The Road to Stage 2 Meaningful Use: Q&A With CMS' Office of E-Health Standards & Services Director Elizabeth Holland

At the end of August, CMS released the final rule for stage 2 of the Medicare and Medicaid Electronic Health Record Incentive Programs. According to HHS Secretary Kathleen Sebelius, the changes intend to lead the healthcare industry to more coordination of patient care, reduced medical errors and greater patient engagement. This is reflected in the final requirements that hospitals and healthcare providers must meet.

Holland ElizabethMany healthcare groups and associations were given a chance to comment on a notice of proposed rule making before stage 2 was finalized. While not every comment or suggestion can be incorporated into the final rule, many are taken into serious consideration. Here, Elizabeth Holland, director of the Health Information Technology Initiatives Group for the Office of E-Health Standards & Services under CMS, discusses the process CMS takes to review comments for the final rule, why patient engagement is a hot issue for stage 2 and how she hopes to move forward with meaningful use.

Question: How did CMS approach comments that hospitals, healthcare organizations and healthcare professionals submitted for the stage 2 proposed rule?

Elizabeth Holland:
[CMS takes] the comments really seriously. There was a lot of discussion before we came out with the NPRM for stage 2, and once we got the comments we had even more discussion. There is a lot of balance and negotiation that goes into those discussions. We try not to make everyone mad, but we also know we cannot please everyone.

Q: What was surprising to you about the comments and how they affected the final stage 2 rule?

EH: I did not think we would end up with a 90-day reporting period in 2014. However, the final rule has that because we tried to be as receptive as we [could] to the comments. That's the whole purpose of putting out an NPRM. That was probably the most surprising to me. Additionally, based on the comments we received, we added an exception on payment adjustments for specialty providers. We included that exception entirely as a result of the NPRM. It was finalized in the final rule because enough people proposed it to warrant the addition.

Overall, I like to hear from people who are complaining [about the proposed rule] — the people who want things changed for the final rule. [However,] I also like to hear from people who appreciate elements of the proposed rule. If [CMS] only heard comments on elements that individuals do not like, then we may assume no one likes it, which could lead to the element being cut or changed for the final rule. It is important to know where people agree just as much as where they disagree.

Q: Did you receive comments that expressed discontent with elements of the proposed rule that CMS found hard to address and/or change?

EH: People were surprised when they saw the NPRM. They thought we would be moving stage one menu objectives to the core. We did that, but we also proposed new core objectives — the requirement for electronic messaging with patients on relevant health information and the requirement that hospitals use their electronic medial record to automatically track medications. We felt that [the] core objectives [we proposed] would have a really positive impact on patient care and safety. [However,] those were the two objectives we got a lot a push back on.

Q: It was clear in the proposed and final rule for stage 2 that CMS is pushing for more health information exchange and patient engagement. Could you speak to why those two issues were a focus for meaningful use in this stage?

EH: From my perspective, stage 1 focused on the capture of information in an EHR and stage 2 is much more focused on sharing information — sharing among providers. That is really important because, through that, we can make great strides in changing patients' outcomes. This is why we added the core objectives that encourage the exchange of health information.

For the patient engagement core objective, [which requires hospitals and providers to provide patients with online access to health information and secure messaging between a patient and a provider], we lowered the threshold from 10 to 5 percent. I know that a lot of providers are not happy with that. They did not even want that element in the final rule because they believe it is outside the scope of their control. However, while providers did not think the core objective was important, some consumer advocates think it is very important. We included it because it is something that CMS believes is important. Since it is something for 2014, it gives [providers] something to work toward.

I tend to make the analogy with the banking industry. Individuals were nervous about putting financial records online. No one wanted to look at their banking account information online because it would not be safe. Now, everyone takes for granted that they do their banking online. As more and more people get access to their medical information through their health plan, they will want to get all of their health information electronically. They will begin to demand it. Therefore, I think the 5 percent is manageable.

Q: Now that the final rule is released, what is CMS focusing on to guide providers and hospitals to meet stage 2 in 2014?

I am trying not to lose sight of stage 1. I know the industry is interested in stage 2 moving forward since that rule was just released. But, everyone still starts in stage 1. The focus for CMS is continuing to get to hospitals and providers to stage 1, and then to stage 2. To do that, we are trying to focus our message. We had done education messages for stage 1. Now our responsibility is to tweak those and rework them to try to reach another segment — to reach the providers and hospitals that may have lagged in preparing to meet stage 1.

More Articles on Stage 2 of the EHR Incentive Program:

CMS Releases Final Rule for Stage 2 of the EHR Incentive Program
6 Highlights From CMS' Final Stage 2 Meaningful Use Rule
ONC Releases Stage 2 EHR Certification Rule

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