Electronic Health Reporter

Robert Hitchcock, M.D., FACEP, is T-System’s vice president and CMIO, leading the company efforts for solving regulatory issues and identifying trends. He is a nationally recognized meaningful use expert and active member of the HIMSS Physician Committee and other HIMSS subcommittees advocating usability and responding to regulatory issues.

Dr. Hitchcock also is a practicing ED physician and an Emergency Department Practice Management Association (EDPMA) board member. In 2001, he earned recognition for excellence in teaching from internal medicine residents, and in the early 2000s, he trained basic and advanced life-support EMS providers. His goal is to advance system adoption and usability to improve the quality and efficiency of ED delivery.

Here, he provides perspective about developments of meaningful use Stage 2 and Stage, how meaningful use is impacting vendors and practices, how they feel — or should feel — about it, and what Stage 3 means for everyone in the industry.

How do you see the market responding to meaningful use? How are physicians moving forward, or beyond, it?

The market’s overall response to meaningful use is generally clear: they’re pushing back, particularly on Stage 2. Vendors aren’t ready, so there are not as many certified products out there. Physicians and hospitals are both calling for delays. By some estimates, as many as 50 to 70 percent of physicians who were successful in Stage 1 will not be successful in Stage 2.

To give some perspective, the Eisenhower interstate system was authorized and construction began in 1956. Phase 1 was completed in 1992. It took 35 years to build roads in this country, a decidedly low-tech undertaking. With meaningful use, we’re attempting to take a relatively un-automated industry and automate it beyond what was ever considered possible in six years. Everyone is pushing back because it’s simply too much, too fast.

What are some of its ultimate strengths; what about glaring weaknesses?

The greatest strength of meaningful use is the end goal of a data-centric, connected healthcare environment, which should ultimately lead to better patient care and outcomes. At the same time, this is also its weakness: How do vendors and physicians get to this connected healthcare environment given the available resources, associated costs and time constraints?

While the end goal is valuable, the results of meaningful use thus far are unclear. We have yet to identify how meaningful use has improved healthcare or reduced costs, but we do know that it has increased provider costs, negatively impacted provider productivity and reduced the number of patients they’re able to see on a regular basis.

How is Stage 2 evolving into Stage 3? Is it even on physicians’ radar at this point?

For most physicians, Stage 3 is not on the radar, because Stage 2 is keeping them preoccupied. Most physicians have expectations that there will be further delays, and Stage 3 is, at least from what we know now, over two years away.

Could you give some more details about the process of finalizing meaningful use rules? Where are we currently with Stage 3?

On Feb. 4, 2014, the Health IT Policy Committee received an update from its subcommittee with preliminary recommendations for Stage 3. The Committee discussed and considered these recommendations and plans to formally submit an approved draft to Office of the National Coordinator for Health IT (ONC) in March 2014.

2017 Edition Certification and Stage 3 meaningful use notice of proposed rule-makings (NPRMs) will be issued in fall 2014 for public comment, with final rules expected in summer 2015. Stage 3 will begin in 2017 for eligible providers and hospitals who’ve performed at least two years of Stage 2.

Discuss some of the positive and negative effects that the proposed ideas for Stage 3 would have on physicians, patients and vendors.

Physicians: From a positive perspective, physicians will have access to a vast amount of information that will provide them with the opportunity for better clinical decision support and recommendations for care. On the negative side, the proposed measures for Stage 3 will make managing a patient visit overwhelming: There will be about 19 external touch points for physicians for any given visit, including things like transition of care management, public reporting for vaccines and syndromic surveillance and patient portals – this is a potentially a huge administrative issue.

Patients: Patients will have more access to their medical records in near real time with the ability to submit corrections to their medical records for consideration and engage in email interaction with their physician. This is both a positive and negative. I like the idea of empowering patients with more information, but many patients will find it difficult to understand the relevance of that information. For example, a patient may see an abnormal lab result and panic even though the abnormal lab is insignificant.

Vendors: With the increased focus on information flow and standards that support interoperability, enterprise vendors will have a tremendous opportunity to enhance their offerings through acquisitions or partnerships with specialty solutions without having to build the breadth of Stage 3 functionality on their own. Properly implemented, the proposed meaningful use interoperability standards will also provide an opportunity for specialty vendors to thrive and produce solutions focused on subsets of healthcare, such as registry reporting and patient communication systems. While vendors may be able to capitalize on these opportunities, the substantial expansion of meaningful use requirements may also pose significant distractions. With relatively short periods of time between stages, vendors will be spending so much time developing for meaningful use that it will inevitably inhibit innovation and result in solutions that are not optimized for end users or patient care.

From a cost perspective, what are the implications of the proposed Stage 3 ideas?

Meaningful Use is an unfunded federal mandate. Physicians will bear the full cost of buying and maintaining systems and, quite frankly, these costs could wipe out smaller practices. Practices should to look to group purchasing power or even consolidating with other practices to survive financially. We have already seen federal clarification of Stark laws to allow hospitals to furnish physician practices with EHRs, helping to reduce the cost burden to those practices.

Many of the ideas proposed for Stage 3 center around post-care follow up and referrals. What does this mean for the physician?

The proposed Stage 3 ideas should help physicians provide better patient care by giving them information to more effectively manage transitions of care and follow up care. However, there is a substantial administrative burden on the physician practice, which will have to invest in additional staff to keep up with these new requirements and increasing costs.

The leap from Stage 2 to Stage 3 is a large one. Can you offer some practical considerations for both physicians and vendors to be successful in this transition?

We are indeed looking at a very large leap from Stage 2 to Stage 3, but here is some advice to physicians and vendors:

Physicians

• Focus on what’s really necessary to provide value to you, your organization and patients. Look for solutions that are certified for meaningful use, but do these things in an efficient and effective manner.
• Determine what will be the most difficult measures to meet and develop strategies for these as early as possible.
• Start evaluating Stage 3 as early in the process as you can. Become involved in the rulemaking process and provide comment on the proposed rules
• Consider consolidation – whether that be structural mergers or group purchasing power. The costs for Stage 3 are likely to be very large and any opportunity to share these costs should be evaluated.
• Work with your vendors early to understand how they plan to meet the requirements. Be careful about vendors who will try to develop solutions for “everything.”
• Don’t get bogged down with a one-vendor strategy. Look into specialty systems for specialty aspects of meaningful use. Some vendors may try to do it all, but this will make it difficult for you to meet increasing demands and still be productive.

Vendors

• Get involved as early as possible. Make sure lawmakers understand limitations vendors have on developing solutions, meeting timeframes or complying with immature or underdeveloped standards.
• Make sure your voice is heard during the proposed rule-makings.
• Develop specialized, modular systems that can coexist with other solutions. Look for ways to grow, but not through a single-platform development.
• Pay particular attention to the impact your new solutions will have on workflow and productivity.
• To survive, focus on bringing value – not to the bottom line, but to care providers and the patients they serve.