Stage 3 Meaningful Use Proposals: Too Ambitious?

The Health IT Policy Committee (HITPC), which advises the government on its electronic health record incentive program, released its preliminary recommendations for Meaningful Use stage 3 requirements that will go into effect in 2016. After the recommendations are published in the Federal Register, possibly this month, there will be a 45-day public comment period.

The bulk of the stage 3 objectives in the 44-page document reiterate stage 2 goals, with higher thresholds for showing Meaningful Use. This should please hospitals and eligible professionals, Chris Giancola, a principal consultant at CSC, told InformationWeek Healthcare. "They're going to be grateful that these are mostly increase-of-adoption sort of changes, where you ratchet up the percentages you have to comply with to meet the objectives."

Michelle Holmes, a senior manager with ECG Management Consultants in Seattle, agreed. "The stage 3 proposal is a lot about coordination between different provider organizations, whether practices or hospitals," she said. "It's about more extensive use of decision support at the point of care, and more patient engagement. There isn't anything new in those three areas; they've just taken them further."

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There are new objectives, however, and some of them are quite ambitious. For example, one new item would require providers to give 10% of patients the ability to submit patient-generated health information to improve performance on high-priority health conditions; to increase patient engagement in care; or both. HITPC suggests this could be accomplished through "semi-structured questionnaires."

Physicians are likely to push back against this requirement because they don't have control over patient behavior, Holmes said. She said the recommendation will probably make it into the stage 3 final rule, but with exclusions for physicians who would have trouble meeting this objective. For example, she noted, a geriatrician might have difficulty finding 10% of elderly patients willing to fill out a Web-based questionnaire.

Another proposal would expand the information that eligible clinicians and hospitals would have to provide at transitions of care to include a care synopsis, setting-specific goals, and instructions for care during the transition. If EHRs could be programmed to extract this additional data automatically, it would be no big deal, Giancola said.

Even if that's the case, it could lead to a change in workflow, Holmes said. Today, primary care physicians often have a staff member assemble information -- the latest visit note and lab results, for example -- to send along with a referral to a specialist, she said. "The idea here is that everything needed to support that referral is being generated [in the EHR] as the provider orders the referral. When he does that, the material is packaged in electronic format, and the patient could walk out the door with it. It puts the burden on the provider to complete the relevant information sooner and not be as reliant on someone else to do it."

Beyond transitions of care, Giancola was surprised that HITPC proposed requiring that certified EHRs be able to query other systems and respond to queries. "'Push' has been hard enough to achieve -- just getting people to send information from one place to another," he noted. "But the ability to ask another system for information or to answer a request for information -- that's gigantic."

On the other hand, Giancola pointed out, HITPC is still not talking about having providers use their EHRs to exchange data with disparate EHRs in separate business entities. This was originally proposed as a Meaningful Use stage 2 criterion, but that was later watered down, he noted.

Holmes was also a little surprised that the policy committee hasn't yet required this kind of data interchange. "That part seems a little bit soft to me," she said. She suggested that there might be some changes in the final stage 3 proposal.

What HITPC does propose, however, is that hospitals be required to electronically inform a care team member, such as a primary-care physician or a care coordinator, when a patient visits the ER or is admitted to or discharged from the hospital. Although the mechanism isn't specified -- it could be via pager, text, secure email, or a clinical summary sent to another EHR -- the mere fact of requiring such an event to trigger a message to the patient's care team would be a major change, Giancola said.

Another big step is to require that providers implement 15 clinical decision support interventions, compared with just five in stage 2. Certified EHRs would also need more clinical decision support capabilities under the stage 3 proposal.

In Holmes' view, providers could use patient registries capable of generating alerts to meet this requirement. Although EHRs have not had good registry capabilities up to now, they're improving, she said. Third-party registries connected to EHRs might enable providers to satisfy this objective in the meantime, she said.

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