Overview: Here Come Stages 2 and 3 of HITECH!

We’ve spent the past year creating the MU (meaningful use) requirements for Stage 1 of the HITECH act.  As shown by the diagram above, Stage 1 focuses on Data Capture and Sharing. Now it’s time to begin to focus on Stage 2 (Advanced Clinical Processes) and Stage 3 (Improved Outcomes).

The current generation of EMRs (electronic medical records) were designed primarily to assist care providers with clinical documentation, billing, and maximizing revenues. They were not designed to enable care coordination and optimize population health.  

This essay is the first in a new, ongoing series that will highlight:

• Design and metrics for Stages 2 and 3 of the HITECH act
• Companies and care providers developing and using applications targeting Stage 2 and 3 MU objectives

This first essay will provide an overview of what we’ve seen in Stage 1 and what we might expect in Stages 2 and 3.

What are Major Objectives of HITECH Stages 1, 2 and 3?

While details will be outlined in future rulemaking, CMS has provided some general guidelines about the phasing of MU objectives in Stages 1, 2 and 3.

 Stage 1

• Electronically capturing health information in a coded format
• Using that information to track key clinical conditions
• Communicating that information for care coordination purposes
• Initiating the reporting of clinical quality measures and public health information

 Stage 2

• Disease management
• Clinical decision support
• Medication management
• Support for patient access to their health information
• Quality measurement and research
• Bi-directional communication with public health agencies

 Stage 3

• Improvements in quality, safety and efficiency
• Decision support for national high priority decisions
• Access to self-management tools
• Access to comprehensive patient data, and improving population health outcomes

 What Are the Planning Horizons?

• Stage 1: January 2009 to July 2010
• Stage 2: July 2009 to end of 2011
• Stage 3: 2012 to 2013

 Who’s primarily affected?

• Stage 1: hospitals and EP (eligible professionals, primarily doctors)
• Stages 2 and 3: all other health care stakeholders, e.g.,
  • Patients
  • Health plans
  • Other care providers (home health, behavioral health, SNFs, etc.)
  • Application development companies (more on this later)
  • Medical device companies
  • Pharma
  • Employers
  • Etc.

 What technologies are involved?

• Stage 1: mostly existing functionality of current EMR offerings, with enhancements to achieve specific MU objectives
• Stages 2 and 3: EHR (electronic health record) technology platforms and thousands (yes, thousands) of applications, many of which are early in-development or not-yet-dreamed-of. 

For example, the Patient Centered Primary Care Collaborative recently described the range of technologies that will be necessary to fully implement the Patient Centered Medical Home:

Definition of Health Information Technology and Exchange (HIT&E):  Any computer hardware, software, electronic service, and/or related technologies that provide or enhance the capabilities of the patient centered medical home across the community . These may be installed solutions, service solutions, or solutions provided in some way by a third party (health plan, community organization, RHIO, etc) and could include – but are not limited to – EMRs, PHRs, EHRs, interactive web portals, patient or population registries, e-prescribing software, communication platforms such as secure e-mail, online scheduling, connectivity to home monitoring systems, data aggregation and reporting services, electronic decision support tools, and other online or web services that accept and process personal health data for the purpose of supporting better health care decisions.

Unintended consequences?

Stage 1:

• One well recognized unintended consequence was that development of Stage 1 MU effectively stalled EMR purchases by hospitals and doctors – the opposite of the intent of the stimulus legislation. Everyone waited to see the details.
• A less well recognized unintended consequence of Stage 1 was that vendors who bring functionality not directly contributing to achievement of Stage 1 MU criteria have had a difficult time getting hospitals and doctors to pay attention or even return phone calls. Care providers are paying attention to Stage 1 MU criteria — and little else.

Stages 2 and 3: lot of possibilities for unintended consequences…future articles in this series will discuss these.

How will all this play out?

We don’t know.

My cautiously optimistic side foresees a golden era of care coordination and population health improvement.

My skeptical side foresees a complex regulatory scheme micromanaging care provider incentives and actions — bureaucrats practicing medicine.

What we know: achieving data interoperability will not be easy.

What we know we don’t know – achieving the next level of technology enabled workflow interoperability across care providers is an issue hardly anyone has even thought about. For a refresher on the critical differences between data interoperability and workflow interoperability, revisit the essay Geek Wisdom: “Interoperability” Must Include Process Collaboration.

There are exciting and challenging times ahead….