The quest for Meaningful Use Stage 2 kicked off once the Centers for Medicare and Medicaid Services and the Office of the National Coordinator for Health Information Technology issued the notices of proposed rulemaking (NPRMs) in late February.

With the NPRMs, CMS and ONC collectively signaled a desire to continue to move healthcare providers and technology innovators closer to the ultimate goals of the HITECH Act. At the same time, some provisions of the NPRMs suggest a dawning recognition that it may take a little longer than originally envisioned to achieve the quality, safety and efficiency gains that proponents believe are possible when healthcare providers are supported in the right way by the right kinds of health information technology tools.

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The NPRMs attempt to strike a difficult balance between sustaining forward momentum toward meaningful goals and ensuring that providers who face greater impediments to EHR adoption have the time, support and incentive to catch up.

Reports from the Front Lines
In order to understand the balance CMS and ONC attempted to strike, it is important to note the context into which CMS and ONC issued the proposed rules. While it is still too early in the meaningful use experience to draw reliable conclusions from the first round of Meaningful Use Stage 1 attestations, the end of 2011 and beginning of 2012 saw the release of a number of statistical reports that revealed some interesting data. The annual survey published in November by the Centers for Disease Control's shows while that there is a wide variation among the states in EHR adoption rates, ranging from a low of 40 percent to as much as 84 percent, overall adoption rates and intent to apply for MU incentives continue to grow among physicians throughout the country. Statistics recently released by the two agencies on attestations under the Medicare Meaningful use stage 1 incentive program also show an increased pace of provider attestations and payments.

Some discernible themes are beginning to emerge from the statistical and anecdotal information available on MU1:

• The physicians and hospitals that were first to the attestation flag tended to be early adopters of EHR systems that were well along the psychological and physical paths of implementing these systems even before the MU1 gate opened in 2011.
• On average providers exceeded MU1 thresholds by a wide margin, suggesting that once providers overcame the initial workflow and technical hurdles to meaningfully using EHR systems in one area of their practice or facility or for one type of patient, they faced fewer impediments to propagating that use throughout their practice or facility or for all types of patients.
• The MU1 menu items relating to patient engagement and health information exchange showed very low rates of attestation, with the two reasons most often cited by providers for why they were not prepared to attest to meaningful use in these areas being the difficulty of revamping internal procedures to incorporate this process and the failure of EHR vendors to provide the necessary product features or technical support.
• While more physicians are adopting EHRs into their practice, choosing EHRs that are capable of achieving MU1 attestation requirements and expressing an intention ultimately to apply for meaningful use incentives under either the Medicare or Medicaid programs, there are still a significant number of physicians remaining on the sidelines waiting for greater preparedness, certainty or clarity.

CMS and ONC were also facing countervailing political pressures from all directions. On the one hand, politicians and diverse coalitions including health organizations, technology companies and payers have been advocating for a more aggressive push toward health information technology utilization and health information exchange. On the other hand, many groups, especially those representing providers have urged caution—pointing to the medical risks associated with the introduction of unfamiliar, distracting and intrusive technology into the care setting. Consumer groups are arrayed on both sides of the issue, with some raising alarms about the enormous risks to personal health information security posed by e-health initiatives and others demanding a faster pace of implementation in order to hasten the advent of truly coordinated care and greater patient involvement in care decisions.