By now, you’ve certainly heard the news: The "meaningful use" freight train has continued rolling forward and has finally arrived at the proposed criteria for stage 2. The specifics are available online for review and comment, and already – even in the pages of this newspaper – the medical world is abuzz with speculation about what they’ll really mean for docs.
Many wonder if the authors of the guidelines have overstepped and are proposing standards simply too cumbersome to meet. Others have described them as "a logical progression" to follow stage 1. Either way, the proposed rules certainly point to themes that will resonate across the medical world, and it is worth taking a moment to reflect upon the key elements and their potential impact.
So, What’s the Big Deal?
If you’re among the 39% of physicians who have collected meaningful use incentive payments so far (or are planning to be one of them soon), you’re likely aware of the stakes: $44,000 per provider in increased Medicare reimbursements for those who comply, with penalties starting in 2015 for any laggards who have not jumped on board.
Neil Skolnik and Chris Notte
You are probably also intimately aware of the requirements for stage 1. Included among these are specific goals for common and sometimes uncommon workflow items, such as entering electronic orders and providing clinical summaries for each visit.
A cursory review of the stage 2 requirements reveals more of the same, but with higher target goals. For instance, in the case of e-prescribing, the required percentage has risen from 40% of eligible prescriptions to 65%. In addition, measures that previously just required a "test" of ability now find themselves with target percentages of their own.
One clear example of this is the new requirement that physicians must transmit a summary of care record for more than 10% of referrals or transitions of care. This highlights the underlying core of the new measures: better communication.
Communication Is Key
Reading through the proposed rule, it doesn’t take long to recognize its emphasis on the sharing of health information. This is not limited just to information exchange among care providers in different settings, but also includes improved communication between physicians and patients.
For example, the new guidelines really put pressure on providers to have a secure and interactive web portal for electronic correspondence with their patients. Certain measures underscore this, such as the reduced time allowed to provide patients with a clinical visit summary (down from 3 days to just 24 hours).
The ability to publish this information through a Web portal will really become a necessity to comply with the tightened schedule. In addition, having a portal will pave the way for other measures, including those that provide for immediate patient access to labs and test results.
Of course, this also presents a unique challenge, as it may raise significant questions about patients’ studies prior to the physician’s opportunity to review the results with them. Most patients don’t have the luxury of a medical education with which to interpret their own results, and this could introduce significant anxiety and unnecessary phone calls to their physicians.
One final note about communication is the emphasis on sharing information with vaccine and syndromic data registries. Although practices were only required to perform a test in stage 1, stage 2 requires practices to carry out this process regularly. This, combined with the routine use of transition of care records, will begin to lay the groundwork for robust data exchange and population management.
Quality Matters
Stage 1 required providers to implement one clinical decision support rule to help insure best practice at the point of care. With the dawn of stage 2, the proposed number of such interventions is now up to five. In addition, the Centers for Medicare and Medicaid Services (CMS) will be looking for providers to report on 12 clinical quality measures, up from the current 6.
Reporting these should probably be taken quite seriously; some experts have postulated that, while stage 1 was a test of the EHR’s ability to collect the data, stage 2 is a test of the doctor.
It is not entirely clear what CMS is doing with the data being captured, but one thing is definitely worth observing: These quality measures are the same as those required for other government programs such as the Physician Quality Reporting System, and at some point the data will likely be used to determine physician reimbursement. This is no different from what is being expected from many private insurers, so it’s not surprising that CMS would capitalize on the power of the EHR to collect information and analyze physician performance.