In my last post, I commended CMS for responding positively to many of the comments that were submitted regarding the Proposed Rule for Stage 2 of meaningful use. However, there were also troublesome areas that were acknowledged in the Final Rule, but addressed in a way that remains problematic for physicians. This post will review some of those issues.
Most notable are the two measures that make physicians’ incentives dependent on actions by patients—actions over which the physician does not have control. The Final Rule requires that:
- More than 5% of all patients seen by the physician during the reporting period actually view, download, or transmit their available health information, and
- More than 5% of patients seen send a secure message to the physician (containing health information, not just a request for an appointment).
The proposed rule had set the threshold at 10% for each of these measures. The response from the provider community was almost universal, arguing that no matter how much education, encouragement, and cajoling the practice provides to encourage this form of patient engagement, the physicians could not guarantee patient compliance. Alternatives were offered—my company suggested having the physician be the source of the messages, or holding him/her responsible for responding to a minimum percent of the messages received from patients. However, CMS held firm in its belief that it is incumbent upon the physician to encourage patients by offering an attractive, patient-friendly portal. By way of compromise, the Final Rule reduced the threshold from 10% to 5%, but this solution does not address the principle involved—i.e., the inequity of making the physician’s incentive dependent on the actions of patients. Just imagine if after successfully meeting all of the Stage 2 requirements for the 1,000 patients a physician saw during the reporting period, only 49 of the patients (instead of 50) actually viewed their information on the portal that the physician installed—his entire year’s incentive payment would be lost.
The menu set of measures is intended to afford physicians some flexibility—there are 6 measures from which they must select 3. Part of the rationale for this structure is to make meaningful use more meaningful for specialists. Yet in Stage 2, the menu measures that a physician is eligible to exclude will no longer count as being met, so many specialists will be left with no real choices at all—the menu measures become de facto core measures. Many specialists will find 3, or even 4, of the menu measures to be in that category—CMS acknowledges that syndromic surveillance is still premature, cancer registry reporting is likely irrelevant to most physicians, diagnostic images are only relevant to a few specialties, and many others will find no viable specialty registry to which to report so CMS “does not expect every EP to select this measure.” An ophthalmologist, for example, will have to report on the family history measure and the electronic progress note—not a measure they would choose if the menu were truly a menu.
Patient reminders is another measure that may be problematic for specialists who provide episodic care. Stage 2 requires the physician to send an appropriate reminder for follow-up or preventive care to 10% of the patients seen during the prior 24 months. No exclusion is available for physicians who see patients two or three times to treat a particular problem, but have no reason to ever recall the patient.
The above are examples of where CMS may have listened to the physicians, but didn’t really hear them. I hope that some further guidance related to these issues will be forthcoming to ensure that physicians are able to successfully demonstrate meaningful use in Stage 2.