Monday, March 14, 2011

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.

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