At the July 10 Health IT Policy Committee meeting, CMS and the Office of the National Coordinator for Health IT reported the latest Stage 2 attestation numbers: 972 eligible professionals (EPs) and 10 eligible hospitals (EHs) through July 1.
Nearly the entire industry is amazed by the paltry attestation volume so far. However, the Stage 2 bar is very challenging to reach, and from our previous research, we anticipated such a dramatically slow attestation trend. Last year, we conducted interviews with more than 100 hospitals in integrated delivery networks across the country to assess their levels of Stage 2 readiness. We evaluated interviewee responses on a four-point scale and converted the values to percentages, with 100% being "Process not yet evaluated for Stage 2," and 0% being "No gaps remaining to remediate." The top-two Stage 2 core objectives for which hospitals were least prepared one year ago was Transition of Care (TOC) and View, Download and Transmit (VDT) (see Figure 1).
Preparing for Transitions of Care and View, Download and Transmit
The TOC and VDT objectives have subtle yet important nuances that can prolong planning and incur additional efforts. The TOC objective requires providers to meet three measures that track the transmission of a summary of care record to the next setting of care:
In our study, these hospitals had not yet assessed the available, specific transmission options for TOC's Measure 2, in which a summary of care document must be electronically transmitted for more than 10% of the patient transitions or referrals.
VDT has two measures. The first is to make certain required information available on a patient portal or personal health record within four business days for EPs and 36-hours post-discharge for EHs, with a more than 50% performance threshold. The second VDT measure tracks patients' access of the portal or PHR and requires that more than 5% of the patients view, download or transmit their health information. Last year, we found most hospitals had yet to validate whether all required data elements can be made available within 36 hours for VDT Measure 1. Additionally, these hospitals were in the early implementation phases of their portal or PHR rollouts and had yet to develop a patient engagement initiative.
Based on our experiences with multiple hospitals around the country preparing for Stage 2 attestation, TOC and VDT objectives prove to be the most taxing from both technology and workflow perspectives. The trends we identified last year are confirmed within the preliminary attestation data ONC released based on 474 EPs and 8 EHs that attested by the end of May. We analyzed this new data set with a specific focus on these two most challenging objectives.
Transitions of Care Stage 2 Attestation Trends Show High Level of EP Exclusions
The data show that 77% of EPs did not reach sufficient referral volumes and thus met the exclusion criteria for all of the objective's measures. By removing one of the most difficult objectives from these EPs' lists, that likely made Stage 2 much easier to achieve, resulting in the high number of attestations compared with hospitals.
The story is different for hospitals, which do not have any exclusion criteria. It is impossible to derive statistical significance from a pool of only eight EH attestations; however, their data provide some interesting observations. Only two hospitals reported a performance rate greater than or equal to 25% for TOC's Measure 2 (the required threshold for electronic transmission of a summary of care record is more than 10%). However, the reported performance rates are much higher for TOC's Measure 1, which does not require electronic transmission and can rely on patients to deliver the summary of care record. For that measure, six of the hospitals achieved between 75% and 85% performance. We anticipate that EP exclusion rates will continue for 2014 Stage 2 attestations and that EHs will continue to perform at the margin for the TOC's Measure 2.
EPs Fare Better With VDT Than EHs
Eighty-one percent of EPs performed in the highest range (i.e., 90% to 100%) for the first VDT measure (making information available to patients within specified timeframes for greater than 50% of patients), whereas EH data show a more varied performance. More than half of the EPs met the second VDT measure (the percentage of patients who viewed, downloaded or transmitted their information) within the 5% to 30% range. However, for all eight EHs, the performance was right at the margin (5% to 10%).
New portal implementations will affect both EP and EH performance, but we expected EPs to fare better than EHs for the second VDT measure for several reasons. The patient portal implementation continued well into 2014 for the majority of our hospital members. Although we have not tracked portal implementation trends for EPs, we assume many practices are rolling out a tightly-integrated portal also designed by their primary EHR vendor. Those portal set-ups may lend implementation benefits for EPs, as opposed to EHs that may experience integration challenges when they deploy a third party portal (e.g., 37% of our interview chose a third-party portal vendor).
In addition, patient engagement may be easier to realize in a provider's office because of the more frequent patient interaction, compared with the acute care setting. For example, EPs can encourage patients to use the portal pre-encounter by setting up an appointment on the portal, whereas for the inpatient domain, admission is condition-dependent and not usually based on "choice" or a patient's schedule. Furthermore, patients seen in the ambulatory setting are generally more "well" than those admitted to the hospital or seen in the emergency department, and that difference in the patient population condition may also make it easier for the EPs to educate patients on the benefits of the portal and encourage its use.
While CMS acknowledged in its Stage 2 final rule that patient portal use will largely be outside the provider's control, we conclude that patient engagement requirements are harder on EHs than EPs and are likely a significant contributing factor to the early differences in the current Stage 2 attestation volumes.
ONC and CMS' reports to the Policy Committee on Aug. 6 will tell us more about the Stage 2 providers meeting this new bar of meaningful use. Undoubtedly, the attestation volume will increase and with it, perhaps, greater insights into these measures that were the most difficult.