According to Rothenhaus, it's not worth it for some labs to build interfaces to ambulatory EHRs if orders are not sent to them electronically. More than a few physician practices have CPOE to get orders into the EHR, but orders then get transmitted to labs via fax or some other low-tech means, regardless of whether the lab can accept electronic orders or not, he says.

Electronic communication among healthcare professionals needs to improve as well, in the opinion of DiCapua, an athenahealth customer. "I cringe with some of the other things that are going on now," the Maine family physician says. Far too often, he has seen other practices send him protected health information via standard, unsecured e-mail, a symptom of poor training or education about HIPAA requirements.

DiCapua says that other physicians start seeing the value of electronic health information exchange when he refers patients to area specialists. His EHR, which produces clinical summaries for referrals, means that consultants can have the information before they even have the referral.

"The next big thing to tackle is the portability of the entire record," DiCapua adds.
Irrelevance to specialists

Specialists have another reason to tune out meaningful use. The program, as ONC has acknowledged, has been skewed toward primary care.

"If you're a practicing subspecialist, meaningful use is so foreign to you," Rothenhaus says. Some radiologists and pathologists may not have any face-to-face contact with patients, so it is difficult if not impossible to meet provisions related to patient education, preventive care and patient engagement.

Ever since Stage 1, providers have had to demonstrate that they are able to send data electronically to an immunization registry, a disease registry, a syndromic surveillance database or a public-health agency. This is a potential sticking point for specialists. "Many think they can claim hardship exemptions because they don't know that their specialties even have registries," Rothenhaus says.

If a registry exists, whether they know it or not, some physicians will fall short of meaningful use, since compliance is all-or-nothing; there is no partial credit. Numerous associations representing providers have asked for this to change, but CMS so far has not budged.

Private insurers have not yet insisted that providers in their networks meet the federal meaningful use standards. "It's a recognition that these criteria do not necessarily lead to better care," Tennant says, since compliance really is just a matter of checking off boxes that may not really apply to certain physicians.

Will orthopedists truly improve outcomes by counseling patients on smoking cessation? "There is hope that Stage 3 will take this into account," Tennant says.

Tennant also notes that radiology has been using advanced information systems for a long time, but radiologists and imaging centers still might not satisfy meaningful use, as defined by CMS.

Patient engagement and education
The meaningful use criteria themselves are causing trouble, particularly the provision that calls for 50 percent of patients to be given an electronic means of viewing, transmitting or downloading personal health data and for 5 percent of patients to take it upon themselves to be "engaged" by sending unsolicited electronic messages to their healthcare providers, according to Tennant. "For some specialties, 50 percent may not be as difficult as others," he says.

For example, dermatologists, ophthalmologists and otolaryngologists may only see a patient once, and only for a few minutes, so there is not much incentive for their patients to engage in electronic communication with their doctors. "When the patient is handed a clinical summary, they have everything they need from the visit," Tennant says.

Every month, CMS holds a public conference call on meaningful use. During the January call, Tennant reports, CMS suggested that specialty practices put a kiosk in the waiting room so patients can fill out history forms electronically and print copies of their records for themselves, satisfying the engagement requirement. However, it might take a dedicated staff member to walk people through the steps. "That's not a viable option for a small practice," Tennant said.

Regarding secure messaging, Tennant wonders if elderly patients are likely to try it. He says MGMA and other provider representatives have asked CMS for more flexibility in meeting the standards, but thus far, the rules have not changed. "We are concerned that the momentum from Stage 1 could be lost," Tennant says.

"Patients are the most underused resources in healthcare," says Nimesh Patel, CTO of Chicago-based healthcare communications company Emmi Solutions. But they need good reasons to log onto a portal and be engaged as patients. "If there's no content that they're getting value from, they're not going to come," Patel says.

"How do you tie it back into a metric that you can get credit for?" Patel asks. The answer is integration with the EHR. "The mindset is shifting (from just providing a portal) to creating content to engage patients," he adds.

Patel recommends personalizing content delivered through portals to add value to patient-clinician communications, "so it doesn't feel like something you Google." To get to this point, Patel says, hospitals want technology tightly integrated with existing information systems. "Let's make it easier," he says.

At Wells Family Practice, the front desk has been educating patients about the existence of the portal and how to use it ever since the athenahealth EHR went live in June 2012. "You can motivate people very well if they understand what you're doing and why," says DiCapua.

"The most difficult piece is getting patients to understand why it's so important," DiCapua says. "It's particularly difficult when you're dealing with seniors," he adds, and meaningful use depends on Medicare populations.

"If you tell the patients how you access the portal, it's easy," says the practice's manager, Betsy DiCapua, the physician's wife. "The word 'portal' can be intimidating," she says. Staff tries to make the portal seem more accessible by explaining practical uses, such as how patients can see lab test results.