Stage 2 Meaningful Use - Patient Engagement and HIE

Some of the most important changes in the rules for Stage 2 Meaningful Use and the 2014 Edition Standards & Certification Criteria (S&CC) are around patient engagement and health information exchange. While these requirements were backed off some from the proposed rule, there is still a strong emphasis on these aspects of the program. I think these are two of the most critical aspects of meaningful use and could help us eventually achieve the goals of improving the patient experience and lowering healthcare costs.

One new Stage 2 Meaningful Use Core Objective that all providers must meet is to use secure electronic messaging to communicate with patients on relevant health information. Another new Stage 2 Core Objective that all providers must meet is to provide patients the ability to view online, download and transmit their health information within four business days of the information being available. The specifics require that 50% of all unique patients are given access to information, and that five percent (down from 10% in the proposed rule) are able to view, download or transmit to a third party relevant health information. These measures require patients to take action in order for a provider to achieve meaningful use and receive an EHR incentive payment.

In the proposed rule CMS would have required 10% of patients to send a secure message, and 10% to actually view, download or transmit relevant information contained in the longitudinal record. But the final rule reduced these thresholds to 5%. The continued implementation of patient portals and PHRs incorporated into EHR functionality could make this an achievable goal if care providers implement and then offer them to their patients.

The American Hospital Association had reacted strongly to the proposed rule, stating that the requirements "raise the bar too high and are not feasible for the majority of hospitals to achieve." And in a statement indicated they were still not entirely pleased with the final rule. "While we appreciate that CMS has allowed for a shorter meaningful use reporting period for 2014," they said, "we are disappointed that this rule sets an unrealistic date by which hospitals must achieve the initial meaningful use requirements to avoid penalties. In addition, CMS complicated the reporting of clinical quality measures and added to the meaningful use objectives, creating significant new burdens."

The Health Information Management and Systems Society (HIMSS) noted in a statement that the final rule both adopts and concurs with a number of HIMSS recommendations made in comments on the proposed rule. Specifically they were pleased that the rule appears to streamline the administrative process of certifying EHR products. However, there did not appear to be any emphasis on utilizing mobile technology. I spoke with Pam Matthews, RN, MBA, the Senior Director of Regional Affairs at HIMSS who said, "We had made comments in several places where mobile could be considered in terms of being a benefit for patient engagement and data exchange, yet in the final rule they remained silent on mobile. HIMSS supports the development of guidelines to achieve transitions of care through patient centered mobile interfaces. We encourage consideration of including mobile health technology in future stages of meaningful use."

Stage 2 criteria also place an emphasis on health information exchange between providers to improve care coordination for patients. One of the core objectives for both eligible providers (EPs) and eligible hospitals and Critical Access Hospitals (CAHs) requires providers who transition or refer a patient to another setting of care or provider of care to provide a summary of care record for more than 50% of those transitions of care and referrals.

There are also new requirements for the electronic exchange of summary of care documents:

• For more than 10% of transitions and referrals, EPs, eligible hospitals, and CAHs that transition or refer their patient to another setting of care or provider of care must provide a summary of care record electronically.
• The EP, eligible hospital, or CAH that transitions or refers their patient to another setting of care or provider of care must either 

1. conduct one or more successful electronic exchanges of a summary of care record with a recipient using technology that was designed by a different EHR developer than the sender's, or
2. conduct one or more successful tests with the CMS-designated test EHR during the EHR reporting period.

There is also a movement in the right direction for interoperability under the S&CC rule with the cementing of data content utilizing Consolidated CDA, CCD/C32 and CCR standards which is imperative to a platform all stakeholders can now design for. Also, including Direct Project as a requirement for transport is a smart move. You can use it with XDM, or with XDR (over the Exchange SOAP Stack)

The exchange requirements are a bit weaker than in the proposed rule and elicited some robust discussion from a post by Wes Rishel on the subject. The discussion thread is very interesting and Wes adds some clarity to his comments. The whole issue is from statements made by Farzad Mostashari, MD, ScM the National Coordinator for Health Information Technology. I highly recommend you listen to them HERE. He gives an artistic and eloquent rendering of a segment of the final rule, which also contains a warning:

"We continue to believe that making vendor-to-vendor standards-based exchange attainable for all meaningful EHR users is of paramount importance. In that regard, and as we look toward meaningful use Stage 3, we will monitor the ease with which EPs, eligible hospitals, and CAHs engage in electronic exchange, especially across different vendors EHRs," Dr. Mostashari read, "If we do not see sufficient progress or that continued impediments exist such that our policy goals for standards-based exchange are not being met, we will revisit these more specific measurement limitations and consider other policies to strengthen the interoperability requirements." 

He the said, "I want there to be no question about the seriousness of our intent on this issue. The bottom line is it's what's right for the patient and it's what we have to do as a country to get to better healthcare and lower costs."