The Stage 2 final rules make good on the promise of advancing interoperability through care transitions and data exchange standards, and that of increased patient engagement aligned  with Shared Savings goals, and does so through flexible quality measure and certification requirements.

At the same time an inclusionary message was sent through a trio of program enhancements to the provider community through the elimination of Medicare penalties for some late adopters of EHR technology, allowing some hospital-based providers to receive individual incentives and an expansion of Medicaid eligibility.

While arguments will be made that this meaningful use program, set to begin in 2014, is either overly ambitious or achievable, there are key timeline aspects that bring more providers to achieving Stage 2.  

For example, the CMS eligible professionals (EP) and hospitals Final Rule maintains the 90-day reporting period if the first year of Stage 2 is 2014. As to the ONC’s EHR certification Final Rule, Stage 1 certification and attestation can extend into 2014 for those still in their first or second year of the program, which speaks to the prior expansion of Stage 1 administered last year. These are some of the provisions recommended by organizations such as the EHR Association.

Within this flexible timeline, Stage 2 and Stage 3 (set to being in 2016) are also set up as two-year programs that can extend through 2020 depending on start dates. (But keep in mind the incentive dollars continue to be greatly front-loaded to encourage early adoption.)

For Stage 2, flexibility is also seen by the expansion of menu items, from five to six for EPs, and from four to six for eligible hospitals (EH) and critical access hospitals (CAHs). Here too, certification keeps pace, allowing for custom certification matching only the measures being sought, a gap analysis upgrade to move from Stage 1 to Stage 2, and a new provision allowing batch attestation that bundles EPs within group practices.

The goals of care coordination can be evidenced through sampling the core set of measures for EPs, for example:

- CPOE maintains the additions of lab and radiology orders (at least 30 percent each) along with increasing medications to at least 60 percent of orders.

- The use of Clinical Decision Support increases from one to four clinical quality measure interventions and adds the provision for drug-drug and drug-allergy checks.     

- CMS is seeking to improve interoperability through the exchange of lab results between hospitals and ambulatory clinics via common data exchange.

- From menu meaningful use criteria to core meaningful use criteria, and from 40 to 55 percent of all lab results ordered, is the requirement to incorporate results into the EHR as structured data.

- Also, menu criteria to core criteria is the generation of patient lists by specific condition to enhance research and analysis, though only one report per condition is required.

The Need for Patient Engagement

Patient engagement is stressed in two measures, one to simply provide patients with clinical summaries within one business day for more than 50 percent of office visits and the other requires that patients have the ability to view online, download and transmit their health information within four business days of EP availability.

That second key patient engagement measure has been much discussed, and as predicted following its introduction in the Stage 2 proposals, has experienced a reduction in the CMS Final Rule. That second measure also moves from menu criteria to core criteria.

The rise of patient portals and PHRs incorporated into EHR functionality makes this an achievable goal if care providers adopt and then offer them to their patients. The specifics require that 50 percent of all unique patients are given access to information, and that five percent (down from 10 percent) are shown to view, download or transmit to a third party.

For practices and hospitals becoming members of CMS or private payer Accountable Care Organizations, provisions for patient engagement are also becoming a prerequisite for financial success. These are achievable goals that speak to the business side of medical care as patients increasingly become consumers of affordable and accessible care, motivated in part by the rise of high-deductible employer health plans.

Summary of Care and Data Exchange

Likely no other individual EP measure has garnered or will get as much attention as the requirement for a summary of care document to be exchanged electronically during a transition of care.  It is noteworthy that public comment recommendations about what should not be included within the 17 total elements making up a summary of care document were not adhered to by CMS Final Rule authors.

The basics state that summaries are to be sent for more than 50 percent of transitions and referrals, down from the proposed threshold of 65 percent.

The accompanying measure that more than 10 percent of summaries are to be sent electronically has been maintained.

What has changed to a large degree is original language that the entire 10 percent or more of care summaries be exchanged by the referring provider to one with no organizational or EHR supplier affiliation. In other words from a provider with EHR company X to a provider using EHR company Y, a goal to advance healthcare “across organization and vendor boundaries,” as ONC Director Dr. Farzad Mostashari put it during the issuance of the Stage 2 proposals. This threshold has been reduced by requiring only at least one instance of exchange with a provider using EHR technology designed by a different EHR supplier, or through exchange with a CMS-designated test EHR.

Through the ONC’s own Direct Project for secure messaging, for example, different EHR solutions have successfully demonstrated data exchange, making this an achievable goal that should ramp up within Stage 3 for true interoperability and care coordination to take hold. And there’s good reason to believe it will continue to advance outside of the parameters of meaningful use, equaling the advancement of health information exchanges.

The positive step for interoperability is the cementing of data content utilizing Consolidated CDA, CCD/C32 and CCR standards imperative to a playing field all stakeholders can design for. And it’s noteworthy that the CMS Final Rule allows exemption from the measures if a care provider embarks upon a care transition less than 100 times within a reporting period.

What went against public comment recommendations does not speak to data exchange, but instead to elements within the 16 unique points of data included within the summary of care for EPs, and 15 for hospitals, namely a current problem list, medication list and medication allergy list.

All three were separate Stage 1 measures then those three measures were placed into the summary of care document within the Stage 2 proposals. During the public comment phase though, it was recommended that they be removed from clinical summaries and emerge as separate Stage 2 measures, however CMS chose to have them remain as elements within clinical summaries.  This decision also strongly speaks to advancing care coordination, in this case at the front end of referrals and transitions of care.

Flexibility Meets Transparency

Overall, the flexibility being offered to EPs and hospitals through quality measures and certification standards is being accompanied by elements of transparency.

For patients, the provisions afford a greater understanding of and accessibility to their care plans. For providers, the ONC Final Rule also mandates that certification test results be made public, and that EHR pricing elements be made available to EPs.

These requirements can only aid the aspects of quality and trust that can advance a crowded health information technology marketplace as patients and providers become consumers of best practices. Likewise the rules themselves are an advancement of best practices that can align with multiple care coordination and quality reporting programs to improve care and contain costs. It is encouraging to see another successful step towards creating a smarter and sustainable healthcare system in America.

Justin T. Barnes is co-chair of the Accountable Care Community of Practice (ACCoP), chairman emeritus of the Electronic Health Record Association (EHR Association) and a vice president at Greenway Medical Technologies, Inc.

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