When you picture the first handful of providers able to successfully attest to the rigors of Stage 2 meaningful use, a place like tiny Cottage Hospital might not be the first that leaps to mind.

[See also: CMS reports paltry numbers for Stage 2]

Nestled on the forested border of New Hampshire and Vermont, the 25-bed critical access hospital was one of the first few to attest to Stage 2 in the first quarter of 2014.

Cottage has experience being at the head of the class. Back in 2011, it was the the first critical access hospital in New England to attest to Stage 1. And it did so handily – for instance, it far surpassed the 30 percent minimum computerized provider order entry threshold, logging 70 percent of orders via CPOE.

[See also: Stage 2 core objectives for hospitals]

But Stage 2, as most hospitals and providers are discovering, is orders of magnitude more difficult that Stage 1.


"I didn't really know what to expect when I came into it," says Rick Frederick, Cottage Hospital's chief information officer. "That said, I wasn't expecting the challenges that we did in fact encounter."

Nonetheless, he says, the hospital staff's approach to Stage 2 started with a promise to themselves.

"It began with the statement: 'We will achieve MU2,' says Frederick. "We were not going to have our software slow the process if we could avoid it. Fortunately our mandate came from the top at Cottage, and our vendor was just as committed to helping us achieve this goal."

That vendor, Medhost, specializes in serving small hospitals, and its integrated electronic health record – alongside its YourCareCommunity healthcare engagement platform and YourCareLink public health reporting tool – was critical to helping Cottage clear the many hurdles of Stage 2.

Not to say that all the proverbial ducks were in a row from day one, however.

"We started off with the specification and came up with a rough scope, and even though our vendor wasn't quite ready, the gaps were readily identifiable," says Frederick. "Fortunately, we were able to work together to close all these gaps."

Cottage Hospital CEO Maria Ryan, who's also an advanced practice RN, says the challenges were many – especially in the early going, when trying to pull the relevant patient data.

"We had a (business intelligence) tool … and the staff was doing all the right things," she says. "But with any new tool you have to keep looking at it, reevaluating it – why isn't it pulling the right data? It took time."

"For Stage 1, we needed less than one-tenth of that data," says Frederick, whose IT staff comprises just six FTEs. "This additional logging/processing dictated most of our need for more capable hardware. For Stage 2 it was a complete forklift upgrade of our core servers that handle the system."

As it has been for many hospitals, the 5 percent view/download/transmit threshold seemed especially daunting – especially for a hospital like theirs.

"Five percent of patients have to access their record electronically; how can you possibly make a patient do anything?" says Ryan. "Even though we're lucky at Cottage to have good bandwidth, we serve 13 towns in New Hampshire and 13 towns in Vermont and a lot of them are rural, and don't even have Internet. Also, our demographics are elderly."

So the hospital staff came up with a plan to inform each patient about the benefits of electronic access, assiduously taking down their email addresses as they prepared for discharge and walking them through the process of logging on and viewing their data.

"I think our plan was best practice and it worked for us," says Ryan.

As for another widely problematic measure – summaries of care for more than 10 percent of transitions and referrals – Cottage was already well-positioned, she says.

"We've been sharing data with (area) doctors' offices for a while," she says. "They're all on different systems – one FQHC on the New Hampshire side is on Centricity, one on the Vermont side is on eClinicalWorks – but we'd been sharing data with them for a while. We were quite used to that. So to be able to send them the continuity of care document, it didn't seem that challenging."

There were some surprises along the way. Frederick, for instance, says CMS fine print tripped up the process at least once.