Looking Forward to MU Stage 3


Every year Galen carves out a few days to regroup internally, looking towards the future of the healthcare IT industry, as well as recapping where we’ve come from.  As we do this, I’d like to do the same with Meaningful Use (MU) – reflecting on lessons learned from the past four years, as well as looking forward to MU Stage 3.

The goals for the three MU stages can be summarized as:

Stage 1: Data capture and sharing

Stage 2: Advanced clinical processes and decision support

Stage 3: Improved outcomes

The three stages were originally geared to support the healthcare industry’s move towards controlling costs, increasing quality, and improving patient health outcomes. Since the start of the meaningful use initiative in 2011, the healthcare industry has experienced significant changes with a particular shift toward Accountable Care Organizations (ACOs), where providers specialize in managing outcome risks for patient populations through patient care coordination.

Last month, the Office of the National Coordinator for Health Information Technology (ONC) and the Centers for Medicare & Medicaid Services (CMS) announced a delay to the start of MU Stage 3 to 2017, listing the following benefits for the changes to the MU Stage 3 timeline:

  • More analysis of feedback from stakeholders on Stage 2 progress and outcomes;
  • More available data on Stage 2 adoption and measure calculations – especially on new patient engagement measures and health information exchange objectives;
  • More consideration of potential Stage 3 requirements;
  • Additional time for preparation for enhanced Stage 3 requirements;
  • Ample time for developers to create and distribute certified EHR technology before Stage 3 begins, and incorporate lessons learned about usability and customization.

The delay impacts participants who began MU Stage 1 in 2011 or 2012, as they will now demonstrate MU Stage 2 for a third program year in 2016 before proceeding to MU Stage 3 in 2017.  For those who did not begin in 2011 or 2012, the last year to start participation and receive a payment was 2014.  Beginning January 1, 2015, eligible providers (EP) who do not successfully demonstrate meaningful use are subject to a negative payment adjustment. EPs who attest for the first time in 2015 will not receive an incentive payment, but can still avoid the penalty.

ONC and CMS have also proposed a new approach to the Certified EHR Technology (CEHRT) certification process, though the “2014 Edition” will still remain the baseline.  Vendors who have certified applications to the 2014 Edition will not need to recertify their products, and providers participating in incentive programs will not be required to upgrade beyond a 2014 Edition CEHRT application.  Per CMS, the goal of the new approach is to “to provide public input on policy proposals, enable our certification processes to more quickly adapt to include newer industry standards that can lead to greater interoperability, and add more predictability for EHR technology developers”, all the while allowing vendors more time to react.

As of January 12, 2015, CMS has not released a notice of proposed rulemaking (NPRM) for Stage 3, or the corresponding ONC NPRM for the 2017 Edition, or proposed interim 2015 Edition of the ONC Standards and Certification Criteria.  They document current recommendations for Stage 3 on their website.

CMS and ONC will continue to review all stakeholder comments before the final rules are published. The following is a sampling of feedback that has already been presented.

Stage 1 Lessons Learned

In the beginning, providers and healthcare organizations were challenged to understand what was needed. It took the organizations time to assemble teams with the right skills, build the infrastructures, and learn new processes to support Stage 1 requirements.  And while the incentive money has been a valuable motivational tool for providers and organizations, it took time to gain their attentions and to learn new requirements.

Stage 2 Lessons Learned

Transitions of care require community infrastructure and cooperation, with a reliance on patient actions and costly technology. To meet the new criteria, organizations have had to define new strategies, processes, and workflows for referrals and transitions of care.  It was, and still is, challenging to implement additional technical and organizational infrastructure in time for attestation.

Resource needs are greater in Stage 2 to develop the understanding of the requirements of the multiple activities and the coordination between the multiple vendors (MU, ICD10, PQRS, eRx, Direct Message IDs, etc.).

Key Takeaways and Recommendations for Stage 3

One of the biggest lessons learned is to allow enough time, especially when the objective is to improve outcomes and reduce costs, all the while emphasizing interoperability, care coordination, and quality of care.

Stage 1 and 2 are two-year reporting cycles, but the implementation required more, sometimes up to five years. The Stage 3 implementation could take even longer considering the stricter vendor requirements, higher user adoption, the fact that obsolete systems must be replaced, and that new systems must be integrated to support these measures.  CMS and ONC need to allow sufficient time for those changes in organizational infrastructure and workflows, meaning all required materials, such as CQM specifications, need to be available at least eighteen months before the start of Stage 3.

In addition to important time considerations, recommendations from providers and healthcare organizations include:

  1. Providing additional incentives for interoperability.
  2. Improving financial incentives for ACOs to assume risk and reward providers that do share risks.
  3. Streamlining high-value quality measures.
  4. Considerations for the impact on usability, development and implementation costs.
  5. Reconsideration of the “all or nothing” approach to attestation and full year reporting.
  6. Allowances for group reporting as is done with PQRS.
  7. Avoiding measures that require third party action (patients and other care settings). Engage patients, but do not force their engagement.

Healthcare organizations and EPs have gone through many challenges since the beginning of MU.  CMS and ONC responded to the providers’ feedback by delaying the start of Stage 3, and their intent is to deliver a final rule with smaller, more incremental changes that will be smoother for organizations to adopt. In addition to incorporating the lessons learned from Stages 1 and 2, organizations recommended that Stage 3 align with other pertinent healthcare initiatives such as ACOs.  We look forward to receiving the Stage 3 final rule sometime in Q1 or Q2, with new requirements that will hopefully result in the adoption of positive, manageable changes for healthcare organizations.

Reference: http://www.cms.gov/eHealth/ListServ_Stage3Implementation.html

Getting data from your EMR does not need to be like drinking out of a fire hydrant

Maybe we just need to optimize the fire hydrant

Maybe we just need to optimize it.

“Reading an EMR is like taking a drink out of a fire hydrant, it is bloated with repetitive data” – Keith Kein, MD http://www.kevinmd.com/blog/2015/01/emrs-can-hurt-physicians-lawsuits-heres.html …was the tweet that led me to Keith Kein’s blog on risks of EHR data in lawsuits.     I would be lying if I didn’t admit that I was irritated by the headline and even more frustrated by the content.   Dr. Kein went on lament that Electronic Health records are systems designed to make billing more efficient, and that in the absence of efficiencies for physicians many are “copy and pasting” from one note to another to add efficiencies and instead often add incorrect, old or repetitive data to the chart.

These are not new assertions, and I have spent many hours sitting next to physicians listening to these complaints and more, as we work to implement new systems or improve existing ones.     In many facilities there is a tension between the clinicians and the administration that gets simplified by one group saying “The Problem is the EHR” and another saying “The problems is how they are using it.”   The truth is much more complex.

The first generation of Electronic Medical records were built to replace a paper process.   The act of transforming what we did on paper to what we do on computers was revolutionary at the time – we have data saved, easily available, legible and yes, codeable and auditable.   Billing is faster and more efficient.     Capturing the necessary clinical information for billing appropriately has been a part of the landscape of American medicine for some time before electronic health records, and was a focus of this first generation of applications.    

We are now in a new and exciting time in the development of EHRs.     We are starting to move beyond the phase of translating the paper process of electronic.     The question before us now is – what is the best technology to practice the best medicine?       This is the conversation that I have with physicians, nurses, office managers and Administrators when we start to talk about build, design and/or optimization.

We know the tools that we have today, and we know that there is great potential within those tools, as well as the potential for growth.     When you find yourself tempted to complain about the process…I challenge you to push that aside, push your paper workflows aside, push your departmental divisions aside and ask these questions:

  • Who are the stakeholders in this process? (providers, nurses, office staff, patients, administrators)
  • What is the data that we need to collect and how will it be used by the stakeholders?
  • How do we make the job of data collection & transfer of information easy for all parties involved?
  • What is the ideal workflow to provide the best medicine?
  • What are the tools that we currently have at our disposal?
  • Can we meet our goals with our current tools and resources?

These are my favorite discussions.     We are often limited in our thinking to what we understand an application to be capable of.   I think all too often we forget to take a step back and explore what will really help move an organization forward and use that as our starting point.   Often times we even find the solution is using our existing technology in a different way, or investing in one area of improvement will improve user satisfaction and in the end help us all provide better medicine.

It is not easy.  In a climate of ever changing regulations, incentive programs, billing models and software updates, we are all to often focused on what is the next big project insead of on what is the right thing to do for this practice, this organization, this health care setting.   

Every conversation should always come back to this. How are we going to practice the best medicine today, and tomorrow?

Electronic Prescribing of Controlled Substances (EPCS) – Part 1

Allscripts’ TouchWorks EHRTM version 11.5 is GA as of 1/14/2015. One of the primary enhancements in 11.5 is the Electronic Prescribing of Controlled Substances (EPCS).

EPCS will allow designated, approved providers to submit controlled prescriptions (Schedules II-V) electronically. System administrators of the TouchWorksTM application will have new preferences to configure and will need to perform several setup requirements in order to utilize this new feature.

The Drug Enforcement Agency has approved the submission of electronic prescriptions for controlled substances (Schedules II-V) to pharmacies. Each organization should check with their state regulations. There are 48 states participating in EPCS thus far, and New York is mandating all prescriptions be electronic starting March 27, 2015. Each organization will need to verify if your state and local pharmacies are ready to perform EPCS, as it will need to be enabled by each pharmacy in order to function. As part of the new EPCS functionality, providers and organizations may be concerned about the security of transmission. The two-factor authentication process relies not only on a user password, but also on a physical one-time password (OTP) device. This two-factor process will ensure the extra security required when prescribing controlled medications. There is a rigorous setup process in place in order to ensure the proper security is in place for the process’s execution, and in future releases, it will allow for biometric devices as well.

What’s new in the application for EPCS?

Area Function Purpose
TWAdmin>Queue Admin Message Center Setup Allows the areas previously configured within the AHS CSS Configuration Manager to be set directly from within the application.
TWAdmin>EPCS Admin (eRx) EPCS Admin and Surescripts Admin Both the EPCS configuration and Surescripts administrative functions are embedded directly into the TouchWorksTM application. Starting in 11.5, system analysts do not need to log in to Enrollment Blaster to enroll providers into Surescripts, as it can all be done from within the TouchWorksTM application.
TWAdmin>TWUser Admin Allscripts Security Account Allows the setup of the initial Tenant Administrator and subsequent Tenant Administrators for EPCS.
TWAdmin> Security Admin Security Gates Two new security gates are available for EPCS: EPCS Admin and Tenant Admin.
TWAdmin>Preferences General and Meds There are several new preferences for EPCS, ranging from enabling the feature to deciding on security account setup (manual vs. automatic).
Touchworks>EPCS EPCS reports Provides the ability to view and audit EPCS daily incident reports.

Message Center Setup

Message Center Setup

EPCS Admin and Surescripts Admin



There are several key high-level areas for consideration when beginning to configure TouchWorksTM for EPCS, as described below:

  1. Designate the Administrators for the application and EPCS enrollment and also provider identity proofing. Provider identity proofing is the process to verify the provider is who they say they are. This process may include a notary and/or your credentialing department.
  2. Review existing policies for prescribing and update any policies and procedures prior to implementation on who can and cannot prescribe, who will be monitoring of audit reports, etc.
  3. Enable Surescripts enrollment in the Message Center Setup.
  4. Turn on the EPCS functionality (via the new preference) and assign security for the EPCS Admin/Tenant Administrator to the appropriate system analyst team members.
  5. Set up the initial Tenant Administrator. Allscripts will enable the initial Tenant Administrator. This individual will then add subsequent Tenant Administrators as deemed appropriate. Tenant Administrators will manage the enrollment of user/providers in EPCS and set the initial preferences.
  6. Designate the appropriate EPCS approvers.
  7. Review the preferences for medications and make necessary adjustments (i.e., disable faxing of controlled medications, changing authorization to Prospective for medication authorization ordering).
  8. Begin enrollment for EPCS of appropriate providers.
  9. Monitor/audit EPCS reporting regularly.
  10. Perform maintenance and monitoring of user setup (e.g., DEA, NPI) and proper administrative actions as needed for suspension/removals/inactivation of EPCS.

EPCS has several areas of configuration, and the above is just a high-level overview for what is available in 11.5. This functionality will certainly allow providers to improve patient care and safety, particularly around the prescribing and delivery of controlled medications.






Professionalism, Constructive Feedback, and the Four Gates of Speech


In this world of electronic communications, it has become easy to have a thought pop into our heads and spew forth from our fingers without us giving a second thought to how the message will be received.  I nearly found myself in this situation last week when I received what I am sure was intended to be constructive feedback from a colleague.  As a true Floridian who loves the sun, compounded with the fact that as I was fighting a raging head cold in wintry New York City, I realized I was probably not in the best frame of mind to receive that unsolicited opinion.  Still, the critique came across as harsh, unpleasant, and negative, and it left me irritated and hurt.

As I was attempting to process this feedback and formulate a semi-professional response, I happened across a bio from a co-worker citing her utilization of the Four Gates of Speech in her everyday life. Putting it all together, it struck me how we could all use a reminder on how to frame our interactions with others in a mindful way.

For those unfamiliar with the tool, the Four Gates of Speech is a framework to evaluate the message we are deliver to others before actually speaking. As we formulate our feedback we should attempt to pass through the four gates in the order listed below.

  • Is it truthful?
  • Is it necessary to say?
  • Is it the appropriate time?
  • Can it be said in a kind way?

If the answer to any of the gates is “No”, take a closer look at what you are trying to say and the underlying motivation in your communication.

Maybe your co-worker didn’t follow through on the deliverables as promised, your client still hasn’t sent you the spreadsheet due two weeks ago, or you’re unhappy with the service you’ve received from a vendor, does that justify a shoot-from-the-hip communication approach?  Before you send that email, text, or instant message today that you may regret having sent tomorrow, take a quick second to ask yourself the following questions:

  • Is what I have to say true?  Was that really THE worst service you have ever received? Were there truly hundreds of mistakes in the spreadsheet? Stick with facts and be accurate in your statements. Try to be subjective in your feedback and comments and realize that every situation is tainted with your own experiences. Don’t project your suppositions and history on to the recipient.
  • Is what I have to say necessary?  Do you really need to say anything at all or are you just having a knee jerk reaction to the situation? Is it really your place to be the one to provide the feedback or would it be better received from someone else?
  • Is it the right time?  Timing is everything. We work in such a physically disconnected world it’s easy to forget not everyone is in the same mental space at any given moment. Heck, chances are they’re not even in the same time zone. We are bombarded with input from our cell phones, email, Facebook, Twitter, Instagram, Slack, instant messaging, etc. all day long. Take a minute before you hit the send or post button and ask yourself does this message pass the Four Gates criteria? Is this really the right medium to be sending this message? It is difficult to sense tone in most electronic formats, so give pause to reflect on how the message may be received, not just how you intended it to be received.
  • Is what I am saying kind?  Oh, we’ve all been there. You fire off that email or instant message without a second thought only to stumble across it a few days later. Yikes! You cringe scanning your words and wonder, “What was I thinking?”  Yeah, it might have felt good being a little too harsh or flippant in the moment but is it a message you would want your child to receive from his or her colleague? Would you be proud to tell your grandmother you spoke to someone else in that way?  From a professional perspective, do you want to look back on the message with your manager when trying to show what a good worker you are or when you are applying for a promotion?  Take a big picture approach. Is it really that important for you to air your frustrations in the grand scheme of things?

The world we live in is complex, fast-paced, and filled with countless interdependent moving parts and people. It’s understandable that we often don’t have or take the time to reflect on the things we say and do, but that doesn’t mean we shouldn’t try. Down the road, our actions inevitably will have an impact for better or worse, so why not take a moment, reflect on the Four Gates of Speech, and skew the odds in your favor? And remember, The words you speak become the house you live in. — Hafiz

Syndromic Surveillance


Syndromic surveillance is a method of collecting and using clinical data for the early detection of potential disease outbreaks. For Meaningful Use Stage 2, there are several scenarios in which Eligible Providers (EP) can meet the Syndromic Surveillance Menu Set measure.  Each of those scenarios can be grouped into one of two categories:

Syndromic Surveillance is Available in your State

The first scenario occurs when an EP has been submitting information using an ONC certified EHR prior to the EP’s MU Stage 2 attestation, and continues to submit during the reporting period.  At this point in time, very few EPs fall into this category, but for those who do, no changes are necessary.

The next scenario happens when an EP registers intent with the state within 60 days of the reporting period and achieves ongoing submission of data for the reporting period.

Syndromic Surveillance is not Currently Available in your State

For many states Syndromic Surveillance is not yet up and running, so ongoing submissions are not an option for meeting the measure.  In this scenario CMS requires you to register intent with your state within 60 days of the start of your reporting period. Once you’ve registered, intent your organization will need to engage in the required validation and testing, or wait for your state to approach you about validation and testing process.

The key to this measure is to register intent within 60 days of your EP’s reporting period.  For 2015 that would be March 1st, so make sure to mark that date on your calendar.







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