An EHR vendor recently got some bad news about a doctor who chose not to implement EHR. In the response, the doctor gave them this message:

“Meaningful use is the destructive component that all of medicine should be fighting as it clearly prevents the EMR from achieving it’s potential.”

My gut reaction to this comment is: He’s right.

I’ve often talked about how meaningful use and certified EHR have hijacked an entire EHR development cycle. That means that all 300+ EHR companies had the same development list for that time period instead of focusing on creating a broad variety of innovative solutions for doctors and patients.

I imagine some would argue that EHR vendors had a lot of years to create innovations and they fell short of doctors’ expectations and so meaningful use will get them to implement features they should have implemented long ago. In some cases, this is accurate. I actually love meaningful use stage 2′s focus on interoperability. A feature that should have been developed long ago and should have been. Although, on the whole I think we are missing out on a lot of potential benefits that EMR could provide an office because the EMR developers aren’t being allowed to innovate.

I’d also argue that our billing system has had that same effect on EHR. Instead of developing EMR software that will improve patient care, it was built to maximize reimbursement.

Going back to the doctor mentioned above. While I can agree that meaningful use diminishes the value of what an EHR could potentially provide a clinic, that doesn’t mean that the EHR doesn’t still provide value. That’s like saying that a $10 bill isn’t worth as much since with an extra 0 it would be a $100 bill, so I’ll throw out the $10 bill because it’s not providing all the value that it could provide if they’d done something a bit different.

At this point, I always refer back to my list of EMR benefits. There are benefits to EHR adoption beyond government handouts. Although, for some reason we get all crazy when the government starts handing out money and forget about other outside reasons to do something.

An EHR vendor recently asked me for some suggestions of PHR or portal options that they could use with their EHR software. Turns out that this is going to be particularly important given the changes in meaningful use stage 2 that require you to not only share medical information with the patient, but the patients have to actually access that information as well (unless that gets taken out in the MU stage 2 rule making process). Regardless, the question of which PHR and/or patient portal solutions was an interesting question. Here’s my answer to him (with a little bit added):

I only know of a few and you’ve probably heard of the ones I know about. I’m also not sure of the price of the various options really [He wanted to know of an inexpensive option]. Here’s what I know:

I like what NoMoreClipboard has done and that they’ve been doing it a really long time. They have a good understanding of how to work with many different vendors and also sizes of practices or healthcare institutions. Plus, you can be sure they’re going to be on top of all the meaningful use stage 2 requirements you’ll need to meet.

I also know that Medical Web Experts was working hard on a patient portal. I’m not sure how far it’s come since I first talked to them though. It might be one worth checking out. Just be sure that they can meet the meaningful use stage 2 requirements.

Then, of course you have Microsoft HealthVault. Everyone seems to know about them. I’ve heard that they’re a bit of a challenge to integrate with. Hopefully they also don’t have the same fate as Google Health. Although, Microsoft has a much better position in healthcare than Google ever did.

Coincidentally, I also was just emailed about a brand new book just released by O’Reilly Media about HealthVault and how to integrate with it. It’s called Enabling Programmable Self with HealthVault: An Accessible Personal Health Record. I’ve heard it’s a pretty technical book that would be quite useful if you decided to go with Healthvault for your PHR.

What other PHR and/or patient portal options are out there? I’m sure there are more that I’m missing and have probably just forgotten about them.

I’ll be interested to see if meaningful use stage 2 will drive the return of the PHR.

Full Disclosure: NoMoreClipboard is an advertiser on this site.

Lynn Scheps is Vice President, Government Affairs at EHR vendor SRSsoft. In this role, Lynn has been a Voice of Physicians and SRSsoft users in Washington during the formulation of the meaningful use criteria. Lynn is currently working to assist SRSsoft users interested in showing meaningful use and receiving the EHR incentive money. Check out Lynn’s previous Meaningful Use Monday posts.

The end of March will likely bring a host of meaningful use attestations as the first 90-day period in 2012 draws to a close. Before you sit back and wait for your check, make sure that you assemble all the documentation that supports the information you provide to CMS. There will be provider audits, and EPs who cannot back up their attestation could forfeit their incentive payments. Documentation can be in paper or electronic format, and should be retained for 6 years. 

CMS does not specify all the necessary documentation, so the following are some suggestions:

• Your EHR’s Automated Measure Calculation report – showing the numerators and denominators for each of the meaningful use measures that are numerically based
• Clinical quality measures report – clinical quality measures must be reported “exactly as generated as output from the certified EHR technology.”
• Clinical decision support rule – perhaps a dated screen shot to show that a CDS rule was implemented for the reporting period
• Evidence of your data exchange test – whether the test was successful or not
• Documentation of the security risk analysis you conducted – what you did, deficiencies you identified, corrective actions you took
• Your test of the ability to submit immunization data and/or syndromic surveillance data – either proof that you conducted the test or documentation that the registry/public health agency cannot electronically accept the data (if you claim that exclusion)
• The actual Patient List you generated (if you selected this menu measure)

 For more information, see the CMS website.

I’ll admit that I’m far from an expert on all the various HIE transport standards and movement happening in making health information exchange a reality in healthcare. However, meaningful use stage 2 is a big step towards getting doctors to exchange information. So, I’ll leverage some experts comments on HIE in meaningful use stage 2 to hopefully get the conversation started. Then, I’m sure some other HIE standards geeks will join in the comments to help us all further understand what’s happening.

John Moehrke has some of the best information I’ve seen for those interested in HIE and meaningful use stage 2. In one post he described his initial “fantastic” impressions of meaningful use stage 2 in regards to security privacy and HIE transport. Here’s the section on HIE transport:

HIE Transport:They have given us one or two Push style transports, and recognized that they interoperate by way of a proxy service that can convert forward and backward. There is no real surprises here as ONC has spent much time developing the Direct Project. Healthcare Providers and EHR developers should really be focusing beyond Direct, but supporting minimal Direct is a good thing to do. It allows us as an industry to move away from the FAX, and start universally communicating and manipulating Documents. I will note that these more Exchange like HIE models would still be considered compliant under the optional third transport.

I think he’s dead on that the majority of providers are going to get to know Direct really well in order to meet the meaningful use stage 2 requirements. In another more detailed post on the various HIE transport options including 3 options within the Direct Project: Full Service HISP, email integration, and integrated into the EHR.

John Moehrke has 3 great images I’ve embedded below which illustrate the above 3 models:

In the Full Service HISP, the user uploads the health information to a web portal or possibly emails the information to the HISP. This model reminds me of the various physician portals I’ve seen out there. They’ve worked really well for doctors who do a lot of referrals and need to exchange data. Although, logging into a portal isn’t the most seamless way of sharing data.

The email integration option requires you to have some good IT experience to be able to configure your email properly to support the identity and security configuration that will be required on your email system. Considering the number of doctors I know that still use aol.com, yahoo.com and gmail.com accounts, this won’t be a good solution for them. I bet even Google Apps accounts won’t support this, but it would be really cool if they did. Would be a really smart move by Google to have gmail support it if they could. The nice part is that once it’s configured you can sign and encrypt the email in a pretty seamless fashion.

Integrating the direct project specification directly into the EHR is the best option since it provides the user a seamless experience. The challenge will be on the EHR vendors to be able to integrate it into their EHR software, but I expect many will see this as the best way to service their customers. It will be harder on the EHR vendor, but the EHR vendors that do this extra effort will have much happier users.

Hopefully this gives a decent overview of the Direct Project options. John Moehrke has a lot more technical details on the subject if you want to read more about those. I know he’s pretty active on Twitter, so I’ll ping him now to have him take a look at this post so I can add any clarifications if needed as well.

I’m excited to see the Direct Project in widespread use. I think the Direct Project vision has best been described as replacing the fax machine. The move to exchanging documents using direct will be a good step forward. Sure, it’s just the first step, but it’s an important and useful one.

As I look forward to EHR in the year 2012, it was suggested to me at HIMSS that we’re going to see an EHR adoption rush starting in August 2012. If you think about the timeline and all the other EHR happenings, I think this very much will be the case.

I saw a tweet (which I can’t find now) which said something to the effect of meaningful use attestation in January of 2012 was as big as all of 2011. I also have read about the mass of meaningful use attestation that happened at the end of 2011. With only having to attest for 90 days it makes sense why so many people waited until the end of 2011 to attest to meaningful use.

I expect we’re going to see the same rush to meaningful use attesation in 2012 as well. However, you don’t just implement and EHR and then start your meaningful use attestation the week after you implement an EHR. In most cases, you need at least a couple months (more in the hospital case) after implementing an EHR to “get your feet under you” and be ready to concern yourself with the meaningful use requirements.

With this in mind, I expect these next 3 months will be critical for EHR vendors that want to fill their Fall EHR sales pipeline. EHR adoption will slow down a bit during summer when doctors head out on vacations. Then, Fall 2012 will start the rush of EHR adoption in order to meet meaningful use requirements in 2012.

Of course, it’s also likely that many doctors will procrastinate their EHR selection process. They’ll wait until Fall and then rush through EHR selection. I think this would be a real tragedy for EHR since selecting the right EHR is the mot important part of the EHR implementation.

Lynn Scheps is Vice President, Government Affairs at EHR vendor SRSsoft. In this role, Lynn has been a Voice of Physicians and SRSsoft users in Washington during the formulation of the meaningful use criteria. Lynn is currently working to assist SRSsoft users interested in showing meaningful use and receiving the EHR incentive money. Check out Lynn’s previous Meaningful Use Monday posts.

With all the attention that meaningful use Stage 2 has received in the last 2 weeks, it’s easy to forget that most providers are just ramping up for meaningful use stage 1 and are still trying to understand the requirements they must satisfy for the next 2 years. So I’m going to let the dust settle a bit on the Stage 2 proposal and go back to addressing lingering questions about Stage 1.

Last week’s post talked about the increased frequency with which providers are switching EHRs. Some are replacing legacy EHRs that are not ONC-certified in order to qualify for meaningful use incentives, while others are switching from one certified EHR to another to better meet their practice needs. An EMR and HIPAA reader who is changing EHRs in mid (meaningful use) stream submitted the following question:

Q:  “If we attest for 2011, then 3-4 months into 2012 we change to another software vendor, is there a way to attest using both software vendors since we have to combine or run reports to attest for the whole year of 2012?”

A: Yes, you can attest using both EHRs—in fact, you must report from both EHRs. First, enter both certified complete EHRs into the Certified Health IT Product List (CHPL) website to generate a new EHR Certification ID number to use for 2012 attestation. You will need to combine the results, measure by measure including clinical quality measures, from the two sets of reports that you run. For measures that require a count of actions, this is fairly easy—you simply add the numerators and denominators. Where this becomes somewhat challenging is in reporting measures where the denominator is “unique patients.” According to a CMS FAQ regarding a similar situation, (i.e., providers who see patients in multiple locations with different certified EHRs), “…it is the responsibility of the EP….to reconcile information from multiple certified EHR systems in order to ensure that each unique patient is counted only once for each objective.”  No further guidance is provided on how to accomplish that.

For the past year or so I’ve been predicting that one of the top EMR and EHR related topics will be EMR switching. Yes, that’s right. A practice or doctor switching from one EMR to another EMR. At HIMSS it was suggested to me that meaningful use was a big driver in doctors switching EMR software.

I find the idea of meaningful use driving doctors to change EHR software quite interesting. It makes some sense when you consider that some of the EHR software that doctors currently use isn’t a certified EHR and/or will make it difficult for them to show meaningful use. More common is the HUGE number of physicians that have to upgrade their EHR software. This is a bit of a travesty to me. In any release of EHR software there’s always a mix of new features, security fixes and other optimization. Why a doctor wouldn’t want all of these things is hard for me to understand.

I guess part of the problem with staying updated to the latest EHR software has to do with the client server model that many EHR software companies use. Upgraded client server software isn’t always easy or fun. There’s some things you can do to streamline it, but it takes time. When the upgrade doesn’t offer a new feature that a doctor wants to get his hands on, it’s hard to justify the costs associated with the upgrade. I’m talking about time costs to upgrade, not software costs to upgrade. Unfortunately, most doctors don’t think too much about the security implications of not updating their EHR software.

Meaningful use has definitely gotten a lot of doctors to upgrade or replace their EHR software. This seems like something that should have happened naturally, but I believe it’s a good outcome of meaningful use.

Going back to switching EMR software, I’ve heard from a number of EMR vendors that some of their best EMR sales are to those that already have an EMR. I know I’ve done a much better job buying my second cell phone than I did my first. I knew what I really wanted when I bought my second one. The same seems to apply to doctors buying their second EMR.

Don’t get me wrong. I’m not advocating that doctors switch EHR in order to get a better one necessarily. It would be a really terrible thing if the way to get a quality EHR was to implement one first and then switch EHR. However, as time goes on there are going to be a HUGE variety of reasons to switch EHR software. Meaningful use might be driving EMR switching today, but there are going to be other factors driving doctors to change EMR in the future. Not the least of which could be a large number of doctors who focused too much on meaningful use and EHR incentive money and not nearly enough on the way the EHR selected will impact their practice. The other likely cause will be EHR consolidation and EHR software companies going out of business.

The real problem with all this EHR switching will be the lack of standards and flexibility around pulling the data out of the old EHR. I still have in mind some ways to hopefully help with this problem, but it’s a monumental task.

For this week’s Meaningful Use Monday, I decided I’d go through the large list of meaningful use stage 2 commentary that’s been put out over the past week. I’ll do my best to link to some of the most interesting commentary, summaries, etc of meaningful use stage 2 and point out some resources that I’ve found useful.

John Halamka on Meaningful Use Stage 2
First up is the blog post by John Halamka about MU stage 2. I really like his recommendation to read pages 156-163 of the MU rule (PDF here). Sure, the rule is 455 pages, but many of those pages are a recap of things we already know or legalese that is required in a government document. Halamka also created a meaningful use stage 2 powerpoint that people can reuse without attribution. Worth looking at if you’re not familiar with MU stage 2 or if you have to make a presentation on it.

Health Affairs on MU Stage 2
Health Affairs has a nice blog post covering meaningful use stage 2. They offer “3 highlights that seem particularly important:”

1. The bar for meeting use requirements for computerized provider order entry (CPOE), arguably the most difficult but potentially the most important EHR functionality, has been raised: now a majority of the orders that providers write will have to be done electronically.
2. There is a major move to tie quality reporting to Meaningful Use. We knew this was coming, but CMS has laid out a host of quality measures that may become requirements for reporting through the EHR.
3. Health Information Exchange moves from the “can do it” to the “did do it” phase. In Stage 1, providers had to show that they were capable of electronically exchanging clinical data. As expected, in Stage 2, providers have to demonstrate that they have done it.

Health Affairs also talks about the timeline for this rule and the feedback that CMS is likely to get on MU stage 2. I’m sure they’re going to get a lot of feedback and while they suggest that the rule will look quite similar to the proposed rule, I expect CMS will make a couple strong changes to the rule. If nothing else to show that they listened (and I think they really do listen).

Stage 2 Meaningful Use by The Advisory Board Company
The Advisory Board Company has a good blog post listing the 10 key takeaways on stage 2 of meaningful use. Below you’ll find the 10 points, but it’s worth visiting the link to read their descriptions as well.
1. Centers for Medicare & Medicaid Services (CMS) affirms a delay for 2011 attesters.
2. Stage 1 requirements will be updated come 2013.
3. Medicaid definitions are loosened; more providers are eligible.
4. While the total number of objectives does not grow, Stage 2 measure complexity increases significantly.
5. Information exchange will be key, but a health information exchange (HIE) will not be necessary.
6. Patients will need to act for providers to succeed.
7. Sharing of health data will force real-time, high-quality data capture.
8. More quality measures; CMS’ long term goals—electronic reporting and alignment with other reporting programs—remain intact.
9. The Office of the National Coordinator’s (ONC) sister rule proposes a more flexible certification process and greater utilization of standards.
10. Payment adjustments begin in 2015.

AMA MU Stage 2
The American Medical News (done by the AMA) has a blog post up which does a good job doing an overall summary of where meaningful use is at today (post MU stage 2). Meaningful Use experts will be bored, but many doctors will appreciate it.

Justin Barnes on Meaningful Use Stage 2
Justin Barnes provides his view on meaningful use stage 2 in this HealthData Magement article. It seems that Justin (and a few other of his colleagues at other EHR vendors) have made DC their second home as they’ve been intimately involved in everything meaningful use. I found his prediction that the meaningful use stage 2 “thresholds and percentages will remain largely in place come the Final Rule targeted for August, and should not be decreased via the broader public comment phase next underway like we saw with Stage 1.” Plus, he adds that the 10 percent of patients accessing their health information online will be a widely discussed topic. Many don’t feel that a physician’s EHR incentive shouldn’t be tied to patients’ actions. Add this to the electronic exchange of care summaries for more than 10 percent of patients and the healthcare data is slowly starting flow.

Meaningful Use Stage 2 and Release of Information
Steve Emery from HealthPort has a guest post on HIT Consultant that talks about how meaningful use stage 2 affects ROI. This paragraph summarizes the changes really well:

The bottom line for providers is that Stage 2 MU changes with regards to these specific criteria will drive organizations to implement a patient portal or personal health record application; and connect their EHR systems to these systems. Through these efforts it is expected that patient requests to the HIM department for medical records will decrease; as patients will be able to obtain records themselves, online and at any time.

e-Patients and Meaningful Use Stage 2
e-Patient Dave got together with Adrian Gropper MD, to put together a post on meaningful use stage 2 from an e-Patient perspective. This line sums up Adrian Gropper MD’s perspective, “My preliminary conclusion is that Stage 2 is a huge leap toward coordinated, patient-centered care and makes unprecedented efforts toward patient engagement.”

Meaningful Use Stage 2 Standards
Those standards geeks out there will love Keith Boone’s initial review and crosswalks from this rule to the Incentives rule here.

Shahid Shah on Meaningful Use Stage 2
I like Shahid Shah’s (the Healthcare IT Guy) overview and impressions as well. He’s always great at giving a high level view of what’s happening in healthcare IT.

Are there any other meaningful use stage 2 resources out there that you’ve found particularly useful or interesting?

Lynn Scheps is Vice President, Government Affairs at EHR vendor SRSsoft. In this role, Lynn has been a Voice of Physicians and SRSsoft users in Washington during the formulation of the meaningful use criteria. Lynn is currently working to assist SRSsoft users interested in showing meaningful use and receiving the EHR incentive money. Check out Lynn’s previous Meaningful Use Monday posts.

Although I cannot claim to have read through the entire 455-page Proposed Rule on Stage 2 Meaningful Use, the fact that it is shorter than the 864-page rule that defined Stage 1 does not mean that it is simpler—it just requires less explanation since the basic structure of the program has not changed.

Rather than trying to summarize the Rule at this point, I am just going to point out some highlights gleaned from the presentations at HIMSS last week and from my quick skim through the document:

• The meaningful use bar has been raised significantly for Stage 2.
• The earliest that any providers will be subject to Stage 2 requirements is 2014; all EPs operate under Stage 1 requirements for their first 2 years of participation, regardless of when they first enter the program.
• Most measures have higher thresholds, some have increased complexity, and new measures have been added.
• Providers have fewer choices—there are 17 Core Measures that all providers must meet (subject to the same types of exclusions as Stage 1), all Stage 1 Menu Measures except syndromic surveillance become Core Measures, and providers will have to meet 3 of the 5 Stage 2 Menu Measures.
• True interoperability is required—Stage 2 no longer asks providers to test their ability to exchange clinical data, but rather requires them to successfully exchange information on an ongoing basis across organizational and EHR vendor boundaries.
• Providers will be accountable, to some degree, for actions by patients. For example, it will no longer be sufficient to make clinical information available to patients online—in Stage 2, a percentage of patients will have to actually access this information.
• Providers will have the flexibility to purchase just the capabilities that they need to meet meaningful use—e.g., a chiropractor who does not prescribe will not have to have an EHR with ePrescribing capabilities, and a provider who is still at Stage 1 will not have to possess the meaningful use capabilities relevant to Stage 2 (until he gets to Stage 2).
• Providers will report on 12 clinical quality measures, and there will be a broader array of measures from which to choose. One option under consideration would consolidate reporting for meaningful use and PQRS.
• 2015 penalties can be avoided by demonstrating meaningful use in 2013, or for those who enter the program in 2014, by successfully attesting no later than October 3, 2014.

For more information, see the CMS Stage 2 Meaningful Use Fact Sheet.

Yep, that’s the major noise you heard at HIMSS today. The Meaningful Use Stage 2 NPRM sucked the life out of HIMSS today it seems. It was funny seeing many of the major EHR vendors scrambling to get their thoughts on MU stage 2 out. I’m not sure what’s the big rush.

You can also get the meaningful use stage 2 fact sheet on CMS.gov.

I will refrain from any rush to judgment about meaningful use stage 2. It’s not going to be implemented for quite a while, so we have time to digest it properly. I’m sure we’ll cover meaningful use stage 2 a lot more to come in the future.

Until then, I’m ready for my post-HIMSS recovery. Although, both keynotes look pretty interesting tomorrow.