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Posts Tagged ‘meaningful use’

Just as Healtheway looks to ween itself off the federal gravy train, Surescripts comes along and in a couple of quick strokes looks ready to drive a stake into the heart of Healtheway or at least any desire Healtheway may have to become the Nationwide Health Information Network (NwHIN).

It all started when Surescripts acquired collaborative HIE messaging vendor Kryptiq in late August. This was quickly followed a week later with Surescripts’ announcement that it would become Epic’s vendor of choice for cross-EHR connectivity. It appears that Epic has finally succumbed to the inevitable; that it will need to open up its system (Epic’s purported Epic Elsewhere, to address cross EHR connectivity was in reality Epic Nowhere – just vaporware) to communicate in a heterogeneous EHR environment. The Surescripts Clinical Interoperability (CI) network solution will become an “Epic Unit” and on Epic’s price sheet. The details of this story were covered in our September Monthly Update for CAS subscribers.

What drove Epic to make such a drastic move? Pretty simple really, Stage Two meaningful use requirements which were released on August 23rd. Within those new requirements for certification, EHR vendors must demonstrate that they can send a message across EHR boundaries (outside their ecosystem). Epic really had no choice in the matter – they had to do something to address this requirement. Chilmark has also been hearing an ever louder drumbeat that Epic customers were also demanding that Epic do something to address messaging in a heterogeneous EHR environment. (Note: eClinicalWorks is another EHR vendor that was forced to open up their notoriously closed peer-to-peer networking service for clients, though eCW twisted it around to make it appear like an act of generosity.) Surescripts provided Epic an easy way out with a non-competing entity.

Last week, Surescripts announced that another major ambulatory EHR vendor would adopt the CI network, this time it was NextGen. Surescripts now has three of the top five ambulatory EHR vendors (Epic, GE, and NextGen) on its network. If one were to just look at the numbers, these three EHR vendors combined represent over 50% of practicing physicians in the US.

Surescripts is likely to add more EHR vendors in the coming months as these vendors look to grapple with the latest Stage 2 MU requirements for both Direct Secure Messaging (DSM) and cross EHR messaging. Adopting Surescripts CI network as a module into their existing EHR solves that issue in a non-competitive manner.

Surescripts’ intent is to leverage its core competency of providing lightweight, network services to reach beyond eRx to address basic clinical messaging. Some may argue that DSM accomplishes the same thing. Not really. The Kryptiq solution, upon which Surescripts’ CI network is built, provides collaborative, threaded messaging and not just the simple point-to-point messaging of DSM. Surescripts also brings to the table what is arguably the largest physician directory, that currently supports its eRx capabilities.

Surescripts jumping into the mix of HIE solution vendors will only complicate what is already becoming an increasingly competitive HIE market for services. In our 2012 HIE Market Trends Report we called such services as Surescripts’ CI a micro-HIE for they are self-forming, starting at the physician practice level, rather than being sponsored by some large entity, be it a public agency or larger hospital system. One of the findings of eHealth Initiative’s latest survey released last week is that HIEs are seeing increasing competition from other HIEs in their community. This competition will only increase with the advent of micro-HIEs.

Combining Surescripts’ existing national provider directory, its partnerships with three of the top five ambulatory EHRs and you have a truly, commercial NwHI – something that Healtheway wishes to become but has a long journey ahead to get there. This will likely force Healtheway to only tackle issues for its federal sponsors (Social Security Administration, Veteran’s Administration and to lesser extent Dept of Defense). Dreams beyond those limited confines will likely remain such if Surescripts is able to effectively execute on its own vision.

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This week I had the pleasure to be the keynote speaker at Orion Health’s HIE User Conference in the beautiful state of my youth, Colorado. In preparing for this conference I was struck again by just how quickly this market continues to evolve and just how messy evolution can be. By the time my slide deck was completed, I came to the conclusion that the health information exchange (HIE) industry is moving from HIE 1.0 to HIE 2.0. While no trend happens over night, certainly the release of Stage 2 meaningful use  (MU) requirements had a significant impact.

HIE 1.0: All About the Message
Within the realm of HIE 1.0 the primary focus is on fairly simple, message-based, transactional processes. Large healthcare organizations (HCOs) adopted HIEs to facilitate orders and referrals with the hope that by making it easier for an ambulatory provider to place an order and receive timely access to lab results, that the provider would be more inclined to push business to that HCO, rather than a competing HCO in the community. It was all about physician alignment. Countless HCOs installed such HIEs, which are typically based on a lightweight, federated model. It was simple, inexpensive and relatively quick to deploy.

In the public sector, most HIE’s were meant to serve public health reporting functions and facilitate physician access to records to minimize duplicate tests and deliver better care. The objectives of public HIEs are far harder to reach, the value far harder to articulate and have contributed to a lack of sustainability and ultimately failure of may a public HIE. In a somewhat bizarre twist, last summer Health and Human Services (HHS) sent forth new mandates to all statewide HIEs to focus first and foremost on Direct Secure Messaging (DSM). DSM is little more than secure email, thus the original grand plans of public HIEs have been whittled down to much more modest goals.

With the release of Stage 2 meaningful use, which will require EHR vendors to embed DSM functionality within their EHR to become certified, messaging solutions provided by HIE vendors have now become commoditized. Messaging in the context of HIE is now passe.

HIE 2.0: All About Delivering Care
It has always been Chilmark Research’s opinion that the enterprise market will lead the public market in adoption and use of new, innovative HIE technology. With the move towards value-based contracting and associated reimbursement models, accountable delivery systems (ADS) (note: we don’t like to use the term ACO unless we are specifically talking about CMS), of all sizes are now looking to adopt an HIE platform and those that adopted a messaging-based HIE are looking to replace it. This will result in a high level of turnover in the HIE market, which we began seeing during middle half of last year.

The move to an ADS model requires a HCO to manage a given patient across all care settings. To meet these objectives, HIE 2.0 solutions will have such common attributes as data normalization services, patient disease registries, care management tools (care plans, templates and workflow) and some form of patient engagement capabilities. In adopting and deploying an HIE that goes beyond simple federated messaging, the HCO hopes to insure that appropriate care is delivered to a patient across all care settings and that all individuals (patient, loved one, case manager, nurse, doctor, etc.) that are a part of a given care team have the most current and relevant information associated with that patient, at their finger tips.

This is the goal of an HIE 2.0 but we are still quite a ways from getting there. Our latest end user research finds a market that is full of frustration. Despite all those Stage 1 certified EHRs that have been deployed, very few of them can actually create and/or parse a CCD. We are still in the land of simplistic and cumbersome HL 7 messaging. Some pretty big steps forward were made by the feds in Stage 2 to rectify this now well-known, but also fairly well-kept secret that HIEs today simply cannot readily support care management processes across care settings in a heterogeneous EHR environment. This week’s announcement to further push the envelop, via certification of HIE/EHR in conjunction with efforts that are being led by NYeHC are also a welcomed sign.

Ultimately, though, it will be market need that presses this issue forward, not the efforts of HHS, NYeHC and others. As HCOs continue their acquisition spree to build a robust ADS to serve their communities, these organizations will begin to have the marketing clout to force vendors to change their ways. For example, while Stage 2 may have had some impact on Epic’s decision to finally admit Care Elsewhere would forever be vaporware and have them strike a partnership with Surescripts, it is our belief that Epic’s customers were the ones that really forced Epic’s hand. Now if we could only apply similar clout to those ambulatory EHR vendors who hold their clients hostage with exorbitant interface fees – maybe this is where the feds can play their greatest role and Stage 2 is a strong step in the right direction.

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Yesterday, I was in Washington DC to attend ONC’s Consumer Health IT Summit. While having high hopes for some breathtaking new developments, ultimately walked away disappointed as this event ultimately devolved into a Blue Button promotional event. Now I have nothing wrong with some promotion, after all my background is heavily steeped in marketing. What I do have a problem with, as an analyst, is major hype around any concept, technology, etc. that is not balanced with some serious, thoughtful critique.

There were times when I thought this event felt more like a channeling of a Health 2.0 event with the clarion call of “Give me my damn data” being chanted. At times like that I had to pinch myself to remember, no, I’m in the grand hall of the Hubert Humphrey Building. Of course the multiple, large portraits of past HHS Secretaries hanging from the walls was also a clear reminder of exactly where I was.

But despite some shortcomings, the event was focused around what may be the government’s (VA & CMS) finest contributions to promoting patient engagement – the Blue Button. The Blue Button was first released in 2010 by the VA to allow veterans to gain access and control of their personal health information (PHI). CMS later released their own version of Blue Button that allowed beneficiaries access to their claims data. The VA thought Blue Button would be a success if they saw 25K Vets use this capability. The VA passed that number long ago and now, two short years later, the doors have literally been blown off that original estimate with some one million patients now using Blue Button to gain access and control of their PHI.

That is a phenomenal rate of adoption especially when one considers what they actually have access to.

A Blue Button download does not give one a well formatted easy to read file of their PHI. No a Blue Button download is nothing more than a simple ASCII text file and when you look at such a file dump, it isn’t pretty. Thankfully, ASCII has been around since we were hunting the great wooly mammoth during the ice ages so just about any piece of software (e.g., legacy EHRs and claims data bases) can easily create an ASCII file and developers can likewise take an ASCII file and repurpose that text into something fairly legible.

One company doing just that is Humetrix who I first met at the HDI Forum in June. They were also present at this event where they gave me a quick demo of their latest version of iBlueButton – a nice piece of mHealth software that takes the ASCII file from a Blue Button download and reformats it into a very easy to read and decipher file that a consumer can share with their care team. There is even an iPad version designed specifically for physicians, which gets to my next point.

Whenever I am in the company of physicians, I often ask them how they are coping with the changes taking place and specifically adoption of HIT. Had one such conversation Sunday while I was doing the charity Jimmy Fund Marathon walk for cancer research. On this walk there are always quite a few oncologists and nurses and seeing as you’re walking for a good many miles, plenty of time to talk.

I asked one oncologist about HIT adoption at Dana Farber and meaningful use to which he quickly replied: “Meaningful use is the bane of our existence right now.” So I asked further: What problem could HIT really solve for him? He had a ready answer: “Rather than a new patient showing up with a mound of paper records that I must laboriously review, I want a digital version of a new patient’s record with labs, pathology, images, meds, etc. all readily laid out so I can make a more rapid assessment to define a treatment plan for that patient.”

Now we could wait until all the HIEs are in place, all DURSAs are signed resulting in frictionless data flows between healthcare institutions. We could wait until every certified EHR for Stage Two is deployed and physicians start using Direct messaging. We could also wait for patients to request under Stage Two that their provider transmit records to another (still not sure how complete those records need to be to meet Stage Two). Or we could enable Blue Button, educate the public and let them take direct control of their PHI and share it with whom they see fit. Plenty of options but if we really want to change healthcare, the last one is the most impactful, the most viable, but unfortunately like the others, it will take some time, though likely less than getting those DURSAs signed.

Getting back to yesterday’s event and my disappointment, following is what I would like to see in the future:

Honest and frank discussion on giving patients access to their records. The American Hospital Association was in vehement opposition to the Stage Two rules on patient access to their records. Let’s put them on stage to explain why, to give that contrarian viewpoint, to provide balance.

Enlist providers to discuss the benefits and challenges of giving patients access to their records. How does patient access to records change the conversation of care? How does it impact the workflow of a practice? What fears may physicians have and how do we address them?

Fewer panels of talking heads and more real world perspectives. The event had a wonderful moment when a Vietnam veteran talk about his healthcare challenges and how Blue Button contributed significantly to his self-management. Let see more of that, e.g. a Medicare patient using Blue Button.

And my biggest disappointment of all had nothing to do with this event – it had to do with Stage Two.

If indeed the feds really believe in the Blue Button the same way they believe in Direct then why the h*ll did they not directly put it into the certification criteria for EHRs. Clearly something went amiss and it is unfortunate.

Thankfully, many vendors have stated they will support Blue Button in a forthcoming release including Allscripts, athenahealth, Cerner, Greenway, and many others. Our last HIE report also found just over 25% of vendors profiled intend to support Blue Button in 2012. There is momentum here already, now we just need to on-board physicians to talk to their patients about the value of having access to and control of their PHI for as we move to more capitated models of care, the engaged patient may indeed be the miracle drug to rescue our healthcare system from financial collapse.

Addendum: Have received feedback regarding Stage Two and patient access to their records so let me clarify. Stage Two does indeed grant a patient the ability to access, view and transmit their records. This is incredibly powerful, especially with the push towards standards and the transmitted file being in a CDA standard format. As Keith Boone so clearly articulates, the content package that is transmitted under Stage Two is a fairly complete, summary document of care received and an individual’s health status. But Stage Two does not support an ability to transmit a full and complete longitudinal record. It is my understanding that the Blue Button, at least the instance at the VA, allows a patient to download their complete record thus why I took the argument down the path I did. 

In time it is my hope that the Blue Button becomes a symbol, as Keith puts it, “a verb,” that all will understand instinctively – click this, get your data and move on. Other services will take that data dump, transpose it the way you want it for the purposes you intend. The technology and standards behind it will simply become irrelevant to the user. It just works. Getting there will be the task of the S&I Framework workgroups. I wish them God’s speed in accomplishing that task for the benefit of all citizens.

Many in both the private and public sectors are working hard on that vision – keep up the good work!

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Recently upon leaving my doctor’s office I was presented with a print-out of my visit summary. Knowing I worked it the HIT space my doctor proudly stated that this was one the ways that they planned to meet one of the menu objectives of Stage One meaningful use (MU). This is great I thought, until I began looking over that visit summary.

A significant portion of the summary listed the basics such as who I was, why I paid them a visit etc., all pretty boiler plate – nothing new. Then I turned the page to see the lab results of the routine blood-work – YIKES! nothing but acronyms, values and acceptable ranges. I think I was able to decipher about 10% of those lab results and I work in this industry! I can only imagine how difficult and mind-numbing these figures may appear to an “ordinary” patient/consumer.

So seeing some out of range values I began asking my doctor:

What does this acronym stand? Why is this out of range? Is this something I need to worry about?

Being the great doctor that he is, he took the time to explain my results (some of those out of range values are the result of meds) but also expressed a certain level of frustration stating: “I’m not a big fan of passing this information on to a patient for I worry that they won’t understand results such as these and then I need to take time out to walk the patient through their results which can be quite time consuming. Is this another contributor to physician burnout I wondered?

Now I am all for patient/consumer empowerment and do believe that providing patient’s access to their personal health information (PHI) as a critical component of such empowerment. But does providing a patient a visit summary really empower them or does it simply make them confused (as I was) and resigned or worse endanger?

Stage 2 meaningful use rules released last week state that an eligible physician or hospital will be required to:

Use Certified EHR Technology to identify patient-specific education resources and provide those resources to the patient.

But what will that “patient-specific education resource” look like? Will it solve the problem I encountered?

I want more than a generic here is what these type of acronyms and values mean that litter the internet. I want personalization. I want a system that will take my lab results, my problem list, match it up with my meds, allergies etc. and provide me with personalized knowledge of what these results mean to me and my future health. I then want to be provided suggestions as to how to improve those values? This is what I see as true patient/consumer empowerment.

Unfortunately, what I have actually experienced as a result of this grand HITECH effort under Stage One falls far short of empowerment, if anything, it is closer to disempowerment.

Getting a bunch of data in a visit summary without putting it into context is not meaningful, it is meaningless.

My hope is that there are some novel, creative solutions now being developed that will leverage the new concept in Stage Two, the Base EHR, and provide a module that automatically digs into a patient’s PHI and presents the patient with an empowering visit summary. This is one of the ultimate intents of the HITECH Act, I now want to see it happen.

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Last week we attended the big healthcare IT confab HIMSS in that grand city of sin, Las Vegas. While many spoke of how HIMSS hit an all time record of over 37K attendees (an impressive number), HIMSS is still dwarfed by what is arguably the largest US-based healthcare trade show, RSNA, which had a 2011 attendance of just over 57K, (roughly 54% greater than HIMSS). Why such a radical difference you ask? As one colleague put it:

RSNA is where providers come to make money and HIMSS is where they go to lose money.

While that may be the case today, it is unlikely to be so in the future. The healthcare industry is undergoing a massive transformation that will likely take a decade to complete as we transition from a reimbursement model largely based on fee for service to one based on outcomes. Under this new model, providers will be taking on a greater portion of risk. In reward, these providers have an opportunity to receive a significantly higher net reimbursement. This transition is making for some interesting bedfellows as payers and providers join together to create new care delivery models such as Accountable Care Organizations (ACOs) and Patient Centered Medical Homes (PCMHs). These new models will be increasingly dependent on a robust HIT infrastructure to effectively measure quality, risk and performance, something that simply cannot be done effectively with the antiquated systems that are in place today in many healthcare organizations (HCOs).

Nearly every vendor we met with at HIMSS had a story to tell about how they had the solution the market was seeking for ACO enablement. This was not entirely unexpected for last year we thought that would be the year of ACO. Obviously, we were a little ahead of ourselves and the industry with that prediction but alas it has come to pass. Small problem though: HIT vendors have had plenty of time to prepare their solutions for ACO enablement but to our surprise, most solutions were still far from mature. Frankly, we are not too worried about this right now for Chilmark is forecasting significant evolution, innovation, and in short-time maturity in these solutions as customers (HCOs) further define what they truly need to succeed in this new world order of reimbursement for healthcare delivery in the US.

This raises what our research team found to be the most significant learning from HIMSS’12.

As most of you already know, ONC made quite a splash at HIMSS by announcing the release of Stage 2 meaningful use (MU) requirements (we’ll have a future post on the implications of these requirements later this week). But honestly, we did not see a wild wrangling of commentary and discussion in the halls of HIMSS’12 regarding these new requirements. Maybe this was because most attendees were simply addressing the needs of today and did not have time to thoroughly review these new requirements. But we believe something else may be at work here.

Our Thesis:
The MU requirements have become little more than a “spec-sheet” for vendors, consultants and IT shops and departments. These requirements have nothing to do with innovation and have little to do with the dramatic changes that will occur in this industry in the next decade. Quoting that oft-used phrase, “follow the money” one can quickly see that the billions in funding for incentivizing providers to adopt EHRs under the HITECH Act is relative chump change to the dramatic fortunes that may be won or lost under the new value-based payment models that are proliferating throughout the industry – payment models that commonly fall under the rubric of ACO or PCMH. In each of these models, EHRs are important to a degree, they are part of the basic infrastructure. But it is what one does with the data that matters (collect, communicate, collaborate, synthesize, analyze, measure and improve). Therefore, if you want to see innovation look beyond today and the tactical push to effectively adopt and meaningfully use EHRs and towards the future of how that data will be used to drive quality improvements, better outcomes and lowering risk exposure.

And speaking of risks…

What was clearly lacking at this year’s HIMSS was patient engagement. Yes, there was a seminar on the topic and sure, everyone speaks of patient-centric care but there was little evidence among exhibitors at this year’s HIMSS (with a few exceptions, e.g., Cerner, MEDSEEK, RelayHealth) that spoke to the need to engage patients as part of the care team. Get a clue folks, one will never get to that nirvana of a truly effective ACO or PCMH without active, effective engagement of the patient. Not having an engaged patient is your greatest risk.

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As with the last shuttle mission making its re-entry into the Earth’s atmosphere yesterday, I am re-entering the world of healthcare IT after an extended family vacation in the wilds of Alaska. No, I did not see John Halamka up there, it is after all a VERY BIG state, but I did get the chance to go completely off-the-grid, a blessed reprise and observe what is one of the more beautiful and still untouched landscapes in the northern hemisphere. Upon finally arriving in Vancouver I made the vow to return, but next time it will be to spend more time in the small coastal towns of the Alaskan peninsula, likely via an expedition kayak, to get up close and personal with the people and environs of this small corner of the world.

After being away for nearly two weeks, it is a challenge to pick up where one left off. Cruising through the reams of email (please excuse any delays in getting back to you I’ll get to your email yet, I promise), trying to catch up on my reading of the various industry rags and tapping twitter I feel pretty comfortable in stating the more things change, the more they stay the same (not exactly the best quote for an analyst to say as we thrive on turmoil…).  That being said, following are a few items that did catch my attention and may look into further:

FDA Releases Proposed mHealth App Regulations
On Tuesday, the FDA finally released guidance on how it intends to regulate mHealth Apps. Having taken a cursory review of these proposed regs, have to say I’m quite impressed as the FDA has struck a careful balance of  applying regulatory review where warranted while allowing plenty of room for innovation in this very young and still immature industry sector.  MobihealthNews has a fine write-up on this story.

WebMD Provides Abysmal Guidance and Tanks
WebMD, which has been seemingly immune to the recession, provided Q2’11 guidance that sent its stock into a tailspin and leading to a very rapid (next day) letter to investors from the Chairman to quell fears. Why is this significant? First, pharma is feeling the effects of the recession and is pulling advertising dollars off the table. Over the last few years, WebMD has been putting virtually all of its “eggs in one basket” – pharma. It appears that the golden goose of pharma is no longer laying golden eggs which will likely have a ripple effect on the multitude of other smaller Health 2.0 like companies whose business models are advertising based. Secondly, once again WebMD is projecting contraction in its “private portal” business. This is, or at least was, the 800lb gorilla in the PHR market for employers and payers. WebMD has milked this cow for about all its worth and do not be surprised if others start aggressively moving in. Cerner is one and we’ll talk about another tomorrow.

Stage 2 Meaningful Use Likely Delayed till 2014
Can’t say we didn’t see this coming as ONC’s advisory board basically recommended such but it does complicate the schedule for incentive payments which, as part of ARRA were meant to create jobs and create those jobs quickly. As the recession continues to drag on, there appears to be an acceptance that getting back to near full employment in this country will not occur quickly. Such acceptance has appeared to bring some rationality as to the rollo-out of EHRs. Choosing, installing, mapping workflow, testing, training and going live with an EHR, let alone meet the various requirements of meaningful use (MU) is no small task and this delay will bring a sigh of relief among many a CIO and eligible professional. But now one has to wonder: What does this mean for Stage Three?  Don’t be surprised if Stage Three gets the ax.

I’m sure there are other bits of news that I missed and welcome your input to help educate this off-the-grid analyst on all the wonderful things he missed as he was trudging through the temperate rain forests of Alaska or battling grizzlies for a share of their salmon (note, grizzlies don’t share).  BTW, this last picture is of one of the “deep forest creatures” you’ll find in that rain forest.

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Couple of weeks back the HIT Policy Committee began to seriously consider what a delay of Stage Two meaningful use (MU) might look like. This push for a delay is being driven in large part by EHR vendors. The problem is one of timing. While Stage Two rules are to be released on June 8, 2011, there is growing concern among these software companies that they simply will not have enough time to build, test and deploy the required functionality in time for their customers to demonstrate meaningful use and pick-up their incentive check at the Medicare window.

This does not come as a surprise. When the HITECH Act was first passed as part of the broader Stimulus Bill (ARRA), the primary objective, at least for ARRA and subsequently HITECH, was getting people back to work. The HITECH legislative language was purposely vague highlighting such key objectives as getting physicians to “meaningfully use” a “certified EHR” to promote “care coordination.” Since this was a jobs’ bill, the legislative language also pushed for the billions of dollars in HITECH funding to be doled out expeditiously.

Problem is, installing software into an existing operation is just a tad more difficult than say resurfacing a roadway. When you layer into that software installation issues such as changes in workflow, training clinicians, insuring patient safety is maintained (and ideally improved) you end up with a very challenging situation. In the case of HITECH, this challenge is further compounded by the desire to continuously improve, via the proposed three stages of MU requirements, the quality of care delivered. These are the challenges providers and hospitals are facing but as mentioned previously, the EHR vendors are struggling as well to deliver the functionality required to meet future meaningful use requirements.

Last week at the Massachusetts Governor’s Healthcare IT Conference both Dr. Blumenthal and Dr. Halamka gave their perspectives on this conundrum of whether or not to delay Stage Two MU. Blumenthal was quite cautious in his statements that basically inferred that such a delay could have some repercussions on the entire HITECH Act wherein some of the funding may be retracted if it was not spent in the timeframe allotted to it under this legislative act. In today’s acrimonious federal budget wrangling on the Hill this is a very real possibility.

Halamka proposed another scenario wherein Stage Two would be split into a Stage 2A and 2B. Meeting Stage 2A would not entail new software functionality, but simply attestation that the provider/hospital was meeting the stepped up implementation of their EHR. For example, in Stage One, the CPOE requirement is for 30% of patients to have at least one order via CPOE. In proposed Stage 2, the requirement is 60% of patients. No new software functionality is required, just more physicians trained on how to use CPOE. Stage 2B would address those MU requirements that are new and requiring additional EHR functionality (e.g., record a longitudinal care plan for 20% of all patients).

What is likely to happen?

Looking into its analyst’s crystal ball, Chilmark foresees the following:

  1. Stage Two will be delayed in some form or fashion as there has been a lot of grumbling by healthcare providers who have struggled to meet Stage One (and even Stage One was significantly water-downed from what was first proposed).
  2. Halamka’s scenario of Stage Two being broken up into two makes sense as it addresses both legislative issues (keeps ball rolling) but also allows the industry time to add new functionality and subsequent training to ensure safety.
  3. The delay in full Stage Two MU requirements will put significant pressure on Stage Three with Stage Three subsequently pulled. Those requirements outlined in Stage Three will be achieved through other approaches that HHS has at its disposal, e.g., payment reform.

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