Health information technology legal and policy wonks wading through the final Stage 2 electronic health records meaningful use rules are finding provisions and language that are causing a few “ah-ha!” moments.

Robin Raiford, research director at The Advisory Board Company, a consultancy, gave a big sigh of relief to read in the final rule that hospitals have until July 1, 2014, to have the 2014 Edition of Stage 2 certified electronic health records software, rather than when the 2014 fiscal year starts on Oct. 1, 2013. Being ready in 13 months was going to be a real stretch for hospitals and their EHR vendors, she notes.

Raiford’s biggest gasps when reading the rules were caused by the requirement that 50 percent of hospital patients have the capability to view/download/transmit their records within 36 hours of discharge. “That’s going to be tough,” she says. “Today, hospitals are scrambling to get e-copies within three business days.”

A very big deal in the rules, she contends, is the hardship exemptions given to certain physicians, primarily radiologists, pathologists and anesthesiologists. These specialists don’t have a lot of face-to-face interaction with patients and may not be in position to comply with meaningful use requirements. Consequently, they can apply for an exemption to participating in the program without facing Medicare reimbursement penalties for failure to achieve meaningful use.

Patient education a key

Allison Viola’s ah-ha moment came when she ran across provisions-- not included in the proposed Stage 2 rule-- regarding the recording of electronic notes. EHRs in Stage 2 are required to support the process and recording electronic notes is a menu measure in the meaningful use requirements for providers. These notes can include not just text, but drawings and other content scanned into the EHR and associated with text notes, says the senior director of federal relations at the American Health Information Management Association.

What struck Viola as she read the rule was a realization of the role in educating patients that health information management professionals can perform. “There is a significant potential increase in HIM pros working with patients to understand how to get their information and how to send it appropriately to the people they want to have it,” she says.

Viola was pleased to see a streamlined number of EHR functional measures and clinical quality measures in Stage 2, with minimal and “thoughtful” additions. For instance, secure messaging between providers and patients is a new measure, but the threshold of 10 percent of patients initiating a message in the proposed rule was reduced to 5 percent in the final Stage 2 rule. She isn’t sure anyone today has a good grasp of how ready patients and providers are for secure messaging. “Reducing it to 5 percent is a nice balance. That will give us a baseline on whether it can be raised in Stage 3.”

Still, because secure messaging has to be initiated by patients, providers will be challenged to educate patients on the availability of secure messaging as a communication option, and it remains to be seen how doable that will be. On the other hand, if providers do too good a job educating, they may be overwhelmed with messages, Viola says. It also remains to be seen if getting five percent of patients to view, download, or transmit their information is doable, she adds. “This is a significant change from Stage 1 and it will take a significant effort to educate patients and get them to initiate the exchange.”

She’s also pleased to see that advanced directives remains in the menu set of measures, as the government had sought to make all Stage 1 menu measures become core measures in Stage 2. “There’s so much wrapped around directives in terms of state and federal laws, patient preferences and questions on where to store it. More analysis needs to be done.”

Not much difference

Brenda Pawlak was surprised of the very few real changes in the final Stage 2 rule from what was proposed. It’s clear that federal officials listened to feedback on proposed rules from the industry, but they still managed to substantially stay the course, says the director of the Manatt Health Solutions unit of Manatt, Phelps & Phillips LLC.

Most clinical quality measures remain, and the decrease of required patient-initiated actions in secure messaging and downloading, viewing or transmitting their information is not that meaningful, Pawlak believes. The bar is lowered on providers who need to get 5 percent of patients to view/download/transmit, but the burden also rises on them because they also have to get five percent of patients to initiate secure messaging.

Pawlak was surprised to see use of an electronic medication administration record as a core measure in Stage 2 despite calls for it to be moved to Stage 3. “Providers are not opposed to eMAR, but it’s a heavy lift on implementation and cost.” She also calls “a really big deal” the requirement of electronic submission of meaningful use measures. “Providers have to get their arms around that.”

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