Meaningful Use 2: A work in progress for physicians

From January through August of this year, just 3,152 eligible professionals (EPs) and 143 hospitals attested to Meaningful Use stage 2. Some critics of the EHR incentive program have said the slow rate of attestation shows that the program should be revamped or dropped. But physicians interviewed by Medical Economics say that they’re soldiering on to meet the stage 2 requirements, despite difficult challenges in some areas.

The government has attributed the slow progress of stage 2 partly to the tardiness of many EHR vendors in meeting the 2014 certification criteria of the Office of the National Coordinator for Health IT (ONC). In response to this challenge, the Centers for Medicare and Medicaid Services (CMS) has decided to allow physicians who have not received or fully implemented 2014-certified EHRs to postpone stage 2 attestation until 2015 without facing a Medicare payment penalty. This year, they can use 2011-certified EHRs or a combination of 2011 and 2014 models to satisfy stage 1 or stage 2 requirements.

But even doctors who have upgraded their software and who have considerable EHR experience are finding stage 2 an arduous slog. For one thing, they and their staffs have to motivate patients to view their electronic records and communicate with their providers online. Moreover, the infrastructure for exchanging health information with other providers, as required, is not fully in place yet.

The financial incentives for showing Meaningful Use are front-loaded in stage 1 and diminish quickly in stages 2 and 3. So at this point, the primary motivation for physicians to continue with the program is their desire to avoid the back-end penalties for not attesting.

Some doctors have decided it’s not worthwhile to go on. Michelle Holmes, a Seattle-based principal with ECG Management Consultants, says that several of her clients have chosen to budget for the Medicare penalties and the loss of the remaining incentives rather than continue. One of the reasons why they’re giving up: “The technology hasn’t caught up with the criteria,” she says.

But other physicians are trying their best to comply with the MU stage 2 criteria. Some hope to attest this year. Here’s what they’re doing, and what you can do to make attestation easier.

Patient engagement
Few of the stage 2 requirements present serious challenges, but doctors must attest to all of them to achieve Meaningful Use. Among the most difficult areas are the transition-of-care and patient engagement requirements.

To meet the patient engagement criteria, practices typically use patient portals that interface or are integrated with their EHRs.

According to the regulations, EPs must:

• provide at least 50% of patients seen within the MU reporting period with updated health records in four business days after the information becomes available to the EP,

• ensure that 5% of patients seen within the reporting period “view, download or transmit to a third party their health information,”

• provide 50% or more of their patients with a clinical summary within one business day after their office visit,

• ensure that 5% of patients seen during the reporting period communicate with them online,

• supply preventive and/or chronic care reminders to 10% of the patients who made two or more visits to the doctor in the prior 24 months, and

• provide patient-specific educational resources identified by the EHR to 10% of the patients seen during the reporting period.

Edward Gold, MD, an internist in a large primary care group based in Emerson, N.J., says that, while he is able to meet most of the stage 2 criteria, he is having trouble getting enough patients to communicate with him on his patient portal. Only 3% of his patients have done so to date, and he needs 5%.

Kenneth Kubitschek, MD, who practices in an internal medicine group in Asheville, North Carolina, says engaging patients electronically requires constant effort, including asking patients to “please send us a message.”

“We don’t necessarily need to, but we want them to do it, because we want to meet our 5%,” he says.

Jennifer Brull, MD, a family physician in Plainville, Kansas, says that she and her colleagues, who have had a patient portal for nearly five years, have enrolled 60% of their patients on it. Earlier this year, just 39% of patients were using the site, but the practice has made a point of contacting non-participants and signing them up. Brull expects to have no problem meeting the patient engagement requirements.

Portal benefits
Consultants say that practices can increase the percentage of patients using their portals if they stress the value that patients can get from a portal. Among the benefits for patients are the ability to receive lab results, request prescription refills and appointments, see statements and pay bills, obtain education materials, communicate with providers, and view and correct health records.

Practices should approach the portal as a potential winner for themselves and their patients rather than as just another box to check off for Meaningful Use, experts say. For example, notes Rosemarie Nelson, a Syracuse, New York-based consultant with the Medical Group Management Association (MGMA), using a portal for patient communications can greatly reduce pressure on a practice’s phones and free up front-desk staff for other duties. Improving patient
engagement can also enhance patient satisfaction, she adds.

Practices that view the portal as a tool for patient engagement should have no difficulty getting 5% of their patients to use the portal for viewing records and communicating with providers, says Holmes. But Nelson points out that practices still must take certain steps to ensure that a large enough portion of their patients sign up to meet the MU stage 2 criteria.

To begin with, physicians should recognize that patients won’t find the portal on their own, even if it’s linked to their practice site. Boris Rachev, senior principal and global health economist in CSC’s global healthcare group, agrees that many patients are unaware of portal technology and what it’s used for.

Another mistake that some practices make, Nelson says, is asking for patients’ e-mail addresses when they register with the practice. Patients often decline because they think it will lead to them getting junk mail, even though the practice just wants to notify them when they have new messages on the portal.

It’s more effective to have doctors or nurses urge patients to use the portal and explain why the practice wants their e-mail address, she says. A new study in the Annals of Family Medicine confirms this insight, although the study finds that involving the entire staff in the portal promotion effort gets the best results.

Reminders and education
Physicians can choose whether to use patient portals to meet two other MU stage 2 criteria. The first is the requirement that practices send preventive and chronic care reminders to 10% of the patients they see, and the other requires them to provide 10% of patients who visit them with educational materials. Their EHR has to generate the reminders and identify the patient-specific
educational content, but how practices transfer these items to patients is up to them.

To send reminders, Holmes notes, a practice may be able to use its EHR to create and address letters to patients, but staff members still have to insert letters in envelopes and meter and mail them. While the same activities could be done more easily and cheaply online, many practices haven’t activated that part of their portal, she says.

Brull’s practice uses a combination of methods to alert patients that they’re due for preventive or chronic care. She prefers to use the portal because it doesn’t cost anything. But the practice phones or mails reminders to patients who aren’t portal
users.

Kagan says that the accountable care organization (ACO) to which his practice belongs identifies his patients’ care gaps, using claims data and EHR reports. When he’s ready to start his reporting period for stage 2, he says, his practice will probably mail reminders to patients.

One further point about portals: they’re not all created equal. Particularly if your portal is not integrated with your EHR, using the portal to send care reminders to patients may require some manual data entry, Nelson observes.

But the physicians interviewed by Medical Economics say that it was fairly simple to transfer EHR updates or lab results to their portals. “Everything we do on the portal is completely automated,” notes Gold.

Transitions of care
To exchange care summaries at transitions of care, physicians may be able to use a regional health information exchange, but those are still not widespread. The other major approach is to use Direct messaging, which is similar to but more secure than regular e-mail.

According to DirectTrust, a trade association that accredits the entities that exchange Direct messages, about half of the nation’s physicians have Direct addresses. In many cases, these addresses have been provided to the doctors by the healthcare systems that employ them or the hospitals with which they’re affiliated. But a minority of physicians use Direct today, making it difficult for some doctors to reach the 10% threshold for MU stage 2, says Holmes.

Gold says that only two or three practices in his area are using Direct, although he thinks that will be enough for him to meet the stage 2 requirement. Kagan has started using Direct messaging to send clinical summaries to consultants when he refers patients to them. All of the local specialists have gotten Direct addresses from the hospital, but he doesn’t know whether they’re opening the electronic messages, so he continues to fax the same materials to them.

Brull has received three Direct addresses-only one of which she signed up for-from the facilities where she’s on staff. She’s afraid that she’ll miss messages that were sent to the wrong address, but that’s not an issue now.

“Nobody’s using Direct anyway, so it doesn’t matter too much at this point. But it’s frustrating, because it could be very good. It hasn’t lived up to its potential yet.”

Kubitschek has a different problem with Direct. He knows that doctors in a hospital-owned group are receiving his Direct messages, because the count in his EHR keeps rising, he says. But they can’t open the messages because they’re on a 2011-certified EHR that doesn’t have Direct capabilities. So this group and others with 2011-certified products have asked his practice to stop sending them Direct messages.

Technology and culture
It’s apparent from these reports that the infrastructure for health information exchange at even the most basic level is still largely missing in many areas of the country. Where electronic data exchange does work, it can have wonderful results.

Nelson cites a hospital in Syracuse that Direct-messages discharge summaries to its doctors before recently-discharged patients show up in their offices. But that won’t help the many other physicians who can’t exchange enough care summaries to show Meaningful Use.

Similarly, many doctors will find it hard to meet the MU patient engagement requirements. But here the problem is not technological, but cultural and administrative, says Rachev. While granting that some practices-particularly smaller ones-lack the in-house IT resources they need to make complex systems work smoothly, he also stresses the need for practices to redesign their workflow to take advantage of portals and other new technologies.

But that’s easier said than done. Nelson notes that a physician in a small practice may not have the time to figure out all of the new EHR features and how to use them to show Meaningful Use.

“He or she is trying to see patients to keep revenue coming in and meet payroll and keep the lights on,” she says. “But you need somebody to think about this stuff.”