On paper, it sounds easy. Eligible hospitals that refer patients to another care setting must electronically transmit "a summary of care record for more than 10 percent of such transitions and referrals."

[See also: For portals, speak patients' language]

The twelfth of Stage 2 meaningful use's 16 core measures requires that such a summary of care be either transmitted to another recipient using certified electronic health record technology, or with help from an organization that's either an "NwHIN Exchange participant or (operates in) a manner that is consistent with the governance mechanism ONC establishes for the nationwide health information network."

Turns out that's easier said than done.

[See also: Direct Project: A new way to transfer data]

A common theme emerging as hospitals work toward Stage 2 is that the hardest measures are those that depend on cooperation or connection with outside parties: whether it's the 5 percent threshold for patients to view, download or transmit their health data, or the 10 percent threshold for electronic transmission of care summaries.

In June, we showed how New York Hospital Queens, by making a "full-court press" on patient access, is well-positioned to achieve the former measure. But the latter requirement is still posing a formidable challenge, says Kenneth Ong, MD, the hospital's chief medical informatics officer.

That 10 percent hurdle is hard to clear for a variety of reasons, says Ong. Among them: the majority of other practices his hospital deals with don't have EHRs enabled with HL7's Clinical Document Architecture standard; some regional health information organizations still don't support Direct messaging inboxes or CDA exchange via the NwHIN protocol; many receiving providers don't have Direct inboxes and are unwilling or unable to pay for them.

"The summary of care measure? It's been a challenge for us, as well as others," said Ong. "One problem is actually getting the technology to work."

Direct messaging has been a particular problem. "We've been working on that with our vendor now – who I will not name – for more than two months," said Ong when we spoke in late June. "Despite adding a number of hotfixes, they still have not been able to get it to work."

His colleagues at other hospitals across the country are facing similar issues, he said. "One person told me it took them six months to get it to work. And someone else told me it took them two years."

It seems surprising that such a core functionality would be so hard to make work. But Ong suspects that compacted calendars are somewhat to blame.

"I'm hypothesizing here, I really don't know," he said. "But I'm guessing that this is new technology, given a short timeline for meaningful use. If you'll recall, the recommendations from HIMSS was that there be at least an 18 month period between a new requirement and when it was actually put in place, to give vendors, as well as providers, a chance to debug the new technology an get it to work."

When launched in 2010, Direct was touted as a "simple, secure, scalable, standards-based" solution to exchanging authenticated and encrypted data. But for New York Hospital Queens, implementing the process has hardly been simple.

"In our particular instance, we have not been able to send one Direct messaging transmission successfully," said Ong. "At least not yet. Clearly, we're still working on it, but we haven't been able to do it yet."

And that's just the technology for sending. Even if it was firing on all cylinders, another big question is how many providers are ready and able to receive those messages.

Ong cites a study on EMR adoption published earlier this year by the Centers for Disease Control and Prevention.

"In their survey of 1,000 of physicians in ambulatory care, they found that no more than 13 percent had a meaningful use Stage 2 compliant EMR. No more than 13 percent of physicians could even receive an exchange document."

So Ong's hospital, like so many, is chasing after a percentage of a percentage to meet the measure's requirements.

"In our own particular geography, there are way fewer physicians that have EHRs that can accept exchange documents," he said. "I generated a report and analyzed who we actually discharge patients to. And this particular organization discharges 37 percent of its patients to either long-term care facilities or to home health agencies.

"As you know, neither of those types of providers are actually required to meet meaningful use," he added. "So they are not going to have EHRs that can receive exchange documents. And they would have to purchase a Direct messaging inbox from a health information service provider in order to receive them."

Luckily, said Ong, "We were fortunate in that our local hospital association, the Greater New York Hospital Association, decided to offer to fund long-term care facilities and home health agencies to get Direct inboxes from MedAllies."

For other providers who'd require the same, the cost could vary. Individual inboxes can be had for a couple hundred dollars per provider, per year – but at least one vendor Ong knows of "only offers a minimum of 100 licenses at $10,000 a year. Quite clearly, that's not an option for a small physician practice. Or even a medium physician practice. Let alone a nursing home or a home health agency."

All this has led to some "workarounds" at New York Hospital Queens that Ong hopes will be successful.

"Our care management team has offered to send the summary of care notes to our long-term care partners once they become available," he said. "If we send 30 percent of our patients to long-term care and home health, hopefully it will meet the 10 percent."

But of course, "if our vendor cannot send exchange documents, there is no way we can meet that threshold," he added.

When we spoke, Ong was about to sign on to a four-hour ("four-hour!") webinar sponsored by the vendor to hopefully get to the bottom of the issue.  

In the meantime, he said, "I think that at least these two particular measures from Stage 2 – summary of care, and the patient access; 10 percent an 5 percent – should be removed. Or made not mandatory, but optional."

Maybe there "might be additional incentives or separate penalties for meeting or not meeting those thresholds," he suggested. But as it is, the necessary involvement of "other stakeholders" to arrive at those numbers simply makes the measures too onerous to be core requirements.