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What does 2013 hold for EHRs, meaningful use, and interoperability?


Stage 2 of meaningful use for EHRs is on the horizon. Here's how to survive this challenge with flying colors.

With stage 2 of the financial incentive program for meaningful use of electronic health records (EHRs) just over the horizon, 2013 is shaping up as a crucial year for meeting the biggest challenge to meaninful use compliance: the ability to exchange patient health information among providers.

The reason is simple. Currently, wide-scale interoperability challenges exist, leaving primary care physicians and other providers with few options for meeting the health information exchange objectives included in meaningful use 2 (MU2). EHR vendors, along with the federal government and the states, are taking steps to address the interoperability issue and provide doctors with the tools to meet the MU2 requirements, but it is unclear how many of the proposed remedies will be available by the start of 2014 when MU2 attestation begins.

The rush to meet the MU2 interoperability requirements comes at a time when close to two-thirds of the nation’s family physicians have implemented EHR systems, yet a recent survey of 17,000 doctors revealed that nearly 25% of them are considering changing EHR systems because of dissatisfaction with their current systems.

The weakness of EHR interoperability has not gone unnoticed in Congress, either. In October, four powerful Republican members of the U.S. House of Representatives’ Ways and Means Committee wrote to Kathleen Sebelius, secretary of the U.S. Department of Health and Human Services (HHS), expressing “serious concern” that MU2 rules “fail to achieve comprehensive interoperability in a timely manner, leaving our healthcare system trapped in information silos.” The letter urged Sebelius to suspend incentive payments and delay penalties until HHS promulgates universal interoperable standards.

The health information exchange requirements are among the 17 “core” objectives physicians must meet to qualify for MU2 under the program’s final rule, which the Centers for Medicare and Medicaid Services (CMS) issued in August. (The rule also includes six “menu” objectives, from which providers must choose three to meet.) Doctors who began meaningful use in 2011 or 2012 will have to begin meeting the MU2 objectives in 2014. (See “MU2 objectives,” below.)

Although many of the MU2 objectives are similar to those in stage 1, MU2 includes key differences in the areas of health information exchange, patient access to information, and securing patient information. In health information exchange, physicians must:

  • provide a summary of care record for more than 50% of the patients they refer to another provider or transition to another care setting,

  • supply the summary of care record electronically for more than 10% of those referrals or transitions, and

  • conduct at least one successful electronic exchange of a summary of care with a recipient who uses a different EHR system.

In the area of patient access to information, doctors must:

  • provide their patients with the ability to view online, download, and transmit their health information within 4 business days of the information being available to the physician, and

  • have at least 5% of a practice’s patients access their information online.

In the area of data security, physicians are required to protect electronic health information created or maintained by certified EHR technology.

For most doctors, especially independent practitioners, the biggest challenge posed by MU2 will be the health information exchange requirements, for the simple reason that the EHR systems of various vendors currently are able to communicate with one another (several vendors have formed a new organization designed to address that issue, however; see “Interoperability is goal of EHR vendor alliance”). That need to promote greater interoperability among systems was the impetus for including the information exchange objectives, according to Robert Anthony, deputy director of the health information technology (IT) initiatives group in the CMS Office of e-Health Standards and Services.

“At base, there really isn’t a business motivation for vendors to make that information sharable. In fact, there’s sometimes a case to be made for doing the opposite,” Anthony says. “So we’re really trying to move meaningful use in the direction of getting information across boundaries, so doctors can coordinate patient care among multiple sites of care.”


The ability to improve patient care by moving patient information seamlessly among providers is one of the goals of health information exchange, Anthony says. Other goals he cites:

  • reducing costs by avoiding duplication of tests and other services, and facilitating the operations of practices using alternative payment models such as the accountable care organization and the Patient-Centered Medical Home;

  • being able to examine various patient populations with a view toward improving public health and controlling chronic diseases; and

  • improving clinical quality measurements.

“Within the different medical organizational structures, be it a hospital system or integrated practice, the existing EHR tools work pretty well at addressing internal work flows,” says Robert Rowley, MD, a family physician with Hayward Family Care in Hayward, California, a healthcare IT consultant, and author of the blog, says. “But each system handles data so differently from each other that, without standards-which is what MU2 is really designed to promote-there’s really no way to send information from one place to another.”


So what can you do when you need to send patient information to meet the MU2 requirements but can’t find another provider with the ability to accept the information electronically? Depending on where you practice, one solution may lie in becoming part of a health information exchange network. Among other services, networks provide a set of common standards to their members for sending and receiving healthcare data electronically. Many integrated healthcare networks, and even some smaller hospital systems, already have developed their own proprietary networks for use among their affiliated providers.

Along with the private exchange networks, states are establishing regional and statewide network groups for use by providers, organizations, and payers, although these vary in their degrees of robustness.

“What I tell physicians is that they have to get to know what’s going on around them,” says Pamela Matthews, RN, MBA, senior director of regional affairs for the Healthcare Information and Management Systems Society (HIMSS). “They need to inform themselves about all the [health information exchange] players at their state and local level, because every situation is unique. The market forces are different, the demographics are different. The physician needs to find out what’s available or being planned for their area so he or she can take advantage of it.” (See “4 tips to help you exchange health information with other providers,” below.)

States with robust statewide or regional exchanges, she says, include Colorado, Florida, Indiana, Michigan, New Mexico, New Yor, Texas, and Virginia. Doctors seeking information about exchanges, she adds, should contact their state medical society, state healthcare agency, or the IT staff of the local hospital. More information about regional and state-wide exchanges is available on the HIMSS Web site at

Another possibility for undertaking health information exchange is by using point-to-point communication protocols being developed by the Direct Project, a consortium of EHR vendors, medical organizations, government agencies, and consultants working to develop secure ways of sending encrypted health information between providers. Direct Project protocols will be embedded in EHRs certified for MU2 and are expected to become available to doctors and other providers in 2014.

In addition, CMS says it is establishing an EHR test site that physicians who can’t find another provider to receive information electronically can use to meet the information exchange objective. The site is scheduled to go live early in 2014.


A second challenge physicians will face in meeting the MU2 requirements is in the area of patient engagement; specifically, persuading patients to access and transmit their health information via online patient portals.

“A lot of the patients just aren’t there yet in terms of their computer skills,” says Cindy Blain, CPA, FACMPE, director of SS&G healthcare services in Akron, Ohio. “I think it will get better with time and efforts to increase patient involvement.”

In the meantime, Blain recommends that doctors and practice staff members constantly remind patients of the benefits of online portals.

“It’s telling patients, ‘You can get that information on our portal,’ or ‘Please fill out these forms on our portal before you come in,’” she says. Also important: Getting patients’ email addresses so you can send them reminders and links via electronically.

The key to getting patients to use portals, Rowley says, is having information and services on it that patients value.

“Most of the stuff people will want to get are lab results, or [they want to] know they can make an appointment when they think of it at 11 at night,” he says. “If it includes functionality that gives them value, then people will use it.”

Doctors and staff members in Rowley’s practice give patients information about the practice’s portal when they come in. Posters in the exam rooms communicate the portal’s URL and information about services available on it. Rowley also has suggested to the practice’s EHR vendor that it should automatically e-mail patients every time the patient puts something new on the portal.

Dean Sorensen, principal consultant and chief executive officer with Sorensen Informatics Inc. in Lombard, Illinois, suggests that physicians who have practice newsletters include portal links in them. Posting information about the portal on a practice Facebook page also a useful. Overall, however, Sorensen is skeptical about the ability of practices, especially those with a large proportion of elderly patients, to attain the patient engagement objectives.

“I can guarantee you that doctors in a gerontology or rheumatology practice won’t get anywhere with a patient portal. Most of those [patients] don’t even have computers,” he points out. In those cases, Sorensen says, doctors’ only option is to try to engage a family member or other caregiver on behalf of the patient.


A third additional challenge posed by MU2 is ensuring the security of patients’ health information when it is stored and transmitted electronically. In general, experts and consultants recommend using the same security techniques as those used to comply with the Health Insurance Portability and Accountability Act, such as:

  • encrypting data,

  • installing and maintaining antivirus software,

  • using robust passwords that are changed regularly,

  • installing strong firewalls that also alert the practice when breach attempts take place, and

  • using software that tracks log-in attempts.

In addition, Sorensen recommends to his clients the use of software or outside security firms that can regularly scan browsers and software for vulnerabilities and provide patches for them.

SS&G’s Blain suggests to her clients that when other physicians request patient information, they provide nothing beyond the specific information requested.

“If a specialist wants results of a particular test, don’t give them the whole chart,” she says. Blain also emphasizes the importance of disaster recovery plans.

“Most private practices don’t have one. They say, ‘We’ll just revert to paper,’ but there’s a lot more involved. You can’t lose protected health information,” she says.


MU2 objectives

As was the case with stage 1 of the meaningful use program, stage 2 consists of a set of core objectives that all electronic health record (EHR) users are required to meet. In addition, users must choose three from a set of six “menu” objectives.

Core objectives:

  • use computerized order entry for medication, laboratory, and radiology orders;

  • generate and transmit permissible prescriptions electronically;

  • record demographic information;

  • record and chart changes in vital signs;

  • record smoking status for patients 13 years or older;

  • use clinical decision support to improve performance on high-priority health conditions;

  • protect electronic health information created or maintained by certified EHR technology;

  • incorporate clinical lab test results into certified EHR technology;

  • generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach;

  • use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care;

  • use certified EHR technology to identify patient-specific education resources;

  • perform medication reconciliation;

  • provide a summary of care record for each transition of care or referral;

  • submit electronic data to immunization registries; and

  • use secure electronic messaging to communicate with patients on relevant health information.

Menu objectives:

  • submit electronic syndromic surveillance data to public health agencies,

  • record electronic notes in patient records,

  • have imaging results available through certified EHR technology,

  • record patient family health history,

  • identify and report cancer cases

  • to a state cancer registry, and

  • identify and repot specific cases to a specialized registry (other than a cancer registry).



4 tips to help you exchange health information with other providers

Health information exchanges tie together patient data between medical practices, health centers, and hospitals. But as the exchanges move further into the public eye, one important question remains: Will doctors in small, private practices be involved?

If you really want to succeed, you want primary care providers to be involved,” said Chris Hobson, MBA, MB ChB, a former internist who is now chief medical officer for health information exchange software provider Orion Health.

That’s the same opinion held by Laura Kolkman, RN, MS, and Bob Brown, authors of The Health Information Exchange Formation Guide: The Authoritative Guide for Planning and Forming an HIE in Your State, Region, or Community, which was named 2012 HIMSS Book of the Year. The two also write a monthly column in the HIMSS HIELights newsletter.

In an exclusive interview with Medical Economics, they offer four tips to help small practices with the process of exchanging  health information:

1. Implement an electronic health record [EHR] system-and use it. Health information exchanges operate by pulling and aggregating data provided by many different EHRs. By making your practice’s system part of your daily workflow now, you’ll be able to make better use of health information exchange in the future, Kolkman explains, adding, “Otherwise, we find people don’t use it because it’s an extra step and too much trouble.” (Hobson adds that some health information exchanges, including those using Orion products, provide a “light” form of the EHR software, allowing practices that don’t have their own systems to enter data manually as they go so they can participate.)

2. Find out  all you can about health information exchanges and the pros and cons of participating in them. The pros, Kolkman says, include the ability to get a more complete picture of the patient’s health status by accessing data from other providers and the fact that participation in accountable care organizations and other types of bundled payment arrangements depend on seamless information exchange. The main downside of participation is the cost, which Kolkman says can run in the thousands of dollars, even for small practices Also important:  ensuring that data obtained through the exchange can be easily integrated into your practice’s workflow. “That’s an absolute must for any chance of success,” she says.

Good sources of information about exchanges, Kolkman says, include regional extension centers, state and local medical societies, and local hospitals or health systems.  Once you contact an exchange, it will provide information regarding service agreements, privacy standards, interoperability standards, and costs. And don’t forget to notify your EHR vendor that you will be participating in an exchange, so that the vendor can provide the necessary interface between your EHR and the exchange.

3. Look for  incentives for participation. Up front, it may be “difficult to find a return on investment because it is costly to invest in the software,” Kolkman says. So look for meaningful use incentives from the government or quality incentives from private payers.

4. Be proactive in influencing how health information exchanges are developed and run in your area. Brown suggests that primary care doctors ask themselves: Do my patients ever interact with other physicians or providers? Do they ever go to the hospital? “If that’s the case, they’re going to want to get involved in health information exchange to make sure they’re providing the information and that they have the information” they need, he says.

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