Meaningful Use Opens Up Its Deep End: With Some Providers Still Dipping Toes, CMS has Opened up its Health IT Program's More Challenging Deep End with Stage 2

By Mary Butler; Illustration [in print version of article] by Michelle Barbera

Sink or swim. These are the two choices participants of the "meaningful use" EHR Incentive Program will soon face now that the federal government has opened up the program's deeper, more complex second stage.

Though physician and hospital involvement in the program has increased dramatically since stage 1 was implemented in 2011, graduating to the more advanced stage 2 could cause some providers and their health IT systems to struggle in more challenging waters, according to Brent Holman, the director of consulting for Health Management Solutions (HMS) who has worked with large and small providers on meaningful use. "Stage 1 is the physician dipping their toe in the water and taking the temperature," Holman says. "In stage 2, they get kicked in."

This month, eligible hospitals can begin attesting to stage 2 of the meaningful use program, which was created by the American Recovery and Reinvestment Act of 2009 (ARRA) to help ramp up adoption of electronic health records (EHRs) through financial incentives. Independent physicians and other eligible medical professionals can start attesting to stage 2 in January 2014.

The program, as administered and enforced by the Centers for Medicare and Medicaid Services (CMS) and developed by the Office of the National Coordinator for Health IT (ONC), was intended to help bridge the digital divide for healthcare providers. Providers must figure out how to embrace this rapid change or pay a hefty price—including penalties if they don't meet meaningful use requirements by 2015.

Stage 2 ups the interoperability ante and requires providers to demonstrate that their patients can electronically view, download, and transmit their health information. To get a sense of how this will all play out, it's important to take a look at how stage 1 is going and find out what providers and HIM professionals are doing now to ensure a smooth transition to stage 2.

Early Implementers Get a Jump

Providers that started practicing their stroke early in the shallow waters of stage 1 appear to be most confident about starting the attestation process for stage 2. Steve Smith, the chief information officer for Evanston, IL-based NorthShore University HealthSystem, is hopeful that his hospital will be ready to attest to stage 2 in October and that the rest of the system's eligible providers will begin attesting in January 2014. NorthShore went live with its EHR in 2003, so much of the EHR infrastructure has been in place and functioning for a decade. The NorthShore system has four hospitals serving Chicago's northern suburbs and more than 100 medical offices across the region. Still, there are stage 2 objectives that will pose a challenge for NorthShore. For example, the electronic transitions of care requirement.

"Transitions of care are one of the newer ones [criteria] where meaningful use is asking that 10 percent of transitions from the hospital to providers outside of NorthShore be done electronically. It's the beginning of making sure that organizations can share patient data with each other," Smith says, adding that his organization has been working on stage 2 preparation extensively.

Christopher H. Tashjian, MD, who practices in three rural satellite clinics in the Wisconsin towns of Ellsworth, River Falls, and Spring Valley with one other physician and a physician assistant, plans to attest to stage 2 in April. Tashjian also serves as an ONC Health IT Fellow, a voluntary position in which he advises other providers on meaningful use.

Tashjian says his practice had implemented an EHR prior to joining the meaningful use program, and relied heavily on Wisconsin's regional extension center (REC) to comply with the requirements. Tashjian explains that while the criteria for stage 1 and stage 2 might seem daunting, "It's hard to argue that any of these don't improve care. So we don't look at them as trouble, more as a way to move the electronic record forward."

Tashjian doesn't see his location or the size of his practice as a hindrance to implementing an EHR or complying with meaningful use. This is notable since ONC has taken several steps to reach out to rural providers who they felt may have a more difficult time with meaningful use due to a lack of resources, such as high-speed Internet access and funding from major research hospitals.

"Virtually everyone in our area is adopting because they don't want to get left behind," he says.

Highly REC-ommended

Many providers have praised the efforts of their local RECs, which—modeled after agricultural centers—were established to help small, rural providers or those in medically underserved areas comply with meaningful use requirements and implement certified EHRs. Based on the statistics ONC provided to Congress in June, the 62 RECs nationwide have provided assistance to 100,000 primary care providers. What's more, according to ONC data, Medicare providers working with a REC are 2.3 times more likely to receive an EHR incentive payment than those not working with a REC.

ONC's Judy Murphy calls RECs the "foot soldiers" of meaningful use implementation. However, the federal funding that keeps many RECs up and running is set to run out in 2014, causing some concern in the provider and HIM community.

Kimberly Lynch, ONC's director of the regional extension center program, says that the RECs are in the process of testing and developing new business lines that will keep them running far beyond the ONC funding period.

"They will be looking for other funding opportunities," Lynch says. "Some are already the recipients of streams of federal funds. But they also have state level opportunities and many RECs are partnered with Medicaid programs to sustain services."

Lynch says that RECs' revenue streams and business models will vary state to state. Some will partner with and get paid directly by hospitals, independent physician associations, physicians, patients, and small practice providers as paid health IT consultants and support firms.

"It's really knitting together the marketplace needs and opportunities that exist," Lynch says. "So each REC will look a little different, but that's as they were designed to be. To be responsive to their marketplace and to their providers."

Getting Providers Comfortable with the Deep End

But not everyone in the healthcare environment is ready to tackle stage 2. Holman is concerned that the industry—including HIM professionals, EHR vendors, and providers—might still be unprepared for stage 2. Holman consults with hospitals ranging in size from 25-500 beds on meaningful use compliance. While his primary focus has been stage 1, he says he ends every consultation with a conversation about stage 2. One of Holman's biggest concerns about stage 2 involves hardware upgrades.

"I feel like with the requirement of everyone having to be on a stage 2-certified system, that's really going to create a bottleneck for every hospital and vendor alike, because a lot of them are requiring upgrades to support the new systems," Holman says.

Industry groups and even some lawmakers have wondered if extending meaningful use implementation deadlines might ease these problems, an option some are pressing ONC to consider. Holman says he "could argue both sides of the coin."

In the long-run, though, Holman says the thing he really likes about stage 2 is the standardization of SNOMED CT codes and how that "is going to allow systems to talk to each other, and I think all that can improve outcomes and allow for more utilization of data."

Meaningful Use's Victories

While it might be too early to determine whether providers are ready for stage 2, let alone whether it will be a success, there are plenty of opinions—and statistics—on stage 1.

In testimony before the Senate Finance Committee in July, Farzad Mostashari, MD, ScM, the now former national coordinator at ONC, reported that as of May 2013, 293,000 eligible professionals and over 3,900 eligible hospitals had received incentive payments from the Medicare and Medicaid EHR Incentive Programs, representing almost 80 percent of eligible hospitals and over half of physicians and other eligible professionals.

Christine Bechtel, vice president of the National Partnership for Women & Families and a member of ONC's Health IT Policy Committee—the committee that helps create the meaningful use measures—says that without a doubt meaningful use has been the single largest driver of health IT adoption in history.

Bechtel says that the financial incentives provided by meaningful use, combined with external factors and other delivery system innovations, are driving EHR adoption in a significant way.

"That's been a huge victory for us," Bechtel says. "We now have majorities of health professionals in this country using EHRs. Patients and families have begun to expect that EHRs are a normal part of healthcare delivery, a standard, important part of health delivery... patients and families are being engaged in new ways.

"And by that I mean, for example, a core requirement of stage 1 requires a provider to give a summary of an office visit. We didn't have that before."

Tim Klemme, the clinic administrator at Ridge Family Practice in Council Bluffs, IA, has seen the benefits of EHRs firsthand. As a successful stage 1 attester, Klemme says both he and his office's patients love the clinic's EHR, which helps the practice look "cutting edge." His office also has an online portal that patients can log in to.

"It allows patients to have a voice in their care—review current diagnoses, ask for a refill. Years ago they weren't able to look through and discern if it's what they felt it should be. That portal allows them to provide powerful input," Klemme says.

Allison Viola, MBA, RHIA, vice president of policy and government affairs at the eHealth Initiative, agrees that as a program meaningful use has had a positive impact on healthcare delivery, giving physicians "more awareness to the value it can bring to patient safety and exchanging data."

But Viola acknowledges that implementation has been difficult for many providers. And that can get trickier in stage 2, since physicians will be tasked with getting their patients to log in to a portal to access their health records—a program measure requirement.

"The provider has to set up a mechanism so patients can get info. It puts the responsibility on the provider to actively encourage patients to go online," Viola says. "There's only so much a provider can do to encourage patients to go online and access their records."

Meaningful Use Criteria and Objectives for Stages 1, 2, and 3

Meaningful use objectives, criteria, and measures will evolve over the five-plus years of the program.

Source: ONC

Stage 1's Darker Side

For Douglas Morgan, MD, who is the sole practitioner in a family practice in the New Orleans suburb of Metairie, LA, patient portal use and other stage 2 measures will be a challenge. Morgan attested to stage 1 in January 2012, but says his patients don't seem interested in interacting with the EHR.

Patient interaction with the EHR—or lack of it—seems to be tied to the patients' age, Morgan says. His practice is 39 years old, and many of his patients began seeing him when they were in their 30s and 40s. These patients aren't tech savvy and many don't have computers.

"Meaningful use is supposed to mean that it has to do with improving patient care, but so far I haven't seen it. I'm not sure what it would take to see it," he says.

Morgan has had other frustrations with the program. Even though he attested successfully in 2012, he said it took CMS eight months to send his incentive payment. The reason for the eight-month delay: CMS thought Morgan's practice was in Missouri, not Louisiana, where his practice has always been located.

EHR Incentive Program Timeline

This table provides an overview of the EHR Incentive Program payment timeline for eligible healthcare professionals.

Source: ONC

Uncertainty Ahead for Stage 2

To gauge the readiness of healthcare providers and HIM professionals for stage 2 meaningful use it might help to catch an episode of the beloved sitcom "The Office" in syndication.

The show's characters, employees of a paper company called Dunder Mifflin, struggled to sell a product in decline. Their customers were entering the digital age, where information could be accessed instantly and remotely, and archived indefinitely. Some characters rushed to embrace new technologies, some were hesitant, but many were skeptical. Sounds similar to the current healthcare environment when it comes to meaningful use.

Officials at ONC and CMS acknowledge that EHR adoption and meeting meaningful use criteria is a bumpy road, even for the most prepared providers.

Judy Murphy, deputy national coordinator for programs and policy at ONC, understands the frustrations of providers such as Morgan. "Now, do all the benefits just magically come because we got EHRs in? No, and that's why I emphasize we were setting the infrastructure," Murphy says. "If we're going to talk about exchanging information between settings of care, hospitals and long-term care providers, ambulatory care centers and pharmacies, we have to have the electronic infrastructure first."

Having the infrastructure in place is critical for stage 2 measures that tighten requirements for electronic transition of care referrals and summary transmissions. Hospitals participating in meaningful use could have trouble with this requirement when discharging patients to post-acute care providers. Nursing homes, rehabilitation facilities, assisted living communities and other post-acute providers are exempt from meaningful use requirements and may or may not have electronic records, which poses a problem for hospitals seeking to meet the electronic care transition requirement when transferring patients to these facilities. "EHR adoption is hard," Bechtel agrees. "When any industry automates, it's just hard." She adds that meaningful use needs to continue to exist because it's the only standard for interoperability requirements. "The program is the lever," she says.

But Bechtel concedes that there's a chance there will be delays in the timeline for stages 2 or 3. If that happens, it would hurt the momentum of EHR adoption. Officials at HHS agree.

At press time, officials at ONC and CMS said they had no plans to delay stage 2. Robert Tagalicod, the director of CMS' office of e-health standards and services, says his office is being sensitive to providers already tasked with implementing ICD-10-CM/PCS, meeting RAC audit requirements, and other regulations over the next several years when considering any sort of delay.

"I think part of it is we're trying to think strategically and understanding that several folks within the industry have said the 'B' word, the burden word," Tagalicod says. "And so we're trying to be sensitive to that, and mitigating any unintended consequences."

However, delays are just what some groups—such as the American Medical Association, the American Hospital Association, and the College for Health Information Management Executives—are pushing ONC and CMS to offer.

In a joint July 25, 2013 letter to HHS Secretary Kathleen Sebelius, the AMA and AHA urged the government to add "no less than three years" to each of the three stages of the meaningful use program, as well as extend reporting periods and other modifications. Even members of Congress have pressed ONC over whether a delay could improve interoperability of EHRs. Still other congressmen have sent letters to Sebelius stating the meaningful use program should be suspended since, they feel, it is not accelerating the improvement of care or EHR interoperability fast enough.

There has been some speculation in the HIM and provider community that CMS and ONC might extend its meaningful use and certification programs to a stage 4 or stage 5. ONC's Murphy suspects that speculation stems from people wondering "Are we ever going to be done? And we will never be done," she says. By its nature, health IT must continuously improve and update, much like Apple updating the iPhone or Microsoft issuing Windows upgrades.

Murphy adds that as health IT continues to advance, and providers become more comfortable and prolific with the technologies, the bar for success will need to be continually reset. A need for a new set of goals will also be re-evaluated. But whether those goals are set by the government, the market, or by quality and health IT organizations remains to be seen, according to Murphy.

Words from the Wise

Providers just starting their EHR implementation or meaningful use participation might have a hard time seeing the forest for the trees. "And it's a big forest," admits NorthShore's Smith. "If you're starting out fresh right now and trying to catch up, it's a daunting task and an expensive one.

"The earlier on you get started the better off you'll be."

This is particularly important as interoperability and transitions of care requirements grow more stringent in stage 3. Smith says providers must choose their EHR vendors carefully and with full cooperation from physicians.

"It has to be a partnership between operations and IT as you look at these solutions. Make sure it's a clinician-run process, so that it's meeting their needs and not IT bringing a solution to the table that won't fit the workflows of a clinician," Smith advises.

Succeeding with meaningful use and EHRs is partly about mindset, according to Tashjian, especially for physicians like him who have been working on paper for 20 to 25 years. "You cannot look at it as making paper electronic. You have to step back. You have to look at it as a completely separate method of documenting," Tashjian says.

One lesson Tashjian learned from his REC is that if you think of converting to an EHR as just putting paper on a computer, you're not going to be happy. "You have to learn how the computer works and take advantage of the things the computer can do that paper can't.

"If you do that, and stop making shortcuts, then you can be very productive."


ONC. "Update on the Adoption of Health Information Technology and Related Efforts To Facilitate the Electronic Use and Exchange of Health Information, A Report to Congress." June 2013.

Mary Butler ( is associate editor at the Journal of AHIMA.

Article citation:
Butler, Mary. "Meaningful Use Opens Up Its Deep End: With Some Providers Still Dipping Toes, CMS has Opened up its Health IT Program's More Challenging Deep End with Stage 2" Journal of AHIMA 84, no.10 (October 2013): 24-29.