HIT Evolution and Meaningful Use Stage 3: From Finance IT to Patient IT

Joe Wivoda, REACH HIT Consultant

The evolution of information technology (IT) in health care has been remarkable, and very similar to what other industries experienced in the 1980's and 1990's. Health care is definitely behind manufacturing, banking, education, and other industries when it comes to using IT, but we can learn from those industries to (hopefully) leap ahead. The new Meaningful Use Stage 3 Request for Comment made me realize that IT professionals working in health care should perhaps consider this and begin to call themselves Patient Information Technology workers instead.

Meaningful Use Stage 1 started the trend with the requirement that hospitals and clinics provide patients with an electronic copy of their health information upon request. Funny thing is that few people requested it! Medical Record staff did not make it a clear option for patients requesting their information, and staff did not realize the data was displayed in a user-friendly way. It was okay to provide patients with a paper copy of their chart, but some organizations decided that it was necessary to encrypt their electronic copy. This is a misunderstanding, and provides yet another barrier to engaging patients in their care.

Stage 2 took a new approach to patient engagement: Portals and Personal Health Records (PHRs). Not only do half of the patients need to be set up in the portal or PHR, but 5% must actually access and use the information. Like it or not, we will need to get patients used to accessing their information online. Banks have been able to do it, and so have schools, car dealers, and just about every other industry. Heck, I know exactly when my UPS package arrives at my front door via an email, but it takes several days for a phone call from my physician to tell me my lab test was normal. UPS did not need a government-funded incentive program to begin to offer this service, they did it because customers asked for it and their competition was doing it.

The proposed Stage 3 measures that are currently out for comment take patient engagement even further. Patients will have to have the ability to request amendments to their records and submit patient-generated information. By 2014 I expect there will be blood glucose monitors that connect to your smartphone that will automatically update a designated portal or PHR. Imagine the benefits to patients! Imagine the concerns from providers ("How do I know that is accurate?").

Health Care IT professionals need to take a lead role in creating excitement around patient engagement technology. Until recently, HIT was primarily Finance-IT, and with meaningful use it has finally become true HIT, but I argue we need to be Patient-IT. If we take a patient-centered approach to everything we do in IT we will make a real impact on the health of patients. If we took a patient-centered approach wouldn't the bills be easier to understand for the average patient? If we took a patient-centered approach wouldn't there be a portal that was user-friendly? Wouldn't we have a help desk for patients to call to get help in understanding how to log in and understand their information? Wouldn't we have higher quality, safer, more efficient processes if we put the patient at the center of our implementations and not the physicians and staff?

Starting today I am going to consider myself a Patient Information Technology worker. It will take a while for me to get used to calling myself that, but I will start today. Will you join me?

Eligible Professionals Working in Multiple Organizations: A complex area of meaningful use

Rich Gehrman, REACH HIT Consultant

Attesting for eligible professionals (EPs) who work in multiple organizations is an especially complex area of meaningful use (MU). It affects large institutions, independent practices and safety net clinics alike. Key issues include:

1. Which organization(s) should get an EP’s incentives and which one should attest?
2. What is the easiest way for institutions to assemble attestation data?
3. What if organizations are attesting to different menu or quality measures?

Recently REACH has worked on these questions with a collaborative of large health care systems in Minnesota. Here are some of the lessons learned.

Know Where Providers Work. Even full time employees may moonlight in urgent care or volunteer at a safety net clinic. Since combined data from all sites is needed to attest for MU, employers need to know where else their providers work. Ideally, institutions gather as much information as possible before asking EPs to complete any forms. For example, find what HR and credentialing staff already know, and check federal websites for other institutions that have proxies registered for individual EPs. Institutions also use written agreements asking EPs to provide and update information about other work.

Prepare to Share. Set up data collection and reporting procedures so it will be as easy as possible to give and receive data about a provider’s encounters in other institutions.

Separate Data from Dollars. Questions about which institutions receive which shares of an EP’s incentive payments are best addressed in a different forum from issues about assembling data needed to attest for MU.

Keep an Eye on Medicare Penalties. Some institutions may not be ready to provide data that specialty practices such as radiologists, cardiologists and anesthesiologists will need to attest to MU. For example they may not build out their EHRs to produce appropriate clinical quality measures for these groups. Conversely some specialists may not realize that they will be exposed to Medicare penalties if the institutions they work for do not plan with them in mind. It is in the interests of both partners to start talking about Medicare penalties quickly.

Remember: A provider can't split up their incentive and designate shares to more than one organization. All of the incentive has to go to just one organization. So when a provider signs over their incentive to more than one organization the last one to enter their identifying information gets the incentive. Identifying information includes the organizational NPI and their Tax ID or Employer ID.

An attestation isn't valid unless the organization doing the attesting enters numerators and denominators from all the places an EP works that have a certified EHR. This will get picked up when the CMS systems see a mismatch between all the places an EP has had Medicaid and/or Medicare encounters and the ones that were attested to. The incentive won't get approved until the attesting organization backs out the incorrect attestation and re-enters a correct one. Not only does this mean they have to make sure they find out where else a provider is working, they need to contact those other organizations and get them to share their data.

Stage 1 Changes Enacted by Stage 2 Final Rule

Reid Haase, REACH HIT Consultant

During the lead up to CMS publishing its Stage 2 final rule for the EHR Incentive Program, the policy makers at ONC reflected on public input and their own internal consideration to streamline aspects of Stage 1 for eligible professionals (EPs), eligible hospitals (EHs) and critical access hospitals (CAHs). What resulted from this were sensible changes, some of which are mandatory for all Stage 1 participants and others that are optional. You’ll need to pay close attention to when each of the changes will be enacted as some started as early as October 1, 2012 for EHs and CAHs, whereas others will be optional in calendar/fiscal year 2013 and then become mandatory for calendar/fiscal year 2014.

Gone is the need to conduct a separate and unique test of HIE (replaced in Stage 2 through other objectives that accomplish exchange of patient information) and the ‘yes/no’ attestation question on submission of clinical quality measures was eliminated. You’ll also see that the clarifying wording of some objectives was changed to deal with claiming exclusions, such as in the menu set to ensure that participants were making the best attempt at accomplishing five of the 10 measures rather than claiming an easy exclusion such as for syndromic surveillance which many states are not prepared for.

Conversely, a new exclusion was provided for e-prescribing. Some providers are not able to send an electronic script as a pharmacy accepting the electronic prescription is not within a sensible distance (chosen as 10 miles in the new wording). Feedback was also incorporated for the charting of vital signs including blood pressure, height, weight and specified age ranges. Providers will be able to claim exclusions for those parts of the objective that do not make sense to their practice or patient population including age ranges.

The objective to provide electronic access or an electronic copy of a patient’s record has also been modified based on the Stage 2 requirements, specifically those surrounding the use of patient portals.

We’d recommend that you take a few minutes to review the changes in detail. They are outlined in a succinct, six page PDF document that you can download via the link below.

Stage 1 Changes Tipsheet > 

Stage 2 Overview Tipsheet >

Getting Ready for Stage 2 Meaningful Use – What Providers Can Do Now

Paul Kleeberg, MD, REACH Clinical Director for Minnesota and North Dakota

I am sure by now that many of you are aware that ONC and CMS have released new rules for the electronic health record (EHR) incentive program. These rules create new requirements in 2014 for those who will be attesting to Stage 1 as well as those who will be attesting to Stage 2 of meaningful use in 2014. For Stage 2, in addition to increasing some of the Stage 1 requirements, there is an increased emphasis on exchange of information and patient involvement.

Under Stage 2, patients will be allowed greater access to their EHR and will need to be more involved in their care. They will see their problems, medications, allergies, lab results and other items as they have been recorded in the EHR. For some providers, Stage 2 will mean that they will need to make sure their notes are complete; others may need to decide what information may need to be withheld. All providers will need to encourage patients to become more involved since there are measures of patient involvement. It would be wise to begin preparing your patients now. If you don’t have a portal, start getting one. If you do have a portal, make sure it is working and start encouraging patients to use it.

Stage 2 increases the focus on exchange of referral summaries and transfer of care summaries between providers. If you're in a clinic you will need to send a certain percentage of these documents electronically to another facility. Get ready now by thinking about who you're going to exchange with and begin to consider technology options. Note that the requirement is to exchange with facilities that run a different EHR from yours and are part of a different organization.

Finally, you may have heard that there is a new standard for EHR certification. Under the new rules, you will need to upgrade to 2014 certified software and use it meaningfully for at least one quarter during the 2014 payment year. We hear that vendors will be able to start the certification process for their products in January of 2013. If you have not done so already, contact your vendor to discuss upgrade plans and timeline so you know what to expect.

These changes may appear challenging but they will move us in the direction of making the EHR patient-centered so information will be available to each patient wherever and whenever they need it.