Following is a comprehensive first-look at the CMS proposed rule for Stage 2 of the electronic health records meaningful use program from Justin Barnes, co-chair of the Accountable Care Community of Practice and a vice president at physician vendor Greenway Medical Technologies:

From the checklist or foundational mentality of Stage 1, to the “prove it” or workflow design-compelling criteria seen in the Stage 2 quality measure proposals released February 23, the emphases on bona fide data exchange (mere testing is history), longitudinal care plans, evidence-based clinical decision support and single standards for everything from care summaries to vocabulary all signal the maturation of care coordination.

The meaningful use incentive program is living up to its promise as the means to an evolutionary process merging with private payer and the Shared Savings/accountable care program all seeking the same goals: preventive care, documented quality reporting, patient engagement, liquid data, cost savings and of course definable outcomes improvement.

The CMS Stage 2 Notice of Proposed-Rulemaking (NPRM) presents expected criteria from earlier Health Information Technology Policy Committee recommendations already widely published and vetted through internal commentary phases. And it is expected that Stage 2 reporting thresholds and percentages will remain largely in place come the Final Rule targeted for August, and should not be decreased via the broader public comment phase next underway like we saw with Stage 1.

Do expect, though, discussion on the requirement that 50 percent of patients are provided access to their health information online, with 10 percent actually accessing.  While the meaningful use program increases - and Shared Savings stresses – patient engagement, influencing patient behavior and adherence is tricky but doable in terms of signing up for patient portals. Electronic health record (EHR) software providers are widely offering the functionality, but putting a number on patients using portals may be one of the more debatable aspects. Still, we know that practices offering portals are experiencing successful adoption by an increasingly mobile and tech-savvy patient population, so I would expect this requirement to remain, even if in this one instance thresholds do not.

Also as expected, Stage 1 menu items such as  incorporating lab results as structured data, generating patient lists by condition and sending patient reminders have moved to core competencies.  For Stage 2, EPs are met with 17 core objectives and the selection of three of five menu items for 20 total;  and 18 objectives for hospitals made up of 16 core, and two of four menu items.

The proposed rule is touted as a more flexible approach overall to reporting and certification, and evidence of that can be found in the widely-discussed ONC certification provision for batch reporting of eligible professionals in a group practice.

Thresholds in other Stage 1 core objectives are increasing as Stage 2 quality measures, such as CPOE from 30 percent to 60 percent, with the addition of lab and radiology orders along with medications. Electronic prescribing of non-controlled substances rises from 40 percent to 65 percent, and so on. Provisions for 90-day first year reporting also remain.

What’s also new along with themes such as greater patient engagement are specifics such as the viewing of images as a quality measure that ups the care coordination bar, albeit right now as a menu item. Also touted as criteria seeking to bring healthcare “across organization and vendor boundaries,” as ONC Director Dr. Farzad Mostashari put it during a HIMSS12 NPRM preview, is a provision for the electronic exchange of care summaries for more than 10 percent of patients, done during referrals to other providers and specialists, even to those using different EHR solutions.

Also breaking boundaries are data exchange standards expected in the ONC proposed rule widely discussed at HIMSS12. These positive steps include the direction being taken toward a single transport standard within Nationwide Health Information Network (NwHIN) specifications for centralized-type exchange, Consolidated CDA (CCDA) for clinical content and support of direct-based exchange through Direct Project protocols.
But despite what might sound transitory overall between Stages 1 and 2, make no mistake that by expanding the interoperability reach and in some cases the complexities of the quality measures – for example by providing the ability of at least 10 percent of patients to download, view and transmit their health information while also increasing the searchable filters patients can use to access it – it will still take time for eligible professionals (EPs) and EHR providers to master Stage 2 goals.

That is why the Department of Health and Human Services (HHS) was wise to extend Stage 1 through 2013, and for Stage 2 to begin the following year, in accordance with the consensus of healthcare leaders that the time to prepare for Stage 2, followed by a faster implementation of Stage 3 by 2016, would be the best scenario.

This also allows more EPs, practices and health systems – ambulatory and hospital – to build their own health IT foundations and take advantage of front-loaded incentive funds. To date, more than 191,600 care providers in the Medicare and Medicaid pathways have registered, and $3.18 billion in incentive funds have been delivered.

In conjunction, ONC delayed the launch of the permanent EHR certification program to coincide with the Stage 2 Final Rule to keep the program in sync with the new criteria. Expected flexibility here also includes certifying for just what a specialist might need, and just for selected menu items along with core objectives and the continuation of complete and module certification.

This is good news overall for our mutual evolution toward a sustainable, smarter and preventive health care system fueled by quality EHRs and health information technology. The current focus on CMS patients will provide a further evolution blueprint to all patient populations.

And the timing is certainly right to keep the CMS population clearly in sight. In addition to the 50 million Medicare patients currently enrolled, according to the U.S. Census Bureau, as the nation’s 70 million Baby Boomers began reaching age 65 last year, 10,000 people a day are becoming eligible for Medicare benefits.

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