As hospitals, providers and other healthcare institutions are still trying to wrap their collective minds around Stage 1 of meaningful use, the HIT Policy Committee at the Office of the National Coordinator heard recommendations from the Meaningful Use Workgroup in early June to discuss moving forward to Stage 2.
The following week, the Standards & Interoperability (S&I) Framework team met to discuss their ongoing efforts to identify appropriate data standards and language to allow a smooth exchange of data across EHR systems. Although several standards exist around clinical data, the lack of a specified standard for all systems to use is the major obstacle to interoperability between systems that would allow improvements in the quality, safety, and efficiency of healthcare.
Russell B. Leftwich, MD, chief medical informatics officer in the Office of eHealth Initiatives for the State of Tennessee, has been integrally involved in helping propel EHR adoption forward through testimony to the Meaningful Use Workgroup and co-leading the Clinical Information Model Workgroup of the S&I Framework. Prior to joining Tennessee’s eHealth Initiative in April 2010, the double-board certified internist practiced in Nashville specializing in allergy and immunology.
With a background in engineering, he has long been interested in the technology side of medicine and has served as committee chair or thought leader for medical informatics for two national specialty organizations and the Tennessee Medical Association over the past decade. “I’m very much aware of the need for understanding out there in the physician community,” he said of the struggle to move from paper-based practices to electronic formats.
Leftwich noted several points of interest came out of the HIT Policy meeting. He stressed, however, any recommendations from the recent meeting are subject to change … and probably will … until the final rule for Stage 2 of the EHR incentive programs is published next year. However, indications were good that the committee would strongly consider staggering the timeline for Stage 2 implementation. He added the committee favored extending the timeline rather than an across-the-board delay.
“They said that would penalize those who started Stage 1 this year,” he explained. “They are going to allow those hospitals and practices to go on to Stage 2 in 2013. Originally, If you didn’t start until 2014, you’d have to start in Stage 2,” he continued. “But they are indicating they will recommend (to CMS) that practices that haven’t started until 2014 be allowed to start in Stage 1.”
Much of the reason for consideration of altering the timelines comes from the difficulty providers faced in the delayed release of certified EHR software by vendors after the Stage 1 final rule was published. A similarly tight timeline is anticipated for Stage 2, which means the final rule probably wouldn’t be posted until mid-summer 2012.
“Vendor software companies won’t know what they have to do until the final rule,” Leftwich pointed out. Furthermore, he continued, even after software is certified, it still has to be debugged and beta tested before it’s really ready to go. For hospitals that plan to move to Stage 2 in 2013, they would have to be ready to go by Oct. 1, 2012 since hospitals fall under the federal fiscal year calendar (as opposed to physicians who are on a calendar year timetable and would need to be ready to move to Stage 2 by Jan. 1, 2013).
What wasn’t discussed, Leftwich noted, was any change in the incentive money timeline. “The amount of the incentive doesn’t really have to do with the stage, it has to do with when your first year is and depends on whether you are in the Medicare or Medicaid program.” Similarly, penalties … or as CMS prefers to say ‘payment reductions’ … begin in 2015 in the Medicare program. Whether or not that would change remains to be seen.
“There was an indication that they are going to recommend increasing the threshold for the criteria you have to meet,” Leftwich continued of Stage 2 requirements. For example, he noted, “In Stage 1, you’re required to e-prescribe … for eligible prescriptions … for 40 percent of patients. That is proposed to increase to 60 percent in Stage 2.” Leftwich said CMS has always been expected to raise the bar in each progressive stage but actual percentages and impacted objectives have not been previously specified.
While not underestimating the challenge of installing a certified system, Leftwich said that is only the beginning of the work. “If you thought you were going to get a computer and learn to type and you were there, you were way off. That’s the reality of why some people are unhappy. They thought it was going to be easy,” he noted. The next step … changing the actual workflow in the practice… might be the biggest hurdle for providers.
Leftwich said he has several times spoken with physicians who say, ‘Oh yeah, we’ve had an electronic record for three or four years, but I don’t use that problem list thing … it’s too much trouble.’ Not listing specific patient issues on the problem list, however, undermines the system’s capability. “It’s having things in a coded list that allows your computer to identify patients and provide clinical decision support. I think many physicians don’t understand how the computer system has to store things. Google makes you think you can find anything in a split second, but it’s really not that easy. The importance of the coded data is profound. That’s very much a part of Stage 2 and the intent of the Standards & Interoperability Framework.”
He added, “We’re not trying to create new standards. We’re trying to adopt standards that already exist so that in meaningful use Stage 2, they can say, ‘OK, everyone’s going to use this language.’”
By standardizing terminology — type 2 diabetes rather than elevated glucose or sugar diabetes or type II diabetes — then systems can communicate with each other. This is vital since Leftwich said a major emphasis in Stage 2 is coordination of care and exchange of clinical summaries electronically. It will also be important for those putting together Accountable Care Organizations.
“One of the deficiencies in the way we practice is there isn’t communication when people go from one place to another, and it’s true of hospital discharges, as well,” he said, pointing to numerous studies that show many hospital readmissions are due to discharge plans not being followed … often because nobody outside of the hospital walls really knew what the plan was. “For 50 percent of transitions (in Stage 2), there is supposed to be a clinical summary that goes from one system to another.”
Currently, electronic messages are exactly like sending a faxed summary. “Someone has to read it and get the information out of it,” he said. However, Leftwich continued, “If all the systems are using the same standards, not only would (the recipient) not have to key it back in, but the system could take blood pressure and put it where blood pressures belong and other data where it belongs. This will allow systems to actually digest the information … and not only populate fields but compare data about clinical care, and that will allow us to improve the care we deliver.”
It’s a tall order to set standards for the full range of clinical data inherent in the practice of medicine. In fact, Leftwich called the enormity of the task and the timeline (prior to the final rule for Stage 2) ‘breathtaking,’ but the critical importance of the task is highly motivating.
“I’m not sure anything significant that has ever been accomplished is realistic … so no, it’s not realistic, but it’s a determined group of people,” he concluded.