Ready or not, Meaningful Use (MU) Stage 2 is around the corner. The flip of the calendar page from 2013 to 2014 will mark the move from Stage 1 to Stage 2 for those on the leading edge of MU. Some changes are fairly simple, and represent an upping of the denominator on Stage 1 measures. While measures such as increasing the percentage of medication orders placed via CPOE from 30 percent in Stage 1 to 60 percent in Stage 2 are almost a piece of cake, others, particularly patient portals, are far more challenging. To learn more about those challenges and how pioneering organizations are addressing them, Clinical Innovation + Technology spoke with a trio of providers atop the HIMSS EMR 7-stage adoption model.
Patient portals perplex
Seventy-four bed Citizens Memorial Healthcare in Bolivar, Mo., a HIMSS EMR Stage 7 provider, implemented its EHR in 2003, and will mark three years at MU Stage 1. Detail-oriented and data-driven may be the best way to describe the hospital’s approach. Unlike some hospitals that assume they “probably” meet MU measures, Citizens completes a gap analysis on every measure to determine its exact performance, explains CIO Denni McColm. New functionalities, such as patient discharge processes, are assigned to a champion who determines how the measure will be met and handles documenting the implementation for future audits.
One challenge that has bubbled to the top is patient portals.
Early gap analysis of Stage 2, coupled with recent experience with patient portals, suggest the patient portal requirement will be a hefty challenge. Stage 2 requires 50 percent of patients to sign up for the portal and 5 percent to use it. Citizens has been working on a patient portal for nearly three years, but a mere 2.5 percent of its patients use the portal.
The hospital has written scripts to request patient email addresses, and plans to send staff into waiting rooms to encourage patients to sign up for the portal.
Parkview Adventist Medical Center, a 55-bed HIMSS EMR Stage 6 hospital in Brunswick, Maine, also espouses an all-hands-on-deck model. The health system is tapping its marketing team to help develop strategies to encourage patients to self-enroll in the portal, and has connected with the care management department to integrate portal enrollment in the discharge process.
Likewise, the requirement has 2013 HIMSS Davies Award Winner Hawaii Pacific Health scratching its collective head. The state’s largest healthcare provider, and HIMSS EMR Stage 6 organization, operates four hospitals, 49 outpatient clinics and services and is affiliated with more than 1,300 physicians. “The single biggest challenge of Meaningful Use Stage 2 will be the requirement to have 5 percent of unique patients view, download and transmit records,” says CIO Steve Robertson. Eligible providers may struggle with the requirement; however, Robertson projects that their challenges may pale in comparison to those of hospitals. That’s because Hawaii Pacific has been focusing on patient portal adoption and dissemination in its ambulatory clinics and physicians, rather than in its hospitals.
The relatively weak emphasis on the emergency department and inpatient side may have the system playing catch-up. “We have to drill back and examine how we are going to meet this measure,” admits Robertson. One major plus, he says, is the organization’s strong partnership with its EHR vendor, which has rolled out an inpatient portal. The health system plans to deploy the tablet-based inpatient portal by fall.
The goal is to engage inpatients to view information such as blood pressure and heart rate during the hospital stay and have that behavior stick after discharge, with patients logging into the system to view information for Hawaii Pacific to meet the measure.
The health system is developing its plan, and will apply the same project management methodology as other deployments, says Melinda Ashton, MD, VP of patient safety and quality service. There are two possible paths, she explains. “The hospital is a confusing place. We may highlight for inpatients information they may want to check on, such as urine test results or medication lists.” After discharge, the patient could return to the portal to build understanding of the intervention.
At the same time, the organization has set its sights on quality measures such as reducing readmissions and understanding end-of-life issues. It may tap the inpatient portal as part of its strategy to address these measures, notes Ashton, who emphasizes that the project remains in the planning phase.
The devil is in the details
While the patient portal challenges loom large for many providers, Stage 2 also brings other new trials. The alphabet soup of standard nomenclature and code standards plays an increasing role in Stage 2.
Early gap analysis of Stage 2 measures suggests challenges in implementing more standard nomenclature for quality reporting, says McColm. “We only applied SNOMED where we had to in Stage 1. We need to apply SNOMED much more in Stage 2, which will be great in the long run, but a challenge in the short run,” she notes. Stage 2 specifies reporting via a common dataset for all summary of care methods, which means providers need to use SNOMED for reporting vital signs, encounters diagnoses and procedures.
Citizens has tested its public health registry interfaces and has started submitting data in nonstandard formats. The plan, says McColm, is to go live with the exact interfaces and meet the measure in the fall or next spring. The timeline may be tough as vendors appear to be re-writing some interfaces to new standards, and these may not be released until summer, she says.
Other providers also anticipate challenges related to common standards.
Hawaii Pacific has not focused on LOINC standards, primarily because two major laboratories handle 95 percent of lab services in the state. Thus, these providers, rather than health systems like Hawaii Pacific, have developed the interfaces for reporting to public health agencies. That means Hawaii Pacific depends on these external organizations to meet the requirement for uniform formatting and secure submission of lab test results using LOINC and needs to verify that their processes are compliant.
Parkview Adventist also has identified electronic submission of quality measures in 2014 as an early challenge. The system’s quality metrics are on target, but the workflows for standardized electronic capture and submission need to be ironed out, says McQuaid.
Software & more
Parkview has taken its gap analysis process to the next step and purchased dashboard software to provide real-time reports. “Instead of running reports and responding to gaps on a 30-day basis, we can spot issues on the fly,” says McQuaid. Prior to installing the software, staff noticed problem list documentation dropped from 90 percent to 78 percent in one month. “We had to dig in to determine the problem and re-educate physicians. We hope we won’t ever go that long again [before identifying trouble spots].” The software should provide an immediate warning in such cases.
Most providers agree that successfully meeting Stage 2 requires robust partnerships. “If you don’t have a vendor that is completely on its game and moving quickly, you are going to lose out,” opines Robertson.
Other key external players include regional extension centers (RECs) and health information exchanges (HIEs). One MU challenge is getting various vendors’ EHRs to talk to each other; an HIE can provide the framework and expertise to handle this challenge. And RECs can assist independent physicians. Hawaii Pacific has approximately 120 independent physicians using its EMR; the REC provides resources and knowledge to help them report and certify for MU, says Robertson.
On the internal side, a physician champion is essential, says McQuaid. “Engaging providers plays a huge part in this process, and peer-to-peer communication is the best way to communicate in the physician world.” Parkview’s clinical application manager leads monthly physician advisory board meetings to review best practices and challenges. The group is comprised of six physicians from various specialties and owned and non-owned practices. This configuration thus casts a wide net as far as representing diverse physician needs.
A final critical player is the compliance group, says Robertson. As health systems receive MU funds, they also face potential audits. “Get those internal audit systems in place and verify that the reporting and measurement systems that qualified the organization for those funds are rock solid.”
McColm of Citizens offers final advice on where to focus in Stage 2. “It is not going be easy,” she says. “Don’t get bogged down in standard nomenclature. Focus on the larger needs—and emphasize solid reporting and project management.” It’s not quite a piece of cake, but it is a tolerable prescription.