Meaningful Use: Stage 1 Final Rule and Proposed Objectives for Stages 2 and 3

Improving Quality, Safety, Efficiency & Reducing Health Disparities

Stage 1 Final Rule

Proposed Stage 2

Proposed Stage 3

MUSE Response

1. CPOE for medication orders (30%)

CPOE (by licensed professional) for at least 1 medication and 1 lab or radiology order for 60% of unique patients who have at least 1 such order (order does not have to be transmitted electronically)

 

CPOE (by licensed professional) for at least 1 medication, and 1 lab or radiology order on 80% of patients who have at least 1 such order (order does not have to be transmitted electronically)

- Please make clear, beyond any doubt, if the appropriately licensed provider must enter the order using a computer or if a pharmacist entering a order first written on paper by the provider meets the requirement.

- This should be a natural progression for most hospitals meeting CPOE for Stage 1.

- The denominator for this measure (unique patients who have at least one medication on their medication list) needs to change. For hospitals, it isn't an issue, but for eligible providers it doesn't make sense. Here is an example: CMH was surprised that one conscientious surgeon showed only 20% on the CPOE measure. This sample shows why:

·       35 unique patients minus 2 patients with no medications at all = 33 (denominator)

·       26 patients only had medications prescribed by another physician or over-the-counter medications (no medications prescribed by this physician)

·       7 patients had at least one medication prescribed by this physician

·       6 of those 7 patients had medications entered by this physician using CPOE.

·       1 of those 7 patients had medications entered by a nurse. So, the physician’s percentage on the meaningful use measure was only 18% (6/33), whereas he entered medication orders on 86% (6/7) of the patients on which he prescribed any medications.

- With the rescinding of the legislation regarding physicians even having to sign lab orders I think this is redundant. (This is what I am referring to: "The American Society for Clinical Pathology (ASCP) is pleased to announce that it has learned that the Centers for Medicare and Medicaid Services (CMS) is planning to rescind its recent rule requiring a physician's signature on requisitions for laboratory tests reimbursed under the Medicare clinical laboratory fee schedule.”) I would think it might make more sense with this rule to work on upping the compliance of the electronic meds from the 50% before adding in the LAB and RAD.

- This needs to be an all or nothing requirement. I am not sure how the government can think that a facility would only have providers enter a medication or lab order. As clinicians we need to encourage them to require all orders should be placed on the patient.

- I would like to know how MEDITECH EHR is certified? Is it modular or do we need all the modules including DR? If a hospital is using a third party LAB HL7 that is not certified by MEDITECH or any agency, how will this affect Meaningful Use of CMS requirement?

- Paper-based systems recognize that physicians are often focused on very sick patients and that their time is best spent in patient care, rather than writing and typing. Stage 2 needs to allow for order input by non-physicians (e.g., unit secretaries and nurses) with timely electronic approval of the orders by the physician. The time of such highly trained individuals may be put to much better use than navigating a computer screen.

CPOE is a late in the game application which is generally implemented long after original order entry type products so those facilities that are using CPOE should already be entering their orders electronically. With this in mind we would suggest that orders should be required to be transmitted electronically, at least within the facility, to create the most productive workflows and to prevent multiple revisions that would need to take place to incorporate orders transmission at a later date, which would require additional proposed resource and expense. Additionally, electronic order transmission creates a better and safer patient care environment with more opportunity for decision.

2. Drug-drug/drug-allergy interaction checks 

Employ drug-drug interaction checking and drug allergy checking on appropriate evidence-based interactions

Employ drug-drug interaction checking, drug allergy checking, drug age checking (medications in the elderly), drug dose checking (e.g., pediatric dosing, chemotherapy dosing), drug lab checking, and drug condition checking (including pregnancy and lactation) on appropriate evidence-based interactions

- I am not certain how this differs from Stage 1.

-What are appropriate evidence-based interactions? Stage 3 Drug-age checking (medications in the elderly): would that be on all medications? Would you expect a pop up reminder? How would they be based? Age? Drug? I would suggest that CMS define a minimum number of high-risk drugs (perhaps 10) to begin with. And define elderly.

Mercy Hospital

- It sounds like in Stage 1 we just have to have the technology and in Stage 2 we actually have to use it. I think this is reasonable, but would like to know a percentage or number of checks etc. to know more what we are really shooting for, but maybe this means utilizing for all patients. I see in Stage 3 it moves on to other interaction checking, so does this mean these 2 types of checks performed for all patients?

- We are unsure why all of the additional checks are being reserved for stage 3 – Many of these types of checks are available in current systems and either already are in use or could begin to be employed in stage 2. If the types of alerts were divided, this could equalize the impact rather than having most of the burden arrive in stage 3. We would also like to understand when it is expected that these pop-ups would occur and be acted upon, at the time of order or with the pharmacist? Finally we would like the required checks to be clearly defined with the perspective of avoiding alert fatigue.

 

- Who is defining "appropriate evidence-based interactions?" Other things I have read indicate they are wanting to reduce alert fatigue by targeting "high yield alerts" and monitoring "metrics." Small hospitals, in particular, do not have the resources to manage this, nor should individual hospitals have to manage this. This seems like an issue with the formulary vendors and it I see they are introducing new products to help hospitals manage alerts. This is too much specificity for stage 2.

 

3. E-prescribing (eRx) (EP) (40%)

50% of orders (outpatient and hospital discharge) transmitted as eRx 

80% of orders (outpatient and hospital discharge) transmitted as eRx 

- Seems reasonable.

- Over reaching. Most hospitals will be lucky to have started implementation.

- One issue to consider is mail order pharmacies. Are they included?

- I think we will be ready to do this.

- There is no mention of how controlled substances will be handled in the measure. It will be great when controlled substances can be ePrescribed, but that isn't true today even though the regulations would indicate there is going to be a way (in the future, not now operationalized on the existing networks). Until ePrescribing of controlled substances is feasible, they should be exempt. This will also be more difficult for hospitals that don't also have eligible providers. There doesn't seem to be widespread adoption of ePrescribing by hospitals. Also, the ePrescribing vendors charge a lot more to hospitals to connect. This may be yet another gimme to the vendor community if hospitals are required to purchase this service and the networks aren't held accountable for reasonable pricing somehow.

- This sounds like it is upping the percentage of the EP orders and adding hospitals in at this time.

- This rule needs to take into consideration the patients' preferences. Some patients may want to take their prescriptions with them to their local pharmacy and not use the big ePrescribing participants as their pharmacy. With no hospital history of ePrescribing, 50% may be too high a starting point.

- Please clearly define outpatient as to whether this includes EH outpatient (Lab, XRay, Emergency, etc..) or is only EP outpatient.

4. Record demographics (50%)

 

 

80% of patients have demographics recorded and can use them to produce stratified quality

reports

90% of patients have demographics recorded (including IOM categories) and can use them to

produce stratified quality reports

- Is CMS referring to: Locally relevant choices from a national standard list of approximately 540 categories with CDC/HL7 codes? If so, how would one help a patient identify their ethnicity? Are you expecting an admitting clerk to review 540 choices? Or how does an EHR vendor, which may be used anywhere define a subset of locally relevant choices for the end-user to choose from?

- I think we can do this.

- This one is reasonable. Once hospitals meet the Stage 1 requirements, most will probably be already meeting this one.

- I would like more explanation for the stratified quality reports. Does this just indicate we want to be able to pull quality (i.e. core measure) reports for specific populations?

- We would request that “can be used to stratify quality reports” be clearly defined. Additionally some thought should be given to standards for some of the demographic fields where none exist today. This would be especially important with regards to demographic data that is then used as patient identifiers.

5. Report CQM electronically

Continue as per Quality Measures Workgroup and CMS

Continue as per Quality Measures Workgroup and CMS

- No more expansion of the quality reporting requirements. Leave quality reporting to QRYX.

- Do not add any new measures until it is proven that the current ones can be adequately captured and a method of electronic submission is clearly identified.

- OK.

- There is a separate group working on this, but no new quality measures should be added until they see how it goes for the ones that are in Stage 1. Just adding the requirement for the Stage 1 quality measures to be submitted electronically would be a big step for Stage 2. For the future, doing the same for the core measures already required by CMS (e-specifying them and converting them to fully electronic submission) would be wonderful and a challenge for even Stage 3.

- Please see commentary in the general comments above.

6. Maintain problem list (80%)

Continue Stage 1

 

80% problem lists are up-to-date

- I was hoping to have a more specific definition of what the "problem list" actually is. I have been finding a multitude of different definitions are in practice. As a result, many organizations are measuring their success rate differently then we do. Without a specific definition it is hard to see what value this criterion will actually provide since many will claim to meet it with different end results.

- Whose care plan are to be included? Will nursing and physicians be expected to work from a mutual problem list? If so, will the problem list maintained in the EMR be expected to be updated by both?

- For Stage 2, this makes sense. 80% is challenging enough. For Stage 3, how is "up to date" going to be recorded and confirmed for reporting?

- This is a much bigger challenge than CPOE is for our providers. They do not understand how this impacts patient safety in the same manner as CPOE, and we believe this threshold is too high.

- In the current final rule, there are many variables in the definition of up-to-date and how it is applied to the EHR. The possible interpretations include, coded from the last visit, patient response upon presentation and anything that is in the record. Please clearly define this term as it applies to this objective and others. (e.g. At each encounter, throughout each hospital stay and at discharge) Our recommendation for appropriate timeline for hospitals is up to date at time of discharge. (We hope you will consider removing ambiguous statements like “if appropriate”.)

7. Maintain active med list (80%)

Continue Stage 1

 

80% medication lists are up-to-date

 

- Is CMS anticipating including outside sources for Med Rec? In other words, will EHRs be forced to include any source of medication information when doing Med Rec?

- Same as problem list.

- With the addition of Medication Reconciliation to the Core list and also the new requirement for electronic medication administration recording, we feel this objective is rendered unnecessary. In order to meet these two objectives, medications would need to be recorded electronically within the electronic health record. If this objective does remain, in the current final rule, there are many variables in the definition of up-to-date and how it is applied to the EHR. The possible interpretations include, coded from the last visit, patient response upon presentation and anything that is in the record. Please clearly define this term as it applies to this objective and others. (e.g. At each encounter, throughout each hospital stay and at discharge) Our recommendation for appropriate timeline for hospitals is up to date at time of discharge. (We hope you will consider removing ambiguous statements like “if appropriate”.)

8. Maintain active medication allergy list (80%)

Continue Stage 1

 

80% medication allergy lists are up-to-date

- Same as problem list.

- In the current final rule, there are many variables in the definition of up-to-date and how it is applied to the EHR. The possible interpretations include, coded from the last visit, patient response upon presentation and anything that is in the record. Please clearly define this term as it applies to this objective and others. (e.g. At each encounter, throughout each hospital stay and at discharge) Our recommendation for appropriate timeline for hospitals is up to date at time of discharge.

(We hope you will consider removing ambiguous statements like “if appropriate”.)

9. Record vital signs (50%)

80% of unique patients have vital signs recorded

80% of unique patients have vital signs recorded

- This one still needs some clarification from Stage 1. Within what timeframe do the vitals need to be recorded? Height may not need to be recorded every visit, but how often?

- I would think if Stage 3 is going to be 80 % that this measurement should have been in between 50 and 50 for Stage 2.

 - Appropriate for stage 2 as is.

10. Record smoking status (50%)

80% of unique patients have smoking status recorded

90% of unique patients have smoking status recorded

- Like the quality measure please make the smoking queries consistent across reporting agencies.

- Now that we have all shifted to the required smoking queries, this one shouldn't be difficult to reach.

 - Appropriate for stage 2 as is.

11. Implement 1 CDS rule

 

 

Use CDS to improve performance on high-priority health conditions.

Establish CDS attributes for purposes of certification: 1. Authenticated (source cited); 2. Credible, evidence-based; 3. Patient-context sensitive; 4. Invokes relevant knowledge; 5. Timely; 6. Efficient workflow; 7.

Integrated with EHR; 8. Presented to the appropriate party who can take action

Use CDS to improve performance on high-priority health conditions.

Establish CDS attributes for purposes of certification: 1. Authenticated (source cited); 2. Credible, evidence-based; 3. Patient-context sensitive; 4. Invokes relevant knowledge; 5. Timely; 6. Efficient workflow; 7.

Integrated with EHR; 8. Presented to the appropriate party who can take action

- Seems reasonable but am not certain that we could meet this measure in time.

- Depends on how far they go. Need to go slow. Minimal number at this time.

- There are many vague terms used in this rule. This would require nimbleness beyond most current EHR vendors, thus imposing a third party, integrated solution. Amongst the current vendors that would provide such information Authentication, Evidence-based and Timely can be achieved. Patient-context sensitive would be very difficult to establish. A scenario such as a patient admitted with pneumonia would be easy to produce authenticated and evidence-based; but what if the patient is immunosuppressed? Is the software to capture that somehow and alter the CDS? What does invoke relevant knowledge mean? Whose knowledge?

- This will take effort to implement. Hard to measure.

- Whoa! Who is defining "relevant knowledge," "efficient workflow" and "integrated with EHR"? If they have those figured out - they should share them with the rest of us! Plus, how is used to "improve performance on high-priority health conditions" going to be measured.

- This is definitely forcing everyone to purchase interfaces with evidence based medicine vendors. I would like better clarification on this as to what will be considered a high-priority health condition.

- This proposal appears to be ok conceptually but nearly impossible operationally. We should try to avoid qualitative measures like these that cannot be easily generated by the certified EHR.

- We are unsure how these attributes would be defined in a practical way for hospitals. We would like to see clearly defined attributes. (For example, Efficient Workflow which could vary by facility) Additionally, we would recommend, rather than outcome measures, that a minimum required number be set for this objective. We believe 5 is an appropriate number for stage 2. Outcomes can be monitored in the reports required in the quality measures objective.

12. Implement drug formulary checks* 

Move current measure to core

80% of medication orders are checked against

 

 

relevant formularies

-This is confusing for many hospitals. Since the formulary is what drugs we stock in the hospital pharmacy and those are the only ones we present to the provider for order entry as "formulary," this seems to have less relevance for the hospital setting.

 

 

 

- Is the hospitals established formulary acceptable or will there need to be a link with the patient’s insurers formulary at discharge?

- OK.

- This is confusing for many hospitals. Since the formulary is what drugs we stock in the hospital pharmacy and those are the only ones we present to the provider for order entry as "formulary," this seems to have less relevance for the hospital setting. On the other hand, for the eligible provider side, the providers can only pull those formularies that are provided across whatever network they are using. That they have this enabled is good, but they can't be held responsible for which pharmacy benefit manager systems participate in ePrescribing.

- We are assuming that the relevant formulary referred to here would be the one that belongs to the patient’s insurance company. Please confirm this.

 

 

 

On the other hand, for the eligible provider side, the providers can only pull those formularies that are provided across whatever network they are using. That they have this enabled is good, but they can't be held responsible for which pharmacy benefit manager systems participate in ePrescribing.

 

-We are assuming that the relevant formulary referred to here would be the one that belongs to the patient’s insurance company. Please confirm this.

 

13. Record existence of advance directives (EH) (50%)*

Make core requirement. For EP and EH: 50% of patients >=65 years old have recorded in EHR the result of an advance directive discussion and the directive itself if it exists

For EP and EH: 90% of patients >=65 years old have recorded in EHR the result of an advance directive discussion and the directive itself if it exists

- Seems reasonable but not sure that we could meet this requirement in time.

- How often does this discussion need to take place? How would a facility track any potential changes to the document? For example, a patient creates an Advance Directive and brings it to their physician office. They then are admitted to the hospital and the AD scanned into the EMR. Now they are admitted 2 months later. How is the facility to know they have an up to date copy? Is the physician required to review the document with the patient?

- The result of a discussion - maybe. The directive itself, that is not reasonable. Patients simply don't carry them around and we can't make them produce them.

- There is a concern on the part of many of our providers that an advance directive document that may be stored within a hospital EHR may not be the most up-to-date iteration and may erroneously guide a clinician’s judgment when the patient is not able to provide input. If this is included, then some mechanism should be in place to ensure that the directive stored is up to date.

14. Incorporate lab results as structured data (40%)*

Move current measure to core, but only where results are available

 

90% of lab results electronically ordered by EHR are stored as structured data in the EHR and are reconciled with structured lab orders, where results and structured orders available

- What does that mean "only where results are available?" 

This one is really odd for a MEDITECH hospital. Even in Stage 3 they seem to think that lab results wouldn't be "reconciled" with structured lab orders. In any system with order entry (even if it isn't entered by the provider), the order and result would be linked.

I do not understand this one or what they are thinking. It isn't difficult to meet, just confusing.

- Appropriate for stage 2 as is.

15.Generate patient lists for specific conditions*

Make core requirement. Generate patient lists for multiple patient-specific parameters

Patient lists are used to manage patients for high-priority health conditions

 

- What is the intent of this measure? Will this strictly be a paper process? Who wants/needs the data? 

Stage 3 
How are the lists used to manage patients for high-priority health conditions?

- Please define which patient-specific parameters would be required.

16. Send patient reminders (20%)*

Make core requirement.  

20% of active patients who prefer to receive reminders electronically receive preventive or follow-up reminders

- The concern here is the "per patient preference" requirement. We need to make sure that this is held to the reasonable standard. Having a couple of options (snail mail and patient portal for example) is fine, accommodating any and every PHR, electronic format, etc. just isn't feasible.

- Appropriate for stage 2 as is.

17. (NEW)

30% of visits have at least one electronic EP note

90% of visits have at least one electronic EP note

- Seems reasonable.

- What is an EP note? Eligible Provider? Sounds vague. No.

- After reviewing the recent PCAST report, we would question whether ONC plans to put the recommendation in place to begin to use tagged meta-data to gather the required healthcare data for exchange and reporting. If so, then we feel it may be counter-productive to allow scanning documents as a stage 2 solution. This may encourage some providers to purchase certified scanning software for these objectives and then need to re-purchase new software, implement and change process to meet the more stringent tagged meta-data requirements that could be forthcoming. We do support gathering data in the most coded, structured and standard format as possible, once clearly defined but it may be worth including some additional parameters that would allow the continued use of scanned documents beyond stage 2 and 3 while the nation moves toward all tagged meta-data exchange.

18. (NEW)

 

 

30% of EH patient days have at least one electronic note by a physician, NP, or PA

80% of EH patient days have at least one electronic note by a physician, NP, or PA

 

- What is EH? Again 'note' sounds vague. No - I don't like it.

- For hospitals, introducing patient days as yet another denominator will complicate the reporting. Couldn't they use unique patients for this one, also?

- Stage 2 seems a little early to move physicians from electronic orders to electronic progress notes. There needs to be more leeway in how these criteria can be met, e.g., will transcription solutions like Nuance suffice, will scribes suffice, etc.

- After reviewing the recent PCAST report, we would question whether ONC plans to put the recommendation in place to begin to use tagged meta-data to gather the required healthcare data for exchange and reporting. If so, then we feel it may be counter-productive to allow scanning documents as a stage 2 solution. This may encourage some providers to purchase certified scanning software for these objectives and then need to re-purchase new software, implement and change process to meet the more stringent tagged meta-data requirements that could be forthcoming. We do support gathering data in the most coded, structured and standard format as possible, once clearly defined. In order to move in the direction of both enhanced clinical support data being available and also standards based exchange, we suggest that this requirement be modified to require that the electronic note be captured via a coded and structured template to allow for the best possible decision support to be engaged as well as a platform for more robust information exchange.

19. (NEW)

30% of EH medication orders automatically tracked via electronic medication administration recording

80% of EH inpatient medication orders are automatically tracked via electronic medication administration recording

- Seems reasonable but not certain we could meet this requirement in time.

-eMAR is OK (again what is EH?)

-They are going to need more definition of "automatically tracked via electronic medication administration recording" although I am glad to see this included.

- We would suggest that the stage 2 measure should perhaps be 50% and that stage 3 be a requirement for bar-coded medication verification due to the enormous patient safety gains through use of this tool.

Engage Patients and Families in Their Care

Stage 1 Final Rule

Proposed Stage 2

Proposed Stage 3

MUSE Response

20. Provide electronic copy of health information, upon request (50%)

Continue Stage 1

 

90% of patients have timely access to copy of health information from electronic health record, upon request

- What is timely? Are there required components? If a discharge summary is required this may be a significant workflow issue.

- With the addition of the objective covering the web-based portal access and timelines, we are assuming that this objective now only applies to downloadable media like CD or Thumb Drive. Please confirm.

21. Provide electronic copy of discharge instructions (EH) at discharge (50%)

Electronic discharge instructions for hospitals (which are given as the patient is leaving the hospital) are offered to at least 80% of patients (patients may elect to receive only a printed copy of the instructions)

Electronic discharge instructions for hospitals (which are given as the patient is leaving the hospital) are offered to at least 90% of patients in the common primary languages (patients may elect to receive only a printed copy of the instructions)

- What are the common languages?

- This would be more difficult to operationalize than meets the eye. 

Obviously patients are already getting paper discharge instructions. Do they understand that? 
So, for this measure, will we be required to offer options on how the information is delivered electronically (PHR, portal, CD/USB)?? 

Will all nurses facilitating discharges have to be able to produce all forms? 

Plus, we don't believe that our patients will want only electronic copies. If they want electronic copies we expect those will be in addition to the paper they take home. 

Which makes this redundant to other measures, such as the "ability to view and download relevant information."

- We agree with the components listed for the discharge instructions. We would like to confirm our assumption that the patient educational materials provided at discharge for any newly identified problems and/or medications is not required to be provided electronically as part of this objective. If we are incorrect and this educational material is also required, then it will be likely that another piece of software (a content provider) and an annual contract will need to be put in place to cover that portion. We would recommend that this not be considered part of stage 2.requirements.

22. EHR-enabled patient-specific educational resources (10%)

Continue Stage 1

 

20% offered patient-specific educational resources online in the common primary languages 

- Is this staying on the menu for Stage 2?

- Please consider removing “if appropriate” and rather set a clear expectation of a percentage and/or set of circumstances that must be met and can be measured electronically within the EHR without additionally review.

23. (NEW for EH)

 

 

80% of patients offered the ability to view and download via a web-based portal, within 36 hours of discharge, relevant information contained in the record about EH inpatient encounters. Data are available in human-readable and structured forms (HITSC to define). 

 

80% of patients offered the ability to view and download via a web-based portal, within 36 hours of discharge, relevant information contained in the record about EH inpatient encounters. Data are available in human readable and structured forms (HITSC to define). 

 

- I think this may be a difficult requirement to complete in Stage 2. It would be nice if we only had to show evidence that we were working on this solution for Stage 2 but only require it until Stage 3.

- No - phase 3

- Who are providers? Will that need to include any provider who sees the patient during the course of the hospitalization (on-call, rounding)? 

What will define a procedure and diagnostic tests? This could be very lengthy when downloading if all lab results were to be included. 

One set of VS lacks relevance and can be misleading. What is the intent of this component? 

What is a care transitions summary and plan? 
Why would you include information that the patient would already know? (age, gender etc.)

- Wow! 80% offered. Nurses are going to flip out with all of these requirements "Do you want to receive your discharge instructions in an electronic format?" "Do you want to view and download relevant information about your hospitalization?" 

These are redundant.

- This is a very lofty percentage. I believe it will be very difficult for most organizations to meet this in the next 24 months.

- Mandatory portals will put an unreasonable burden on EH's in stage 2. So much technology has to be adopted and deployed for stage 1 that a break in time before additional technology is mandated should be considered.

- We would like to clearly understand “when available”. For lab tests, are results excluded that have not been returned yet? For discharge summary, are those that have not yet been dictated and/or transcribed considered not available and excluded for the timeframe that applies to this objective? Additionally, we are under the assumption that “relevant information” refers to the elements you have described here and asked for comment on. If not, please clearly define what is expected. Additionally, there are many practical and process related changes that will need to take place to implement this objective and we would like to see the required percentage for stage 2 around 30% or less while logistical concerns are worked out.

24. Provide clinical summaries for each office visit (EP) (50%)

Patients have the ability to view and download relevant information about a clinical encounter within 24 hours of the encounter. Follow-up tests that are linked to encounter orders but not ready during the encounter should be included in future summaries of that encounter, within 4 days of becoming available. Data are available in human-readable and structured forms (HITSC to define)

Patients have the ability to view and download relevant information about a clinical encounter within 24 hours of the encounter. Follow-up tests that are linked to encounter orders but not ready during the encounter should be included in future summaries of that encounter, within 4 days of becoming available. Data are available in human readable and structured forms (HITSC to define)

- I think this may be a difficult requirement to complete in Stage 2. It would be nice if we only had to show evidence that we were working on this solution for Stage 2 but only require it until Stage 3.

- Phase 3

- "Have the ability" would insinuate that a patient portal or connection to an untethered personal health record is enabled and many patients just don't want that yet.

 Also, follow up test results are normally separately (already) provided via a portal or PHR. A "future summary" doesn't make sense. This is also redundant with they provide timely access measure. 

PHRs and portals should both qualify for whatever this requirement ends up being.

25. Provide timely electronic access (EP) (10%) 

 

 

Patients have the ability to view and download (on demand) relevant information contained in the longitudinal record, which has been updated within 4 days of the information being available to the practice. Patient should be able to filter or organize information by date, encounter, etc. Data are available in human-readable and structured forms (HITSC to define). 

Patients have the ability to view and download (on demand) relevant information contained in the longitudinal record, which has been updated within 4 days of the information being available to the practice. Patient should be able to filter or organize information by date, encounter, etc. Data are available in human readable and structured forms (HITSC to define). 

 - I think this may be a difficult requirement to complete in Stage 2. It would be nice if we only had to show evidence that we were working on this solution for Stage 2 but only require it until Stage 3.

- Phase 3

- 10% will be very difficult to achieve in some areas. Is this staying menu? 

Again, whatever this ends up - a hosted portal or a connection to a personal health record selected by a patient should both qualify.

26. This objective sets the measures for ―Provide timely electronic access (EP)‖ and for ―Provide clinical summaries for each office visit (EP)‖

 

EPs: 20% of patients use a web-based portaliii to access their information (for an encounter or for the longitudinal record) at least once. Exclusions: patients without ability to access the Internet

EPs: 30% of patients use a web-based portaliii to access their information (for an encounter or for the longitudinal record) at least once. Exclusions: patients without ability to access the Internet

-  I think this may be a difficult requirement to complete in Stage 2. It would be nice if we only had to show evidence that we were working on this solution for Stage 2 but only require it until Stage 3.

- Never - how do you measure this?

- Providers CANNOT be held responsible for what patients use a portal. 

Same, a portal or PHR should either one qualify.

- I believe this is a ridiculous rule. The providers should only have to ensure that it is available and should not be measured on how many patients utilize this feature.

- We disagree with measuring the physician based on the patient’s activities. We would alternately propose that perhaps a measure could be based on numbers of active patients versus number of records available for upload upon request. Additionally, it would be difficult for the physician to measure whether the patient has access to the internet.

27. (NEW)

EPs: online secure patient messaging is in use

 

EPs: online secure patient messaging is in use

 

- I think this may be a difficult requirement to complete in Stage 2. It would be nice if we only had to show evidence that we were working on this solution for Stage 2 but only require it until Stage 3.

- Phase 3

- This will be more difficult for many providers than for us. Even for CMH this is fine as long as there isn't a requirement for patients to use it a certain number of times.

- I think this should be an available thing if the patient so chooses. We are getting too far into electronic communication and losing the human touch with these type of things. Again, might be a choice, but should not HAVE to be used.

- This requires transitioning providers to "email management of their patient population.” I believe next 24 months is too soon for this expectation.

28. (NEW)

Patient preferences for communication medium recorded for 20% of patients

Patient preferences for communication medium recorded for 80% of patients

- Once this has been determined is the intent to be that the provider has to communicate in that medium?

- "Communication medium" is a moving target. Recording that a patient would like to receive information via text messaging won't be helpful since we can't accommodate it now. Will we only be required to query patients about their preferences among those options that we offer?

- This one makes sense as opposed to #27 that I commented on above. I do believe we should offer and record that, but it should not be a requirement.

- Please clarify whether this is for EP and EH?

Improve Care Coordination

Stage 1 Final Rule

Proposed Stage 2

Proposed Stage 3

MUSE Response

29. Perform test of HIE

 

Connect to at least three external providers in ―primary referral network‖ (but outside delivery system that uses the same EHR) or establish an ongoing bidirectional connection to at least one health information exchange

Connect to at least 30% of external providers in ―primary referral network‖ or establish an ongoing bidirectional connection to at least one health information exchange

- If the state can get their HIE up and running in time we might be able to achieve this. However, the likelihood off providers in our "primary referral network" being able to accept such a connection is suspect at this time.

- Prefer phase 3

- Connectivity to a patient authorized personal health record should still be allowed! 

Especially for rural communities, there may not be three providers outside the delivery system and there may not be a relevant HIE.

- Does this relate to the CCD information and if so I think the government should provide the data warehouse for ALL of us to send to and receive from instead of having all these separate systems/HIEs. Sounds like this is almost forcing EHR vendors to become the warehouse for their like customers.

- HIE's are still in their infancy. I believe this proposed rule should wait until a critical mass of HIE's are actually up and running.

- We would like to request that comprehensive educational sessions be provided regarding the plans for ELPD so that if this is the direction we are taking, providers and facilities can incorporate this information into their strategic planning and purchase plans as we move toward stage 2.

30. Perform medication reconciliation(50%)*

 

 

 

Medication reconciliation conducted at 80% of care transitions by receiving provider (transitions from

another setting of care, or from another provider of care, or the provider believes it is relevant)

Medication reconciliation conducted at 90% of care transitions by receiving provider

 

- Clarify ... any output hospital interaction vs inpatient. Patient presenting for output testing would be overkill to do this.

- We would like to request that you consider removing the portion of the measure which says “or the provider believes it is relevant”. As stated above, we believe a clear definition of expectations works best for planning, training and measuring.

31. Provide summary of care record(50%)*

 

Move to Core

Summary care record provided electronically for 80% of transitions and referrals

- In stage 1, this care summary could be provided to the next provider of care on paper. Is it your intention to continue this ay in stage 2? If so, we recommend that the percentage of electronic transmissions be lowered to 50 in stage 3 to allow time to develop a good electronic process and for health information exchange vehicles to mature.

32. (NEW)

List of care team members (including PCP) available for 10% of patients in EHR

List of care team members (including the PCP) available for 50% of patients via electronic exchange

- I am not entirely sure what this requirement seeks to achieve. Are they asking us to provide a hard copy list? Electronic? Verbal?

- No

- Does this include nursing staff, housekeeping, radiology, laboratory or only doctors?

- We ask that you clearly define who you believe should be included in the care team which gets recorded. There is much disagreement over how to interpret who should be recorded.

33. (NEW)

Record a longitudinal care plan for 20% of patients with high-priority health conditions

 

Longitudinal care plan available for electronic exchange for 50% of patients with high-priority health conditions

 

- I would like to see more definition for this requirement.

- Phase 3

- This is not in common practice now and would be a stretch for stage 2.

- Define high-priority health conditions

- This proposal is too vague (not easily quantifiable), e.g., define a qualified longitudinal care plan, define a high-priority health condition. Are certified EHR's capable of tracking this based on today's certification criteria? I suspect not.

- Is this objective intended for both EH and EP? The hospital involvement with the care planning will end when the acute event is over and the PCP will be responsible for long term care goals. If EH is included, suggest limited scope of responsibility with regard to time frame of planning.

 

Improve Population and Public Health

Stage 1 Final Rule

Proposed Stage 2

Proposed Stage 3

MUSE Response

34. Submit immunization data*

EH and EP: Mandatory test. Some immunizations are submitted on an ongoing basis to Immunization Information System (IIS), if accepted

and as required by law

EH and EP: Mandatory test. Immunizations are submitted to IIS, if accepted and as required by law. During well child/adult visits, providers review IIS records via their EHR.

- OK (if available to the hospital).

- Is this proposed to move to core, or still be menu?

- Still limited by states.

- Please define “some”. Other than that, appropriate for stage 2 as is as long as the exclusion if the public health department cannot receive the data electronically still applies.

35. Submit reportable lab data*

 

 

EH: move Stage 1 to core 

EP: lab reporting menu. For EPs, ensure that reportable lab results and conditions are submitted to public health agencies either directly or through their performing labs (if accepted and as required by law).

Mandatory test. 

EH: submit reportable lab results and reportable conditions if accepted and as required by law. 

Include complete contact information (e.g., patient address, phone and municipality) in 30% (EH) of reports.

EP: ensure that reportable lab results and reportable conditions are submitted to public health agencies either directly or through performing labs (if accepted and as required by law)

- Seems reasonable but I am not certain that we will be able to reach this goal in time.

- Appropriate for stage 2 as is as long as the exclusion if the public health department cannot receive the data electronically still applies.

36. Submit syndromic surveillance data*

Move to core.

 

Mandatory test; submit if accepted

 

- Appropriate for stage 2 as is as long as the exclusion if the public health department cannot receive the data electronically still applies.

Additional Specific Questions for Public Comment

The Health Information Technology Policy Committee welcomes public comment on all proposed objectives and their associated definitions. In addition, the Committee seeks specific input on the following additional questions.