Today, we continue our series of blog posts on the Department of Health and Human Services’ (HHS) proposed Meaningful Use Stage 2 measures. Currently there are two different Notices of Proposed Rule Making (NPRMs) included in the open comment period:

Department of Health and Human Service (HHS) and Centers for Medicare and Medicaid Services (CMS)

  1. Meaningful Use Regulations — Define the Meaningful Use attestation requirements for eligible providers (EPs) beginning in 2014.
  2. Certification Regulations — Define EHR vendor product certification requirements for Meaningful Use Stage 2 certification.

Recently, HealthFusion submitted our commentary on the Meaningful Use Stage 2 proposed measures to the Centers for Medicare and Medicaid Services (CMS) for the open comment period. We hope that HHS and CMS will heed our comments and recommendations, but rest assured no matter their final ruling on Meaningful Use Stage 2 measures, HealthFusion will be ready and Meaningful Use attestation will be as easy as always with MediTouch and our Meaningful Use Report Card®.

Our submitted commentary below is with regard to the NPRM on Meaningful Use regulations. We will discuss the certification regulations in a future post of the series.

HealthFusion® MediTouch EHR® Comments on Meaningful Use Stage 2 Proposed Rules

We appreciate the Department of Health and Human Services’ effort with regard to the Stage 2 Notice of Proposed Rule Making (NPRM). As a cloud-based Electronic Health Record (EHR) vendor we applaud the efforts of your department to further the adoption and integration of EHRs into the everyday practice of medicine.

The following are our comments with regard to the Stage 2 NPRM:

Core Measure #10
  1. More than 50 percent of all unique patients seen by the EP during the EHR reporting period are provided timely (within 4 business days after the information is available to the EP) online access to their health information subject to the EP’s discretion to withhold certain information.
  2. More than 10 percent of all unique patients seen by the EP during the EHR reporting period (or their authorized representatives) view, download or transmit to a third party their health information.

The first part of this measure seems logical; it is solely within the power of the healthcare provider and their EHR vendor to actualize that part of the measure through a patient portal.

The second part of the measure is the part where we find a glaring overreach by the government. It requires that the patient use the online data by viewing, downloading, or transmitting it. In other words, if your patients don’t go online and use this feature of your patient portal, then you cannot meet Meaningful Use. This is the first situation that we know of where a healthcare payer is tying physician incentives (monetary rewards and penalties) to the social behavior of their patients. If a provider’s patients simply do not have the need to log in and review their health records, then the provider is penalized. If the provider spends time with each patient, such that less than 10% of their patients feel the need to view their record online, the provider is penalized.

Example: If you are a pediatrician and you provide your patients with excellent care:

  1. You explain the details of each encounter to the patient’s parents
  2. You provide an up-to-date paper version of the child’s immunization record
  3. You communicate abnormal test results to the patient in a timely fashion
  4. Most of your care is routine

If the above is true, then what type of demand is there for the parent to view the record online 10% of the time?

The EP provided great care and less than 10% of their patients (or their parents) have the urge or the need to look at the health record online. This scenario should not prevent the EP from meeting Meaningful Use of an EHR.

Recommendation: We propose no threshold for patient viewing of their health data online; instead, we propose that the government require that the EP make a strong effort to promote online access of patient health information through the use of leaflets and signage at their office.

Core Measure #11

Provide clinical summaries for patients for each office visit.

50 percent of all visits within 24 hours (pending information, such as lab results, should be available to patients within 4 days of becoming available to EPs) [up from “more than 50 percent of all visits within 3 business days”].

We agree that clinical summaries should be available to patients in a timely fashion. We also agree that timely notation of a patient encounter is the best way to memorialize a patient visit. We believe that the movement of the timing of 3 business days to 24 hours is too drastic a change and we propose a more gradual progression towards the one-day goal.

Recommendation: We propose that the 3 business days standard (Stage 1) is decreased to 2 business days in Stage 2.

Core Measure #14

Summary of care record transmitted between providers at transitions in care.
Required for 65% of care transitions [up from 50 percent]; must be electronic for 10% (Stage 1 was one test).

We agree with the changes in this measure but we caution the authors of the NPRM that there is no current infrastructure for reliable data exchange between EPs of distinct EHR technology. We encourage HHS and ONC to accelerate the finalization of the data exchange standards ASAP, and provide testing sites for vendors, such that there is ample time for the nation’s healthcare constituents to build the infrastructure required for EPs to meet the 10% threshold.

Recommendation: We propose finalization of the data exchange standards and government sponsored testing sites at least 18 months prior to the start of Stage 2. We also propose that at least one standard of data exchange that allows for easy and inexpensive point-to-point connectivity between providers, as we are not confident that the proposed national network of HIEs will be ready by 2014 to support this measure.

Core Measure #15

Submit electronic immunization data to immunization registries or Immunization Information Systems.
Submit actual immunization data to at least one organization in accordance with applicable law and practice [up from performing just a test; test or “dummy” data not permissible].

We agree with the changes in this measure. We encourage HHS to work with the state registries, such that the “flavor” of the HL7 standard they each use becomes more uniform or they coalesce into a central, national registry, since state borders are not related to the use case of storing a retrieving immunization data. Vendors must work with several dozen registries, and although HL7 is the standard, each state may have a different implementation guide. Patients are mobile; they move from state to state, therefore uniformity with regard to the implementation of this standard is good for vendors and also good for patients.

Recommendation: Mandate that the dozens of state immunization registries use a single HL7 companion guide and communication protocol, or that those registries coalesce into a single, central, national registry.

Core Measure #16

Conduct or review a security risk analysis, and implement security updates and correct identified security deficiencies. Attest that encryption/security functionalities for data at rest (which includes data located in data centers and also data in mobile devices) have been addressed.

We agree that the protection of PHI data is important with regard to patient privacy. We believe that data stored on mobile devices, personal computers and local servers, and NOT located in remote secure data centers, should be encrypted at rest. Data at rest located in secure data centers does not pose the same patient privacy risk as data located outside of secure data centers. In fact, most HIPAA breaches are a result of a lost or stolen computer with PHI data not in the encrypted state, and not data breaches at secure hosted data centers. We believe the additional burden of encrypting data that is hosted in a secure data center poses an additional, costly burden on cloud-based EHRs. In addition, the encrypting and decrypting of data at rest each time a query is made by a user could cause slowing in the response rate of cloud-based applications, placing an unfair burden on users of web-based EHRs. The government should be encouraging the use of web-based technology and the movement away from “local” data hosting at physician offices. It is the data that is hosted locally (at the physician practice) that is at the highest risk of breach, corruption or loss.

Recommendation: We agree that data stored on hardware NOT located in secure data centers should be encrypted at rest. Data housed in secure data centers should not be required to be encrypted at rest.

Core Measure #17

Secure Messaging: A secure message was sent using the electronic messaging function of Certified EHR Technology by more than 10 percent of unique patients seen by the EP during the EHR reporting period.”

We agree that providing technology to patients that facilitates secure physician messaging is appropriate; in fact, our patient portal already offers this capability. We believe that the 10% threshold, and in fact any threshold, poses an unfair intrusion by the government in the very special physician-patient relationship. There are benefits to secure messaging, but there is no proof that a federal mandate that applies to all physicians and practice types would advance the care of all patients. This type of extrapolation is unfair and, in addition, the government should not link financial incentives to the manner in which providers and patients communicate.

Recommendation: Instead, we propose that the government require that the EP make a strong effort to promote secure messaging as an additional mode of communication through the use of leaflets and signage at their office.

Menu Measure #1

More than 40 percent of all scans and tests whose result is an image ordered by the EP during the EHR reporting period are accessible through Certified EHR Technology

The lab industry is a highly consolidated industry with many national and regional labs; therefore the connectivity burden is not overwhelming for providers. The practice of radiology is still a local service. There are thousands of radiology practices across the nation, and connecting to the many radiology practices that a single provider may need to utilize will place an unfair burden on the EP and EHR vendors. We propose that the government lower this threshold until such time that the data exchange infrastructure related to this measure has time to mature. We encourage the same data exchange methods that will be used in the exchange of summary care records.

Recommendation: Lower the threshold to 10% and use the same data exchange standards proposed for the exchange of summary care records.

Menu Measures #3, #4 and #5

Connecting to cancer registries and other registries

Until such time that the nation’s infrastructure supports a centralized repository and method of communication with cancer and other public health registries, the burden on the provider to make more point-to-point connections with their local registries is too great. We also do not believe that there is any evidence that these local registries can support the demand for connectivity and data exchange that these new measures would impose on them.

Recommendation: Remove these menu measures as they pose too great a burden on providers and the nation’s public health agencies. Replace these menu measures with new ones that don’t require more point-to-point connectivity.

Clinical Quality Measures

Report 12 Quality Measures

We applaud the notion of creating a set of clinical quality measures that align with existing quality programs, such as the Physician Quality Reporting System (PQRS). We also believe that it will be very helpful for providers to have the choice to report under “Option 2”, as defined in the proposed rule as “Submit and satisfactorily report clinical quality measures under the Physician Quality Reporting System’s EHR Reporting Option.” Defined as, “Medicare EPs who submit and satisfactorily report Physician Quality Reporting System clinical quality measures under the Physician Quality Reporting System’s EHR reporting option using Certified EHR Technology would satisfy their clinical quality measures reporting requirement under the Medicare EHR Incentive Program.” Since the PQRS program will now be aligned with the Medicare EHR Incentive Program, we encourage HHS to finalize the 2014 PQRS measures for the EHR reporting option ASAP.

We also believe that there are too many proposed measures included in the NPRM, and that supporting that amount of measures will add to the cost of EHR technology and will “water down” the data collected by the program. We propose that the government adopt the 11 core measures and one menu measure model (option 1b). In addition, we propose that the total number of measures should not exceed 50.

Recommendation: The alignment of the EHR reporting program with the EHR incentive program is a great advancement in the simplification of reporting quality measures for providers, and should become law when the final rule is published. We propose that the PQRS program publish the requirements for the EHR reporting option in 2014 ASAP. We also recommend the number of proposed measures be reduced considerably and we prefer the 11 core measures with 1 menu measure model option.