CIOs mostly satisfied, but seeking clarity on Stage 2

By Mike Miliard
10:41 AM

Grateful for more flexibility, but unsure on certain measures

Chief information officers were scrambling to wade through and make sense of more than 1,000 pages of Stage 2 meaningful use rules yesterday afternoon, with some poring over the details late into the night. Most seem pleased, so far, but say there's lots of work to do.

With the caveat that he'd only had a brief time to sift through some 1,100 pages of densely-worded regulations, Bill Spooner, CIO of Sharp HealthCare in San Diego, told Healthcare IT News Thursday evening that he was most of all "grateful that the rules are published."

There were some rumors that Stage 2 might not be unveiled until September  -  or even until after the November presidential election  -  but Spooner said it was crucial that the rules were made public as soon as was practicable.

"It will be a sprint to complete the software development/implementation/adoption cycle," he said. "We need every minute."

At first glance, Spooner said he saw some things he liked. Chief among them: Stage 2's three-month reporting period for meaningful use in 2014, which had been requested by many stakeholders, was a "win," he said, offering much-needed flexibility for providers and developers.

"The overall revised phase-in plan is another win for provider and vendor alike," he said. "Reaching Stage 3 by 2015 would not have been feasible."

Charles Christian, CIO of Good Samaritan Hospital in Vincennes, Ind., said it was good to see federal agencies "getting a better understanding of the product development lifecycle, and how much time is required to move things from regulation to code to successful implementation."

But other areas, especially those with regard to the rule's much-discussed patient engagement stipulations, gave him pause.

"I was surprised to see the continued requirement that providers will held responsible for their patient's behavior related to the patient portal objective," said Christian. "In my experience, the issues are around process, and not technology. We must ensure that we're taking a measured and thoughtful approach to the change required, rather than just trying to check a piece of functionality off the list."

Like Spooner, Christian seemed grateful just to have the rule ready  -  and to know just what he'll be working toward over the coming months and years. Because there's lots of work to do.

"We've been planning based upon the proposed rules," he said. "All total, between the new certification requirements and Stage 2 regulations, it's more than 1,000 pages of information that need to be studied and understood. There are some definitions that will need to be fleshed out so that all the providers can better understand the requirements and how to best be able to document compliance."

For instance, said Christian, rules around imaging access "will require some review and study"  -  especially as they play out in different care settings.

For an eligible hospital, "Providing a link to an imaging study from within their EMR is something that we do today," he said. "However, in our physician practices, it will pose more of a challenge due to the fact that their patients may have imaging studies performed in any number of imaging centers; we need to better understand what the term 'accessible' is referring to."

Ultimately, said Christian, he was satisfied that CMS and ONC listened to the provider community, and took to heart  -  wherever practical  -  the input received during the comment period. The rules "appear to have been thoughtfully considered," he said, "even the ones where the response was that the proposed objective stands as the final. This stage is meant to build upon Stage 1, therefore, the bar was expected to be raised."

For its part, the College of Healthcare Information Management Executives (CHIME) applauded CMS and ONC for "working diligently to prepare final rules" and "seeing the wisdom and practicality of heeding many of CHIME's recommendations," said CHIME president and CEO Richard A. Correll in a statement.

"By allowing providers to demonstrate meaningful use through a 90-day EHR reporting period for 2014, government rule-makers have ensured greater levels of program success," he added. "And by including additional measures to the menu set, providers have a better chance of receiving funds for meeting Stage 2."

Still, said Correll, "many details may need further clarification," especially those around patient engagement and imaging.

"The final rule still puts providers at risk of not demonstrating meaningful use based on measures that are outside their control, such as requiring 5 percent of patients to view, download or transmit their health information during a three-month period," he said. Some areas of clarification include some of the exclusionary language as well as nuances around health information exchange provisions, clinical quality measures and accessing images through a certified EHR."

Writing on his blog, "Life as a Healthcare CIO," John Halamka, MD, chief information officer at Beth Israel Deaconess Medical Center in Boston, took a detailed look at the final rule's technical specs.

He noted with interest that electronic notes must be searchable, and said he looked forward "to vendor implementations of searching free text  -  will they use simply keyword indexing or more innovative natural language processing techniques that enables text to be search with context ... ?"

He pointed out that the imaging stipulation for EHRs "could be accomplished via a single sign on link to a PACS system," and, on the security front, noted that encryption is now required for EHR data stored locally  -  meaning "caches and local databases created by the application and not a user saving a file or doing a screen print." The importance of Direct protocols with regard to care coordination and giving patients access to their personal health information was also noteworthy.

If many of the mandates reflect a careful weighing of stakeholder input  -  "the vocabulary, transport, and content standards" in the final rule "align perfectly with previous recommendations from the HIT Standards Committee," he wrote  -  there's no question that there are some big changes and high hurdles ahead.

"I look forward to industry reaction as to the difficulty of implementing some of the more novel workflows," Halamka wrote.