Seems like this week must be interoperability week on EMR and HIPAA after my post yesterday about HIE transport in meaningful use stage 2 and my post today on drivers of healthcare data interoperability.

I was looking through some past notes from a meeting at AHIMA that I had with Health Language Inc. It was a fascinating conversation with Brian F. McDonald, Executive VP and CFO and Marc A. Horowitz, Senior VP. I remember that these guys eat, drink and sleep medical terminology. One of the really interesting observations I took from talking with them was:

Meaningful use and ACOs are the drivers of interoperability in healthcare.

Months after first hearing this idea, it rings even more true. In meaningful use stage 2, ONC and CMS have made it very clear that they plan to use meaningful use as a motivating force behind the sharing of healthcare data. This includes sharing of healthcare data doctor to doctor and also doctor to patient. I expect meaningful use stage 3 will find these concepts at their core as well.

As we try and evaluate what an ACO would look like, some form of healthcare data exchange has got to be part of the solution. I don’t believe anyone will find a way to really improve health the way an ACO will need to improve care without an exchange of data between EHR systems. Considering the pay for performance days are short at hand, this will be an encouraging factor for EHR systems to start exchanging data.

I’ve often said the big problem with interoperability of data in healthcare is the financial aspects and the governance (ie. when to share data) aspects. I see ACOs and meaningful use pushing healthcare providers to figure out both problems.

If not these drivers, what else will get healthcare to start sharing data?

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.

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.

As the industry anxiously anticipates the Proposed Rule for Stage 2 meaningful use—likely expected during HIMSS this week—many providers are still struggling to understand meaningful use Stage 1. So while we wait for the impending news story to break, let me address another question that was recently posed by a reader. 

Q: Can a physician attest and earn a Medicare EHR incentive for his second reporting year if he will be retiring in the middle of the year? 

A: To my surprise, this situation is not explicitly addressed in the regulations. One would think that a physician who works full time for part of the year would be just as eligible as one who works part time for the full year. The retiring physician, however, faces two obstacles: 1) The regulations require that an EP report for an entire calendar year after receiving a first meaningful use payment. 2) The EP must have an active enrollment record in PECOS (Medicare) to be eligible to attest—if he retires and withdraws from Medicare, he would no longer have active status. These factors suggest that a retiring physician is not eligible for an incentive (unless, of course, he times his retirement for the end of the year!)

In lieu of a definitive answer to the question, however, I offer the following food for thought: 1) Couldn’t the retiring physician simply wait until December 31 to attest and then report on the full calendar year? 2) What if he simply postpones surrendering his PECOS enrollment until the end of the year? (According to a local Medicare contractor, nothing prohibits him from doing that even though he would no longer be submitting claims.) If there are countervailing reasons not to do this that readers are aware of—and there may well be—please share your insights by commenting below. 

(Note: This is not an issue for retiring physicians in their first incentive year since they attest immediately upon the conclusion of their 90-day reporting period.)

It’s Sunday and the excitement to see old friends and hear interesting things at HIMSS 2012 is just around the corner. The #HIMSS12 hashtag is off the charts with people flying into Las Vegas and others talking about what they’re doing, seeing, hearing and expecting from HIMSS Las Vegas.

Most people on Twitter are quite excited for HIMSS (as am I), but a few have said that people won’t be missing much. I thought about it for a minute and realized that the thing I love most about HIMSS is meeting really smart people. With 37,000 people likely to attend HIMSS 2012, there are plenty of smart people to meet and connect with at HIMSS.

Justin Barnes, VP at Greenway Medical, is one of the smart people I like to talk with at HIMSS. Turns out that tonight he was sharing some of that wisdom, information and perspective on Twitter tonight. So, this EMR and Health IT Twitter roundup is the Justin Barnes edition.

Strong #MeaningfulUse progress ~ $3.1+ billion paid to 43,000+ care providers. #CMS #EHR #EMR @ONC_HealthIT @CMSGov #HealthIT #HIMSS12

— Justin Barnes (@HITAdvisor) February 20, 2012

I wish he would have broken this out into ambulatory doctors versus hospitals. $3 billion of ~$36 billion projected. I guess they’re expecting a windfall next year?

That is the billion-dollar question @theEHRGuy. There are good reasons to stay the #ICD10 course & good reasons to delay…. #HIMSS12

— Justin Barnes (@HITAdvisor) February 20, 2012

Is a billion dollars at stake in the ICD-10 delay decision? Regardless of the exact amount, it shows you the magnitude of the ICD-10 delay announcement.

Tuesday looks to be the day now when we should see the #MeaningfulUse Stage 2 proposed rule. #CMS did try to get it out on Friday. #HIMSS12

— Justin Barnes (@HITAdvisor) February 20, 2012

Someone on Twitter asked if it could be delayed past Tuesday. Neil Versel from Meaningful Healthcare IT News answered well: “Never underestimated bureaucracy.”

Good #MeaningfulUse update ~ $71M+ paid to 3,379 Nurses & Physicians Assistants under #Medicaid #EHR Program. #CMS #HIMSS12

— Justin Barnes (@HITAdvisor) February 20, 2012

That’s a little surprising to me that so many Nurses and PA’s got paid so much since they only qualify under Medicaid. I’m glad to hear it.

$412,866,000 in #EHR #MeaningfulUse incentives paid to 22,937 #Medicare Eligible Professionals. #HIMSS12 #EHRAssociation @CMSGov #EMR

— Justin Barnes (@HITAdvisor) February 20, 2012

When the number is totally written out, that’s a lot of 000′s and that’s only millions.

Looking forward to seeing many old friends and making many new friends at HIMSS this week.