Meaningful Use Stage 2 Requirements Debate Begins

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HITECH's Meaningful Use Stage 2 requirements started their year-plus journey through federal advisory committees, regulation writers, public comment, and countless revisions after a draft set of recommendations were floated for discussion at this month's HIT Policy Committee meeting.

Outlined by Paul Tang, M.D., vice chair of the committee and chair of its Meaningful Use Workgroup, the measures generally seek to increase thresholds established in Stage 1 as they climb to a Stage 3 apex. In a preface to his presentation, Tang, who is VP and CMIO at Palo Alto Medical Foundation, emphasized that the committee would have two more opportunities to review the measures. He, and National Coordinator for HIT David Blumenthal, M.D, also wanted it known that, as much as possible, findings from Stage 1 would be analyzed and referenced in the formulation of Stage 2.

Despite Blumenthal's assurance, some committee members were concerned about the increases. "Are the percentages arbitrary?" asked Intermountain Healthcare CIO Marc Probst. "We don't have any history, and we haven't gathered a lot of detail about what's been brought in (from Stage 1) and the success rates, so I don't know if going from 30% to 60% is a high mountain or an average mountain."

Tang had proposed that, in the area of CPOE, 60% of medication, lab, and radiology orders entered by licensed professionals (without specifying transmission mode) be done electronically, as opposed to 30% of just medication orders in Stage 1. In Stage 2, he called for 60% of orders (outpatient and hospital discharge) to be transmitted thorough ePrescribing, if that fit the patient's preference. Hospital discharge was not included in Stage 1, Tang said, because that functionality was not available in the marketplace. "We're hoping that, with two years experience, vendors can put this functionality in their systems in the inpatient sector."

But Probst said he was concerned about the aspirational nature of such a measure. "There are a lot of challenges with ePrescribing -- just certifying an application takes months and months. I don't know where vendors are with this, but it seems that if it doesn't exist today, it's a pretty high bar to put out there, and then have faith they will get there in time for hospitals to actually implement that functionality."

Judy Faulkner, CEO, Epic Systems Corporation, said some of the wording used in the regulations needed to be tightened up.

"I think we need to be specific everywhere we say 'in general' or 'appropriate' evidence-based interactions. Anything that is vague at the end of this won't be vague, and if the vendors are to do this on time -- and there's very little time -- all that vagueness needs to be cleared up very quickly. 'Appropriate' demographics needs to be defined throughout everything if we're going to make the dates."

Blumenthal said ONC was "acutely aware" of the tight timeline, but couldn't make the dates so early "that we don't take into account the experience of Stage 1. The question is how late can we make it so that we can learn from Stage 1, how early can we make it so we can provide a warning to the industry about where we are going? I don't think there's a right answer to that."

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Larry Wolf, senior consulting architect, Kindred Healthcare, thought the right answer was to push the whole Stage 2 schedule out. "I'd like to point out that the proposed timeline at the end of this, in fact, puts us in the same bind we were in with Stage 1. The NPRM goes out at the end of 2011, presumably, we'll get the final rule in the summer, so it will only be three or four months until the clock starts on qualifying. We should think about moving out the start of Stage 2 so we signal that Stage 1 continues longer, and then we can give the industry time to implement the things we are proposing in Stage 2 with feedback from Stage 1, and not start Stage 2 until 2014."

Later in the meeting, after discussing a number of other measures, Probst voiced his support of Wolf's proposal. "I actually hope we get back to Larry's comment of 2014 … it does have an impact on the reality of people being able to put all these pieces into place."

Reacting to Blumenthal's comment that Stage 2 thresholds "may not have to be justified scientifically" because they constituted a stepping stone from Stages 1 to 3, Probst continued to urge caution.

"They must be realistic based on what people can actually achieve in Stage 2. Even if they are a stepping stone, if they are an unrealistic stepping stone, everybody's in the river," he said.

Despite having Stage 2 measures in hand, Blumenthal threw two wild cards in the mix. Echoing a sentiment he expressed in an earlier meeting, Blumenthal repeated the idea of creating new paths to MU qualification.

"It is still possible to mix atomic objectives with disease -- or problem-related objectives. One could even imagine a total reconfiguration of the framework that would give people or institutions a chance to take an alternate path altogether with a set of objectives around disease management," he said.

In a second curveball, this one actually thrown by the President's Council of Advisors on Science and Technology -- a group of presidentially appointed experts from universities, industry and other organizations -- its latest report will now have to be heavily considered by the Policy Committee in its formulation of MU Stages 2 and 3. The report "would very much impact what we consider and recommend … would have very important implications … and we will have to take that into account," Blumenthal said.

Specifically around health information exchange (HIE), he said the report, "which is strongly supported by the President and the White House," shows their commitment to it. As such, he advised the Policy Committee to "think, on this issue, more aggressively than we have on some others … this is one area where the administration will feel strongly about pushing us."