Article Date: 1/1/2012

Beyond Stage 1 Meaningful Use: A Forecast

Beyond Stage 1 Meaningful Use: A Forecast

Get a jump-start on preparing for Stage 2 and the future of eyecare delivery.

Lorie Lippiatt, O.D., Salem, Ohio and Kim Castleberry, O.D., Plano, Texas

Even if you've never surfed before, taking on the North Shore's pipeline may seem easy compared with implementing EHR Meaningful Use (MU) ( Sure, you have to balance on a thin piece of polyurethane foam on the ocean's surface and the waves are in excess of 10 feet, but implementing MU requires you to balance meeting time-consuming and challenging government-mandated sets of healthcare objectives with operating your practice. And, failure to meet MU deadlines results in stiff financial penalties that may be in excess of thousands of dollars. In addition, each progressive Stage of MU becomes a bit more difficult to achieve.

The good news: Although the final rule on Stage 2 MU implementation isn't expected until mid-year 2012 with the requirements deadline currently scheduled for January 2013 (See “Proposal to Defer,” below), the Centers for Medicare & Medicaid Services (CMS) have outlined the direction of Stage 2 MU saying, “We will consider every objective that is optional for Stage 1 to be required in Stage 2, as well as reevaluate the thresholds and exclusions of all the measures both percentage-based and those currently a yes/no attestation.” 1 Also, the Health Information Technology (HIT) Policy Committee, which advises the U.S. Department of Health and Human Services (HHS) on federal HIT policy issues, including how to define EHR MU, has released recommendations regarding Stage 2 MU measures. Therefore, you can use these forecasts to prepare your practice for Stage 2 MU implementation now. We base this statement on the CMS' past history and the Office of the National Coordinator for HIT (ONC) adapting recommendations presented by the HIT Policy Committee and HIT Standards Committee. (See “Stage 1 MU: An Overview,” below.)

Here, we provide the specific recommendations of the HIT Policy Committee. Also, we provide a glimpse into what may comprise Stage 3 MU implementation and what you can expect post-MU.

HIT Policy Committee recommendations

Basically, the Stage 2 measures recommended by the HIT Policy Committee (meeting held June 8, 2011) fall into the following five categories:

1. Unchanged measures from Stage 1. These pertain to both eligible professionals (EPs) and hospitals:

Maintain an active problem list (more than 80% of all unique patients have at least one entry or an indication that no problems are known recorded as structured data).
Maintain active medication list (more than 80% of all unique patients have at least one entry or an indication that no medications are currently prescribed recorded as structured data).
Maintain active medication allergy list (more than 80% of all unique patients have at least one entry or an indication that no known medication allergies exist recorded as structured data).
► Implement drug-drug and drug-allergy interaction checks.

2. Unchanged measures from Stage 1, but all required for Stage 2. These unchanged measures recommended required for Stage 2 are for both EPs and hospitals:

► Implement drug formulary checks according to local needs (e.g., may use internal or external formularies, which may include generic substitution as a “formulary check”).
► More than 40% of all clinical lab test results ordered whose results are either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data.
Medication reconciliation performed for more than 50% of transitions in care when the EP or hospital was the receiving provider.
► Record and provide (by paper or electronically) a summary of care record for more than 50% transitions of care.

3. Measures with higher thresholds or wider scopes in Stage 2 than in Stage 1. The scope and/or threshold changes in Stage 2 (all now core; changes from Stage 1 are underlined):

► More than 60% of unique patients with a medication in their medication list have at least one medication order entered using computerized physician/provider order entry (CPOE) [up from 30%].
► More than 80% of patients have demographics recorded and can use them to produce stratified quality reports [up from 50% and includes more granular categories].
► More than 80% of patients have vital signs recorded during the reporting year [up from 50%; BP age increased from two years to three years].
► More than 80% of unique patients older than age 13 have smoking status recorded as structured data [up from 50%].
Use clinical decision support to improve performance on high-priority health conditions [up from implement one rule].
Generate patient lists for multiple patient-specific parameters [up from “at least one report listing patients with a specific condition”].
► More than 10% of patients are provided with EHR-enabled patient-specific educational resources [threshold unchanged but “if appropriate” removed].
Submit actual immunization data to at least one organization in accordance with applicable law and practice [up from performing just a test; test or “dummy” data not permissible].
Report clinical quality measures to CMS or the States (note: new measures are still TBD).
► Conduct or review a security risk analysis, and implement security updates and correct identified security deficiencies. Attest that encryption/security functionalities for data at rest (which includes data located in data centers and also data in mobile devices) have been addressed.

EPs only:
► More than 50% of medication orders transmitted as an electronic prescription [up from 40% of medication orders]
► More than 10% of all “active patients” were sent a clinical reminder (reminders for appointments do not count) [threshold decreased from 20% to 10%, but scope expanded from “patients 65 years or older or five years or younger” to “all active patients”].
► Patients are provided a clinical summary after more than 50% of all visits within 24 hours (pending information, such as lab results, should be available to patients within four days of becoming available to EPs) [up from “more than 50% of all visits within 3 business days”].
► More than 10% of patients/families view and have ability to download their longitudinal health information; information available to all patients within 24 hours of an encounter (or within four days after available to EPs) [change from unique patients seen by the EP are provided timely access (available to the patient within four business days of being updated in the certified EHR technology) electronic access to their health information].
► The HIT Policy recommends that CMS consider two additional measures for EPs: (1) Submit actual syndromic surveillance data to at least one organization in accordance with applicable law and practice and (2) submit reportable cancer conditions to at least one organization in accordance with applicable law and practice.

4. New measures unique to Stage 2. The new measures in Stage 2 (all considered “core”) are for both EPs and hospitals:

► More than 60% of unique patients with a structured lab result have at least one lab order entered using CPOE.
► At least one radiology test ordered using CPOE (during reporting period).
► For more than 10% of patients, record care plan fields (goals and instructions).
► For more than 10% of patients, record care team members (including PCP, if available).

EPs only:
► More than 25 unique patients have an advance directive (with date and timestamp or recording) and access to a copy of the directive itself if it exists (or have direct access to it or instructions for how to access the most recent copy).
► More than 30% of EP visits have at least one electronic EP note (scanned notes that are not text-searchable do not qualify).
► Patients are offered secure messaging online and at least 25 patients have sent secure messages online.
Patient preferences for communication medium recorded for at least 20% of patients.
Summary of care record sent electronically for at least 25 transactions during the reporting period.

5. Stage 1 measures eliminated or combined with other measures in Stage 2. Because some measures in Stage 1 have been superseded, the HIT Policy Committee is recommending that the following measures be eliminated:

►More than 50% of patients who request an electronic copy of their health information are provided it within three business days.
►Perform at least one test of certified EHR technology's capacity to electronically exchange key clinical information.

Stage 3 and post-MU

Stage 3 MU will likely focus on achieving improvements in quality, safety and efficiency, including decision-support for national high-priority conditions, patient access to self-management tools, access to comprehensive patient data and improving population health outcomes.2 (According to the CMS website, Stage 3 is expected to be implemented in 2015.)

So what happens after MU?Looking ahead, the answer is Cloud computing. While many of us currently utilize legacybased software and hardware that require constant updates and upgrades, a few already have their heads and practices in the “clouds.” Specifically, these eyecare practitioners (ECPs) are documenting their care via tablets, smart phones, etc.

Cloud-based computing eliminates the need for the client-server “network” and allows for information to seamlessly stream in to patient portals. In addition, software upgrades can easily be achieved without the hardship of shutting down an information system.

This forthcoming generation of computing will open a whole new world of eyecare connectivity. A rich network of insurance, supplier, patient and doctor portals for sharing information with secure communications is on the way. Social media, reputation management, business analytics, supply chain information, clinical-decision support, secure e-mail, e-marketing and data backups will all be managed automatically in the cloud.

With such connectivity, patients will soon find their eyecare practitioner on a health cloud network where they will be introduced to the practice website, which is connected to the practice's office in the cloud. Further, patients will submit their health information on the cloud, and it will automatically be placed in the EHR, eliminating the tedious and time-consuming check-in process at the front desk. Patients will even be able to check themselves in for their appointments. They can also have vendor-supplied rebates for their personalized progressives ready for their visit. Up-to-the-minute eyewear and contact lens tracking will let your patients know the status of their order without having to contact your office. Automated satisfaction surveys will let doctors and vendors know how patients are doing with their products.

Such systems will reduce staffing and hardware needs, allowing ECPs to concentrate on patient care, boosting quality of care, efficiency and our bottom lines. While we will spend more on the cloud for these services, we will save on costs on the ground. There may be an opportunity for advertising-based business models to reduce or eliminate IT costs based on the various operations described above.

Surfing vs. EHR

Although many of us would choose surfing or attempting to surf 10 foot-plus waves vs. MU implementation any day, the fact is we don't have this choice. In order to remain profitable, we must comply with the ONC for HIT or suffer a financial wipeout. The aforementioned forecast regarding Stage 2 MU implementation should help to make managing this next wave in EHR a bit more manageable. OM

Proposal to Defer
In addition to releasing specific recommendations regarding Stage 2 MU implementation, the HIT Policy Committee has also proposed the ONC defer it by one year for EPs who qualified for Stage 1 MU in the 2011 payment year. The reason: Currently, these early adapters are required to start demonstrating Stage 2 MU beginning January 2013. Since the final rule on Stage 2 MU implementation isn't expected until mid-2012, these diligent folks — you, perhaps — will have only months between knowing the final Stage 2 requirements and being responsible for actually meeting them.
Should the ONC for HIT accept this proposal, however, those who qualified for Stage 1 MU in the 2011 payment year would actually have three years under Stage 1 instead of two — a clear advantage for early adapters, as Stage 1 MU is much easier to achieve. In other words, the longer a provider can remain in Stage 1, the easier it is to achieve MU for that period. And, it looks like this may very well become the case, as Farzad Mostashari, M.D., Sc.M, leader of the ONC, has indicated that the ONC supports this recommendation, according to the U.S. Department HHS. So, if you attested to Stage 1 MU in 2011, there's a good chance you're going to be rewarded with extra time in addition to your incentive payments.

Stage 1 MU: an Overview
By now, everyone knows that CMS has opened the registration process for EPs. If you haven't registered and plan on demonstrating MU, you should register now at https:// Once you've registered, you are now eligible to begin demonstrating Stage 1 MU.
The Stage 1 criteria for MU focuses on electronically capturing health information in a coded format, using that information to track key clinical conditions, communicating that information for care coordination purposes and initiating the reporting of clinical quality measures and public health information.
The criteria for MU are based on a series of objectives, each of which is tied to a measure that allows EPs to demonstrate they are meaningful users of certified EHR technology. (Some objectives and measures are not relevant to every provider and can be excluded. In fact, citing exclusions counts the same as meeting the objective. (To check out and download the objectives and for complete details, visit
If you, the EP, show you've met 20 of 25 objectives and report Six Quality Reporting Measures to CMS no later than February 29, 2012, you can receive 75% of your Medicare allowable fees up to $44,000 in payments from CMS. The first installment begins with a maximum payment of $18,000 beginning in 2011 or 2012 for any 90-day period. The second installment is up to $12,000, then $8,000 and then $4,000.(Visit for the complete payment schedule chart.) Because the money is front-loaded, you want to attest to Stage 1 MU as early as possible. For every year after the first payment year, the EHR reporting period is the entire year. Remember, a payment year equals a Calendar year. Something else to consider: If you register and attest by the aforementioned date, you'll likely be under Stage 1 criteria for three years instead of two. But if the Incentive payments and likelihood of additional time to ready your practice for Stage 2 MU implementation aren't enough to interest you, perhaps the penalties beginning in 2015 will. Specifically, under the Medicare program, no incentive payments will be made to EPs whose use of certified EHR starts after 2015. Also, professionals and hospitals otherwise eligible for incentive payments under Medicare who fail to become meaningful users by 2015 will be subject to payment penalties or “downward adjustments” to their Medicare payments. Moreover, the reporting data from physicians will be made available to patients.

Some final tips:
► With the threshold and scope of many future measures certain to increase, reevaluate your current Stage 1 plan to ensure you will be able to build off your approach to Stage 1 in upcoming years.
► Begin as soon as possible to implement the Stage 1 menu set items you've chosen to defer. Addressing any issues related to deferred menu set measures through the course of the next couple years will enable you to focus on meeting the new Stage 2 requirements.
► Nothing is final until it's final. So, visit the CMS site periodically to check for changes/ updates.

1. Federal Register. Wednesday, July 28, 2010. Part II Department of Health and Human Services. Centers for Medicare and Medicaid Services. 42 CFR Parts 412, 413, 422 et al. Medicare and Medicaid Programs; Electronic Health Record Incentive Program; Final Rule. (Accessed 12/20/11')
2. For Immediate Release: Friday, July 16, 2010. CMS Office of Public Affairs. CMS Finalizes Definition of Meaningful Use of Certified Electronic Health Records (EHR) Technology. www.go 1610%20(2).pdf (Accessed 12/20/11')

Dr. Lippiatt is CEO of Salem Eyecare Center, Inc., in Salem, Ohio. She is a technology consultant to the eyecare industry and a pioneer in EHR and healthcare information technology. E-mail her at
Dr. Castleberry is CEO of Plano Eye Associates, a group single-location private practice in Plano, Texas. He is a technology consultant to the eyecare industry and a pioneer in EHR. E-mail him at, or send comments to

Optometric Management, Volume: 47 , Issue: January 2012, page(s): 22 - 28