Mind you, those are the earliest dates when hospitals and EPs can apply. But many feel an urgent need to get meaningful use Stage 2 done so they can tackle the other pressing items on their plate, such as ICD-10 compliance work, as well as multiple components of the health reform law such as new care and reimbursement processes. As Bill Spooner, senior vice president and chief information officer at eight-hospital Sharp HealthCare in San Diego explains it, ICD-10 is in October 2014, state insurance exchanges are in January 2014, Stage 2 is in fiscal 2014, "and we also have to take care of our patients."
Providers that struggled with Stage 1 won't have an easier time with the second stage, as the bar for compliance is raised. In particular, two meaningful use measures in Stage 2 could be very troublesome for providers to comply with, HIT leaders say.
The final Stage 2 rules require that patients have the ability to view, download or transmit their health information within four business days of the information being available to an eligible professional, and within 36 hours of a hospital discharge, AND then getting at least 5 percent of patients to actually use the service.
Eligible professionals have another hurdle, as they must use secure messaging technology to communicate with at least 5 percent of patients on relevant heath information.
Having the technology for view/download/transmit won't be difficult for providers under Stage 2, since patient portal products are readily available, says David Borden, chief technology officer at MRO Corp., a vendor of release of information technology and services.
There will be process changes and workflow challenges associated with adopting the portals, but the real heavy lifting will be in getting the required threshold of patients to participate. "For the first time, meaningful use attestation will depend not just on what the provider does, but in changing patient behavior," Borden adds.
Consequently, some providers are in a hurry-up mode to get a handle on how they will obtain proof of a certain level of patient engagement. At Greater Baltimore Medical Center, initial meetings on implementation of a patient Web portal started in October 2012 with Jeanne Day, director of health information management, and David Hynson, CIO, leading the project and working with the hospital's meaningful use governance committee.
The initial plan calls for completion this month of a charter document outlining the purpose of the project, key stakeholders and participating personnel within the hospital, selection of a patient portal vendor by the end of February 2013, and portal implementation starting in July when the hospital's new fiscal year-which includes portal funding-begins. The hospital is not yet considering process and workflow changes that the portal will require, believing it will better understand what changes are needed as they learn of various portal functions during the vendor selection process, Day says.
A patient portal is a must-have to comply with view/download/transmit, and it also could help with secure messaging as well, Spooner says. He envisions discharge coordinators, admissions staff and nurses will handle patient education in the hospitals with front desk personnel and nurses doing the same in ambulatory settings, although that might vary based on the practices.
But his message on the timetable to get ready is clear: "You need to be thinking of it now and you don't have a lot of time. There are a lot of moving parts and it does overlay with ICD-10 and everything else, so don't delay."
There's another timetable factor associated with meaningful use as time periods for Stage 2 were changed in the final rules and trying to figure out the best time to attest may be confusing .
Challenges await
In some ways, Sharp HealthCare is in decent shape at this early stage with portal readiness. The seven-hospital delivery system two years ago built an ambulatory portal, which gets significant traffic, and an inpatient portal, which has had little use so far. And the ambulatory portal already supports secure messaging.
CIO Spooner got a good roadmap on Stage 2 preparations from Sharp's core inpatient EHR vendor (Cerner) and ambulatory vendor (Allscripts) this fall. "Both vendors were pretty good with Stage 1, so I'm comfortable they'll be moving along well with Stage 2," he says.
But challenges remain to meet the view/download/transmit and secure messaging measures in Stage 2, not the least of which is reaching the 5 percent patient threshold. The move toward accountable care organizations, with their heavy reliance on health information exchange and data analytics to make treatments more personalized will help with patient engagement, Spooner believes. He hopes that becoming more customer-focused will get organizations past the 5 percent threshold.
Another challenge will be using the SNOMED-CT terminology for problem lists under Stage 2, and that means a large learning curve ahead for physicians as most do not use the terminology, he adds.
Even with portals in place, work remains at Sharp Healthcare to enhance them for Stage 2 requirements. The organization built its own portals to ease interfacing and that worked well. But the portals are first-generation, offering online scheduling, payments, refill requests, lab results, recent visits, problem lists, e-mail with providers and downloading of patient summaries.
One portal enhancement certain to come will be how patient identities are authenticated. "I wish we had done the configuration differently," Spooner muses. Right now, it can be difficult for a patient to get authenticated. Sharp Healthcare is using a commercial product that quizzes a patient about things they should know about, such the name of their elementary school. But it is cumbersome and they've gotten complaints, so the search is on for a more patient-friendly process.
How information flows and is re-used between the portal and EHRs will be a technical challenge for Sharp and everyone else, Spooner says. View/download/transmit capability will require that the EHR receiving the request be able to format the data in addition to storing it, he explains.
The EHR will have to look at a lab result and know it goes in the patient summary and has to be in a format to be received in the requesting EHR system.
A learning curve
At Greater Baltimore Medical Center, an inpatient portal to support patient access to their health information is just part of the overall meaningful use plan. "We're looking to do more with the portal than just meaningful use," says HIM director Day. Functions such as online payment and pre-registration, among others, will offer patients more convenient services and make the portal more valuable.
The medical center already has a patient portal for its more than 40 owned multi-specialty ambulatory practices, but HIM wasn't involved in that project and has a learning curve to learn the basics of portals. Day expects to get advice from practice administrators, and already has reached out to HIM peers in the region with an inpatient portal to get ideas on addressing such issues as providing access not just for adult patients but also minors.
Greater Baltimore hopes to do a full 90-day test reporting period for Stage 2 during the fourth quarter of 2013, then do the formal reporting period at the start of 2014 and attest in early April.
That timetable would have Stage 2 compliance off the hospital's plate six months before the ICD-10 compliance date in October to ease that initiative, but also give the hospital a little wiggle room during the April-June quarter if it needed more time to finish attestation, with still three months to focus on completing ICD-10, Day explains. "Why schedule other projects to coincide with ICD-10 if you can avoid it?"
Exchange options
A patient portal will be a core tool for complying with Stage 2's view/download/transmit and secure messaging requirements at Hays Medical Center serving northwest Kansas, but it won't be the only way to get patients their information electronically.
The hospital presently uses CDs to give patients their information when requested, and is considering providing flash drives to patients who don't have ready Internet access to satisfy the meaningful use measure, says Deloris Farthing, director of health information management.
Hays Medical has been live on a physician portal to serve local physicians since 2008, with up to 40 doctors being heavy users, 20 others "rather consistent," and spotty use among the rest, says Scott Rohleder, I.T. director. A big push to sign up physicians and giving portal access to the picture archiving and communication system helped fuel use.
To meet the various data exchange requirements under Stage 2 and better coordinate care, the hospital also is getting ready to build its own health information exchange, and was in the vendor selection process in late 2012. Rohleder is hoping the HIE option will further drive physician buy-in of data exchange.
The hospital now is piloting a patient portal with a large family medicine clinic, learning what data is actually displayed and where the data flows to. Staff members at the clinic have worried about a portal inundating them with patient requests and the hospital is considering having a centralized service to accept and route messages from the portal or sent by secure messaging.
Hays Medical has a big stake in getting physicians and staff comfortable with exchanging data with each other and patients in a variety of ways, as it employ more than 90 percent of the area's physicians.
More exchange options
In the ambulatory portal pilot, enrollment has proven to be cumbersome as patients need to come to the clinic and have staff enroll them.
That process could be streamlined by also offering self-registration online and via kiosks in the clinics.
Hays Medical's hospital vendor won't be ready to offer an inpatient portal until January 2013, and that worries Rohleder and his peers in other hospitals. They wonder how ready vendors will be for all of the technology changes necessary under Stage 2, and are afraid that they'll be pushing up against deadlines for completing implementations and workflow changes. Hays Medical, for instance, doesn't expect to get coding for updates until spring 2013.
How to handle secure messaging between patients and physicians is still a moving target, Rohleder says. "I don't think we yet have a firm idea of the technology or the process at this point."
Secure messaging software using federally developed Direct Project protocols won't be ready for Hays Medical's inpatient and ambulatory systems until late 2013.
But the technology is available now through the Kansas Health Information Network, so that may be an option.
Vendors Also Face Stage 2 HIE Challenges
Health care providers have plenty of challenges ahead of them to be able to quickly give patients the ability on online view, download and transmit their health information under Stage 2 of the electronic health records meaningful use program, and so do their services and software vendors.
Vendors that offer outsourced release of information services have to expand out of the traditional boundaries of what they do-copy images of records and give them to patients, says David Borden, chief technology officer at MRO Corp., King of Prussia, Pa. Now, they'll have to generate and hold discrete data.
MRO created a patient portal to make electronic copies of records or discharge summaries available to providers who wanted to comply with a menu (optional) measure under Stage 1, Borden notes. In Stage 2, he believes every EHR will have to include a portal, but MRO will continue to offer its portal if clients want them to handle view/download/transmit functions.
The vendor also is building a personal health record to offer another tool for facilitating patient access to their information. The PHR will support a Continuity of Care Document at a minimum, but also will be able to access data from multiple sources. Further, MRO is becoming a health information services provider, which builds secure gateways for health organizations, to support the core measure for physicians to use secure messaging technology to communicate with at least 5 percent of patients, and to provide clients with Web domains and e-mail addresses.
Release of information outsource vendor IOD Inc., Green Bay, Wis., also is building an infrastructure to support view/download/transmit and secure messaging. The company has adopted the Direct Protocol messaging specifications embedded in an Inbox for physicians to communicate with patients, and is creating a digital rights system to manage the process of authenticating the identity of physicians and patients, says Bill Sweeney, chief technology officer. Among other features, a database from identity management firm IDology Inc. in Atlanta, will store specific consumer information pulled form a multitude of market intelligence and public records databases across the nation to ask patients specific questions, such as, "What was the name of your landlord in Washington, D.C."
IOD also is working with personal health record vendors HealthVault and Dossia to enable patients to access their records via the PHR platforms.
The Delay In Stage 2 Delivers A Convoluted Timetable
Under the original timetable for the electronic health records meaningful use incentive program, providers who were early adopters and attested the first time for Stage 1 in 2011, then again in 2012 during the second year of Stage 1 (each stage is two years long and requires two attestations to receive payments), only had a few months to get ready for Stage 2, which was to begin in October 2012 for hospitals and January 2013 for eligible professionals.
Providers and software vendors lobbied federal officials for a delay in Stage 2 and got it in the final Stage 2 rule, with the second phase now starting in October 2013 for hospitals and January 2014 for eligible professionals. Further, those who attested in 2011 got a third year to attest to Stage 1 meaningful use.
With the delay, the feds in the final rule laid out timetables for meaningful use reporting periods in Stage 2 and subsequent stages, but the timetables are a bit confusing.
Under the new timetables, providers in their first year of participation in either stage have a 90-day reporting period of their choosing, while subsequent years of the stage require a one-year reporting period. That seems simple enough. But there is an exception for 2014 when providers have a 90-day reporting period for Medicare-fixed by quarters in the federal fiscal year for hospitals and quarters in the calendar fiscal year for eligible professionals. Hospitals and eligible professionals can choose their quarter, and hospitals also would attest for Medicaid meaningful use under the federal fiscal year.
But Medicaid reporting periods for eligible professionals will vary according to the rule: "Medicaid EPs will attest using an EHR reporting period of any continuous 90-day period between January 1, 2014, and December 1, 2014 as defined by the state Medicaid program, or if the state so chooses, any 3-month calendar quarter in 2014." Put another way, that means no one presently knows when eligible professionals can attest to meaningful use in 2014 and that won't been known until states start deciding.
Understanding the various timetables for 2014 isn't rocket science, but there is a chance of trading partners not interpreting the timetables exactly the same way. "I think there's definitely some confusion out there," says Scott Rohleder, information technology director at Hays Medical Center, in Kansas. He strongly suggests that providers talk to all of their information systems vendors whose products play a role in achieving meaningful use to make sure they are on the same page about when certain reporting functionalities must be ready for providers so they can attest within the various 2014 attestation timetables.
Jeanne Day, director of health information management at Greater Baltimore Medical Center, doesn't believe the timetable is confusing, nor is the first-year, fixed 90-day Medicare attestation periods a problem, with one caveat. A provider wanting to start a reporting period in January 2014 but consequently isn't ready until February must wait two more months, until the April-June quarter, to start the reporting period. That means rather than being done in March 2014 and having six months to focus on ICD-10, they'll be done with meaningful use in June and may not be as far along with ICD-10 as they hoped to be. So, the fixed reporting periods could impose some degree of time pressure for other major projects an organization is working on.
Overall, however, moving Stage 2 to 2014 remains very beneficial for all involved in meaningful use, says Lorna Green, R.N., senior business analyst for document management vendor Hyland Software in Westlake, Ohio. "It just gives us a little longer time to make sure we have the functionality in place and for hospitals to implement it, and that it's done well."
