Sunday, March 04, 2012

Meaningful Use - Part 2 Intro

The Notice of Proposed Rule Making (NPRM) for Stage 2 requirements for meaningful use of electronic health records (EHRs) was released by the Centers for Medicare & Medicaid Services (CMS) on February 23, 2012. There will be a 60-day comment period starting on March 7, and then a final rule will be published. The final rule is expected in the summer of 2012. Here are some key links and summaries:

Hints if you want to submit anything to CMS (from a HIMSS meeting with the CMS folks):
1. The best comments are well thought out explanations based on evidence whenever possible.
2. It is fine to comment as an individual, but of course it's more powerful if you comment as the consensus of a larger group.
3. Make sure to comment on both the pros and the cons.  If you just comment on the cons - then CMS needs to just focus on fixing those.  In other words, if you like something - let them know that too... otherwise someone who does not like the same thing will have more sway if they comment negatively about it and no one comments positively. 

Things I like include focus on CPOE and messaging.
Things which worry me include:
- The increase in eRx from 40% to 65%: As there are still many patients who want a printed Rx since they are not sure of their pharmacy address or want to shop around first; and not all pharmacies or PBMs accept eRx.  It's actually easier for docs to do eRx than print... but CMS has to understand that not all patients or pharmacies are ready for eRx yet.  Maybe going to 50% is a good compromise.
- Imaging requirement: As a PCP, do I really need to view the images of an xray... I am quite happy just seeing the report.  I don't think I am going to see anything the radiologist did not!  I am not sure if they are saying this requirement is for both inpatient and outpatient.
- Med Reconciliation: If a requirement for ambulatory care - I am curious on how they monitor it. On one hand, I do this every time I see a patient.  On the other hand, I don't use a special function to do this... so I am not sure how we measure it.
- Structured Family History: I am curious as to whether this will mean vendors create a new functionality for this since we've been using an older functionality for 10 years... and they might find it is easier to meet the letter of the law by using a new function rather than support an old one.

High level Summary (per HIStalk Blog)
The broad themes to be addressed in the Notice of Proposed Rule Making for Stage 2 are:
  • Increased emphasis on health information exchange.
  • Increased emphasis on patient engagement.
  • New requirements for hospital patient safety, specifically with regard to electronic medication administration records.
  • Requirements involving tying clinical decision support to quality measures.
  • A philosophical goal of flexibility and reducing provider and vendor burdens.

Specific issues are:
  • The Direct protocol will be required.
  • SNOMED will become the standard for encoding problem lists.
  • Infobutton (i.e. the blue button initiative) will be expanded, with requirements that patients be able to view, download, and exchange their own information. The proposed legislation calls for 10% of patients to actually do this.
  • While Stage 1 required theoretical information exchange capability in test mode, Stage 2 will require providers to exchange information “across organizational and vendor boundaries,” which also includes submission to public health agencies.
  • Encryption and usability requirements will increase.
  • Viewing of images will be supported as an optional item.
  • Physicians in group practice will be allowed to submit their quality measures electronically as a group.
  • Stage 1 will be extended for another year, though 2013 for those who first attest in 2011. Providers can then stay on Stage 2 for another two years.
  • The last date to attest without penalties will be October 1, 2014.
  • An increased emphasis will be placed on making referrals electronic.
  • Electronic submission to cancer registries will be added as a menu item.
(per a memo from the Global Institute for Emerging Healthcare Practices at CSC)
This memo provides a summary of the most significant changes and clarifications in the rule. A more detailed white paper will be published later. The Stage 2 proposed rules for meaningful use have many changes — some are subtle.
In addition to the new requirements to be a meaningful user of EHRs, there is one important clarification to the requirements for avoiding penalties. To avoid penalties starting in 2015 for not being a meaningful user, hospitals and eligible providers (EPs) need to either attest to meaningful use in 2013, or have achieved and attested to the first year of meaningful use by July 1, 2014 (October 1, 2014 for EPs).
As reported earlier, the requirement as to when different Stages of meaningful use need to be met was officially relaxed. Those that attest to meaningful use first in 2011 must meet Stage 2 criteria in 2014 and Stage 3 in 2016. All others will be required to demonstrate 2 years at Stage 1, 2 years at Stage 2 and then 2 years at Stage 3 (assuming the cut-off date for the program’s payments have not passed).
Quality measures are still not final, but in 2014 they will be submitted electronically. Quality measures are now a distinct category of meaningful use and the schedule is not tied to a particular Stage. In 2014, all those attesting to any Stage of meaningful use will need to electronically report the 2014 quality measures. The proposal is that EPs will submit 12 measures (some may be required, others selected from a long list of potential measures). Hospitals will select 24 measures (50 possible measures are proposed). In both settings, at least one measure will need to be reported from each quality domain: patient safety, care coordination, population and public health, efficient use of resources and clinical effectiveness. The final list of quality measures will be published with the final rule. This delay affects both users and vendors, vendors are likely to require significant development effort to be able to capture and report on the expanded list of quality measures.
There are many changes in requirements. The proposed rule generally makes Stage 1 optional (menu) items required (core) in Stage 2. Stage 2 does retain the concept of core and menu requirements for new requirements; for example use, of e-MAR is now a core requirement for hospitals and the ability to view images is a new menu requirement. Many of the thresholds from Stage 1 have been raised — some to a higher level than those recommended by the HIT Policy Committee. For example, the requirement for CPOE for medications is 30% in Stage 1, the Policy Committee recommended it be raised to 50% and the proposed rule raises it to 60%. Other new requirements include CPOE for laboratory and radiology orders, the ability of patients to view, download and transmit their health information, and public health reporting to cancer registries and other specialized registries. The CPOE measurement was changed from being based on one order per patient to a percentage of all orders — which will raise the bar considerably.
The only major recommendation from the policy committee that was not included in the NPRM was for an electronic physician note for 30% of office visits and 30% of hospital days. While no longer required for meaningful use, physician notes are a major source of data that will be required for electronic reporting of quality requirements.
To ensure that systems certified for Stage 2 can also meet Stage 1 requirements, a few Stage 1 requirements will be modified somewhat for 2014 onward. All the changes in requirements (even small ones) will have a major impact on vendors, since the entire installed base will need systems that meet these requirements. It is likely that vendors will only have the more recent versions of their products certified for Stage 2 — increasing the number of customers that will need a major upgrade.
The table below provides a summary of all the changes in requirements proposed for Stage 2. Hospitals will have 16 core (required) measures and must select two of four menu (optional) objectives. EPs will have 17 core objectives and be required to select three of five menu objectives.
Summary of Requirements for Stage 1 and Proposed Changes for Stage 2
Stage 1 Final
Minimum Requirement
Stage 2 NPRM
Minimum Requirement
Maintain medication, problem/diagnosis, allergy lists
80% of patients have an entry or indication of none
No longer separate requirement, must be included in the electronic record for patient access and transmitted at transitions in care.
Demographics recorded
50% of patients
80% of patients
Vital signs recorded
50% of patients over 2
80% of patients over 3
Smoking status recorded
50% of patients over 13
80% of patients over 13
Family history
Not required
Menu item: 20% of patients have family history recorded as structured data
Computerized Physician Order Entry (CPOE)
30% of patients have a CPOE medication order if they have any med orders
60% of medication, laboratory and radiology orders entered using CPOE
Info on Advanced Directive
Menu option for hospitals — indicate if patent has advanced directive for 50% of hospitalized patients 65+
Remains menu item for hospitals.
Drug-drug and drug-allergy checking
Enabled — now combined as one requirement for decision support
Drug-formulary checking
Menu option
Incorporated as a requirement for e-Rx
Medication reconciliation
Menu option, performed for 50%
40% of prescriptions for eligible providers
Required — 65% of prescriptions for eligible providers
Menu 10% of new or changed medications for discharged hospital patients, must include a drug formulary check
Summary of care record transmitted between providers at transitions in care
Menu option, performed for 50% of transitions (can be on paper)
Required for 65% of care transitions; must be electronic for 10%
Ability to view images
No requirement
Menu option: 40% of all scans and images available for viewing on the EHR
Secure messaging
No requirement
10 % of patients have sent at least one message to eligible providers
Electronic medication administration (eMAR)
No requirement
Required for 10% of all medication orders for hospital patients