Meaningful Use Stage 2: Targeting Specialties

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As specialty practices and physician groups grapple with Stage 1 requirements, Stage 2 might be on their distant horizon, priority-wise. But it shouldn't be. It is closer than you think.

What's it mean for cardiologists?

In many practices, the biggest question about the requirements for Stage 2 meaningful use is a simple one: What about Stage 1? Nationally, approximately 10 percent of all office-based physicians have a fully functional EMR, according to a 2010 survey by the National Center for Health Statistics. In addition, 41 percent of all office-based physicians plan to apply for EHR incentive payments, and 79 percent plan to apply in 2011 or 2012.

In mid-January, the Office of the National Coordinator (ONC) Health IT Policy Committee requested comments regarding the Stage 2 definition of meaningful use for EHRs. According to the timeline established by the Centers for Medicare & Medicaid Services (CMS), finalized measures for Stage 2 are slated to be issued this month.

One of the criticisms leveled at the Stage 1 measures was that they were primary care driven and didn't include enough consideration of specialty practices. "For Stage 2, the Quality Measures Workgroup is working hard to define specialty-specific measures," says George Hripcsak, MD, chairman of the biomedical informatics department at Columbia University in New York City and co-chairman of the HIT Policy Committee Meaningful Use Workgroup. "We in the meaningful use workgroup are trying to define measures that are relevant to all specialties, although we recognize that some measures will need exemption for some specialties."

Specialty practices, like general practices, are challenged by where they are in their EHR implementation process, says Jack Sunderman, director of IT at Wellmont CVA Heart Institute, a 36-physician practice and division of Wellmont Healthcare, an eight-hospital organization based in Kingsport, Tenn., that serves Northeast Tennessee and Southwest Virginia.

With Wellmont's cardiologists in the 90-day reporting period for Stage 1, Sunderman's department is starting work to prepare the practice for Stage 2—as much as he can. "In general, some are suggesting that the thresholds will increase in Stage 2, and that's what we've been working toward," says Sunderman. In IT terms, that means tweaking the group's EHR, and doubling some Stage 1 thresholds for some core measures, he says. For example, Stage 1 calls for 30 percent of medication orders to be entered via computerized provider entry. In Stage 2, that may increase to 60 percent—with at least one medication and one lab or radiology order for 60 percent of unique patients who have at least one such order.

Specialty practices should keep a close eye on proposed higher data gathering and reporting thresholds. For example, the requirement that demographics be recorded could rise from 50 percent in Stage 1 to 80 percent in Stage 2, with a requirement for stratified quality reports based on that information.

The proposed changes to the clinical summary requirement could take some work as well. Stage 1 includes a requirement that 50 percent of patients receive a clinical summary. Stage 2 proposes those data be available in a "uniformly human-readable form by 2013," and patients have the ability to view and download relevant information about a clinical encounter within 24 hours of the encounter.

This could present a challenge to practices because doctors often enter their summary information in language that is intended for other doctors, and patients might not understand the summary. "It's not an 'average joe' statement," says Sunderman.

His practice developed a screen in the EHR where doctors can select "human-readable" statements, which explain instructions to the patient in colloquial language. "In cardiology, there are many similar statements: doctors discuss weight, improved diets and smoking cessation. One of the challenges when you're looking at these objectives is whether you're using the tool correctly to meet the objectives."

Sprinting to the finish line

Getting the tools in place is the major issue for many practices. "If they haven't started, they've got the entire development cycle that they have to go through—identify processes, get the software in place, then view how to capture data, as well as achieve meaningful use and reporting it accordingly.

However, the EHR Incentive Program stipulates that eligible professionals who begin from 2011 to 2013 have two years in Stage 1, and those who start in 2014 have at least one year in Stage 1. "That ameliorates some of the concern about the timetable for Stage 2," Hripcsak says.

As 2012 gets closer, Sunderman says there will be a re-evaluation of the timeline, "particularly because Stage 2 is on a calendar timeline."

The timeline for Stage 2 has taken some heat during the comment period, including from professional societies. "[I]t would be far preferable to be in a position to evaluate actual experience under meaningful use Stage 1 prior to considering potential meaningful use objectives and measures for Stage 2," states the College of Health Information Management Executives (CHIME), a 1,400-member organization of CIOs and other health IT executives, in its response to Stage 2 proposals. It would be prudent not to move to Stage 2 until about 30 percent of eligible hospitals and eligible professionals are able to demonstrate EHR meaningful use under Stage 1, according to the college.

Farzad Mostashari, MD, the ONC's deputy national coordinator for health IT, says he understands the desire for more clarity, but "we have to do rulemaking; we can't predetermine the rules." Like the Stage 1 proposed requirements, Stages 2 and 3 must be proposed and revised with input from all stakeholders.

Meaningful use has a vital role as a plan for nationwide health IT adoption, Mostashari says. With such a large scope, rules will change as lessons are learned. Meaningful use's stages must include enough flexibility to accommodate these changes and enable as many providers as possible to achieve those goals. "We'd rather build into the process a sense of clear targets for health outcomes and flexibility in how to achieve them. Perhaps we need to articulate more clearly what it's all for," he says.

However, if facilities have worked tirelessly to meet Stage 1, moving to Stage 2 should not be too difficult. "From an IT perspective, can we meet the timeline for Stage 2? Yes, the capabilities are there," Sunderman says. "The challenge is the people—how to train practices to use these tools."

The tools by themselves will not magically propel a facility from stage to stage. "Along the way, you have to review your objectives, focus on the methods to achieve them and continually monitor your progress," he says. Without this type of concerted effort between man and machine, no amount of data will improve patient care.