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The Department of Health and Human Services (HHS) recently announced the long-awaited rule for Stage 2 of its EHR incentive program, set to begin in 2014. As per usual by this point with all matters regarding Meaningful Use, the announcement was met with skepticism by some and scrutiny by many. Ahead, I will explore some details of what awaits clinicians who continue along with the program.

Stage 2: The Details

First, let's begin with what many clinicians likely anticipated from the new rule. On performing vital signs, HHS raised the minimum patient age from two years of age to three. More importantly, they separated the vital signs themselves. Specifically, physicians will be given the same exclusion rule as last time. If neither height, weight, nor blood pressure is relevant, you can claim an exclusion. Additionally, if you believe that blood pressure is relevant, but height and weight are not, you can report on blood pressure and exclude height and weight— or vice versa. This can be used already as a definition in 2013. Notably, starting in January, you don't have to take blood pressure, height, and weight on 50 percent of patients, and you can opt only to take one vital sign, or otherwise claim exclusions.

The other significant change that some clinicians will find welcome is that 2014 will not be a full year of Meaningful Use. In other words, physicians will only have to comply for 90 days to qualify. However, the difference between Stage 2 and Stage 1 (which also had a 90-day qualification period for the first year) is that the qualification period for clinical quality measure is only available on a quarterly basis. This may be a difficult adjustment for some physicians, but for those who have already been qualifying for 2013 and part of 2012, meeting clinical quality measures within a quarterly period should be achievable with ease. Vendors, however, may find it more of a challenge to update their software to ensure Meaningful Use-ready for specific periods of 90 days. This remains to be seen, though.

But perhaps more significant than altering the timeframes for recording clinical quality measures is how HHS will require patients to take an active part in the Stage 2 qualification process. In this sense, the bar has been raised significantly. Through patient portals, HHS will require five percent of your total patients seen to request clinical information online. Importantly, requesting an appointment through a portal will not be enough to satisfy the requirement. It must be a clinical information exchange. The clinician may also initiate contact, which may encompass how a patient is responding to a treatment or whether they need a refill.


There are other details about Stage 2 that clinicians can read about at the HHS website, but these items represent the major crux of the next stage of Meaningful Use and provide a snapshot of what qualification for incentive dollars will entail in 2014. The most noteworthy aspect of the proposed rule is the new requirement for patients to interact with clinicians online in order to satisfy clinical quality measures. This has been a point of major criticism, as many clinicians are understandably concerned that their incentive dollars will be determined by whether patients are motivated or savvy enough to participate in the portal. The incentive program is supposed to be for physicians who utilize EHRs in their practices, which is why it stings that we will need to rely on something not necessarily within our control. Fortunately, only five percent of patients seen need to have a clinical exchange via the patient portal; however, even a small amount is enough to raise concerns about the direction of the EHR incentive program in the future.

If I were to speculate, I would suggest that the patient participation requirement returns to the “blue button” issue that strikes to the heart of what the EHR incentive program is meant to be about. The notion is that you can press a “button” on a keyboard and get a patient's entire health record. (The VA recently implemented a structure similar to this.) Then eventually people can go home onto their PCs and access their entire health record. Whether or not this can truly happen is not for me to speculate; however, it is clear that HHS is taking a small step toward encouraging that with its Stage 2 rule.

While universal access to health records via EHR technology across platforms may be an ideal scenario, there are other issues worth considering that may pose roadblocks to those efforts. For example, communication with other providers is likely going to be a challenge, if only because each system is configured differently. This can spell out a logistical nightmare for providers as they try to agree upon a universal platform by which health information can be accessed easily. In fact, it may result in clinicians needing to purchase and maintain an email address by which information can be encrypted and decrypted as it leaves/enters other systems.

What is It Worth?

There is no doubt that the government is rolling the dice with the patient portal requirement. They initially proposed the percentage to be 10 percent, but they since lowered it to five percent after a blitz of campaigning against the measure. Nevertheless, it is likely only a matter of time that the percentage is raised over time, as the incentive program continues to gain prominence along with the broader adoption of EHRs. But given the apparent unrest regarding the proposals, the question must be asked whether those who participated in Stage 1 will be willing to continue along in Stage 2. In reality, Stage 2 will probably be more of an issue for dermatologists to comply with than anything in Stage 1. And since the majority of available incentive money to receive through the program can be achieved through Stage 1, the lack of significant incentive money available in Stage 2 may tip the scales for some clinicians' decision to continue along or take the penalty.

The anticipated argument against giving up on Stage 2 will likely be that anyone who elects to do so will be on the outside of the mainstream when the shared ACO models in which everyone is connected take effect. This is a point worth considering, as it relates to your expected time horizon of practicing medicine. If these alternative payment models stick and replace fee for service, then anyone who is not on board with the program will indeed be “left out.” For those clinicians with an established following, this may cause little concern. But for the next generation, this raises serious questions about whether it is worth the risk of not participating in the EHR program. These are important points to bear in mind as the EHR incentive program continues to evolve. But at the moment, response to the Stage 2 requirements introduces another question as to the perceived threshold at which physicians will take the incentive dollars earned from Stage 1 and walk away from the program.

Mark Kaufmann, MD is co-chair of the Dermatology work-group for CCHIT. He is on the Medical Advisory Board of Modernizing Medicine.

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