The Latest Stage 2 Meaningful Use Attestation Data: Shocking Yet Anticipated

by Naomi Levinthal and Anantachai (Tony) PanjamapiromTuesday, July 29, 2014

TOPIC ALERT:

• Meaningful Use

Click on topic to receive periodic emails.

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:

• The first measure allows providers to use any method to deliver the summary of care record (including patient delivery);
• The second measure requires electronic transmission; and
• The third measure is a "yes or no" attestation that a provider has exchanged at least one summary of care record with another user on a different electronic health record system than their own.

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.

http://www.ihealthbeat.org/perspectives/2014/the-latest-stage-2-meaningful-use-attestation-data-shocking-yet-anticipated

Physical therapy mHealth app logs compliance

For Jonathan Ware, M.D., the best mHealth app is the one in his pocket.

The medical director of population health management at Florida's Orlando Health carries PT Pal around with him on his iPhone. The physical therapy app, which is also available for Android devices, can be used by patients on their own or in concert with their physical therapists.

Ware's job responsibilities at the nonprofit healthcare system, in addition to hospitalist rounds and managing four accountable care organizations, includes introducing new medical devices and programs into various departments. After using PT Pal himself, he's getting it into the hands of his physicians and physical therapists.

But like many busy people currently rehabbing an injury, Ware doesn't have a lot of free time to go to PT. So he's using PT Pal to rehab -- often on work time during short breaks -- a twisted left ankle he suffered in April rushing down a flight of hospital stairs.

Pilot planned for pediatric PT practice

I was going a bit nuts. I thought there had to be an app for this. I couldn't find it, so I built it.

Naveen KhanCEO, PT Pal

And he'll soon observe PT Pal in action in a pediatric clinic trial overseen by John Dimino, manager of acute care and outpatient rehabilitation services at Orlando Health's Arnold Palmer Hospital for Children. One advantage of the app for pediatric patients with disabilities such as cerebral palsy is that patients, their caregivers and therapists will be able to record videos of their own movements andaccess them in the app, instead of trying to reach what could be an unattainable ideal presented by a model, Ware noted.

Ware says PT Pal makes it easy for him, and Orlando Health patients, to understand the sometimes tricky exercises in the physical therapy canon. Traditionally, therapists send their charges home with printed pictures of the movements, most of them derived from 1980s vintage stock and which many patients find hard to follow and easy to lose -- contributing to high non-compliance rates in many PT settings.

"Some of our physical therapy patients drop out. Those who show up for appointments only retain about 40% of it," Ware said. "A lot of them leave the paperwork in the car and find it three weeks later."

Gentle reminders of tough rehab work

PT Pal also reminds users when it's time to do their PT work, a gentle reinforcement mechanism that is a key part of the mHealth methodology, akin to the buzzes and blips that popular consumer devices such as the Jawbone UP and Fitbit bands use to remind wearers they've been immobile too long.The program actively supports such patient engagement by actually making the hard work and occasional tedium of physical therapy sometimes approach fun, Ware said.

"It's nice to see a video of what you're doing, or a picture," Ware said. "And it's really nice for me to have the reminder. It's like having the iPhone schedule it."

The story of PT Pal's inventor and CEO, Naveen Khan, a Los Angeles resident, dovetails with Ware's and others' frustrations with the limitations of traditional physical therapy.

The British-born Khan -- who met Ware and introduced him to her product at a February HIMSS conference in Orlando -- imagined the app when she was rehabbing from a bone marrow biopsy but was too busy at her management job at a big company.

"I couldn't fit in my PT," Khan said. "I was going a bit nuts. I thought there had to be an app for this. I couldn't find it, so I built it."

U.S. clinics sign on

That was a little over a year ago. Now, PT Pal has more than 200 individual users and is in place in more than 25 U.S. clinics and hospitals. Khan, meanwhile, says she has a number of deals brewing.

A new version of the program was released in July that is optimized for the iPad and adds video recording, among other features. The app now hosts videos of about 400 different PT exercises. Khan is planning to add new capabilities in future updates, such as game-like features for pediatric patients.

Khan and company CIO John Dzivak tout other benefits for the technology that mesh with trends in the EHR and mHealth worlds.

One that stands out is compliance, the lack of which is an oft-observed major drawback of physical therapy. Many PT clinics lack tracking capabilities to monitor how many of their prescribed exercises patients are doing, not to mention electronic records of their progress at home.

Dzivak pointed out that insurance companies and doctors and therapists themselves perhaps ought to be able to know patients' compliance rates. Each exercise has its own CPT (Current Procedural Terminology) code, so payers can track compliance rates by specific exercise.

"One of the goals of PT Pal was to get people to do their exercises," he said. "Payers have been interested in the compliance rate. They're paying for the rehab. If I'm a payer, I don't want to know what was prescribed. I just want to know the percent that was completed. Before, it was just anecdotal."

Potential side benefit: Meaningful use compliance

Another benefit of the app is the ability it gives patients to contribute to their own electronic health record by noting and recording their own PT exercise activity, Dzivak noted. One of the criteria for stage 2 of the Centers for Medicare and Medicaid meaningful use is allowing patients to do that.

Khan, who is also trained as a lawyer, said in addition to healthcare reform issues, devising the program for herself originally came down to a simple issue.

"As a single mom working for corporate America, PT Pal provided the ability to do [physical therapy exercises] anytime, anywhere," she said.

Let us know what you think about the story; email Shaun Sutner, news and features writer, or contact @SSutner on Twitter.

http://searchhealthit.techtarget.com/feature/Physical-therapy-mHealth-app-logs-compliance

A Primer on Meaningful Use and HISPs

The Massachusetts State government offers low cost HIE services including Direct transport to all the stakeholders of the Commonwealth.    Recently. Micky Tripathi wrote this FAQ which is so good that I wanted to share it on my blog.   Feel free to use it with your stakeholders.

1. What is a HISP?
A Health Information Services Provider (HISP) is an organization that manages security and transport for health information exchange among health care entities or individuals using the Direct standard for transport.  There is no specific legal designation for a HISP, nor are HISPs specifically regulated by Meaningful Use certification rules.  The term HISP was coined to describe specific message transport functions that need to be performed to support scaled deployment of the Direct standard in the market.  HISP functions can be performed by existing organizations (such as EHR vendors or hospitals or HIE organizations) or by standalone organizations specializing in HISP services.

HISPs perform two key functions that support scalability of exchange using the Direct standard. 

a. Issue security certificates.  HISPs establish trust networks by defining policies for network participation and issuing security certificates tied to a HISP anchor certificate to enforce such policies
b. Issue direct addresses.   HISPs issue direct addresses tied to the HISP anchor certificate in accordance with conventions defined by the Direct standard

2. Do I need to use a certified HISP to attest for Meaningful Use Stage 2?
No, because there is no such thing as a certified HISP.  Meaningful Use certification applies to technology, not to organizations.  In order to attest for Meaningful Use Stage 2, you need perform certain activities using certified EHR technology (CEHRT).  For most EHR users, their EHR is certified for all of the functions that they need.  If it is not, you will need to incorporate specific additional certified technology solutions to fill the remaining gaps.  It doesn’t matter whether that additional technology comes from an EHR company or a HISP company – the only thing that matters is that the technology is certified.

3. Doesn’t DirectTrust certify HISPs?
DirectTrust is a private, non-profit organization that voluntarily certifies HISPs through its EHNAC DTAAP program.  This private, voluntary certification often gets confused with Federal Meaningful Use certification.  DirectTrust is NOT a Federal certification entity, and its EHNAC DTAAP certification process is purely private and voluntary and has no relationship with Meaningful Use Stage 2 attestation or certification requirements.

4. What role does a HISP play in Meaningful Use Stage 2?
A HISP provides specialized network services that connect your EHR to other EHRs that are also using the Direct standard for communications.  You don’t need a HISP in order to create Direct-compliant messages, but you do need to be connected to a HISP in order to send and receive Direct messages with other parties.  Using an email analogy, you may have Microsoft Outlook installed on your computer, but if it isn’t connected to an email network, your emails can’t go anywhere and none can get to you.  Similarly, your CEHRT can send and receive Direct-compliant messages, but those messages won’t go anywhere unless you and those who you are communicating with have valid
Direct addresses and are connected to a secure network that can get the messages safely and reliably from one endpoint to another.  These are the message transport functions that HISPs perform.

There are two Meaningful Use Stage 2 attestation requirements that require Direct transport:

• Summary care record for transitions of care (TOC)
• Patient ability to view, download, transmit their medical record (VDT)

Most HISPs (including the Mass HIway) do not yet have the ability to connect directly with patients, so they are not able to assist with the VDT requirement.

For the purposes of attestation, the Meaningful Use Stage 2 TOC requirement specifies that you must electronically send a standardized summary care document to another care setting, and that you must have reasonable assurance that the other care setting actually received the document.  The HISP performs the message transport functions to provide you with the assurance that your messages have been delivered to their intended recipients.

In order to attest for the TOC requirement, you need to send CCDA care summaries containing at least problem lists, medications, and medication allergies.  These summaries must be transmitted with your CEHRT using either the SMTP/SMIME or XDR/SOAP protocol.  There is no Federal certification for HISPs, so you can send your message to its intended recipient using any HISP or any number of HISPs, as long as you have assurance that the message will get delivered.  The only certified system that you need to use is the one that creates the Direct-compliant SMTP or XDR message – after that, your message may take any number of “hops” between your EHR and its final destination, and as long as you’re confident that the message will get delivered, you will have completely fulfilled your Meaningful Use Stage 2 attestation requirement.

5. How do I get assurance that my messages are delivered?
Meaningful use attestation requirements do NOT specify how you get assurance of delivery, they specify only that you have taken reasonable steps to be confident of delivery.  The most robust way for you to be assured of message delivery is for your system to receive message disposition notifications (MDNs) for each message sent by your EHR to the intended recipient.  However, not all receiving systems or HISPs can generate MDNs, and not all EHR systems can consume MDNs even if they are returned. 

Fortunately, you are not required to receive MDNs in order to be assured of delivery.  Other acceptable methods of assurance are through HISP guarantees of delivery after successful setup testing and/or notification of failure of delivery (like emails) and/or HISP central maintenance of delivery logs that can be made available as needed. 

The Mass HIway provides you with assurance of delivery through rigorous setup testing, and maintenance of a central log of delivery successes and failures.  This log is made available to participants as necessary in the event of an audit.  The Mass HIway will also return any MDNs or application-specific responses or acknowledgements generated by receiving endpoints, however, the Mass HIway cannot guarantee that any receiving endpoint will generate notifications, acknowledgements, or responses.

The one exception where delivery notification is available and required is public health.  The Massachusetts Department of Public Health requires that participants receive delivery notifications in order to satisfactorily meet the Meaningful Use Stage 2 public health requirements.  Massachusetts DPH does generate automated acknowledgements, which are sent automatically via the Mass HIway in response to each message successfully received.

6. Is the Mass HIway a HISP?
Yes.  The MA HIway is a trust community that issues security certificates and Direct addresses to eligible participants and provides Direct-compliant message transport services for its participants.

7. Is the Mass HIway certified as an EHR module for Meaningful Use Stage 2?
No, the Mass HIway is not certified as an EHR module for Meaningful Use Stage 2.  Most providers will not require the Mass HIway to be certified in order to use it to help fulfill their Meaningful Use Stage 2 attestation requirements.  (See discussion above in FAQ on HISP roles.)  As long as your CEHRT delivers a Direct-compliant SMTP or XDR message to the Mass HIway (either to the LAND appliance or directly to the central site), you do not need the Mass HIway to be certified.

If your CEHRT does not send a Direct-compliant SMTP or XDR message to the Mass HIway (for example, if you are sending messages to the LAND appliance in a format other than SMTP or XDR), then you will need to change your interface to send Direct-compliant SMTP or XDR to the Mass HIway (including the LAND appliance) in order to count any of these transactions for Meaningful Use Stage 2 TOC requirements.

Even though you do not need the Mass HIway to be certified for Meaningful Stage 2 in most cases, you will still need to have assurance of delivery of messages sent over the Mass HIway to meet your Stage 2 TOC attestation requirements.  The Mass HIway provides this assurance by delivery after successful setup testing.

8. Must I be connected to the Mass HIway in order to attest for Meaningful Use Stage 2?
Yes, you need to be connected to the Mass HIway in order to meet the Meaningful Use Stage 2 public health requirements for immunization and cancer registries, and syndromic surveillance.  The Massachusetts Department of Public Health will accept public health transactions only through the Mass HIway.  Thus, though there is no Federal requirement that you be connected to the Mass HIway for Meaningful Use Stage 2, you will not be able to meet core public health requirements for Meaningful Use Stage 2 without being connected to the Mass HIway.

You do not need to be connected to the Mass HIway in order to meet the Meaningful Use Stage 2 TOC requirement.  However, over 100 providers and payers are already live on the Mass HIway HISP.  Thus, connecting to the Mass HIway will likely make it easier for you to meet your TOC requirements because you will be immediately connected with many of the providers you share patients with.

9. The Meaningful Use Stage 2 rules refer to the eHealth Exchange – is that the same as the Mass HIway?

No.  The eHealth Exchange is a health information exchange network comprising federal agencies and other large non-federal organizations.  The Mass HIway is not connected with the eHealth Exchange in any way.

10. Do I have to be connected to the eHealth Exchange in order to meet my Meaningful Use Stage 2 attestation requirements?

Absolutely not.  While the Meaningful Use Stage 2 rules do allow special dispensation for eHealth Exchange members, few providers will attest using this mechanism.  No Massachusetts providers or payers are currently members of the eHealth Exchange.

11. Who are the other HISPs in Massachusetts, and can I join any HISP that I want?
There are a wide variety of HISPs operating in the Commonwealth.  Whether you join any particular HISP depends on a number of factors.  The biggest factor is which HISPs your EHR vendor allows you to join.  Some vendors require that you use a specific HISP (either their own or the one they are integrated with), while other vendors (such as Meditech and Epic) allow the provider to choose which HISP they would like to connect to.  CMS and ONC do not require that you use any particular HISP for meaningful use, but in practice, your EHR vendor will dictate which HISP options are available to you.

If your vendor allows you to choose which HISP to connect to, you can connect directly to the Mass HIway HISP.  If your vendor requires that you use their designated HISP, you will have to connect to the Mass HIway through their HISP, as long as their HISP is connected to the Mass HIway.
Please contact the Mass HIway (http://www.masshiway.net) if you have any questions about your connection options.

12. Is the Mass HIway part of DirectTrust?
No, the Mass HIway is currently not a member of DirectTrust.  DirectTrust is a voluntary private non-profit collaborative that is helping HISPs to connect with each other.  The Mass HIway is connecting directly with the major HISPs operating in the Massachusetts market.  The Mass HIway may join DirectTrust at some point in the future if it provides additional value to participants.  Providers, EHRs, or HISPs do NOT need to be part of DirectTrust in order to meet their Meaningful Use Stage 2 certification and attestation requirements.

13. If I’m in another HISP, can I still be on the Mass HIway?
Yes.  You can connect to the Mass HIway even if you are a member of another HISP.   The Mass HIway is actively connecting with the major HISPs operating in the Massachusetts market so that messages can be sent between HISPs.  You do still have to join the Mass HIway by signing a participation agreement even if you are in another HISP.  As a member of another HISP, you will pay whatever fees are charged by your local HISP and your Mass HIway fees will be waived.  Once you have joined the Mass HIway, your local HISP will configure your system to enable access to the Mass HIway network.  Your local HISP will still provide you with your security certificate and your Direct address, but you will be able to send and receive messages over the Mass HIway network. 

Below is a current list of HISPs that are expected to be connected to the Mass HIway.  The HISP market is evolving rapidly so more HISPs will be added as demand grows.  Please contact the Mass HIway (http://www.masshiway.net) if you would like to discuss your connection options.

HISP Live date
eClinicalWorks April 2014
Surescripts April 2014
eLINC/SES April 2014
Allscripts/MedAllies TBD
Athenahealth TBD
Wellport/Alere TBD

http://geekdoctor.blogspot.com/2014/03/a-primer-on-meaningful-use-and-hisps.html

Tavenner: No ICD-10 Delay, But Expect Some MU Relief

Lena J. Weiner, for HealthLeaders Media , February 27, 2014

CMS Administrator Marilyn Tavenner has announced that the ICD-10 deadline will not be delayed, but she is offering relief to providers, payers, and health information technology vendors struggling to meet Meaningful Use Stage 2 requirements.

Two announcements from Centers for Medicare & Medicaid Services Administrator Marilyn Tavenner at the HIMSS 2014 conference in Orlando Thursday will have wide-ranging implications for healthcare providers, insurers, and vendors.

The deadline for implementing the ICD-10 diagnostic coding set, which had already been delayed one year to October 1, 2014, will not be delayed again, Tavenner said.

And while the Stage 2 Meaningful Use deadline will also not be delayed, Tavenner said that providers and vendors struggling to meet the incentive program's requirements will see some flexibility.

During the keynote presentation Thursday morning at HIMSS 14 in Orlando, Tavenner announced a partial reprieve for physicians and medical systems finding it difficult to adjust to Meaningful Use guidelines—but urged professionals to come up to speed quickly.

"We have decided to permit flexibility on how hardship exemptions will be granted," Tavenner said. "I must stress we expect all providers to meet requirements in 2015. I urge you to meet the requirements this year." Scattered applause broke from members of the crowd as Tavenner made the announcement.

"We certainly have experienced… difficulties, and I can personally relate to the challenges of new systems, relationships with vendors, and charting a course through previously unnavigated waters," Tavenner said, referring to the well-documented difficulties with thehealthcare.gov website.

When confronted by a question regarding patient safety during the Q & A session after the keynote, National Coordinator for Health Information Technology, Karen DeSalvo, said, "We are exploring our options to help you… we want to make sure you are not penalized for doing the right thing."

These comments come at a time when many within the healthcare industry are expressing concerns regarding the ability to adopt the Meaningful Use standards as specified in the HITECH act. On the Friday before HIMSS, more than 40 healthcare industry groups penned a letter to Health and Human Services Secretary Kathleen Sebelius seeking more time for Meaningful Use attestation, and citing concerns over patient safety and lack of vendor support.

On Thursday, in an exclusive interview with HealthLeaders Media, Intermountain Healthcare CIO Marc Probst disclosed that his organization is unready to seek MU Stage 2 attestation and will forgo incentive payments and trigger penalties.

'It's Time to Move On'While concerns from within the industry are being taken seriously, there will be no turning back. While CMS will be offering exemptions on a case-by-case basis, "Now is not the time for us to stop moving forward," Tavenner said. She was especially unyielding regarding the new ICD-10 coding system.

"Let's face it guys; it's time to move on," Tavenner said. "There will be no change in the deadline for ICD-10. CMS began installing and testing systems for ICD-10 in 2011. All fee for service systems at CMS are ready."

Earlier this month, in response to concerns raised by providers and a group of U.S. senators, CMS agreed to perform end-to-end ICD-10 testing with a small sample group of providers selected to represent "a broad cross-section of provider types, claims types, and submitter types."

The College of Healthcare Information Management Executives (CHIME) responded to Tavenner's comments at HIMSS in a statement released shortly after the keynote speech.

"[CHIME] welcomes CMS Administrator Marilyn Tavenner's announcement this morning, acknowledging the need to provide relief for our nation's providers. Such relief is vitally important for the future success of Meaningful Use, as ICD-10 deadlines and continued shifts in payment policies demand an ever-increasing amount of IT and workforce resources," the statement read.

In the event that expansion of the Hardship Expectations provides the "kind of relief the industry desperately needs," CHIME will pledge to assist CMS "in every way possible," the statement continued. "It will be CHIME's highest policy priority to ensure that providers receive the kind of relief they need in order to deliver quality care."

http://www.healthleadersmedia.com/print/TEC-301496/Tavenner-No-ICD10-Delay-But-Expect-Some-MU-Relief