Success Strategies for the Second Stage of Meaningful Use

For providers who are scheduled to meet the Stage 2 requirements for meaningful use this year, the attestation process has been frustrating at best. Early adopters who are prepped to begin the three-month reporting period under the Medicare EHR Incentive Program have been stymied, in many cases, by the backlog of software vendors awaiting 2014 certification. Others are voicing concern about the criteria for patient engagement and summaries of care - which can make or break their ability to collect incentive payments. CMS, of course, has proposed a rule that would allow providers to use their 2011 certified EHR, or a combination of 2011 and 2014 certified software, for the 2014 reporting period, which could ease some of the immediate pressure facing practices. But until a final decision is rendered, it also leaves timelines in question for 2014.

As healthcare providers await guidance, IT experts, practice consultants, and physicians in the trenches say there is much you can do in the weeks ahead to ensure your practice measures up when it's your time to attest. First and foremost, advises Jim Hook, a healthcare management consultant with The Fox Group in Upland, Calif., do not sit on your hands. Regardless of whether CMS offers leniency for 2014, he notes, providers who completed two years of Stage 1 will still be required to begin full-year attestation for Stage 2 on Jan. 1, 2015. "It's still only a proposed rule, so while you may be able to continue using Stage 1 criteria for this year, you're betting a lot of incentive money on that new rule being adopted - or rejected in enough time for you to start Stage 2 attestation if needed," says Hook. You don't want to find out the rule wasn't adopted on Oct. 2, he notes.

Far better to assume you'll need to attest this year, he adds. Continue gathering documentation to ensure you still meet Stage 1 criteria and, if you don't yet have certified software available for 2014, pursue the higher Stage 2 thresholds on your own. Participating providers, for example, must use computerized provider order entry (CPOE) for more than 60 percent of medication (up from 30 percent for Stage 1), 30 percent of laboratory, and 30 percent of radiology orders during the reporting period for Stage 2. The criteria for electronic prescriptions also jumped to 50 percent of all permissible prescriptions, from 40 percent in Stage 1. And, you must now provide clinical summaries of care to patients for 50 percent of all office visits within one business day instead of three. "Continually generate reports to determine how close you are to meeting the performance measures and objectives for Stage 2," says Hook. "Some of the really progressive practices may have already achieved Stage 2 meaningful use and have data to support it."

Jeff Grant, a practice-management consultant with HCMA in Shell, Wyo., says every practice should also make their staff accountable during attestation. "In the beginning of your reporting period, run those reports every day and make individuals and departments responsible for specific measures," he says. "Make sure staff understand the measures, share the numbers with them, get them involved, and make sure they know how important meaningful use is to the practice." Throughout the process, practice managers should keep their fingers on the pulse of performance and flag departments immediately that need to step up. If patient demographic information is low, your front desk should be pushed harder to collect and enter that information at check-in. Look, too, for opportunities to shift workload as needed so the requirements of establishing meaningful use don't disproportionately burden any one person, which could negatively impact quality or patient satisfaction.

While Stage 1 of the incentive program primarily focused on data capture and sharing, Stage 2 seeks to increase the exchange of health information between providers and promote patient engagement by giving patients secure online access to their health information. To establish meaningful use, providers will need to meet 17 core measures, which are mandatory and include higher thresholds for CPOE, e-prescribing, clinical summaries, secure electronic messaging (new); and the recording of demographics, vitals, and smoking status. To successfully attest, providers also must report on three of six menu measures, five of which are brand new. They include recording electronic notes for 30 percent of patients, making 10 percent of imaging results accessible through a certified EHR, and recording family health histories as structured data on 20 percent of patients. Separately, providers must also report on nine clinical quality measures (CQM) as they attest to Stage 2 that focus on patient safety, health outcomes, care coordination, and patient engagement.

Hook notes CMS has simplified the CQM objective by offering two sets of core measures, one for adults and one for pediatrics. As they prep to report, practices should review these lists and see which CQMs are applicable to their specialty, take steps to incorporate the measures, and implement a method to report their use, he says. The measure on screening for clinical depression, for example, requires a standardized depression screening tool, such as a questionnaire. Thus, the practice would need to obtain the tool, administer it to patients when a provider suspects depression, record the administration and its outcome in the medical record, and report the activity via use of G-codes, says Hook. That takes planning and resources.

Be proactive

Practices that are revving up to report should also reach out to their vendors to find out which menu objectives their software is certified to track. CMS does not require EHRs to be certified on all objectives for 2014, but those that are make the provider's job that much easier, says Rani Aravamudhan, senior implementation consultant for McKesson Business Performance Services' meaningful use team in Westland, Mich. "The more that a vendor is certified on, the more a provider has to choose from," she says, noting flexibility is especially important for specialists as many of the CQMs may be outside their scope of practice to begin with.

Mary Griskewicz, senior director of health information systems for the Health Information Management Systems Society (HIMSS), says practices should ask specifically if the vendor's product is certified to capture and export, electronically submit, and import and calculate.

For example, find out whether the system can capture syndromic surveillance data to help detect and control outbreaks and submit it in the appropriate electronic format to public health agencies. It's critical that practices understand in advance what their systems are capable of. "Be proactive about having those conversations," says Griskewicz.

Promote your portal

For smaller practices, however, it's the requirements for patient engagement that have proven most challenging. To meet the Stage 2 criteria, more than 50 percent of all unique patients seen by the provider during the EHR reporting period must be provided timely (within four business days of the information being available to the provider) online access to their health information. More than 5 percent of them must also view, download, or transmit that information to a third party. That can be tough for providers with a large percentage of Medicare patients, who are generally technology averse, says Shaukat Qureshi, a urologist in Pennsville, N.J., "It's been a challenge," he says. "From the get-go, patients don't want to give you their e-mail addresses. No matter how much you explain to them that it's regulation, they don't trust where their personal health information is going to go." Some deny having an e-mail address at all, he says. "Or they'll give you their address, but say they're not interested in viewing their records online and that if they need anything they'll just call your office," says Qureshi.

Harder still, providers who attest to Stage 2 are now newly required to use secure electronic messaging to communicate with patients on relevant health information. Here again, the measure requires that more than 5 percent of patients seen during the reporting period actually correspond using the secure messaging function. Thus, practices must become more adept at promoting their portal at every turn. "One practice I know gives handouts at the end of each visit to patients which meet the criteria for providing a summary of care, but also includes instructions for how to set yourself up and access the patient portal," says Hook. "It explains why the portal benefits the patient and what they can do with it, including viewing their medical records, sending secure messages, and scheduling appointments."

Aravamudhan says waiting room kiosks can also help give patients the technological boost they need. "It's very effective to provide a monitor and keyboard in the waiting room with a browser loaded and have either a tutorial program available, or make someone available to walk patients through the portal and answer questions," she says. One six-physician practice she works with uses volunteers from a senior living facility nearby to help older patients learn the ropes. "That really adds a huge level of confidence," says Aravamudhan. "Patients think, 'Well if she can do it, so can I.'" Consider, too, offering $5 gas cards or ice cream coupons to patients who message you at least once prior to their appointment. "Those little things don't cost much money, but they go a long way toward promoting your portal," she says. Your regional extension center, which may have helped your practice attest to Stage 1, can also be a valuable resource in helping your practice achieve patient engagement and improve work flow during Stage 2 attestation, notes Griskewicz.

Summary of care

The summary of care requirement has also caused great angst among providers, though CMS has taken steps to mitigate the pain. Under Stage 2 of meaningful use, eligible professionals who transition their patient to another setting of care or refer to another provider must provide a summary of care record for more than 50 percent of their patients during the reporting period. More than 10 percent must be made by electronic transmission using a certified EHR or via a nationwide health information network (NwHIN). They must also conduct one or more successful electronic exchanges of a summary of care document with a healthcare recipient who has an EHR system that is different from their own. "Some of the practices that are in more rural settings or those that are insulated don't do all that much work with other providers, so they've been worried about how they are even going to test this," says Griskewicz. To assist, CMS has developed a test site that allows practices to meet the requirement by exchanging summary of care records with a designated test EHR.

"That will help," says Griskewicz, noting practices should still confirm with their vendors that their software can capture all the required summary data, including demographics, lab test results, vital signs, and functional status. A little tip? It should also include a blank field within the medication allergy list that allows providers to indicate that a patient is healthy and does not take any medications or have allergies, says Griskewicz.

Patient privacy

Hook notes many of his clients who are in the throes of Stage 2 attestation are also confused about the HIPAA security rule. "Some practices think that just because their vendor tells them that their EHR is HIPAA compliant that [it] satisfies the requirement," he says. "It doesn't." Practices have been required to perform a HIPAA security risk analysis annually since 2003, but that's now explicit as a meaningful use requirement. "There was no real monitoring or auditing process prior to the Stage 1 and Stage 2 requirements," says Hook, noting practices must conduct a thorough inventory of their health IT, including the security of their encrypted network, their internal system, and their safeguards for ensuring vulnerabilities are promptly remedied.

Don't panic

As your practice begins to report on meaningful use, says Grant, office managers should remember to take a deep breath. You need not meet every measure when you begin attestation. "If you start your reporting period and you're not yet hitting all the numbers, but you're close, don't fret," says Grant. "Keep pushing your staff to fix the problems over the course of the quarter and you'll get better and better. As long as you get to the end of the period and you've met all the percentages, you're fine." Practices that start off missing the mark in the first month, measure up in the second, and exceed in the third will still collect their incentive payment, he adds.

Depending on your practice, you may also qualify for CMS exclusions. For example, eligible professionals are excluded from the summary of care requirement if they transfer patients to another setting or refer to another provider fewer than 100 times during the EHR reporting period. Likewise, any provider who has no office visits during the EHR reporting period, or who conducts half or more of his patient encounters in a county that does not have 50 percent or more of its housing units with broadband availability is excluded from the secure electronic messaging requirement.

Despite the uncertainty surrounding Stage 2 deadlines, providers who communicate with their vendors and set their own bar higher will be well-positioned to demonstrate meaningful use next year. "Put all of that supporting documentation in place and pretend you are going to attest tomorrow," says Aravamudhan. "Until we get a final ruling in ink from CMS we are going to assume that everybody who attested to Stage 1 in 2011 and 2012 needs to be on 2014 certified software this year. Either way, they need to begin full-year attestation in 2015. Nobody should lose sight of that."

In Summary

Physicians who plan to participate in Stage 2 of the government's EHR incentive program need to brace for more complex and rigorous reporting requirements. They include:

• Using computerized provider order entry for more than 60 percent of medication orders (up from 30 percent in Stage 1).

• Using e-prescribing for at least 50 percent of all permissible prescriptions (up from 40 percent in Stage 1).

• Providing clinical summaries of care to patients for 50 percent of all office visits within one business day (instead of within three days as required in Stage 1).

• Getting more than 5 percent of patients to view, download, or transmit online health information to a third party.

• Getting more than 5 percent of patients seen during the reporting period to correspond using secure messaging.

• Reporting on three of six menu measures, five of which are brand new in Stage 2.

Shelly K. Schwartz, a freelance writer in Maplewood, N.J., has covered personal finance, technology, and healthcare for more than 17 years. Her work has appeared on CNBC.com, CNNMoney.com, and Bankrate.com. She can be reached via editor@physicianspractice.com.

This article originally appeared in the September 2014 issue of Physicians Practice.