilot, he says it's been well received. "We are helping our doctors gain back some of the time that they could lose in having to navigate the electronic system."
BJC is at an early point even in Stage 1; its academic medical centers and community hospitals are on systems from two separate vendors, each with a different set of gaps in functionality to get in place. Kelly sees attesting to meaningful use no earlier than the second half of 2012. But just as important is preparing doctors for the necessity of making new tasks routine, says John Krettek, MD, VP of clinical improvement at BJC. "There's a whole cultural awareness that has to occur in the electronic world that physicians have not had to grapple with in the past," he says.
Healthcare organizations already have had to deal with significant new demands in Stage 1; problem lists being a standout example. Typically documented in a free-text progress note and later abstracted by health information professionals searching charts to code diagnoses, patient problems have been moved further forward in the patient-care progress by the Stage 1 requirement, requiring some structure to the content as well, says Velasco.
"Unlike order entry, a problem list is a novelty within the concept of medical documentation in the hospital environment," he says. Combined with an initial threshold of 80 percent, "it's a bit of a high bar early on in the program."
Despite the difficulty of implementing the objective, allowing such leeway with a problem list is "a significant flaw" that may have lasting consequences, says McCoy. "If it's put in electronically 30 days after the patient goes home by some coder, how much did that really help in the care of the patient?"
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