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June 2015

MU: Keep an Eye on the Future
By Mike Bassett
For The Record
Vol. 27 No. 6 P. 12

Organizations with a myopic view of meaningful use are likely to struggle to meet new objectives and gain little from those they do attain.

There are many aspects of meaningful use that cause serious disagreement among industry observers. However, if there's one item they all can agree on it's that approaching the incentive program as an IT project is bound to create problems down the road.

"I'm sure that for some organizations this was the case," says Jeff Smith, vice president of public policy at the College of Healthcare Information Management Executives. "Many CIOs spend much of their time trying to convince executives in their organizations that what they do is foundational to the delivery of care and not an IT project.

"Yet, I think that there are some organizations that didn't necessarily think of [meaningful use] as the wave of the future, but as an opportunity to offset some costs on an IT project," he continues. "And I would suggest those who thought about it like that are struggling—and will continue to struggle—until they figure out how to integrate meaningful use into their broader plans."

"When I go to new clients who are struggling to get up and running with stage 2, that topic is one of our first discussions," says John Hoffstatter, delivery director of clinical advisory services at CTG Health Solutions. "Meaningful use cannot be just an IT initiative. It has to be owned by the clinical leadership and executives. Health IT is the enabler."

Too much of meaningful use is related to workflow and clinical data to leave everything up to IT, says Tom Grove, principal of Phoenix Health Systems, which provides IT project leadership and consulting services. "As smart as your IT guys are, they just won't understand those issues," he says. "That's why it's important to have a strong relationship with clinicians because they need to be able to explain how they do things efficiently and effectively, and then you need to figure out how to implement processes on the backside. But driving this from an IT perspective is a set up for failure."

Hoffstatter says a by-the-numbers approach is destined for failure. "I think those organizations that built a foundation to meet the intent of the law rather than the letter of law have been more successful," he says. "When we started with stage 1, the bar was pretty low and the ability to meet certain measures by twisting interpretations was relatively simple, so a lot of people jumped on the bandwagon and tried to do that. One of the things we tried to do is lay a foundation for organizations not only to meet the stage they are preparing for in that particular year, but also to meet the foundational requirements needed to be successful going forward."

Hoffstatter says one reason there has been a drop in the number of organizations attesting to stage 2 is that they ignored or neglected those foundational pieces and then needed to take a few steps backward. "And that kind of rebuild is going to take time," he points out.

For example, take meeting the requirements for problem lists. "It's very easy in meaningful use to meet the letter of the law—you could just use postdischarge ICD-9 coding for diagnosis. The intent, however, was to diagnose up front so you can do an intervention at the point of care prior to discharge," Hoffstatter says. "Now with stage 2 and clinical decision support, that is being leveraged even more. If we don't have that diagnosis in the EHR and it's not being worked by an active problem list, then it becomes more problematic and hospitals have to figure out how to fix it moving forward."

Richard Schreiber, MD, chief medical informatics officer at Holy Spirit Hospital in Camp Hill, Pennsylvania, says the organizations most likely to successfully navigate meaningful use are large, coordinated, university-based systems with strong leadership. Small hospitals with leaders who understand informatics also stand a good chance of meeting the criteria.

"My hospital is now affiliated with Geisinger, a very potent, well-respected health care system, and they have made a very concerted effort with strong physician leadership that is very successful at meaningful use," Schreiber says. "I think there are a lot of other places like that across the country that will succeed [at meaningful use] because it is in their financial and reputational interests to do so."

The endgame is what matters, Schreiber says. "Meaningful use requirements are there because they are, in large measure, good things for patients," he says.

According to Grove, organizations that have mastered the meaningful use program share several characteristics, including the following:

• a proactive IT strategy;

• solid relationships with doctors and clinical staff; and

• a focus on becoming "meaningful users" rather than just asking, "How do I meet the numbers?"

Grove references the approach one hospital took to meeting the computerized physician order entry (CPOE) for medication orders objective as an example of what not to do. "Rather than implementing a real CPOE process, this hospital talked to its emergency department doctors and anesthesiologists—who did 90% of their admissions—and asked them to put in their admission orders electronically," he says. "That way each patient will have a med and the hospital could say it met its CPOE goal. So they did that until 2014 came along and all of a sudden it was looking at a requirement of 30% of all orders, and there was just no way to do it. They didn't build a CPOE, they just built a strategy that met the number."

Patient Engagement and Transitions of Care
As far as stage 2 of meaningful use is concerned, the patient engagement and transitions of care objectives "continue to be problem spots," Smith says. "It's hard for me to make broad generalizations on what we know of stage 2 so far because as a total percentage of the population, somewhere in the neighborhood of 30% of hospitals have demonstrated for stage 2 capability, with much less on the physician side. I think 2015 will be very informative because a larger portion of the eligible hospital and eligible physician cohorts will be required to do stage 2."

The transitions of care objective requires hospitals to provide a summary of care record when they transition or refer a patient to another setting or provider. Stage 2 core measure 15 is composed of the following three submeasures, all of which must be met in order to achieve credit for the measure:

• Provide a summary of care record for more than 50% of transitions of care in which you transition patients to another provider or setting of care.

• Provide an electronic summary of care record for more than 10% of transitions in which you transition patients to another provider or setting of care using the digital referral workflow within the EHR.

• Conduct one or more successful electronic summary of care exchanges with a recipient using a different 2014 edition certified EHR.

The summary of care record objective requires an extensive set of data be captured and correctly populated into the consolidated clinical document architecture (C-CDA). It mandates the use of 16 specific data elements such as problems, medications, and laboratory results. Providers and their staffs must standardize and increase their documentation efforts to ensure the record includes those data.

According to Hoffstatter, the challenge here is that years ago hospitals and providers could not exchange these data between different organizations. And while the technology is there now, the infrastructure hasn't grown to support it. "The infrastructure isn't as mature as it should be, so when you are exchanging things like the C-CDA across immature HIEs [health information exchanges], it becomes problematic," he says.

When it comes to patient engagement, Smith says one of the issues is that it's "a fairly new concept." He believes that prior to the arrival of meaningful use few providers invested in patient portals simply because they thought it was the right thing to do for their patient populations. "So what you're doing is asking providers to roll out systems that have very little—if anything—to do with the core clinical and financial technologies they've ever dealt with," Smith says. "It would be one thing if consumers were clamoring for patient portals and there was an expectation that these would be available. But for most people the notion of going to hospital portals after discharge rather than going to their general practitioner or specialist is a foreign concept."

And therein lies the rub. As Hoffstatter points out, patient engagement is the one meaningful use measure that providers have no control over. "We can encourage. We can incentivize. We can educate, and do everything to bring patients to the table, but at the end of the day if they don't do it, they don't do it," he says. "And most of the providers I talk to feel as if it is almost an unfair approach to hold them responsible for something that ultimately they have no control over."

The patient engagement objectives in stage 2 require providers to have 5% of their patients view, download, or transmit their health care information through secure patient portals. The recently released proposed criteria for stage 3 increases that percentage to 25. "For some places like us, getting to 5% was very difficult," Schreiber says. "Our reported number was about 10%, and we fought hard to get there."

What Lies Ahead
In March, the Centers for Medicare & Medicaid Services (CMS) released a notice of proposed rulemaking for stage 3. The proposed rule's comment period was open as this article went to press.

According to Health and Human Services Secretary Sylvia Burwell, the proposed rule is supposed to simplify reporting requirements and reduce program complexity by reducing the number of objectives to eight: protect electronic health information, ePrescribing, clinical decision support, CPOE, electronic access to patient data, coordination of care through patient engagement, HIE, and public health reporting.

The objective is to streamline meaningful use by removing objectives, said a panel of federal officials at the April HIMSS conference.

Still, the patient engagement measure should continue to cause providers grief. The stage 3 measures are "aggressive," Hoffstatter says, "particularly regarding patient engagement. People are struggling to make 5% and you're bumping that up to 25%. Even your most successful organizations are nowhere near 25%."

Grove concurs the measure may be onerous but ultimately will be a benefit to consumers. "[The patient engagement measure] is going to be a challenge, but it does sound like a real meaningful thing—that patients are actually accessing their information," he notes.

Grove says the stage 3 objectives signal that providers "have to start becoming meaningful users," calling some of the earlier stages' goals artificial but necessary. "Is it really meaningful use to get demographics? I don't think so, but we had to have them because they were foundational," he says.

In the stage 3 rules, the CMS proposes to significantly increase the threshold for patient care summary exchange during transitions of care and patient record sharing. The HIE objective has the following three proposed measures:

• send an electronic summary for 50% of transitions of care and referrals;

• obtain an electronic summary for 40% of transitions of care and referrals; and

• perform medication, allergy, and problem list reconciliation for 80% of transitions of care and referrals.

 "It's not that 50% [of electronic summaries] is hard—we're producing the transitions of care—but we don't have the underlying infrastructure to support it," Grove says. "The local exchange I'm working with at a hospital right now is bragging when it hits 10%, so 50% is just not there yet."

At HIMSS, federal officials said stage 3 is "aiming toward broader goals that improve care." In the end, achieving the proposed objectives may come down to how well the organization approached meaningful use from the program's inception.

— Mike Bassett is a freelance writer based in Holliston, Massachusetts.