By William Foltz
Patient engagement, interoperability two challenges physicians face in meeting requirements in the Meaningful Use program. And Stage 3 is looming.
The Meaningful Use program, instituted as part of healthcare reform, has been the primary tool of policymakers to incentivize electronic-health-record adoption and proficiency. 2015 marks the last year that eligible providers – including physicians and hospitals – must attest to Meaningful Use Stage 2 (MU 2), else they risk a 1 percent reduction to their Medicare reimbursement beginning in 2017.
Meanwhile, EHR vendors and providers are already turning their attention to Stage 3, for which the federal government issued proposed rules in March.
While MU 1 brought its own set of challenges, requiring many physicians to install new technology and adapt to an unfamiliar workflow, providers trying to attest to MU 2 have encountered two primary obstacles that can sometimes lie outside of their control: patient engagement and interoperability.
One of the most notable features of MU 2 compared to MU 1 is its focus on patient engagement. MU 2 contains several new criteria requiring providers to issue reminders for care, distribute educational resources to select patients, and increase patients’ access to their personal health information. However, getting enough patients to use online portals and other tools poses unique problems. “Involving patients more in their own care is absolutely a cornerstone of a better U.S. healthcare system, but so far providers are finding it immensely difficult to coerce patients into participation,” says Matt Douglass, Co-Founder and VP of Platform for EHR vendor Practice Fusion.
Data from CMS highlights the varying degree of success for specific patient engagement measures even among eligible providers who met MU 2. For the requirement that patients view their health information, roughly 62 percent of successful attesters had patient participation rates of 40 or below, with about a tenth hitting the minimum rate of 5 percent. For the patient reminder measurement, which had a 10 percent minimum, 72 percent issued reminders to half of their patients or less.
Part of the reason MU 2 patient engagement targets have been so difficult for some to meet may be inexperience with population health management in general. “Historically, providers have rarely involved patients directly in their own care outside of the healthcare setting other than giving them hand-written prescriptions or perhaps copying specific pages of the medical chart to hand to them in certain situations,” says Douglass. Much like other healthcare reform programs, MU is forcing physicians to redefine their daily operations.
“If you step back and think about what is being asked of providers with the patient portal-related aspects of MU,” Douglass says, “it’s quite a paradigm and workflow shift from what they are accustomed to.” The requirements have also led to some frustration among medical practices. “In general, physicians do not appreciate being measured based on activities that are outside their control,” according to Karen Ferguson, Senior Director of Public Policy for the American Medical Group Association (AMGA). “The decision to use a patient portal is completely within the discretion of the patient, yet medical groups are held accountable for their choice to use, or not to use, the portal.”
In response, many physicians are taking proactive steps to encourage greater patient participation. “Some medical groups have kiosks in their waiting rooms that are equipped with computers and a staff person ready to help patients enroll in the portal or login to their record,” Ferguson says. “This requires the creation of designated workflows for front office staff and clinical team members.” Physicians often point to the greater convenience of the portal for functions such as appointment-making to sell patients on the system. Features such as appointment reminders and online access to condition-specific educational materials, both incentivized through MU 2, can also lead to healthier patients, a definite benefit for physicians participating in value-based reimbursement programs.
EHR vendors are well aware of the struggle to get patients more involved in their own care, and some offer additional services to assist physicians in the effort. “Beyond providing what we obviously think is an excellent product, we realized that in this particular case physicians need services as well,” said Jim Brule, Solutions Director of Regulatory Affairs for Meaningful Use at Allscripts. “One of our services is producing the marketing materials that people need because Meaningful Use requires much more than simply providing a portal, but finding a way to reach out to patients.” Allscripts also sends out teams to help enroll patients directly into the portal and hosts webinars on best practices to increase patient participation.
Providers struggling with patient engagement may also get some help from CMS. In April, the agency issued a proposed rule modifying several MU 2 requirements, including the mandate that 5 percent of each provider’s patients communicate through a secure online message, a measurement criticized by the American Medical Association and the American Medical Group Association due to the limit of physician control. Under the new requirement, attesting providers would merely need to demonstrate that the capability exists. In addition, CMS would no longer require 5 percent of patients to view their health information online, instead allowing a single patient download to suffice.
Though providers have generally welcomed the change, some fear the proposal could set physicians up for a shock when they attest to MU 3. Brule notes that while some changes make sense, such as the elimination of the patient-initiated messaging requirement, easing the patient portal access standards could lead to trouble down the road. “We believe that it’s important to keep some performance threshold, perhaps providing an exclusion for 2015 and ramping it back up. Removing it for the entire period won’t help people in the long run achieve the higher threshold later on,” Brule says.
While effective patient engagement has proven to be a challenging goal of MU 2, a lack of interoperability remains an obstacle for some physicians. One core measure of MU 2 requires physicians to provide a summary care record for each transition of care or referral. To meet the standard, at least 10 percent of the records must be sent electronically.
On paper, the functionality is straightforward, given that all 2014 Office of the National Coordinator- (ONC) certified EHR systems must have the ability to create and transfer summary of care records through a secure direct messaging system. However, the new capability often brings new costs. As providers upgrade their EHR systems, they often face a substantial fee that can range from $50,000 to $80,000, according to a Government Accountability Office report from March 2014, creating a financial barrier for many practices left with systems that can’t properly send documents to other providers.
In addition, the direct messaging standards themselves have not been encompassing enough, leading to variations that inhibit data transfer. In an October 2014 letter to CMS and the ONC, the American Medical Association stated in regards to a pilot project focusing on physician referrals, “ … it was learned that the current vendor systems do not have any functionality to facilitate sharing of patient information, only the ability to request a referral. This is leading to extensive customization (and cost) within each vendor system for a function that should be considered a standard operating practice since it often occurs many times a day.”
The GAO, as well, pointed out data transfer problems in its March 2014 report, saying, “Several providers stated that they often have difficulty exchanging certain types of health information with other providers that have a different EHR system due to a lack of sufficient standards to support exchange.” While transferring the summary of care document remains possible, according to Ferguson, it has caused frustration for many of its member medical groups, and the AMGA has recommended that CMS “place more responsibility on the EHR vendors to create interoperability around a single standard.”
Stage 3 proposals
Given the challenges of providers attesting to MU 2, the recent proposed rules for MU 3 bear some consideration. The rules aim to simplify the program by eliminating measures already widely adopted and reducing the total number of objectives, but they also dramatically increase the requirements for both patient engagement and interoperability. During the MU 3 reporting period, the percentage of patients who must view their health information through a portal jumps from 5 to 25 percent, 35 percent must receive a clinically relevant secure message, and the electronic transfer rate of a patient’s summary of care document increases from 10 to 50 percent.
The new standards may seem high, but providers have reasons to be optimistic. For one, physicians that have successfully attested to MU 2 will have already adapted to the new workflow demands and demonstrated the critical functions needed for a high level of patient engagement. In addition, interoperability between EHR systems is expected to improve by 2018, the mandatory year for MU 3 attestation without payment adjustments. Client pressure upon vendors, as well as government initiatives like the ONC 10-year interoperability plan, should make it easier for providers to share basic patient information.
Though the MU program has set a high bar for providers, requiring adjustments to workflows and sizeable investments in technology, physicians have so far proven that they are up to the task, and MU 3 should be no exception.
William Foltz is an analyst for the Major Accounts Exchange (The MAX), a provider of real-world intelligence for the contracting community in health care. The MAX – which is a product of MDSI, publisher of Repertoire and the Journal of Healthcare Contracting – has been designed to serve as a supply chain “community,” where senior-level executives can find, digest, and act on vital business and market intelligence.
What about Stage 3?
Here’s how the Centers for Medicare & Medicaid Services summarized its intentions for Stage 3 of Meaningful Use in the March 30, 2015, Federal Register:
This Stage 3 proposed rule would specify the meaningful use criteria that eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) must meet in order to qualify for Medicare and Medicaid electronic health record (EHR) incentive payments and avoid downward payment adjustments under Medicare for Stage 3 of the EHR Incentive Programs.
It would continue to encourage electronic submission of clinical quality measure (CQM) data for all providers where feasible in 2017, propose to require the electronic submission of CQMs where feasible in 2018, and establish requirements to transition the program to a single stage for meaningful use.
Finally, this Stage 3 proposed rule would also change the EHR reporting period so that all providers would report under a full calendar year timeline with a limited exception under the Medicaid EHR Incentive Program for providers demonstrating meaningful use for the first time.
These changes together support our broader efforts to increase simplicity and flexibility in the program while driving interoperability and a focus on patient outcomes in the meaningful use program.
Source: Office of the Federal Register, www.federalregister.gov/articles/2015/03/30/2015-06685/medicare-and-medicaid-programs-electronic-health-record-incentive-program-stage-3