A Speed Bump on the Road to Meaningful Use

Meaningful Use has hit a speed bump. It’s of the low, wide and gentle type, not the old raggedy, narrow and mean bump you find in older parking lots. Now that a tentative proposal for Meaningful Use Stage 2 has been published by ONC, and duly commented upon by the public, it just dawned on folks that there isn’t enough lead time between Stage 1 and Stage 2 to allow for an orderly transition, and here is the problem in a nutshell.

Meaningful Use is divided into three, increasingly more demanding, stages, starting in 2011 with Stage 1 and advancing every two years to a higher Stage. So 2013 marks the beginning of Stage2 and 2015 is the start of Stage 3. It seems that ONC and CMS need about a year and a half to define each Stage from start to finish, so if they start working on Stage 2 right after Stage 1 commences, there are only 6 months left for NIST to define certification criteria, EHR vendors to update their wares and certify them, and physician and hospitals to roll the new and improved products out. Oops……

The hand wringing in “industry experts’” circles began immediately after this realization, culminating with an Advisory Board publication advising hospitals in particular to not apply for Meaningful Use incentives in 2011, but instead wait for 2012, which they can do without penalty, and the same advice is applied to ambulatory practices owned by hospitals. They did not recommend anything for physicians in private practice.

Since hospitals have a fiscal year starting on October 1st, three months before private practitioners, and Stage 2 Meaningful Use final ruling is not expected before the summer of 2012, it seems that hospitals are indeed at a greater disadvantage in that according to current regulation, providers must begin Meaningful Use reporting on the first day of their respective fiscal years. Stage 1, which was not finalized until late last summer, would have been a problem too, but the disaster was averted by CMS’s relaxation of requirements to only impose a 90 days Meaningful Use period in the first year, thus effectively pushing out the dreaded start date by up to 9 months. So should you wait for 2012? Before we shoot from the hip in panic, perhaps we should examine a few facts.

The tentative proposal for Stage 2 criteria as published by ONC contains very few new items. Most criteria are restricted to Stage 1 functionalities, but require clinicians to do more of the same. For example, if Stage 1 required that you record vital signs for 50% of patients, Stage 2 may require that you do that for 80%. This type of upping the ante does not require NIST to create new certification tests and does not require EHR vendors to write new software. Other Stage 1 criteria are not changed at all for Stage 2, and a few that used to be optional are now proposed to be mandatory. All these changes have no bearing on NIST, the vendors or the software. Let’s look then at the 10 “newish” requirements proposed for Stage 2.

  1. Clinical Decision Support (CDS) rules must originate from a reputable source and be properly deployed – CDS was part of Stage 1 and the Stage 2 qualification should already be implemented in any EHR worth anything. This is a non-issue unless you bought one of those fly-by-night certified EHRs, in which case you have much bigger problems than missing out on stimulus incentives.
  2. Advanced Directives recording is extended to physicians – This requirement was only for hospitals in Stage 1. Most decent EHRs already have this implemented and NIST has the test written.
  3. Electronic Notes – For hospitals, they allow the notes to be created by NPs and PAs. This is brand new and ONC will need to define what constitutes a Note and NIST will need to create a new certification test, but if your software does not allow you to document a visit note, you probably don’t use an EHR anyway.
  4. Track Meds in the eMAR – Is any hospital that is ready for Meaningful Use in 2011 not doing that already? Anyway, NIST will have some work to do here.
  5. Patient Portal – For Stage 2 there are several requirements that make having a Portal absolutely necessary. Most EHR vendors used their portals to certify for Stage 1, so again, not much work here for vendors, although NIST may have to tweak some tests. An interesting tidbit is that the Stage 2 proposals envision requiring physicians to make sure that 20% of their patients use the Portal. Not sure if I should laugh or cry, but I cannot see this particular requirement withstanding the rigors of a final ruling.
  6. Record Patient Communication Preferences – All but the quackiest EHRs already have this simple functionality. NIST will have to write a simple test.
  7. Care Team Members for each patient – Seriously? Anyway, this is insanely simple to do and simple to test.
  8. Longitudinal Care Plans – ONC is still trying to define what this means, but if everything evolves as it did in Stage 1, it will probably boil down to something like prescribing statins, or having a standing order for HbA1c every 3 months. No work for vendors and very little work for NIST.
  9. Health Information Exchange – This was required to be tested in Stage 1 and now it is required to establish actual connections. Nobody said anything about using those connections. I cannot imagine that this requirement will survive as written, but it should not require much effort from certified vendors and very little adjustments from NIST.
  10. Clinical Quality Measures (CQM) – The ONC proposal had no specifics here, but it stands to reason that they will be adding more measures in Stage 2. CQM has been the Meaningful Use Trojan Horse all along, so it will continue to be so. Unless tempered by reason, the new CQMs will require some doing from all stakeholders.

Contrary to the Advisory Board opinion, Stage 2 is nothing but an incremental change to Stage 1. Just like vendors did not sit idle while CMS and ONC were grinding the Stage 1 sausage, they will not be taken by surprise when the final Stage 2 rule is published either. However, even if enough vendors certify in time for the October 1st 2012 deadline, there is no way hospitals can be ready to move to Stage 2 on the appointed date, and very little chance that ambulatory offices will be ready to rock-and-roll by January 1st 2013.

The Meaningful Use workgroup at ONC held a meeting on March 8 and this very issue was raised. Surprisingly all participants calmly concluded that there are several possible solutions and one will be picked after proper consideration. Here are some of the options and my take on all of them.

  1. Push Stage 2 by one year closer to Stage 3 – Not a very good option for dealing with Stage 3 when the time comes, since the 2015 date is locked into statute and cannot be pushed.
  2. Allow folks to continue reporting on Stage 1 for the first 9 months of the 2013 fiscal year and begin Stage 2 reporting in the last 90 days of 2013 – This is reasonable, but a very complex structure for CMS to accommodate.
  3. Require only 90 days reporting for the first year of Stage 2, just like we did for Stage 1 – Simple, straightforward and my personal favorite.

Either way, hospitals and physicians should feel comfortable that an equitable solution will be forthcoming and there is nothing to be gained from postponing your 2011 attestation if, and only if, you are ready to go. ONC has shown time and again that it has an obvious interest in having as many certified vendors and as many Meaningful Users as possible, by consistently lowering the bar on problematic requirements. There is no reason to assume that ONC will refrain from doing so now. I may add that a bird in hand is worth two in the bush, and nobody knows what will happen to these incentives in 2012, which is an election year, and beyond.

Margalit Gur-Arie was COO at GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS and billing services for physicians. Prior to GenesysMD, Margalit was Director of Product Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large non-profit hospital organization. She shares her thoughts about HIT topics and issues at her blog, On Healthcare Technology.

7 replies »

  1. It’s not yet 9 AM, and after reading these comments, I need a good, stiff drink. Very discouraging.

  2. “And you think the government wants us to reestablish this position? Hah!!!”

    I think I would want want you to do just that and I think a whole bunch of over 50 docs would also want that and probably significant numbers of young and impressionable medical students too….. It’s not going to happen. Anyone left in that role, and I know a few, will soon retire and that will be the end of it.

    And yes, you did answer my question.

  3. Where did physicians go wrong? When they forgot that about 15-20% of their time was spent treating the indigent, that at the end of the day, a doctor could live comfortably and responsibly getting paid for 80-85% of the hours they work. Because it really isn’t about income, it is about being a voice in the community they serve, being seen as a resource and a valid spokesperson for the people. Sometimes, being seen as a leader and caregiver was as important, if not moreso, than just making a buck.

    But, how many doctors do you know today who pine for this role? Little if any.

    And you think the government wants us to reestablish this position? Hah!!!

    And it is not about power. It is about true and honest leadership. A concept so far and away from the minds in DC, they would look at you with as blank a stare as a cadaver would offer!!!

    Does this answer your question!?

  4. My dear Dr. D., I have no clear idea what you are arguing against, but I think it’s about spending money on imperfect technology.

    I assume you drive a car, use electricity, use telephones, have running water and maybe gas lines, watch TV and read your news online from time to time.
    Technology is not waste and it’s not something cows inadvertently step in. Technology never starts out being perfect, but instead struggles all along to become better until a different technology replaces it.
    It won’t be long before paper is not manufactured and not used any longer. I know it’s hard to fathom such things, but those carving into rock must have had misgivings about emergence of new media as well.

    Should the government spend a boatload of money in these hard times to subsidize physicians and hospitals in their completely inevitable transition to electronic media? I don’t think so.

    As I was telling a friend the other day, there is something deeply disturbing about watching billions in tax dollars going to those charging $4000 for an MRI and others who are at the very top of the financial pyramid, while children, elderly and disabled folks living in poverty see one lifeline after the other yanked away by their home States.

    I would really like to see some health care providers/hospitals, who are supposedly paragons of social charity, and those who have amassed fortunes in this field, announce that they are donating their incentives to provide medical care to the poor, maybe just return the money to Medicaid or give it to a community clinic…..
    What do you think are the chances that something like this would happen?

  5. “(these would be the same folks who bring you ICD-10, SNOMED, and RBRVS). Any disruptive players there?”

    Dr. Goel, at the risk of sounding cynical, there are plenty disruptive players there, and they do manage to disrupt work on a daily basis.

    I do agree with you that the health care business model is amiss and technology, however good and disruptive (in the good sense of the word), should not be expected to fix that. It cannot and it actually should not.

  6. Life, has become a sound bite, or an abbreviation of words cleverly put together to form an acronym that is alleged cute and applicable. But, at the end of the day, simplifying life experiences to fit a twitter comment or political agenda does not benefit nor effectively impact on our culture as a whole.

    Figure this one out, and hopefully the owners of this site will allow this comment to stay and I promise not to use questionable words to sullen this site in future comments:

    Bogus Useless Lies Leading Senseless Humans Into Terrible Situations. Put the capital letters together and it sums up what technology has basically lead us to become. I would bet the cows and bulls have better sense to avoid being in it than we seem to figure out these days.

    I pluralized the word because it has become prevalent to a point that a singular term makes it less meaningful. Just remember, technology is made by humans, who by instinct are not perfect, make mistakes, and are not quick to pick them up even if they are genuinely trying to be attentive to catch them.

    EHRs, HIT, EBM, and on and on, just shorten things that take time to do. Quick fixes usually do not solve problems, at the very least just prolong their inevitability. But, the defenders and apologists do not want you to notice this.

    Hey, it’s your dime they are after!!!

  7. This sounds like a typical bureaucratic mess.

    Rather than overdeliver on things that will actually have use cases in the “wild”, instead we see increasingly watered down dates and delivery requirements with a strong administrative process focus springing from the entrenched powers that be (these would be the same folks who bring you ICD-10, SNOMED, and RBRVS). Any disruptive players there?

    The real speed bump on the road to “meaningful use” is that no one knows if any of the collected data will actually be usable across a person…we’re spending a bunch of money on building data silos within institutions on only the promise that we’ll somehow be able to hack it all together and make sense of it. Or that the large organizations that hold that data will want to use it to reduce their own value and power.

    The real issue is that because we’re starting with hospitals and hospital-based systems (because that’s where scaled and expensive provider care is today) instead of focusing on the information and tools that will keep people out of them, we’re losing focus on where the real human and systemic value lies.

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