Posted April 17, 2015 by admin in Latest News

Should CMS Nix Stage 2 Meaningful Use Patient Engagement


Are the patient engagement requirements in Stage 2 meaningful use just too hard for providers to achieve?  CMS seems to think so.  Healthcare organizations are finding the five percent patient engagement threshold to be a stumbling block for Stage 2 attestation, the agency says in a new proposed rule that would make significant changes to the EHR Incentive Programs, and cutting the requirement would help more organizations successfully attest and avoid negative payment adjustments.

The five percent patient engagement measure has always been a worry for providers who dislike the idea of being held financially accountable for what patients do on their own time.  While many providers have successfully cajoled their patients into viewing, downloading, or transmitting their personal health information through patient portals, others have told CMS neither the technology nor the interest are sufficient to clear the bar.

“Providers and system developers have noted…an overall immaturity in the market with health IT equipped with the functions required to support the transmission of health information by a patient or the delivery of a secure message from a patient to a third party,” the proposed rule says.

Instead of pinning patient engagement at five percent, the new regulations would only require eligible providers to record one single patient viewing or transmitting their health data during their reporting period in order to meet the objective.  Eligible hospitals would need to do the same for just one discharged patient.  Instead of a five percent threshold for secure messaging, providers would simply have to prove that they had the ability to send and receive messages enabled during their reporting period.

This would require providers to implement basic patient engagement technologies, but would not place an undue burden on workflows or patient education for those organizations that have challenging populations to work with.

Many organizations have noted that the patients who would most benefit from becoming more engaged in their own healthcare, such as low-income populations who are prone to chronic diseases, poor health literacy, and uncertain access to the healthcare system, lack critical tools like reliable home internet access or smartphones that make patient engagement easier for more tech-savvy consumers.

Other advocates note that the all-or-nothing threshold does not take into account improvement over time or the effort it takes to get most of the way to the finish line.  Robert Tennant, Senior Policy Advisor at the Medical Group Management Association (MGMA), recalls testimony from a recent Senate hearing on health IT progress.

“One of the witnesses, who owns a small family practice in Nebraska, said he only had two hours to go before the reporting deadline, and they were two patients short of meeting their secure messaging threshold,” Tennant told  “So he had to call up these two patients and essentially beg them to send a message, even if it was something irrelevant like the scores to a basketball game.”

“You take a step back and it’s kind of funny, but also it’s disconcerting that the whole point of this program, which is to provide better quality care to patients, isn’t helping us find that,” he added.  “We’re finding that physicians are checking boxes, trying to meet the requirements to avoid getting penalized, and that is simply wrong.”

CHIME and AMDIS expressed similar concerns, condemning the strict yes-or-no framework that has been so challenging to providers during Stage 2.  “We are disappointed by a missed opportunity to remove the largest remaining barrier to long-term programmatic success: namely, the need to address the program’s “pass/fail” construct,” the two organizations said in a joint statement.

“Now that we are well into the penalty phase of the program, we do not believe providers who make good-faith efforts should be penalized for missing 1 percent on one threshold. Rather, policymakers should acknowledge providers who invest resources to become meaningful users, but fall short of perfection, by limiting penalties to those providers who clearly did not make the effort.”

CMS is using the modification as a way to acknowledge that something is amiss with the way patient engagement is included in meaningful use.  “We believe these changes would allow providers the necessary time to work toward patient education about the availability of these resources as well as allowing the industry as a whole time to develop a stronger infrastructure supporting patient engagement,” the rule says.

However, some patient engagement advocates immediately expressed their displeasure with the suggestion that engagement is somehow less important to meaningful use than any of the other, unchanged measures.  Patient engagement is seen as a key part of achieving the Triple Aim, and has been heavily stressed up until this point as a way to manage population health and reduce the costs of chronic disease management.

Former ONC chief Dr. Farzad Mostashari, a stalwart proponent of patient engagement, lashed out at the suggestion during a pre-conference session at HIMSS15.  “For the first time, I’m taking issue” with a meaningful use rule, he said.  “I think we need to show the policymakers that they’re not just pushing rope here. We need to show that there’s demand.”  Mostashari and others are planning a “day of action” that will try to show regulators that patients themselves are eager to get involved with their own care, and that the healthcare system is responsible for providing the tools, expertise, and commitment to allow them to do so.

“Patients are not an advocacy group,” he said. “They are not a special interest. They’re why we do this.”  The theme is likely to be repeated as the 60-day comment period for the proposed changes opens up this week.  A group called the Alliance4Health has opened a petition on to urge CMS to reconsider its ruling, noting how patient engagement can reduce data integrity errors, increase patient safety, and keep the channels of communication open between caregivers, patients, and providers.

“Patients are critical members of their own care teams and we need full and equal access to same health data that everyone else on our care team has and much of that information is now contained in EHRs,” the petition says.

CMS and the ONC don’t disagree with that premise, countered current National Coordinator Dr. Karen DeSalvo in a media briefingat HIMSS15. “Our commitment to consumers and free access to their health information is unwavering.  It is thematic and central for me as a doctor and as a person that the control is meaningful and that they are able to be engaged not just by looking, but by having bi-directional engagement with the record.”

“What’s really exciting about the last few days is the dialogue that’s ensued and what’s going to be essential is that advocacy representatives for consumers sit down and talk with providers to understand technology and cultural challenges,” said DeSalvo. “What we need to do is to find some shared solutions and they probably exist technologically today. Some of this is also about culture. The dialogue is good, and I think it’s gotten a lot of important attention. We need to find out the right path for it.”

The drastic reduction in Stage 2 does not bode well for the 25 percent threshold included in the Stage 3 meaningful use rule, which was instantly viewed with skepticism upon release.  Will Stage 3 see a similar downgrade before 2018 rolls around?  Or will CMS take into account ongoing gripes about the “check box” mentality of the EHR Incentive Programs and overhaul the requirements all together, allowing providers to submit their progress and efforts as proof that they are taking patient engagement seriously?

Healthcare stakeholders who wish to submit their opinions on the issue may do so during the 60-day open comment period by clicking here.


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