MU2: Mission Impossible

Several factors, including the tardiness of electronic health record (EHR) vendors in upgrading their systems, a 12-month reporting period in 2015, and, above all, the lack of interoperability among EHRs, have impeded the ability of even veteran EHR users to attest to MU2.

Many physicians feel they’re between a rock and a hard place. If they’re participating in the Medicare side of the Meaningful Use program, have attested before, and don’t attest to MU2 this year, they’ll not only lose financial incentives but will be subject to penalties in 2017.

If their vendor did not supply a 2014 edition upgrade of their EHR in time for them to start their MU reporting on January 1, they can apply for a hardship exception, and 55,000 eligible professionals (EPs) have done that. But if they had their 2014 edition EHR in place last year, they must start reporting now in stage 2 or face penalties.

For many physicians, the penalty phase has already begun. CMS has informed 257,000 EPs that their Medicare payments will be cut by 1% in 2015 for failure to meet the Meaningful Use requirements in previous years. Appeals are being accepted through the end of February.

A few months ago, Medical Economicsdocumented the problems that doctors were encountering in meeting MU2’s requirements. The biggest challenges were exchanging care summaries electronically with other providers and getting patients to view, download or transmit (V/D/T) their electronic health information. These roadblocks are continuing.

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“I can’t get my patients to communicate with me online,” says Bernd Wollschlaeger, MD, a solo family physician in North Miami Beach, Fla. “That’s the first challenge. The second is getting my EHR to interface with the state vaccination registry and the public health and other systems. We’re hardly able to communicate with physicians who have different systems. We’re still relying on printed out reports from an EHR that are emailed or faxed to me so I can input them into my system.”

As of December 1, 2014, only 16,455 eligible providers (EPs) and 1,681 eligible hospitals (EHs) had attested to MU2, which launched on January 1, 2014. CMS says it expects a last-minute surge that will raise these numbers significantly by the end of February, when attestations from the fourth-quarter reporting period are due.

But Michelle Holmes, MBA, a Seattle-based principal with ECG Management Consultants, is seeing more and more of her clients “de-prioritize” the Meaningful Use program. “They’re preparing for the inevitability that they may not be successful and even starting, in some cases, to budget for that,” she says.

Holmes expects the dropout rate from Meaningful Use-which was 16% from 2011 to 2012 and 19% from 2012 to 2013-to continue rising. “The dropout rate will increase even more if they stick to the 12-month reporting period,” she says. “That could be the straw that breaks the camel’s back” that may persuade CMS  to restore the 90-day reporting period, she adds.

Meanwhile, physicians must begin reporting now to avoid penalties. Here are some tips to help you get over the rough spots.

NEXT PAGE: Tips to stay ahead on MU2 this year

Don’t fall behind

Assuming the 12-month period stays in effect, you can meet the requirements of MU2 at any time over the course of the year. So if you’re having trouble with a particular objective now, you can catch up later on.

Don’t wait too long, however, or your numerators will not keep up with your denominators, warns Robert C. Tennant, an executive consultant with Beacon Partners in Weymouth, Mass. For example, he says, if an EP has a 50% threshold for a measure-i.e., the EP must meet that requirement for half of the patients he or she sees-and doesn’t record any data for that measure in the first six months, the threshold becomes 100% for the second half of the year.

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To ensure that your numbers are on target, you have to track them and check on them regularly, Tennant notes. “Doctors need to understand each measure and what they’re reporting on and how their EHR tracks it. They need a spreadsheet that tracks each of the measures and where they’re at with the numerator and the denominator. Review those weekly, at least, and stay on top of those, increasing where your initial percentages are low.”

Most certified EHRs have a tracking tool for Meaningful Use, but they don’t necessarily supply data on every measure, he warns. Some EHRs have a very basic tracking system that shows only numerators and denominators. Others enable you to find out where the numbers came from in your EHR.

V/D/T and other challenges

The biggest challenges in MU2 all relate to external communications. These include the exchange of care summaries with other providers at transitions of care, the ability to send data to public health agencies and vaccination registries, and the ability to communicate online with patients.

NEXT PAGE: Problems with Direct messaging

The stage 2 criteria for patient engagement include providing 50% of patients with continually updated health records and clinical summaries after visits, ensuring that 5% of patients seen during the reporting period “view, download or transmit to a third party their health information,” and ensuring that 5% of patients seen during the reporting period communicate online with their providers.

The technology that most doctors use for this patient interaction is a web portal attached to their EHRs. Wollschlaeger reports, however, that his patients prefer to communicate with him by insecure e-mail or texting. Fewer than 5% use his portal, in part because it is very basic and doesn’t go much beyond presenting information such as lab results. It’s not easy to use it for communicating with his patients, which is what they want, he says.

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Wollschlaeger knows he has to educate his patients about the importance of using the portal, but doing so is difficult in light of the system’s deficiencies. “Not every portal is beautiful or patient-friendly,” he points out.

However advanced a portal is, a practice’s physicians and staff must develop a strategy to enroll patients in it, notes Tennant. “It’s going to continue to take a lot of work,” he says. “When a patient walks in the door, they visibly need to see that the portal is available. The staff needs to be educated and patients have to be told the benefits of V/D/T.”

Vernon Groeber, another consultant with Beacon Partners, adds, “You can count a V/D/T during an office visit [toward Meaningful Use]. So if you have a computer in the waiting room, and staff to help the patient, the patient can view their records in the office before they leave.”

Direct messaging

As part of MU2, EPs are required to exchange care summaries electronically with other providers for at least 10% of referrals and other transitions of care. In addition, they must perform at least one exchange with a provider who uses a different EHR system.

This is the steepest hill for most doctors to climb, because the infrastructure to accomplish this goal is either not in place or not widely used. The two main choices are to use a health information exchange (HIE), which may not be available in a particular area, or to use Direct messaging, a protocol for sending messages and attachments securely from one provider to another.

The major problem with direct messaging is that not enough providers are using it to enable many EPs to meet the Meaningful Use criteria. For example, Terry Hashey, DO, an experienced EHR user who is part of a two-doctor family practice in Jacksonville, Fla., says he has met every requirement of MU2 except for the exchange of clinical summaries during referrals.

“That’s a key requirement for stage 2, and there’s nobody in Jacksonville-specialty or primary care-that we’ve been able to find that can receive an electronic referral,” he says. “We’ve reached out to every hospital system and every group we deal with, and none of them can receive a Direct message.”

Wollschlaeger, too, reports that few of his colleagues are accepting Direct. Moreover, because he hasn’t yet received his 2014 edition EHR, he has to go to a website to send or receive a Direct message, instead of doing it within his EHR.

NEXT PAGE: Is Meaningful Use 2 worth it?

The DirectTrust network

The problem isn’t with the Direct infrastructure, says David Kibbe, MD, president of DirectTrust, a nonprofit organization that accredits health information service providers (HISPs) that encrypt and convey Direct messages to their addressees. The DirectTrust network includes 27 fully accredited HISPs and 14 candidates for accreditation. Accredited HISPs can communicate with one another because they all meet stringent security requirements.

“HISP-to-HISP communication is at a very high level of reliability for the major carriers,” Kibbe says. “Most of the traffic is being carried by about 12 to 15 HISPs, and among those the reliability of transport from HISP to HISP is better than 95%.”

However, some EHR vendors don’t make it easy for providers to exchange Direct messages, he says. For example, some suppliers have created a Direct module with an inbox that physicians can use to send and receive Direct messages.

In other EHRs, the Direct functionality is embedded in referral modules that may use one of several modalities to make electronic referrals, including Direct, fax or e-fax. In the latter case, the physician doesn’t know how a message is being transmitted, and must depend on the vendor to document which referrals count toward the Meaningful Use requirement.

Another difficulty some physicians have found is that they have been assigned multiple Direct addresses by the hospitals that they use. When that occurs, it’s hard for them to know where to receive Direct messages.

When will enough providers use Direct to make it a way to meet the MU2 criteria? Kibbe believes that use of the technology will grow steadily over the next few years as people discover that it’s not just for Meaningful Use.

Holmes also predicts greater adoption of Direct in 2015, but mainly as a way of getting EHR incentives. EPs who are less focused on Meaningful Use, she says, are less likely to use it. Tennant believes that Direct will be more successful in
areas where hospitals and health systems are pushing it.

But however you slice it, exchanging care summaries at transitions of care will continue to be difficult for doctors. Hashey, who got a reprieve on stage 2 when CMS introduced its flexibility rule last fall, bluntly says, “As soon as we find a specialist that can take the Direct messaging, [he or she] is going to get all of our business.”

Why stick with Meaningful Use?

Hashey says that he and his partner are committed to achieving Meaningful Use however they can. The EHR incentives, which were front-loaded in the first few years, amount to only about $4,000 this year for his practice, he notes. However, he points out, “As a two-doctor practice, we can’t afford penalties.”

Wollschlaeger also isn’t focusing on the incentives as he pursues stage 2 attestation. He qualifies for a hardship exemption for 2015 because his upgraded EHR won’t be delivered until mid-year, but he intends to attest when he can.

His interest is related to his status as a patient-centered medical home, which garners health plan bonuses and makes it easier to deal with payers. The National Committee for Quality Assurance (NCQA) recognized his medical home under its 2011 standards, but he has to be recertified under the 2014 NCQA standards, some of which mirror the MU2 requirements, he says.

Wollschlaeger, who is active in the Florida Academy of Family Physicians (FAFP) says that in a recent conference call he and other FAFP members attributed the low attestation rate in stage 2 to “the very complex, cumbersome attestation process.

“There’s a difference between what we want to achieve and what we can achieve at this point in time” he says. “I don’t think physicians are resistant, we’re just overwhelmed to do that.”