Stage 2 off to a slow start

Many challenges cropping up on the way to the next step
By Neil Versel
12:00 AM

Stage 2 of the federal electronic health records incentive program known as meaningful use is underway for providers that first reached Stage 1 in 2011. Although there will not be any official statistics available for several months, anecdotal evidence suggests that this new phase is off to a slow start.

Healthcare providers, EHR vendors and other health IT industry insiders have identified several pain points that seem to be hindering the migration from Stage 1 to Stage 2. Notably, providers have to juggle multiple healthcare reform efforts simultaneously and are struggling with Stage 2 requirements to engage and educate patients.

Vendors have tight timelines to bring their EHRs up to Stage 2 standards, and are unclear about new testing for usability. Any delay on the vendor side naturally makes achieving meaningful use more difficult for their customers.

And, of course, entities in all sectors of healthcare continue to lag when it comes to interoperability of electronic health information.

All these problems may call into question the viability of meaningful use, but, despite the headaches, there seems to be widespread – though certainly not universal – agreement that this $27 billion, multiyear program is moving healthcare in the right direction.

"I see this as a stepping stone to expanding your abilities down the pike," perhaps moving some patient encounters to telemedicine in the future, says Sam DiCapua, DO, one of three physicians at Wells Family Practice in Wells, Maine.

"I really look at this as an opportunity for physicians like me to get off the hamster wheel," adds DiCapua, who has grown tired of having to cram as many short, often meaningless patient visits into his day in order to pay the bills. "If the doctor is disgruntled and unhappy, it rubs off on their staff and their patients," he adds.

"We are in a major transition in healthcare," DiCapua says. But he believes the payoff will be worth it.

"Before, it was like flying an airplane without instruments," says DiCapua, who reached Stage 1 in 2011 and expects to attest to Stage 2 meaningful use this year.

Prior to having an EHR, he would tell a patient to get a mammogram, the patient would agree, but then there was no way of knowing if she ever followed up, so the order loop was never closed. Now, DiCapua, or one of his colleagues puts in the order for a mammogram or other test and sends the referral electronically to an imaging center or specialist. If no result comes back, he knows the loop has not been closed and he can act accordingly.

"We want [meaningful use] to succeed," agrees Russell Branzell, president and CEO of the College of Healthcare Information Management Executives.

For that to happen, however, various players in the healthcare industry will have to overcome some high obstacles and likely endure significant pain in the short term. Already, problems have cropped up.

Branzell reports that CHIME surveyed CIOs from organizations that were early adopters of health IT. Of the 33 who said they would attest to achieving Stage 2 in January, none did. Close to half of these said they would be delayed significantly, perhaps six months or more.

"It takes a while to get the software in. It takes a while to mature it. It takes a while to get the data flowing," Branzell says.

And there are so many issues to address along the way.

ICD-10 and other reform

Robert Tennant, Washington-based senior policy advisor for the Medical Group Management Association, attributes some of the meaningful use-related stress to the overlap with ICD-10. The last day for hospitals to attest to Stage 2 meaningful use for 2014 is Sept. 30, one day before the new coding system must be in place for all Medicare providers. Individual eligible providers must begin their 90-day attestation period no later than Oct. 1, or they not only lose out on incentive payments for the year, they will face Medicare penalties going forward.

"There's a lot on the plates of vendors and providers this year," Tennant says. In addition to ICD-10, hospitals, physician practices and vendors alike are struggling with healthcare reform initiatives that include health information exchange, accountable care and determining the eligibility of patients who are newly insured through Affordable Care Act insurance exchanges and Medicaid expansion.

Complicating matters, Branzell says that the Centers for Medicare and Medicaid Services' meaningful use attestation website has not been functioning properly for several months.

With this and with the shaky launch of the health insurance exchange, Branzell is losing confidence in the Department of Health and Human Services, wondering if Medicare will be ready to accept claims in ICD-10 by Oct. 1, the date providers must start using the new coding system. "Once you flip the switch, you can't go back," Branzell says.

Vendor readiness

For providers to achieve meaningful use, they must use an EHR certified by an ONC-authorized testing body. Vendors have had to scramble to bring their products up to speed for Stage 2 ever since the federal government finalized the current round of meaningful use standards in September 2012.

Only after the products they use gain certification to the new 2014 standards can healthcare providers begin measuring and attesting to Stage 2 meaningful use. But hundreds or even thousands of complete EHRs and EHR modules certified for Stage 1 have not been upgraded to Stage 2 standards (see sidebar), potentially leaving customers in the uncomfortable position of having to change vendors in midstream.

CMS does exempt providers from certain provisions based on "hardship." There have been some unconfirmed rumors that CMS is considering exempting customers of vendors that do not get certified for Stage 2.

EHR usability

One new twist to certification is that the designated testing bodies now must evaluate EHRs for usability, but they do so based on some rather vague instructions.

Usability certification for meaningful use really isn't a test the way the rest of the certification process is, according to Bennett Lauber, chief experience officer of The Usability People, a Fairfax, Va.-based firm that consults on improving user experiences with technology and offers usability testing services.

"[Testers] go out and observe users, and report back to the certifiers," Lauber reports. There seem to be different sets of evaluation criteria because ONC has not really defined usability yet, he adds.

"There are questions and confusion among vendors about what the usability test is," Lauber says. "[Vendors] think they can just do it themselves," and some want to in order to save money.

"There's some education that needs to be done for the vendors," he says. Vendors: "They're just as confused, too."

Lauber suspects that the usability part could lead to a lot of vendors dropping out of meaningful use, creating problems for customers who might get left in the lurch.

Worse, according to Alexandr Romanychev, CEO of WCH Service Bureau, Brooklyn, N.Y., a medical billing company that recently launched an ambulatory EHR with the help of The Usability People, some physicians would rather take the Medicare penalties starting in 2015 than wrestle with a difficult-to-use EHR. Romanychev says some vendors have built user bases not by delivering good products, but by undertaking successful marketing efforts, a point that is hard to argue.

"The major issue is the features of the software," Romanychev says. He says physicians often choose EHRs based on price, which is why some free products have become popular, even if the EHRs are not flexible enough to meet their particular needs. "They take it, then they complain," Romanychev says.

"Doctors don't know how to use it, so training is pricey," Romanychev adds. Physicians also complain about how much time it takes to document patient encounters.


Interoperability – more specifically, lack thereof – is the source of a lot of headaches, too. "We don't know which doctor has which system" when trying to receive information from referring physicians, according to Romanychev. "I have to call doctor No. 2 and find out what program they use."

Stage 2 is supposed to address interoperability, but problems continue to linger.

A particular sticking point is electronic interoperability with laboratories. The Stage 2 rules require EHRs to be capable of accepting coded lab data. "But there's nothing compelling laboratories to put lab reports in the correct format," notes Todd Rothenhaus, MD, CMO of EHR vendor athenahealth, based in Watertown, Mass. This leads to more typing for providers to meet the Stage 2 requirement that they incorporate structured lab results for 50 percent of patients.

The cost of interface development also is high. Rothenhaus says that "a fairly significant number of labs," particularly independent ones, still do not follow the Logical Observation Identifiers Names and Codes – also referred to as LOINC –standard for transmission of results.

According to Rothenhaus, it's not worth it for some labs to build interfaces to ambulatory EHRs if orders are not sent to them electronically. More than a few physician practices have CPOE to get orders into the EHR, but orders then get transmitted to labs via fax or some other low-tech means, regardless of whether the lab can accept electronic orders or not, he says.

Electronic communication among healthcare professionals needs to improve as well, in the opinion of DiCapua, an athenahealth customer. "I cringe with some of the other things that are going on now," the Maine family physician says. Far too often, he has seen other practices send him protected health information via standard, unsecured e-mail, a symptom of poor training or education about HIPAA requirements.

DiCapua says that other physicians start seeing the value of electronic health information exchange when he refers patients to area specialists. His EHR, which produces clinical summaries for referrals, means that consultants can have the information before they even have the referral.

"The next big thing to tackle is the portability of the entire record," DiCapua adds.

Irrelevance to specialists

Specialists have another reason to tune out meaningful use. The program, as ONC has acknowledged, has been skewed toward primary care.

"If you're a practicing subspecialist, meaningful use is so foreign to you," Rothenhaus says. Some radiologists and pathologists may not have any face-to-face contact with patients, so it is difficult if not impossible to meet provisions related to patient education, preventive care and patient engagement.

Ever since Stage 1, providers have had to demonstrate that they are able to send data electronically to an immunization registry, a disease registry, a syndromic surveillance database or a public-health agency. This is a potential sticking point for specialists. "Many think they can claim hardship exemptions because they don't know that their specialties even have registries," Rothenhaus says.

If a registry exists, whether they know it or not, some physicians will fall short of meaningful use, since compliance is all-or-nothing; there is no partial credit. Numerous associations representing providers have asked for this to change, but CMS so far has not budged.

Private insurers have not yet insisted that providers in their networks meet the federal meaningful use standards. "It's a recognition that these criteria do not necessarily lead to better care," Tennant says, since compliance really is just a matter of checking off boxes that may not really apply to certain physicians.

Will orthopedists truly improve outcomes by counseling patients on smoking cessation? "There is hope that Stage 3 will take this into account," Tennant says.

Tennant also notes that radiology has been using advanced information systems for a long time, but radiologists and imaging centers still might not satisfy meaningful use, as defined by CMS.

Patient engagement and education

The meaningful use criteria themselves are causing trouble, particularly the provision that calls for 50 percent of patients to be given an electronic means of viewing, transmitting or downloading personal health data and for 5 percent of patients to take it upon themselves to be "engaged" by sending unsolicited electronic messages to their healthcare providers, according to Tennant. "For some specialties, 50 percent may not be as difficult as others," he says.

For example, dermatologists, ophthalmologists and otolaryngologists may only see a patient once, and only for a few minutes, so there is not much incentive for their patients to engage in electronic communication with their doctors. "When the patient is handed a clinical summary, they have everything they need from the visit," Tennant says.

Every month, CMS holds a public conference call on meaningful use. During the January call, Tennant reports, CMS suggested that specialty practices put a kiosk in the waiting room so patients can fill out history forms electronically and print copies of their records for themselves, satisfying the engagement requirement. However, it might take a dedicated staff member to walk people through the steps. "That's not a viable option for a small practice," Tennant said.

Regarding secure messaging, Tennant wonders if elderly patients are likely to try it. He says MGMA and other provider representatives have asked CMS for more flexibility in meeting the standards, but thus far, the rules have not changed. "We are concerned that the momentum from Stage 1 could be lost," Tennant says.

"Patients are the most underused resources in healthcare," says Nimesh Patel, CTO of Chicago-based healthcare communications company Emmi Solutions. But they need good reasons to log onto a portal and be engaged as patients. "If there's no content that they're getting value from, they're not going to come," Patel says.

"How do you tie it back into a metric that you can get credit for?" Patel asks. The answer is integration with the EHR. "The mindset is shifting [from just providing a portal] to creating content to engage patients," he adds.

Patel recommends personalizing content delivered through portals to add value to patient-clinician communications, "so it doesn't feel like something you Google." To get to this point, Patel says, hospitals want technology tightly integrated with existing information systems. "Let's make it easier," he says.

At Wells Family Practice, the front desk has been educating patients about the existence of the portal and how to use it ever since the athenahealth EHR went live in June 2012. "You can motivate people very well if they understand what you're doing and why," says DiCapua.

"The most difficult piece is getting patients to understand why it's so important," DiCapua says. "It's particularly difficult when you're dealing with seniors," he adds, and meaningful use depends on Medicare populations.

"If you tell the patients how you access the portal, it's easy," says the practice's manager, Betsy DiCapua, the physician's wife. "The word 'portal' can be intimidating," she says. Staff tries to make the portal seem more accessible by explaining practical uses, such as how patients can see lab test results.

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