Biggest obstacles to stage 2 EHR bonuses revealed

About 251,000 physicians and other eligible professionals already have received more than $2.6 billion in payments for the first stage of the Centers for Medicare & Medicaid Services’ electronic health records incentive program. Collecting for stage 2 will rely on two things that, by and large, physicians have so far skipped: getting patients to look at their paperless records and exchanging data with others.

Data made available by CMS at an October virtual briefing hosted by the Healthcare Information and Management Systems Society show that objectives related to those two tasks were the most commonly deferred in stage 1. In that stage, physicians had to prove, or attest, that they could meet at least five of 10 designated menu objectives. They could defer the rest to stage 2, when the tasks would become mandatory and, in some cases, carry higher thresholds for compliance.

The most commonly deferred menu objective, at 84%, involved providing a summary of care to patients at transitions to other physicians or hospitals. That was followed by, at 80%, using the EHR to send reminders to specific groups of patients about preventive care. Sixty-eight percent of doctors deferred on syndromic surveillance — sending information to public health agencies. And 66% deferred on being able to give patients electronic access to their records. The least-deferred items involved tasks that did not require outside transfers of information: checking drug formularies (15% deferral rate) and generating patient lists (25%).

“It is a little concerning to us that the least popular menu objectives demonstrate one of the biggest hurdles with all of the electronic initiatives, and that is interoperability,” Elizabeth Shinberg Holland, director of the Health IT Initiatives Group in the Office of E-Health Standards and Services at CMS, said during the briefing.

Technology analysts said the numbers reflect physicians gravitating toward meaningful use items “that are an easier work flow change for them,” said Dawn Bonder, director of O-HITEC, the regional extension center serving Oregon.

Deferring items related to connecting with others makes meeting stage 2 more difficult. Doctors will have to meet most of the 10 menu objectives from stage 1, and those objectives will get stricter. “Those are the ones that are most aggressive in stage 2,” said Jason Fortin, senior adviser with Impact Advisors, a health IT consulting firm in Naperville, Ill.

To meet stage 2 requirements by 2014, practices over the next year will need to focus on getting vendors to perform necessary upgrades, improving patient engagement, and getting other organizations to adopt systems capable of receiving and sending data to and from their EHR systems, consultants said.

During the next few months physicians should review vendor contracts to see what provisions they have in place to meet stage 2, said Rob Tennant, senior policy adviser with MGMA-ACMPE, the entity formed by the merger of the Medical Group Management Assn. and the American College of Medical Practice Executives. At a minimum, the contract should address what vendors will do, when they will do it and what penalty they will pay for not delivering the promised results in the given time frame.

One major project that practices should be discussing with vendors is the implementation of a patient portal. Many vendors will rely on third parties for this add-on. Therefore practices need to ensure they have a clear understanding of their vendors’ plans to get these projects done, Fortin said.

Patients slow to connect

As many practices found during their attestation of stage 1, just because patient portals are built, it doesn’t mean patients will use them. Seventy percent of physicians who achieved stage 1 requested an exclusion to the requirement that practices needed to provide, to 50% of patients who requested them, an electronic copy of their records within three days, according to CMS data. They qualified for exemptions because no patients asked for the records. (In some objectives, physicians can apply for an exemption if they can establish it is not applicable to their practice. For example, a surgery practice can get an exemption from keeping vaccine lists.)

However, stage 2 will require at least 5% of patients to download their records — with few exceptions.

Tennant said patient engagement can involve everyone in the practice. When physicians hand patients educational materials, the handout could have the URL for the patient portal printed on it. Or nurses could give patients a briefing on the portal while taking their vitals.

Practices also can “make it fun,” said Carol Steltenkamp, MD, principal investigator for the Kentucky Regional Extension Center at the University of Kentucky. “Think of what other things you can put out there that will be of help to your patients.” She suggested, for example, posting health tips of the week on the patient portal and any other regularly scheduled postings that will keep patients coming back.

A major goal of meaningful use is the ability for disparate systems to “talk” to one another and exchange information. The problem many practices are encountering is the organizations with whom they need to exchange information, such as labs and state health departments, don’t have an incentive such as meaningful use to push them to comply. But practices still have leverage with those organizations, said Mary Griskewicz, senior director of ambulatory health information systems for HIMSS. Despite the fact that labs do not have to abide by meaningful use, they rely on contracts with practices and insurers, she said. Therefore, market pressure is going to force labs to adopt the necessary technology to stay competitive. “Who are you going to send the referrals to now?” Griskewicz asked.

Tennant said practices should keep track of the referral patterns for six months leading up to the reporting period to see whether the thresholds will be met by orders sent during that time frame. As the practice gets closer to attestation, it can make sure the needed percentage of orders are sent to labs that are capable of both receiving the data and sending back results that ensure the thresholds are met.