Electronic Health Records

Transitioning to Stage 2 Meaningful Use: Are you ready?

It’s coming faster than you think! The deadline to attest for Stage 1 Meaningful Use is October 1, 2013 — and while numerous hospitals have already met the requirements, they are quickly discovering that Stage 2 is another much more complicated story. In fact, a recent survey from KPMG found that only 36 percent of hospital leaders felt that they could meet Stage 2 requirements. Among the key reasons is that every threshold but one has changed. Many measures have shifted from menu to core objectives and there are higher thresholds and more exclusions. The resulting challenges add up to a daunting task most hospitals are not prepared to meet.

Let’s dive into the details of these challenges, specifically difficulties related to changes in the scope of specific measures. First, we’ll explore how those changes necessitate altering the EHR to support not only dramatically different and more comprehensive reporting, but also numerous alterations to process and workflow. Next, we’ll cover how, in addition to reporting, Stage 2 Meaningful Use now demands an in-depth examination of patient care through coordination of better clinical decision support (CDS) as well as patient engagement in their own care. Lastly, we’ll build the case that while during Stage 1 many hospitals focused on technology over workflow, they will now need to alter that mindset to focus on workflow first to ensure a successful meaningful use attestation in Stage 2.

Themes for Stage 2 measure reporting

The overarching Stage 2 objective is to use clinical decision support and care coordination to help improve overall care quality. Some of the key themes designed to help meet that objective are:

New criteria: Hospitals have to meet the new criteria for Stage 2 as well as those for Stage 1

Improving patient care: Stage 2 creates new objectives to improve patient care through better CDS, care coordination, and patient engagement

Saving money, time, and lives: EHR implementation must demonstrate a cost and time savings to the United States health care system as well as enhanced patient outcomes

Highlights outlined in the certified EHR technology (CEHRT) of how hospitals must meet these themes are:

• Enhancing standards-based exchange
• Promoting EHR technology safety and security
• Enabling greater patient engagement
• Introducing greater transparency
• Reducing regulatory burden

All the above lead to numerous changes in reporting requirements as well as the process and workflow needed to produce the reports. However, there is much more to consider. The Centers for Medicare & Medicaid Services (CMS) has also increased its requirements around the Office of the National Coordinator for Health Information Technology (ONC) certification.

ONC certification

Another key consideration for hospitals for Stage 2 Meaningful Use is ONC certification. Stage 1 called for only a Temporary Certification Program, which should be thought of more as recommendations. In Stage 2, that certification will definitively require that the EHR prove its functionality and meaningfulness. Hospitals will also be asked to use indicators and requirements for certification that are more comprehensive and rigid than in Stage 1.

Let’s take a quick look, for example, at the requirements for ONC certification (Figure 1). The challenge will be drilling down into the details to see how these requirements really impact the EHR and create a need to alter workflow and processes. First, hospitals need to focus on the details in the actual requirements for the base EHR to determine modules that need to be deployed just to meet the measures. Then, they need to consider the indicators for core and menu objectives and what modifications are required to support inclusions and exclusions to meet thresholds. Finally, they must sort through all of the complexities of the clinical quality measures (CQMs) to do the same.

The next phase is data mapping. Data mapping and modification to the EHR is a daunting task because each and every indicator for core and menu objectives and CQMs has a series of implications and if/then questions that need to be reviewed and answered to help create the report. Many of these answers will then necessitate modifications and additions to multiple modules of the EHR system. However, the all-encompassing issue is that these system modifications mean numerous process and workflow changes to ensure that the data is not only in the record but also entered by care management staff and able to prove compliance. While this seems like an impossible battle, the reality is that such stringent requirements are really the only way that hospitals will be able to prove that the EHR is in fact helping to improve care quality.

What can I keep from Stage 1?

The good news? If you have successfully implemented Stage 1 Meaningful Use, then you already understand the complex shift from other quality reporting programs and that meaningful use is unlike any other federal program because it requires structured and codified data. The bad news: You have to start over again.

Quality or regulatory team professionals will need to reread the requirements because every indicator but one has changed, many measures have shifted from menu to core, thresholds are higher, and exclusions are more numerous (Figure 2–4). The IT team will be required to rewrite the reports and remap the data elements in the EHR to create these reports. Then, the care management team needs to be retrained on new procedures and workflow based on these changes. Odds are that unfortunately many hospitals are in for a rude awakening to meet Stage 2 requirements.

Getting help

My best advice is to keep researching requirements and to try to access help. Read all CMS and the Joint Commission documentation to ensure that you understand the changes. Seek help and advice from your colleagues and other agencies such as CMS. Create a meaningful use team that pulls in administration, quality, information technology (IT), and nursing to ensure that all stakeholders are involved in critical decisions that can impact the entire hospital. Consider talking to a consultant or regulatory reporting vendor that specializes in meaningful use. Information is knowledge, and there is a lot of information available, so locate it and use it before diving into the details of implementation.

Meaningful use is complex and is only getting more complex as the stages progress. However, complexities can be resolved. More importantly, overcoming them is worth the effort. While the changes are daunting, they are moving hospitals increasingly closer to what the EHR Incentive Programs were intended to do — help us use the EHR to improve the quality of care. Change is difficult, but change is often extremely worthwhile. In particular, the changes required for meaningful use are designed to save lives. What better reason to make them happen?

Additional resources

Lantana Consulting Group’s eSpec Navigator
CMS legislation for Stage 2 Meaningful Use
US National Library of Medicine Value Set Authority Center
CMS overview of Stage 2
CMS CQMs Tipsheet
Institute for Health Metrics “Devil is in the Details of Stage 2: Impact to the Practice of Performance Improvement”


Paulette Di Angi, PhD, RN, CPHQ, is the Institute for Health Metrics Chief Clinical Information Officer.  Prior to joining IHM, she held senior leadership positions at Newton Wellesley Hospital, Cape Cod Healthcare System, CIGNA Healthcare, MCC Managed Care, Valley Hospital and Hamot Hospital. Dr. Di Angi holds a PhD from Case Western Reserve University, Frances Payne Bolton School of Nursing, and a Masters from University of Iowa College of Nursing. Her BSN is from Villa Maria College.







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