Stage 2 MU Sticking Points

Compiled by Ken Congdon, Editor In Chief, Health IT Outcomes

Patient engagement and medical image integration are the top Stage 2 Meaningful Use concerns for many providers. Learn how these four EHR early adopters plan to tackle these issues and achieve successful attestation.

The primary goal of Stage 1 Meaningful Use (MU) was to get health providers to establish a technology foundation and to begin adopting new workflow habits that facilitate the collection and distribution of patient data electronically. Stage 2 MU continues this progression, but it also takes a philosophical leap by requiring providers to start giving some patients the ability to access their health data and communicate with physicians electronically. This requirement was vehemently opposed by key medical communities, such as the American Hospital Association (AHA), and it is the area most likely to trip up providers as they prepare for attestation.

While many healthcare organizations continue to complain about how unfair and misguided several Stage 2 MU criteria are, others are rolling up their sleeves to ensure they are on track to meet these new requirements and collect their incentive dollars. These trailblazers will likely engineer the winning strategies that other providers will copy in their journey to MU. I had the opportunity to speak with technology leaders from four of these forward-thinking providers — MedStar Health, Adventist Midwest Health, The Veranda, and South Austin Medical Clinic — to learn more about their Stage 2 preparations.

MedStar Health is a $4.4 billion not-for-profit, regional healthcare system with a network of 10 hospitals and 20 other health-related businesses across Maryland and Washington, D.C. The provider was an early adopter of GE Centricity’s EHR in its outpatient facilities and has successfully attested nearly all of its outpatient providers for Stage 1 MU for 2011.

Adventist Midwest Health is a network of not-forprofit hospitals and outpatient-based health care facilities in Chicago’s western suburbs. The health system was an early adopter of NextGen’s EHR for use by its outpatient physician population. To date, 100 of the 102 outpatient physicians employed by Adventist have successfully attested for Stage 1 MU, generating more than $2 million in incentive dollars.

Providing OB-GYN, endocrinology, pediatric, and family medical services, The Veranda is a multispecialty practice in Georgia. The provider adopted Greenway’s PrimeSUITE EHR in 2004. The practice successfully attested all of its physicians for Stage 1 MU by the end of 2012, accruing more than $144,000 in MU incentive dollars.

South Austin Medical Clinic is an eight-physician group practice specializing in family medicine. The practice adopted an EHR from e-MDs in 2002 and completed Stage 1 MU attestation for all of its providers in the summer of 2011.

Q: What were your initial reactions to the Stage 2 MU final rule?

Basch: They were pretty much what we expected. While not perfect, Stage 2 measures are much more inclusive of specialties, whereas Stage 1 was very sparse. What I like about Stage 2 is it treats doctors like adults. It says, “Look through the quality measures and select the nine that are most relevant to your specialty or scope of practice to focus on.” Stage 2 is a chance for providers to get more advanced use out of their EHRs and truly apply the software in ways to improve clinical processes.

Q: In what areas do you feel you are already well aligned to meet Stage 2 MU measures?

Robson: I think we are about 90% prepared for Stage 2 MU because we have integrated Stage 1 so much into the daily workflows of our physicians and staff. Furthermore, we looked ahead and speculated what the new thresholds would be for a lot of the core measures in Stage 2. We’ve already started down the path of achieving those standards. Most of the core measures have already become routine and habitual for our employees.

Brown: We already do CPOE (computerized physician order entry) for all of our prescriptions and lab and imaging tests, so these areas won’t be an issue for us. We’ve also already incorporated clinical alerts via our EHR.

Q: What is the biggest challenge you face in meeting Stage 2 MU?

Robson: There are actually a couple of challenges that concern us with Stage 2 MU. One is e-prescribing. We like e-prescribing, and we try to do it as much as we can, but e-prescribing is still not commonly understood by all patients we treat, especially older patients. Many patients do not feel comfortable leaving the office without that piece of paper in their hands. Because of the resistance to e-prescribing by some of our patients, we are concerned about meeting the numbers required for Stage 2 MU.

Our second challenge involves the requirement to demonstrate that we are communicating electronically with a certain percentage of our patients. The challenge isn’t so much creating a technology infrastructure to securely enable this type of communication; it’s figuring out a way to get a certain percentage of the patient population to sign up for this program and actively engage in using it.

Basch: The requirements around patient engagement will be the most challenging. I feel providing 50% or more of our patients with timely access to their health information is actually a double step up from where Stage 1 was. Stage 1 was just a menu set.

It’s not that we don’t want to provide this capability. On the contrary, we’re in favor of it. Providing patients with electronic access to their own data should foster collaboration between patients and providers and aid in the management of chronic diseases. It’s just going to be difficult to implement the technologies and workflows necessary to pull it off.

The requirement that 5% of our patients must download the information will also be problematic for some of our physicians. I am a primary care internist, so my patients are hungry for the lab test results and other data I can provide through a portal. However, some of our providers don’t run a lot of tests. Some providers do little more than record demographic information in an EHR. How are these providers going to compel their patients to access a portal to view health information that is already known to them?

Brown: The biggest challenge for us right now is integrating medical images with our EHR so physicians can view patient images from directly within the patient record. We are an AIUM (American Institute of Ultrasound In Medicine)-certified facility, so we perform our own ultrasonography. We’re also ACR (American College of Radiology)- accredited for imaging, mammography, chest X-rays, and things of that nature.

Patient engagement is also a challenge. What scares me most is that we’re not only required to send health information to a certain percentage of patients electronically, but we also have to demonstrate that these patients actively opened and accessed the data we sent. How are providers supposed to control the patients’ actions?

Signing patients up for this type of electronic communication service can be a challenge in and of itself. For example, some patients live in rural areas with poor Internet connectivity. These patients don’t like to communicate electronically because downloading and transmitting data in these areas can be painfully slow. It will be difficult getting these patients to interact with their health data in this way.

Weidmann: The Stage 2 MU requirement that causes the greatest sticker shock and physician vertigo is communication with patients via incoming email or other electronic means. For providers that don’t already do this, this requirement is scary. Many providers feel transmitting certain types of health information via the World Wide Web opens up a conduit of potential liability. Because of this, many providers are waiting to see how this will play out before making investments in this area. They are trying to determine whether the MU incentive dollars are worth the headaches and potential security risks this requirement can cause.

Another challenge for us is HIE. Texas is relatively fragmented in its HIEs, and there is a question as to how much value they are providing. We have four viable HIEs across the state, but there is only one in the Austin area, and it was built upon an indigent care network. We see very few of these patients, so we’re feeding a data system that isn’t providing much interactivity back to us.

Finally, integrating medical images with our EHR is another challenge. There are definitely new infrastructure and interface investments that need to be made to make this work.

Q: What strategies have you put in place to address these issues?

Robson: For e-prescribing, we are focusing on patient education. We are working hard to get patients to understand the value, reliability, and convenience of e-prescribing.

The first step to staying in front of the patient engagement curve is to stay up to date with the upgrades your EHR vendor offers. EHR vendors are required to have their software meet certain requirements related to MU, and they are developing solutions (e.g. patient portals) that will help us address patient engagement.

Basch: The first thing we’re doing is taking a closer look at our patient portal to ensure it is as robust as it needs to be. We’re asking our physicians and staff to consider whether they would use it or find it compelling if they were patients. Ensuring the portal is something patients actually want to use is the first step toward engagement and empowerment.

Once we’re comfortable that our portal is as robust as it can be, we will implement a system-wide initiative to sign patients up for the portal. We need to make this effort part of our corporate DNA. We need to train our employees to solicit patient portal participants with the same fervor with which they collect copays.

Brown: We are currently leveraging PrimePATIENT, a patient portal integrated with our EHR platform to address many of the Stage 2 patient engagement requirements. Our patients can currently get information sent to them online, request appointments and prescription refills, and pay their medical bills using this online portal.

However, in an effort to further our patient engagement initiatives, we are also working to develop a HIPAAcompliant mobile patient app that will allow patients to access our portal (and other online patient services) via a smartphone or tablet, rather than via a static URL.

Weidmann: We are currently revising some workflows to accept incoming electronic messages from patients via our portal system. We are also working to develop strategies to police this activity. I believe most portal systems have some ability to filter messages by diagnosis, patient, user, etc. I also think many of these tools allow you to establish rules that dictate what communications are acceptable and which pose a potential privacy risk. You obviously don’t want to have a message put into an inbox about somebody’s blood pressure spiking and chest pain. We want to ensure we have some sort of backup system in place to police these messages.

We also just deployed a digital imaging system in our office, and we are furthering our interface technology with our local radiology group so that we can satisfy the criterion of embedding imaging results in the EMR.

Q: Are there any best practices that you established in Stage 1 that you are carrying over to Stage 2?

Robson: Ensuring your EHR software and workflows are as optimized as they can be for the specific needs of your physicians is one best practice. When we train our physicians and nurses, we have them use the EHR tools in actual patient encounters. This allows them to incorporate the tool into their method of delivering care and allows them to identify ways to improve the process.

Weidmann: One best practice we’ll continue to employ in our Stage 2 journey is ensuring EHR-related tasks are delegated appropriately. For example, our administrative or nursing staff is always more effective than our physicians at reliably getting repetitive jobs done. So, if I need to make sure something is validated (e.g. a box is checked, a date is entered, bean-counting etc.), this task should be delegated to office administrators or nurses. However, if the activity will result in interaction and intervention that enhances patient care (e.g. smoking cessation data), this task should be performed by the physician.

The other best practice we will continue to employ is ensuring the EHR software “forces answers” when it needs to. In other words, we’ll ensure that our physicians can’t exit the EHR program or template until they check all the boxes and enter all the information that is required of them under Stage 2 MU.

Q: How do you feel your facility and patients will benefit from you meeting Stage 2 MU?

Robson: My hope is that our EHR use will continue to mature due to Stage 2. Initially, many of our physicians looked at the EHR as a barrier that stood in their way of treating patients the way they wanted to. However, I’ve begun to witness a gradual evolution among our staff. They are actually beginning to see EHRs as an asset that can allow them to provide a higher level of care to their patients. Stage 2 MU should take this to another level. My expectation is that Stage 2 will enable us to communicate more effectively with patients and assess quality metrics much better than in the past.

Brown: A lot of people get resentful about MU, but to me, it’s really helpful because it addresses a lot of the problems that we face as an industry. I believe Stage 2 MU is going to improve awareness and improve healthcare in general. I think that’s one of the intents of MU — to make sure patients aren’t just focusing on their diagnosis and how to treat it, but how to keep from acquiring an illness or chronic condition in the first place. Stage 2 MU criteria will make patients more aware of their own lab results, health data, and overall wellness. This should make them more engaged and inclined to take corrective action early on. Stage 2 will also help providers be more proactive in this process through clinical alerts and population health data.

Weidmann: My hope is that Stage 2 MU will help to truly create usable information exchanges between key health entities so that immunizations, community lab data, cancer registries, and other information more readily feed my decision tree with patients. However, I don’t believe that is going to happen in my part of the world in 2014 or even 2015.

The more tangible benefits of Stage 2 MU will be changing physician behaviors and habits. In the past, you had to wait for a generational shift in physicians to see change. With MU, physicians are beginning to realize that EHR adoption isn’t just about automation, but what this automation can do to clarify and facilitate patient care.