Forests and Trees

April 10, 2013
What's most fascinating about the final rule for Stage 2 of meaningful use is not what was surprising, but what wasn't surprising. Then again, the leaders of the pioneering patient care organizations in this country already understand the direction of the new healthcare; for them, meaningful use is just one (very big) element in the overall operational landscape.

Many in the healthcare industry might have been surprised at the timing of the release of the final rule for Stage 2 of meaningful use, under the American Recovery and Reinvestment Act/Health Information Technology for Economic and Clinical Health (ARRA-HITECH) Act—a Thursday afternoon in late August—when most of those in the know had believed that the final rule would “drop” sometime in early September.

But apart from the precise timing of the release, few industry observers are expressing huge surprise at the contents of the final rule; indeed, pretty much everyone agrees that what officials at the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) made official late last week pretty much reflects what had been anticipated, with a few exceptions.

As Senior Contributing Editor David Raths noted in his excellent analysis the next day, CMS maintained the requirement that patients view, download, and transmit their own health information, though it lowered the threshold for that requirement from 10 percent to five percent. CMS also modified the specific parameters around health information exchange, yet maintained the principle, as it required that provider organizations conduct one or more successful data exchange tests with a “CMS-designated test EHR” during the EHR reporting period. CMS also lowered the threshold slightly from 65 percent to 50 percent, when it came to the proportion of transitions of care that must involve sending a summary of care record. Meanwhile, the agency lowered the threshold on performing medication reconciliation during transitions of care to 50 percent from an originally proposed 65 percent, based on the decision of most providers to defer that measure in attesting to Stage 1 of MU. And CMS finalized the threshold for computerized physician order entry (CPOE) use in Stage 2 to 60 percent, while requiring that
more than 30 percent of lab orders and more than 30 percent of radiology orders be recorded using CPOE.

Now, let’s be frank here: some of the requirements, such as the requirement that more than 10 percent of medication orders be tracked using an electronic medication administration record (eMAR), had been telegraphed to providers from the very beginning of the meaningful use process, and mentioned as an eventual requirement virtually at the outset.

Meanwhile, the adjustments to mandates that I mentioned above, here, reflect a degree of flexibility and pragmatism on the part of ONC and CMS officials that should rightly be acknowledged.

More broadly, the reality is that the requirements coming out of Stage 2 of meaningful use reflect the broadest policy goals not only of the federal government, as expressed through the Medicare and Medicaid programs; they also reflect the general direction in which private health insurers are most clearly headed. What payers, both public and private, want, is a far, far more efficient healthcare delivery system, with increased efficiency gains made partly through automation; and of course, the electronic health record and all its sister clinical information systems are inevitably candidates for payer push when it comes to scoping out how best to compel the delivery system forward on a nationwide level.

Just to take the example of the EHR and the eMAR, try to tell the average engaged healthcare consumer that there’s a good reason for maintaining her patient records purely on paper, at a time in the second decade of the 21st century, when she can do all of her banking online, can take photos of personal checks she’s received and deposit them photographically to her account, can book plane tickets to Timbuktu (that’s in Mali, by the way), and can book a taxi via online services like Uber. Try to tell that consumer that it’s impossible for her to look at her basic patient record online, or worse yet, that she was given the wrong medication because there is no automation-facilitated process for ensuring that she be given the right medication, and hope that she’ll expect your explanation.

The pioneering patient care organizations, large and small, in healthcare, already know this, and are looking at the bigger picture—the demand on the part of purchasers, payers, and increasingly, consumers, that healthcare delivery be of higher quality and with fewer medical errors, and be more cost-effective, efficient, transparent, accountable, and patient- and community-friendly—and are already skating towards that big conceptual puck. Consider what Ferdinand Velasco, M.D., the chief health information officer at the Arlington, Texas-based Texas Health Resources, told me earlier this week: “I do think that the MU Stage 2 final rule and standards and certification rule continue to be ambitious,” but I think, reasonable and attainable,” Dr. Velasco told me. What’s more,  he added, “I’ve always maintained that HITECH was not a bailout in the way that the rest of the stimulus might have been. It’s meant to move the ball forward.”

Not surprisingly, Dr. Velasco and his colleagues at THR are not only ahead of the game when it comes to meaningful use; they are also leading the pack when it comes to forging ahead on creating population health, clinical analytics, and other innovations. And most importantly, THR’s senior leaders understand where the healthcare system is going most broadly.

So as challenging as meeting the requirements for Stage 2 of meaningful use will be (and it would be foolhardy to underestimate the degree of challenge involved), industry leaders recognize that the entirety of meaningful use itself reflects the overall direction in which purchasers and payers are pushing the healthcare delivery system as a whole. So even as healthcare IT leaders hunker down to move forward with their colleagues on Stage 2 of MU, it’s important not to lose sight of the forest for the trees here. Those organizations whose leaders are moving them forward most strategically towards the healthcare of the future will inevitably find their MU exertions harmonizing with their broadest initiatives to move towards the new healthcare. In other words, the tree-level view should match the forest-level view—or else it’s time to get an organizational reality check and readjust.

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