An e-Patient Perspective on Stage 2 of Meaningful Use (Adrian Gropper)

At last week’s enormous HIMSS (health IT) conference, ONC (the Office of the National Coordinator for health IT) announced the long-awaited rules for Stage 2 of meaningful use. (These are the rules that must be met, for health IT systems to qualify for Federal incentives and, later, avoid penalties. Stage 1 rules were announced last year, SPM member Regina Holliday was on stage, with “the other Regina” – Surgeon General Regina Benjamin.)

Long-time SPM member Adrian Gropper MD, of HealthURL, has already digested the 450 pages and distilled it into the e-patient impact. He posted it to Google Docs, and agreed to let us cross-post it here. (Adrian is @AGropper on Twitter.)

First, his prolog, then his summary.
__________

My preliminary conclusion is that Stage 2 is a huge leap toward coordinated, patient-centered care and makes unprecedented efforts toward patient engagement.

By mandating comprehensive structured summaries be available to patients for download as well as on-line viewing, Stage 2 enables patient-directed health information exchange as an alternative to hidden provider-provider transactions that characterized earlier HIE efforts.

Although not mentioned by name, the implied use of Direct secure messaging for physician-physician and patient-physician communications will hopefully finally cause all EHRs to communicate with all other EHRs (and PHRs) without costly interfaces.

Also, new requirements for accessible imaging should eliminate the hassle of CDs for patients and doctors alike and make referrals and second opinions easier than ever.

All of these privacy, transparency and accessibility enhancements come none-too-soon as ACO payment reforms implicitly drive providers to keep patients in their particular network.

ABSTRACT

The following is a patient-focused abstract of the proposed Meaningful Use Stage 2 regulation. The text is verbatim but I’ve taken the liberty to snip out much of the detail except in three cases (imaging, online summary content, and messaging) that may not be intuitively obvious. EP refers to eligible providers. Objectives that do not specify providers vs. hospitals apply to both. I edited out some redundancy so please refer to the original document before you conclude that one or another is off the hook.

From the HHS Document:

  • Proposed EP Objective: Provide clinical summaries for patients for each office visit.
  • Proposed EP Measure: More than 10 percent of all unique patients who have had an office visit with the EP within the 24 months prior to the beginning of the EHR reporting period were sent a reminder, per patient preference.
  • Proposed EP Objective: Provide patients the ability to view online, download, and transmit their health information within 4 business days of the information being available to the EP.
  • Proposed Objective: Use clinically relevant information from Certified EHR Technology to identify patient-specific education resources and provide those resources to the patient.
  • Proposed Objective: The EP, eligible hospital or CAH who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care provides a summary care record for each transition of care or referral.
  • Proposed Objective: Capability to submit electronic data to immunization registries or immunization information systems except where prohibited, and in accordance with applicable law and practice.
  • Proposed Objective: Imaging results and information are accessible through Certified EHR Technology.

Making the image that results from diagnostic scans and accompanying information accessible through Certified EHR Technology increases the utility and efficiency of both the imaging technology and the CEHRT. The ability to share the results of imaging scans will likewise improve the efficiency of all health care providers and increase their ability to share information with their patients. This will reduce the cost and radiation exposure from tests that are repeated solely because a prior test is not available to the provider.

Most of the enabling steps to incorporating imaging relate to the certification of EHR technologies. As with the objective for incorporating lab results, we encourage the use of electronic exchange to incorporate imaging results into the Certified EHR Technology, but in absence of such exchange it is acceptable to manually add the image and accompanying information to Certified EHR Technology.

Proposed Measure: More than 40 percent of all scans and tests whose result is one or more images ordered by the EP or by an authorized provider of the eligible hospital or CAH for patients admitted to its inpatient or emergency department (POS 21 or 23) during the EHR reporting period are accessible through Certified EHR Technology.

For Stage 2, we do not propose the image or accompanying information (for example, radiation dose) be required to be structured data. Images and imaging results that are scanned into the Certified EHR Technology may be counted in the numerator of this measure. We define accessible as either incorporation of the image and accompanying information into Certified EHR Technology or an indication in Certified EHR Technology that the image and accompanying information are available for a given patient in another technology and a link to that image and accompanying information. Incorporation of the image means that the image and accompanying information is stored by the Certified EHR Technology. Meaningful use does not impose any additional retention requirements on the image. A link to the image and accompanying information means that a link to where the image and accompanying information is stored is available in Certified EHR Technology. This link must conform to the certification requirements associated with this objective in the ONC rule. We encourage comments on the necessary level of specification and what those specifications should be to define accessible and what constitutes a direct link.

  • Proposed Objective: Record patient family health history as structured data
  • Proposed EP Objective: Capability to identify and report cancer cases to a State cancer registry, except where prohibited, and in accordance with applicable law and practice.
  • Proposed EP Objective: Capability to identify and report specific cases to a specialized registry (other than a cancer registry), except where prohibited, and in accordance with applicable law and practice.
  • Proposed Eligible Hospital/CAH Measure: More than 50 percent of all unique patients 65 years old or older admitted to the eligible hospital’s or CAH’s inpatient department (POS 21) during the EHR reporting period have an indication of an advance directive status recorded as structured data.
  • Proposed Eligible Hospital/CAH Objective: Provide patients the ability to view online, download, and transmit information about a hospital admission.

Studies have found that patients engaged with computer based information sources and decision support show improvement in quality of life indicators, patient satisfaction and health outcomes. (Ralston, Carrell, Reid, Anderson, Moran, & Hereford, 2007) (Gustafson, Hawkins, Bober, S, Graziano, & CL, 1999) (Riggio, Sorokin, Moxey, Mather, Gould, & Kane, 2009) (Gustafson, et al., 2001). In addition, this objective aligns with the FIPPs,3 in affording baseline privacy protections to individuals. We believe that this information is integral to the Partnership for Patents initiative and reducing hospital readmissions. While this objective does not require all of the information sources and decision support used in these studies, having a set of basic information available advances these initiatives. The ability to have this information online means it is always retrievable by the patient, while the download function ensures that the patient can take the information with them when secure internet access is not available. However, providers should be aware that while meaningful use is limited to the capabilities of CEHRT to provide online access, there may be patients who cannot access their EHRs electronically because of their disability. Additionally, other health information may not be accessible. Providers who are covered by civil rights laws must provide individuals with disabilities equal access to information and appropriate auxiliary aids and services as provided in the applicable statutes and regulations.

We propose this as a core objective for hospitals in Stage 2 with the following information that must be available as part of the objective:

●  Admit and discharge date and location.

●  Reason for hospitalization.

●  Providers of care during hospitalization.

●  Problem list maintained by the hospital on the patient.

●  Relevant past diagnoses known by the hospital.

●  Medication list maintained by the hospital on the patient (both current admission and historical).

●  Medication allergy list maintained by the hospital on the patient (both current admission and historical).

●  Vital signs at discharge.

●  Laboratory test results (available at time of discharge).

●  Care transition summary and plan for next provider of care (for transitions other than home).

●  Discharge instructions for patient, and

●  Demographics maintained by hospital (gender, race, ethnicity, date of birth, preferred language, smoking status). This is not intended to limit the information made available by the hospital. A hospital can make available additional information and still align with the objective.

A hospital has any number of ways to make this information available online.

The hospital can host a patient portal, contract with a vendor to host a patient portal, connect with an online PHR or other means. As long as the patient can view and download the information using a standard web browser and internet connection, the means is at the discretion of the hospital.

  • Proposed EP Objective: Use secure electronic messaging to communicate with patients on relevant health information.

Electronic messaging (for example, e-mail) is one of the most widespread methods of communication for both businesses and individuals.  The inability to communicate through electronic messaging may hinder the provider-patient relationship. Electronic messaging is very inexpensive on a transactional basis and allows for communication even when the provider and patient are not available at the same moment in time.  The use of common email services and the security measures that may be used when they are sent may not be appropriate for the exchange of protected health information.  Therefore, the exchange of health information through electronic messaging requires additional security measures while maintaining its ease of use for communication.  While e-mail with the necessary safeguards is probably the most widely used method of electronic messaging, for the purposes of meeting this objective, secure electronic messaging could also occur through functionalities of patient portals, PHRs, or other stand-alone secure messaging applications.

We are proposing this as a core objective for EPs for Stage 2. The additional time made available for Stage 2 implementation makes possible the inclusion of some new objectives in the core set. We chose to identify objectives that address critical priorities of the country’s National Quality Strategy (NQS) (http://www.healthcare.gov/law/resources/reports/quality03212011a.html), with a focus on one for EPs and one for hospitals.

For EPs, secure electronic messaging is critically important to two NQS priorities-

• Ensuring that each person/family is engaged as partners in their care; and

• Promoting effective communication and coordination of care.

Secure messaging could make care more affordable by using more efficient communication vehicles when appropriate. Specifically, research demonstrates that secure messaging has been shown to improve patient adherence to treatment plans, which reduces readmission rates. Secure messaging has also been shown to increase patient satisfaction with their care. Secure messaging has been named as one of the top ranked features according to patients. Also, despite some trepidation, providers have seen a reduction in time responding to inquires and less time spent on the phone. We specifically seek comment on whether there may be special concerns with this objective in regards to behavioral health.

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Comments

22 Responses to “An e-Patient Perspective on Stage 2 of Meaningful Use (Adrian Gropper)”

  1. In order to really have patients be full participating members of their care team there shouldn’t be a four day delay in getting access to our records. If a high school educated MA can see them in real time so should the patients if we are actually members of our own care teams.
    .

    When you are in the hospital getting records 4 days later is simply too long to be useful and in many places patients (Group Health) and the members of the Open Notes project (at Gisenger, Beth Israel and Harborview) are already being given access by default within 24 hours with few exceptions (pathology, AIDS, genetic testing) and members of the Open Notes project which include the homeless (at Gisenger, Beth Israel and Harborview) are given open access to clinical notes as well. (again with few exceptions)

    • Sherry, of course I agree that patients have every sensible right (and need) to see the information promptly and continuously. I’d bet 1000:1, though, that the 4 days was a compromise to make it more feasible for providers who have NO such capability to move in the right direction… I’ve recently started being exposed, too, to the less-than-stellar products they have available to choose from. It reminded of the the 2010 post about “the cream of the crap” that one hospital selected AFTER their first choice system failed miserably.

      What a miserable industry – and just as most patients are severely limited in their ability to move their records around and thus to change providers (i.e. vote with their feet), it appears the same is true for providers. The cost of changing is so big.

      I blog about “We hear patients are the cause of much trouble in healthcare; let’s see what happens when one TRIES to improve costs (or get engaged, or whatever).” The same often applies to providers who try to use IT, like that L.A. one with crap on its windshield.

      We surely must modernize, and step one must be to get (almost) everyone to start using SOMEthing. I won’t be surprised if the result, some years from now, will be that vendors at the HIMSS conference FINALLY start touting that THEIR system doesn’t suck. As so many today apparently do.

      And yeah, I agree with you.

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