Meaningful Use: Your Stage 2 To-Do List

Several months before attesting for Stage 1 of CMS' meaningful use EHR incentive program, solo internal medicine physician Bob Fishman brought home armfuls of patient charts to enter data on the people he was seeing for the next two days.

"I would enter in their meds, their allergies, when their last colonoscopy was," recalls Fishman, who practices in South Hadley, Mass. "I did that for, like, three months."

The extra hours paid off in March 2012, when Fishman, who worked with a representative from the Massachusetts eHealth Collaborative (New Hampshire's regional extension center and an Implementation Optimization Organization for Massachusetts providers), received his first incentive check of $18,000 from CMS.

"It was a big, long, hard road for me, but I feel that I really accomplished something, and I really feel that I've earned my first installment of that $44,000," he says.

And although Fishman expects Stage 2 to go much more smoothly, as much of the burden of change will be on his EHR vendor, eClinicalWorks, chances are he'll have to put in some serious work before CMS hands him check number two.

"In Stage 2, they want you to send data electronically, and there's a subtle but real difference between data being faxed and data being sent in a digital domain," says Fishman. "We're now beginning to embark on the health information exchange and the patient portal."

As of December 2012, more than 82,000 eligible providers (EPs) have attested for Stage 1 and received the first check out of a potential total of $44,000 in Medicare incentive payments per provider (or out of a potential $63,750 for those who attested for the Medicaid program), according to an Office of the Inspector General (OIG) report. (To see a detailed timeline for the stages of meaningful use, visit http://bit.ly/meaningful_timeline).

But while the first stage only requires doctors to meet basic goals -demonstrate meaningful use of an EHR by satisfying 15 mandatory core measures, plus a choice of several clinical quality and other objectives - to prove use, Stage 2 will require a much more in-depth level of EHR use. That includes talking to vendors, changing work flow patterns, and taking an inventory of existing equipment to make sure it's up to par (and possibly purchasing new tech tools).

Not sure where to start? Follow this to-do list to get your practice ready to attest in 2014.

To do: Know your objectives

Though the earliest EPs can attest is in 2014, the changes a practice will have to make to be successful in Stage 2 could be monumental.

"Meaningful use Stage 1 was about getting the standardized processes and work flows in place," says Justin Barnes, chairman emeritus of the Healthcare Information and Management Systems Society (HIMSS) Electronic Health Record (EHR) Association, and vice president of marketing, industry affairs, and government affairs at Greenway Medical Technologies. "Meaningful use Stage 2 is about not just capturing the data but moving to improve the quality of care you provide to your patients."

The first thing a practice should do when it embarks on the road to attestation is to familiarize itself with the new objectives. (For details on the requirements, see our "Meaningful Use Stage 2 Crib Sheet," http://bit.ly/MU_cribsheet). Keep in mind, too, that states participating in the Medicaid incentive program may have attestation requirements that vary slightly, such as with submitting data to immunization registries, says regulatory expert Jason Fortin, a senior adviser for Naperville, Ill.-based Impact Advisors. Practices attesting for the Medicaid program, therefore, will want to check with their respective regional extension center (REC) or state Medicaid agency.

Unlike Stage 1, in which EPs must fulfill only 15 core objectives, Stage 2 requires providers to fulfill 17 core objectives, many of which are Stage 1 objectives with higher margins.

For example, EPs are required to record smoking status for more than 80 percent of all unique patients ages 13 and older in Stage 2, up from 50 percent in Stage 1.

Providers must also meet three of six "menu set" objectives, a list that includes items like "record patient family health history," as well as "identify and report cancer cases to a state cancer registry."

If the core and menu set objectives aren't enough of a meal to chew on, in the Stage 2 final rule CMS introduced new clinical quality measures (CQMs) demonstrating its goal for providers to align more closely with preexisting national quality programs, such as the Medicare Shared Savings Program. In 2014, EPs must submit nine CQMs from at least three of the National Quality Strategy domains out of a potential list of 64 CQMs across six domains published in the Stage 2 final rule. Prior to 2014, EPs are required to report on three core CQMs (or three alternate CQMs) from a table of 44, plus three additional CQMs, from a set of 38.

While some objectives, such as those related to collecting demographics, will be easy to do, experts agree that practices will need to pay particular attention to the following:

• Data-transmission requirements. There's a requirement that "the EP who transitions or refers their patient to another setting of care or provider of care provides a summary of care record" either electronically to a recipient using a certified EHR or via exchange facilitated by an ONC-established governance mechanism or NwHIN Exchange for 10 percent of transmissions and referrals. (For tips, read: How to Meet CMS' Data-Transmission Requirements).

• Patient-engagement requirements. These include a requirement for EPs to "provide patients the ability to view online, download, and transmit their health information within four business days of the information being available to the EP (for more than 50 percent of patients)," as well as a requirement to communicate using secure electronic messaging with more than 5 percent of patients (for tips, read: How to Get Patients Engaged).

To do: Review your attestation history

To figure out where you stand in regard to Stage 2 readiness, Jeff Loughlin, project director with the Massachusetts eHealth Collaborative, which oversees the REC for New Hampshire, suggests printing out a copy of your EHR's dashboard reports to see how far off (or close) you are to meeting certain thresholds. Weaknesses, such as e-prescribing for only 20 percent of patients when the threshold is 40 percent, will be easy to spot right away. Increasing your percentage may mean fixing data-collection processes - and ultimately the work flow - at your practice.

"The biggest things a practice needs to prepare for is to really take a hard look at their work flow, and how they are operating at the practice, and look at who is collecting the data," says Loughlin. "So with e-prescribing, that [process] might need to be re-engineered to start at the front desk, so staff will ask patients, 'What is your pharmacy? Where are you going to regularly?' and make sure that pharmacy is e-prescribing enabled." If it isn't, that could prompt the front-desk staff to suggest an alternative pharmacy that uses e-prescribing, he says.

To do: Talk to your vendor

Your best intentions to meet Stage 2 requirements are useless without cooperation from your EHR vendor: The final rule for the second stage outlines requirements that EHRs all conform to certain technology standards. In other words, if your EHR is not certified for Stage 2, you will not be able to attest.

Experts suggest asking vendors the following questions:

• What is your timing for certification for Stage 2? Finding out your vendor's timeline for Stage 2 certification will help you know how long it will take before you can make an upgrade to your system, and begin activities such as testing data transmission with other entities of care, or implementing new functions to accommodate the new standards and objectives, says Loughlin.

• Are you in direct compliance with the interoperability specifications for data exchange? How you connect to an HIE today might be slightly different from how you will connect in 2014, says Loughlin, adding that to stay certified or gain certification, CMS is now requiring vendors to be compliant with specs outlined in the final rule. If the vendor is not in direct compliance today, a practice should ask when it will be, and what will be the direct impact on processes. "They should be aware of what their vendor's intention is for direct compliant certification," says Loughlin.

• What kind of training will my practice need? To successfully meet CMS' objectives, a practice may need to change its work flow patterns, get documentation done faster, and get used to a revamped EHR that is certified to meet the new requirements. By finding out the extent of the change - whether it's a patch or a whole new release that requires hours of training - your practice can plan ahead rather than scrambling to train before attestation begins in 2014. "Training is important and for an upgrade it may be time-intensive for a practice, particularly if changes to work flow will be required," says Fortin.

To do: Take a technology inventory

Getting an EHR that's up to par isn't the only technology intervention that might be necessary for your practice to comply with Stage 2 mandates. Nor is it the only intervention you might want to make, given that meaningful use should ideally spawn a long-term, ideological shift in patient care.

Your practice should take stock of its current stash of tech wares necessary for Stage 2 that supplement the EHR.

For practice management (PM) systems, the same questions about upgrades apply as with the EHR (and practices should make sure all systems are ready for the shift to ICD-10, too).

Beyond EHR and PM readiness, there are potential purchases to consider. Topping the list are patient portals, those Web-based applications that allow for secure two-way communication between patients and healthcare providers. Portals are available as standalone software or cloud-based programs, or through your EHR/PM vendor.

And although it isn't expressly required by Stage 2 to have a portal to accomplish objectives related to patient engagement -sending secure messages and transmitting downloadable reports to patients, namely - a portal is the easiest, most HIPAA-compliant way to meet these requirements.

However, only about one out of three physician practices is using a portal, according to our 2012 Technology Survey, Sponsored by AT&T, based on responses of more than 1,300 practice-based physicians, administrators, and healthcare workers. If you are among the majority and don't yet have a portal, and you are planning to attest to Stage 2 in 2014, you may want to start looking into portals now. Choosing between one your EHR vendor offers and a standalone portal could take some time, as you weigh different options for the best user experience.

"Patients don't evaluate a portal based on how usable it is with other portals," says Fortin. "They evaluate it with how usable it is compared to Amazon, Expedia. That's where patient expectations are. If someone logs on and it's a frustrating experience, and they don't understand it, they won't use it."

Beyond portals, there are other potential technology purchases that might help a practice attest to Stage 2 and improve patient outcomes.

One example, which is helping Alabama-based Ashland Family Practice meet Stage 2 requirements for reporting CQMs to its state registry and provide better care for some of its most critically ill patients, is clinical analytics software.

Using a reporting program from her software provider Clinigence, practice administrator Debbie Robinson says she was able to isolate certain at-risk patient populations (such as patients with a BMI over 30 or those who smoke), and see how many were prime candidates for quality-care interventions.

"We found that we were dropping the ball at times," says Robinson, whose practice began using its Clinigence software earlier this year. "We had like 75 patients a month who weren't getting all the tests and intervention they needed. Today, we have almost no patients off protocol."

By adding certain interventions to high-risk patient episodes of care (such as tracking hemoglobin A1c levels over the course of three months to measure protocol compliance), Robinson's practice also saw an increase of 5 percent reimbursement for each Blue Cross claim it filed as long as it continued to meet the criteria. The practice also enjoyed a 10 percent premium reduction with its malpractice insurance provider as recognition of the practice's reduced risk.

To do: Put quality first

Practices that succeed in Stage 2 will take to heart what CMS says are its overarching goals for all three stages of meaningful use: improving quality of care, improving efficiency, and reducing unnecessary healthcare expenses.

"Focusing on quality will help you best position yourself to participate in new value-based, care-coordination payment models," says Barnes. "It goes beyond just saying, 'I have interoperability.' Ask yourself, 'Who am I going to have interoperability with? Is it another practice? Is it a local health system?' Understand who and where that data is going to flow. It's not just about the technical capability; it's also about the fundamental strategy of what your practice wants to do, which is future growth."

Barnes suggests practices have a one-year plan, a three-year plan, and a five-year plan for implementing meaningful use objectives beyond attestation.

For example, let's say your practice is a ten-physician organization that wants to join an ACO in the near future. To do that, you'll need to have technology in place that offers bidirectional interoperability with healthcare partners so patient care is transparent across the healthcare continuum.

"That's what you have to follow," says Barnes. "You don't just want to survive, you want to thrive."

In Summary

With Stage 2, providers will have to be take additional steps to use their EHR to initiate permanent changes to patient care. Here's what to do:

• Print out a copy of your EHR's dashboard reports to see how close you are to meeting certain thresholds.

• Ask your vendor about its timing for certification for Stage 2, so you know when to begin activities such as data transmission testing.

• To successfully meet CMS' objectives, you may need to change work flow patterns.

• You may need to consider other technology purchases, especially patient portals.

• You should have a one-year, three-year, and five-year plan for implementing meaningful use objectives beyond attestation.

Marisa Torrieri is an associate editor at Physicians Practice. She can be reached at marisa.torrieri@ubm.com.

This article originally appeared in the March 2013 issue of Physicians Practice.