Little-noticed Stage 3 meaningful use rule could pose big challenges for hospitals

The high threshold for patient engagement in 2019 will probably be amended in future rulemakings, but one MU expert says it highlights the limited utility of patient portals.
By Mike Miliard
01:40 PM

CORRECTION: The Centers for Medicare and Medicaid Services made a change to Stage 3 meaningful use for Medicare-eligible hospitals via the Inpatient Perspective Payment System final rule, published in August. The regulation was amended to change the 2018 compliance dates mentioned in this story to 2019, pushing back the increased thresholds to 2020 or beyond, barring further regulatory updates before that time. We regret the error.

Kathleen Sheehan's job is to focus every day on her health system's meaningful use compliance. But even she was surprised when a Cerner employee alerted her to a handful of percentages listed in the Stage 3 rulemaking.

Sheehan, program director for meaningful use, performance and process improvement at UHS of Delaware, couldn't believe it when she saw the thresholds for which hospitals could be accountable.

The issue has to do with Stage 3 MU measures that are in play for 2018 – but are now optional for eligible hospitals since the Centers for Medicare and Medicaid Services announced in the Inpatient Prospective Payment System final rule that such hospitals have the option to either continue with the Modified Stage 2 program or move forward with Stage 3.

When CMS published the 2015-2017 Stage 2 modified and Stage 3 final rules, they set Stage 3 thresholds that were, by and large, lower than the original Stage 3 measures, said Sheehan.

The catch is that the 2015-2017 Stage 3 thresholds expire December 31, 2018, and then the original Stage 3 measures become effective. "But the thresholds for the Stage 3 measures effective Jan 1, 2019, are incredibly high and most eligible hospitals won’t be able to meet them," she said. 

The thresholds are more than 80 percent for patient access, more than 25 percent for secure messaging and more than 10 percent for view/download/transmit of patient data or portal login through API.

[Also: Meaningful use expert: Time to think about next generation interoperability]

Other health information exchange requirements are similarly demanding: more than 50 percent for an electronic summary of care, more than 40 percent for incorporating SOC for first-time patients an more than 80 percent for clinical information reconciliation.

"To meet a secure messaging threshold of 25 percent means that 25 percent of your patients need to be portal members," said Sheehan. "So the most difficult and challenging measures to meet today increase significantly."

And making matters more complicated is the fact that most of the healthcare industry is not even aware of this, Sheehan added. “When they see this, people are going to be like, 'Are you kidding me?'" 

[Also: How providers and vendors can stop patient portals from collecting dust]

Sheehan approached both CHIME and AMA, in fact, hoping to raise awareness, "and at first they didn't believe me."

Both those groups have been successful in the past getting the Centers for Medicare and Medicaid Services to reduce unrealistic regulations.

"I hope they plan on doing that," said Sheehan. "On the other hand, I do think it's probably an oversight from CMS. And I think the thresholds will definitely be lowered. But we don't know that."

Even if they are reduced, "we don't know what they're going to lower them to, and whether it will still be burdensome. Or whether they'll remove them altogether. Or default back to the Stage 3 measures effective in 2018."

In the meantime, she said, hospitals need to be aware of the potential rules and plan accordingly.

Rules require portal use, despite evidence of limited usefulness

Whether or not CMS changes those thresholds, the existing rule points to some ongoing questions related to patient engagement – and to the future of meaningful use itself.

A secure messaging threshold of more than 25 percent, meaning that one-quarter of patients need to be signed up with and active users of patient portals, is high.

When it comes to use of portals to view, download and transmit data, "our hospitals average about 5 percent, and some of them are lower," she said. "Part of this is because portals just aren't delivering a whole lot of value. Patients are not interested in portals."

Any requirement that demands a five-fold increase in portal usage would also demand that  vendors offer more than what most are currently offering. "It's a problem," said Sheehan. "They need to have more of a value proposition and we need to put more pressure on the vendors to deliver more features and functionality."

A larger question has to do with the future of meaningful use, and just what it will or won't look like in the years ahead. 

"We all think meaningful use is going to turn into something on the hospital side a little more like what they're doing on the quality payment program on the outpatient side," said Sheehan. "That it won't be a standalone program anymore, it will be part of a composite score with value-based reporting and some other things. Incentive dollars ended for hospitals, it's now penalty avoidance, and I just think it's eventually going to go away.”

After all, said Sheehan, the "most important thing about meaningful use – and this was emphasized in the 21st Century Cures Act – was interoperability. The whole industry is struggling with that. So I would not be surprised if this became a purely interoperability game, with some patient engagement still in there."

CMS paid out a whopping $35 billion for IT adoption and Sheehan said the agency essentially achieved what it set out to do. 

“They got widespread adoption, especially on the hospital side, of certified EHRs. We have more digitized information than we've ever had. We're finally catching up to the financial industry.”And now, with all of this data we can do a lot more predictive stuff with it,” she added. “So those investments bought them a lot."

Now, eight years after meaningful use was first launched, it might be time to think hard about what the program should aim to achieve going forward, and just how burdensome – to say nothing of how realistic – its threshold requirements should be.

During a National Health IT Week #AskONC Twitter chat on October 4, Brookings Institution fellow Niam Yaraghi posted a question: " If you could go back in time, would you change anything in #MU requirements?"

The answer, from @ONC_HealthIT: "Fewer 'check the box' measures."

The Office of the National Coordinator showed recently that, on the certification side, it will ease meaningful use rules for vendors where it deems appropriate. Time will tell whether CMS will do the same for hospitals.

Twitter: @MikeMiliardHITN
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