6 Predictions on Stage 2 Meaningful Use

The HITECH Act under the American Recovery and Reinvestment Act of 2009 allows eligible healthcare providers to receive incentive payments upon demonstrating "meaningful use" of electronic health records. In order to meet meaningful use, providers must meet a set of criteria provided by the Office of the National Coordinator. The criterion is published in three phases, with Stage 1 going into effect this year. There has already been a significant amount of buzz and debate around Stage 2 requirements to meet meaningful use, but not much has been said about specific measures and requirements. Here, healthcare industry experts share six predictions on possible Stage 2 meaningful use requirements.

1. Increased measures from Stage 1. Stage 1 meaning use requirements include a subset of clinical quality measures. For Stage 1, although all eligible hospitals must report on all 15 clinical quality measures, some healthcare experts, including Russ Branzell, CIO and vice president of Poudre Valley Health System in Fort Collins, Colo., who is part of the ONC's tiger team for Stage 2 meaningful use that works on quality measures, predicts these clinical quality measures will likely be heightened in Stage 2.

"If you look at it from a building block perspective, the intent of Stage 1 meaningful use is so that the basic components of an EHR are in place and the hospital has the ability to support those metrics for quality outcomes," Mr. Branzell says. "As we move into Stage 2, what we're going to see is not new standards but rather fully implemented standards from Stage 1."

In one such example, Mr. Branzell cites a Stage 1 clinical quality measure that will likely undergo an expansion in Stage 2: computerized physician order entry. Stage 1 meaningful use requires more than 30 percent of all unique patients with at least one medication in their medication list admitted to the eligible hospital's inpatient or emergency department have at least one medication order entered using CPOE. Mr. Branzell says the industry can safely expect this requirement to dramatically increase to 80-90 percent in Stage 2.

Charles W. Jarvis, FACHE, vice president of healthcare services and government relations for NextGen Healthcare, a provider of health IT and EHR solutions, agrees with that notion.

"It's going to be challenging at this point to make any predictions on Stage 2 because we don't even have the recommendations from the ONC Health IT Policy Committee, but what we do expect from preliminary comments made by Dr. Blumenthal and ONC is that there is going to be much higher bars for performance," Mr. Jarvis says. "In fact, we expect most, if not all, measures will be at 100 percent in Stage 2."

2. New focus on patient safety measures. The five core concepts for Stage 2 clinical quality measures are patient and family engagement, clinical appropriateness/efficiency, care coordination, patient safety and public health. Mr. Branzell says other work groups that are part of constructing meaningful use requirements have been focusing on subdomains to fall under the category of patient safety. Among these, he says it is likely Stage 2 patient safety measures will include some measures on medication safety, hospital-associated adverse events such as infection rates as well as patient identification.

"Falls are another patient-safety factor hospitals may be required to start measuring," Mr. Branzell says. "That includes close monitoring and having the predictive modeling to follow and reduce serious falls occurring in hospitals."

Monitoring of medication administration through bedside medication verification is another patient safety measure the work group has felt strongly about including in Stage 2 meaningful use. "There should be an ability in a hospital's EHR system to report what percentage of drugs are administered with the right route, right patient and right dose," he says.

3. Introduction of evidence-based order sets. Evidence-based order sets has emerged in the healthcare arena as a means to reduce medical errors and care variation. Such orders are typically created through collaboration among physicians, nurses and other health practitioners who use evidence and medical literature to establish the best treatment protocols for various illnesses and conditions. Mary Anne Leach, CIO and vice president of The Children's Hospital in Aurora, Colo., says hospitals may find the introduction of evidence-based order sets as part of Stage 2 meaningful use requirements.

"Evidence-based order sets are essentially best-practice treatment, as defined by evidence," Ms. Leach says. "What does the evidence tell us is the best set of medications or procedures related to a specific kind of disease? In some cases though, such as with complex pediatric patients, there is a challenge with those kinds of approaches because many children have some very complex and sometimes multiple problems. There isn't always a straightforward protocol."

4. Introduction of structured and discrete physician documentation. Ms. Leach says although she doesn't suspect Stage 2 requirements will require a 100 percent inclusion of structured and discrete physician electronic documentation, the topic may very well be introduced. Currently, there is still a significant amount of dictating and transcribing of physician-reported data occurring in hospitals, which, while efficient for the physician, does not give the overall organization or the physician the discrete data elements required to support quality reporting, coding or clinical analytics.

"This is likely to start out as a menu set rather than a required reporting requirement," Ms. Leach says.

5. Introduction of patient-contributed, structured data into EHRs. Many hospitals are moving toward incorporating a patient portal with their EHRs to help patients more quickly and directly connect with their healthcare providers. However, as many systems function today, most patient portals do not allow a very wide array of patient feedback regarding their own personal health information. Ms. Leach says hospitals could possibly see the introduction of patient-contributed data as a possible menu item in Stage 2.

"Many organizations offer what they are calling a "patient portal," but oftentimes those systems cannot accept patient-contributed data, such as over-the-counter medications, readings from home glucometers or corrections to their personal information," she says. "It will be important for hospitals and physicians to anticipate eventual integration of provider-'tethered' EHRs with patients' own online personal health records."

Online personal health records allow comprehensive, integrated up-to-date view of data to be available and also allow patients, families and consumers to participate and be accountable for their own health, she says.

6. Move toward true "meaningful use." The stages of meaningful use takes providers from initially simply collecting and reporting various measures in Stage 1 to eventually using that collected information to make meaningful decisions about the delivery of healthcare to patient populations in Stage 3. Although Stage 3 won't be enacted until 2015, hospitals can generally expect Stage 2 to begin the move toward connecting the dots between reported data and healthcare decision-making.

"Another progressive requirement that we're going to start seeing in Stage 2 is making that connection between the use of health IT and improved outcomes, reduced costs and improved population health," Ms. Leach says. "Stage 2 and 3 requirements for quality and population management will progressively require this evidence to be electrically reported as a direct by-product of EHR use. This will help move us forward toward true 'meaningful use.'"

Mr. Jarvis agrees that it is this very idea that will separate providers who are able to meaningfully use EHRs and those who simply have a knack for collecting information and adopting health IT.

"There will eventually be a requirement for 100 percent electronic sharing of data, and I think that is going to clearly delineate those who are able to meet Stage 1 and those who can effectively use health IT to change patterns of care in Stage 3," he says. "It will be much more outcomes-oriented rather than process-oriented."

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