Meaningful Use: Preparation Tips for Stage 2 Rules

Pediatrician Frini Shah and her three physician colleagues at Woodstock Pediatric Medicine in Woodstock, Ga., started preparing for Stage 1 of the Medicaid EHR Incentive Program in September 2011. They successfully attested in April, and the checks have begun rolling in. Yet they're not taking a break from the meaningful use process. Instead, they're already looking ahead to Stage 2.

"We are thinking about things that we will definitely need, and we are trying to get ready to train the nurses as well as train all the physicians as to what they need to do as far as record keeping and documentation goes," says Shah. "Then we'll also have to get a portal, which we don't currently have."

Shah's proactive approach is a smart one. Though Stage 2 doesn't kick off until 2014, the earlier physicians start planning for it, the smoother ride they will have. As internal medicine physician Michael Zaroukian, vice president and chief medical information officer at Sparrow Health System in Lansing, Mich., says, Stage 2 is a "much steeper climb" than Stage 1.

For one thing, you will have fewer options regarding which objectives to fulfill in Stage 2 than you had in Stage 1, as 17 (rather than 15) of the 20 objectives are required "core" objectives. In addition, the objectives themselves are more challenging, both in scope (many of the Stage 1 objectives combine to make up more unified Stage 2 objectives), and in threshold (the percentages required to meet many of the objectives are higher than the percentages required in Stage 1). "There's kind of a 'double jump' in that regard," says Zaroukian, who led the first stage of attestation at Sparrow's ambulatory practices and is now helping them prepare for Stage 2.

Another challenge is that technology that was not necessary to successfully fulfill the Stage 1 requirements, such as a patient portal or secure messaging, is mandatory in Stage 2.

But what might be most challenging of all is that factors not entirely in your control will play a major role in your ability to fulfill the objectives. Will your EHR vendor make the necessary modifications and upgrades to its system? Are your patients actively engaged in their healthcare? These things matter.

To help ensure that you are equipped with the tools necessary to succeed despite these challenges, we asked meaningful use-knowledgeable physicians and consultants to share their preparation recommendations. Here's what they said you should be doing now so that you can thrive when Stage 2 arrives in 2014.

Gauge your readiness

First, contact your EHR vendor to determine whether or not it is upgrading its system to comply with the Stage 2 requirements; and if so, how quickly? "Vendors really had to be prepared for Stage 1 in order to sell their product," says Atlanta-based consultant Elizabeth Woodcock, founder of practice management company Woodcock & Associates. Since you've already bought its product, the vendor may have less incentive to get the ball rolling on Stage 2. "…Having their client/customer base be proactive about [inquiring about their Stage 2 upgrades] will certainly encourage the vendors to move forward," she says.

Physicians will have to step up their game, too. One way is by continuing to "meaningfully" use your EHR as you did in Stage 1, and by trying to exceed those requirements.

"Stage 2 is literally an extension of Stage 1," says nonpracticing internist Bob Kocher, former special assistant to President Obama for healthcare and economic policy, and current partner at venture capital firm Venrock. "If you're comfortable using your electronic health records to do Stage 1, Stage 2 is straightforward I think," he says, noting that "as you gain experience, you gain scope."

Also, review the Stage 2 objectives, as Shah and her colleagues are doing. The sooner you do that, the sooner you can begin adjusting your work flow to adhere to them. That way, when it comes time to participate, you'll be ready. "If we have all the little details in place before we even really get to the point of documenting our 90-day data, then we'll be ahead of the game and we won't have any glitches," says Shah.

Increase patient action

In addition to facing more complex objectives, you will also face several new, challenging objectives related to patient engagement. In fact, some of them are so demanding that your ability to fulfill them will depend as much on your patients' actions as your own. For example, one Stage 2 objective requires that 5 percent of your unique patients send a secure message using the electronic messaging function of your EHR, and another requires that more than 5 percent of all unique patients seen by the physician view, download, or transmit their health information to a third party. "It's no longer sort of a nicety to tell your patients to use the portal and to log in to their personal health record," says Woodcock. "The government is saying, 'You, as a group of healthcare providers, play a role in getting patients engaged in their care.'"

While you can't force your patients to log in to your patient portal, there are some things you can do to build up a number of engaged, active, tech-savvy patients now, so that when Stage 2 rolls around, you - and your patients - will be ready.

• Prepare. Ensure you have the necessary technology in place to comply with the patient-engagement-related objectives. Your most practical option is a patient portal that is integrated with your EHR. Still, such a portal is not required, says Woodcock. In fact, a personal health record may also get the job done. Just review the final rule to make sure that your technology complies with - and allows you to satisfy - the requirements, she says.

• Recruit and retain. Once you have the appropriate technology in place, immediately start encouraging your patients to use it, says San Francisco-based family physician Robert Rowley, former medical director of EHR vendor Practice Fusion. Also, make it easy for your patients to recognize how convenient the technology is by offering secure messaging, online prescription refill requests, and online appointment booking, says Ken Ong, chief medical informatics officer at New York Hospital Queens in Flushing, N.Y.

• Plan. Look closely at the Stage 2 requirements and determine how you can get your patients to help you satisfy them, says Zaroukian. For example, "Online questionnaires or online reporting of information from home would be an excellent way to have patients initiate messages on their own," he says.

(For more tips on how to get patients actively engaged with your patient portal, listen to our podcast with The Advisory Board Company's Peter M. Kilbridge at http://bit.ly/Portal_Engagement.)

Exchange information

In addition to a growing emphasis on patient engagement, many of the objectives also focus on sending information electronically to other providers. As Zaroukian says, "CMS and the ONC [Office of the National Coordinator for Health Information Technology] are both signaling their seriousness and the importance of being able to exchange real data."

For instance, one objective requires that you satisfy one of the following two requirements: Conduct at least one successful electronic exchange of a summary of care document with a recipient using a different EHR platform than yours; or, conduct at least one successful test with a CMS-designated "test EHR" during the reporting period. With respect to the second option, CMS has collaborated with the ONC and the National Institute of Standards and Technology to create an online test EHR with which physicians can exchange information. Other Stage 2 objectives focus on increasing information exchange between providers and public health entities. Again, this poses challenges. "We know the importance of such measures," says Zaroukian, "What we don't know yet is how well and uniformly public health entities will be able to receive such data."

Though much of your success in fulfilling the information exchange-related requirements will be out of your control, there are some things you should start doing now to ensure you are prepared:

• Plan ahead. As with the patient portal, ensure you have the right infrastructure in place. For instance, if your vendor offers a module related to information exchange, consider implementing it, says Zaroukian. In addition, if there is a health information exchange in your community and you have not yet connected to it, seriously consider it. That "may turn out to be a reasonable approach for meeting the measures in a number of areas," he says.

• Start small. Begin building up a network of entities with which you can exchange information. For instance, discuss exchange opportunities with local hospitals, says Rowley. Even if full connection capabilities are not yet available, start connecting in small ways, he says. "At least open that conversation."

• Communicate with other physicians. If you already have the ability to exchange information electronically, do so frequently, says Kocher. That way, satisfying the related objectives will be a natural extension of your current activity.

Quality focus

You'll also want to start preparing for the Stage 2 clinical quality measure (CQM) reporting requirements. The good news is that you will have a broader range of CQMs to choose from. In Stage 1, for instance, you had to report on three core or three alternate core CQMs and three additional CQMs from a list of only 38 measures. In Stage 2, you need to submit 9 CQMs from at least 3 of the National Quality Strategy domains out of a potential list of 64 CQMs across 6 healthcare domains, including patient safety and care coordination. The Stage 2 quality measures also align more closely with measures used in pre-existing national quality programs, such as the Physician Quality Reporting System and the Medicare Shared Savings Program.

That's a big shift in a positive direction for physicians, says Kocher. "If you're a doctor, you could easily have 200 quality measures that you're trying to report on that are all similar but different, and as a result, you really have a hard time designing processes to drive excellent performance on any particular one," he says. Aligning the CQMs will enable doctors to "focus on what matters," Kocher says, such as reducing ER readmissions and increasing preventive health screening.

Zaroukian advises carefully choosing which CQMs to report on. "It comes down to eligible professionals taking a look at the measures as they see them, and trying to determine which of those measures they can align their practice colleagues around as being relevant and important," he says.

Also, consider your EHR when determining which CQMs to report. Consider how, and if, your system will support the work flows necessary to automatically document the quality measures in a way that allows you to gauge how you are progressing, says Zaroukian.

Retain perspective

If you're still not motivated to start preparing for Stage 2, try to keep the big picture in mind. While you might see it as a cumbersome, expensive hassle right now, Kocher says the rewards reaped from participating outweigh the challenges. And he's not just referring to the monetary incentive.

Participating in the various stages of meaningful use, Kocher says, will help your practice - and your patients - thrive in the future. "View the meaningful use thresholds as the minimum acceptable performance, not your best performance, and try to far surpass the thresholds," he says. "If you do, you can be confident that you're among the best doctors in the country, that your patients are getting the best care, and no matter what happens to the payment system or the health IT rules, you'll be in good shape."

Your meaningful use deadline

If you have not yet begun planning for Stage 1, let this serve as a very loud wake-up call. You have already missed the October 3, 2012 deadline to begin your 90-day reporting process in order to receive the full five-year Medicare incentive payment of $44,000.

But that doesn't mean you should give up on the process. If you attest to Stage 1 by the end of 2013, you could still receive a total of $39,000 in incentive payments. "I think participating next year at anytime during that 90-day period is certainly more than acceptable," says practice management consultant Elizabeth Woodcock.

Perhaps more noteworthy than the money you could gain due to participating in the program is the money you will lose if you don't. If you fail to attest to Stage 1 by October 3, 2014, you will see a 1 percent reduction in payment for Medicare reimbursement in 2015, and for each following year that you fail to participate, you will see an additional 1 percent reduction, all the way up to 5 percent.

*For complete details on Stage 2 rules for the EHR Incentive Programs, including tools to help you plan at your practice, visit our Meaningful Use Topic Resource Center at http://www.physicianspractice.com/meaningful-use.

In Summary

The government has just released the second stage of rules for its meaningful use EHR incentive program. Here's how to start preparing:

• Contact your vendor to gauge whether it is making the necessary Stage 2-related upgrades to your EHR.

• Continue "meaningfully" using your EHR as you did in Stage 1. Try to exceed those Stage 1 requirements.

• Familiarize yourself with the Stage 2 requirements and begin complying with them as much as possible.

• Acquire necessary technology to fulfill the patient-engagement-related objectives and encourage your patients to use it.

• Ensure you have adequate infrastructure in place for health information exchange and begin exchanging information with others.

• Review the clinical quality measures and make smart selections regarding which to report.

*Note: Interviews for this article were conducted after the release of the Stage 2 proposed rule, but prior to the release of the final Stage 2 rule.

Aubrey Westgateis an associate editor at Physicians Practice. She can be reached at aubrey.westgate@ubm.com.

This article originally appeared in the October 2012 issue of Physicians Practice.