This is part of a series of blog posts dedicated to Meaningful Use Stage 2. In today’s post we continue to review the proposed Stage 2 measures. We have discussed Meaningful Use Stage 2 in previous blog posts, titled: “Stage 2 Meaningful Use 2014 — The roadmap is finally in place, fasten your seatbelts!”, “The Two Worst Stage 2 Meaningful Use Measures — Your patients need to meet Meaningful Use Stage 2 for you to get paid? Outrageous!”, and “Alignment of the PQRS and Meaningful Use Quality Measurement Programs in 2014 — Will Podiatric Medical Doctors benefit?”. We also provide a Meaningful Use Stage 2 page on our website displaying a table that was included in the proposed rule. That table lists the proposed Stage 2 measures sorted by the Core and Menu set.
The Stage 2 Meaningful Use (MU) Measures are structured as Core and Menu sets just as the Stage 1 measures were. In Stage 2 MU there are a total of 17 core objectives that are required for ambulatory Eligible Professionals (EPs) and 5 menu measures. EPs must report on 3 of 5 menu set objectives. In addition, EPs must report 12 ambulatory clinical quality measures. Many of the menu measures that were optional in Stage 1 are now incorporated into the core objectives of Stage 2. As we review the 22 new measures and the clinical quality requirements, we will try to explain in detail the goals of each measure and its applicability, as well as their impact to physicians that are “in the trenches” providing care.
In Stage 1 of Meaningful Use the government mandated the use of the HL7 Continuity of Care Document (CCD) and ATSM Continuity of Care Record (CCR) as the method of creating Personal Health Records (PHRs). These record types have proved to have limited functionality and have not been as helpful to providers and patients as originally intended. We believe that their utility proved to be limited because the specifications used by the Office of the National Coordinator for Health (ONC) as part of Stage 1 do not assist providers that require interoperability between EHRs or patients that require interoperability between patient portals. There are several measures in Stage 1 that are dependent on these record types. In Stage 2 there are also several standards that are dependent on a newer patient record Meaningful Use concept – the Summary Care Record, based on an HL7 standard called the CDA. In today’s blog post on the proposed Stage 2 Meaningful Use measures, we discuss the specific measures that will depend on the Summary Care Record and the impact to providers these new Meaningful Use standards will fashion. The measures are outlined in the table below.
|Health Outcomes Policy Priority||Meaningful Use Stage 2 Objectives: Eligible Professionals||Meaningful Use Stage 2 Measures|
|Engage patients and families in their health care||Provide patients the ability to view online, download, and transmit their health information within 4 business days of the information being available to the EP (including diagnostic test results, problem list, medication list and allergies)||
|Engage patients and families in their health care||Provide clinical summaries for patients for each office visit||Clinical summaries provided to patients within 24 hours for more than 50 percent of office visits (increased from more that 50% within 4 days to 24 hours and includes providing information that may have been pended awaiting results such as a lab test that was ordered – the results must be posted within 24 hours of becoming available to the provider)|
|Improve care coordination||The EP who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation.||The EP, eligible hospital or CAH performs medication reconciliation for more than 65 percent of transitions of care in which the patient is transitioned into the care of the EP or admitted to the eligible hospital’s or CAH’s inpatient or emergency department (POS 21 or 23).|
|Improve care coordination||The EP who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary care record for each transition of care or referral.||Required for 65% of care transitions [up from 50 percent]; must be electronic for 10% (Stage 1 was one test)|
|MENU: Improve Population and Public Health||MENU: Capability to identify and report specific cases to a specialized registry (other than a cancer registry), except where prohibited, and in accordance with applicable law and practice.||MENU: Successful ongoing submission of specific case information from Certified EHR Technology to a specialized registry for the entire EHR reporting period|
Measures highlighted in yellow are new measures. Note: In the Stage 2 proposed rule providers must report 3 of 5 menu measures, compared with Stage 1 where providers had more latitude and could report 5 of 10 menu measures.
A Discussion of the Above Captioned Measures
- Provide patients the ability to view online, download, and transmit their health information within 4 business days of the information being available to the EP (50% threshold).
Per CMS: “The goal of this objective is to allow patients easy access to their health information as soon as possible so that they can make informed decisions regarding their care or share their most recent clinical information with other health care providers and personal caregivers as they see fit.”
This measure is controversial because it creates a threshold for the patient physically viewing the results (part 2 of the measure). We expect this part to be changed in the final rule and we have discussed this in detail in a previous blog titled, “The Two Worst Stage 2 Meaningful Use Measures – Your patients need to meet Meaningful Use Stage 2 for you to get paid? Outrageous!”
This measure makes the use of a patient portal a de-facto requirement. Currently MediTouch EHR® users satisfy the Stage 1 requirement by using the MediTouch® patient portal at www.YourHealthFile.com. Making health information, including lab results, available within 4 business days is already simple with MediTouch and the YourHealthFile® patient portal, and similar processes will carry over well to the new Stage 2 measure.
- Provide clinical summaries for patients for each office visit within 24 hours (50% threshold).
Although CMS provided 3 business days to send the clinical summary in Stage 1, they now believe that a faster exchange of information with the patient is not only possible but also encourages better quality of care; the new threshold is now 24 hours. Some EHR vendors require that their users print paper summaries at the time of the visit (what a hassle). With MediTouch EHR and YourHealthFile patient portal the clinical summary appears on the patient portal as soon as the note is signed. The change from 3 business days to 24 hours will put more pressure on physicians to complete their encounter notes quickly.
Below is the list of required elements in the clinical summary for patients:
- Patient Name
- Provider’s name and office contact information
- Date and location of the visit
- Reason for the office visit
- Current problem list and any updates to it
- Current medication list and any updates to it
- Current medication allergy list and any updates to it
- Procedures performed during the visit
- Immunizations or medications administered during the visit
- Vital signs and any updates
- Laboratory test results
- List of diagnostic tests pending
- Clinical instructions
- Future appointments
- Referrals to other providers
- Future scheduled tests
- Demographics maintained by EP (gender, race, ethnicity, date of birth, preferred language) (New requirement for Stage 2)
- Smoking status (New requirement for Stage 2)
- Care plan field, including goals and instructions (New requirement for Stage 2)
- Recommended patient decision aids (if applicable to the visit) (New requirement for Stage 2)
Note: This list is not intended to limit the information made available in the clinical summary by the EP. A provider can make additional information available and still meet the objective.
Also, note that the government now proposes a care plan as part of the structure of the clinical summary.
Per CMS: The purpose is to, “Define the management actions for the various conditions, problems, or issues.” For purposes of meaningful use measurement, we propose that a care plan must include, at a minimum, the following components:
- Problem (the focus of the care plan)
- Goal (the target outcome) and any instructions that the provider has given to the patient. A goal is a defined target or measure to be achieved in the process of patient care (an expected outcome).
MediTouch EHR already has a “Care Plan” Section, as part of the standard SOAP note, which is dedicated to assisting physicians in creating care plans and associating them with the patient’s diagnosis. We also supply MediTouch EHR users with dozens of pre-loaded care plans that cover many common patient problems.
- The EP who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation (more than 65% of transitions of care).
Per CMS: Medication reconciliation allows providers to confirm that the information they have on the patient’s medication is accurate. This not only assists the provider in their direct patient care, it also improves the accuracy of information they provide to others through health information exchange. We note that when conducting medication reconciliation during a transition of care, the EP, eligible hospital or CAH that receives the patient into their care should conduct the medication reconciliation. It is for the receiving provider that up-to-date medication information will be most crucial in order to make informed clinical judgments for patient care. For the purposes of this objective, we propose to maintain the definition of a transition of care as the movement of a patient from one setting of care (for example: a hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another.
The electronic exchange of information is not a requirement for medication reconciliation in Stage 1 or Stage 2 of Meaningful Use. This implies that it’s not possible for an EHR vendor to track when and how a provider views a paper record when comparing medication lists during care transitions. We believe the increased use of point to point, direct electronic data exchange using the CDA (Summary Care Record) will make it easier to reconcile and actually assist the doctor in electronically comparing medication lists during transition, but the CDA is not required to meet this measure’s threshold.
Currently, MediTouch EHR uses a similar workflow to compare the patient medication list with the medication list provided by Surescripts®. In MediTouch EHR it is simple to view the Surescripts medication list and check which drugs are appropriate for import. When the import button is clicked the medications automatically become part of the patient’s medication list. We believe this method will also work well with CDA medication lists and assist physicians with Stage 2 compliance (see the screen captures below).
Pick Medications to Import
Confirm the Medication Prior to Final Import
- The EP who receives a patient from another setting of care, provider of care, or believes an encounter is relevant should perform medication reconciliation (more than 65% of transitions of care).
This measure in a sense replaces the following 4 measures:
- Maintain an up-to-date problem list of current and active
- Maintain active medication list
- Maintain active medication allergy list
- Capability to exchange key clinical information
For Stage 2, CMS has consolidated the objectives for maintaining an up-to-date problem list, active medication list, and active medication allergy list with the Stage 2 objective for providing a summary of care for each transition of care or referral and with the ability to exchange the data electronically 10% of the time (increased from one test).
Per CMS: Providing this information is critical to continuity of care, so we are proposing to add these as required fields in the summary of care for the following Stage 2 objective: The EP, eligible hospital or CAH who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary care record for each transition of care or referral. EPs and hospitals would have to ensure the accuracy of these fields when providing the summary of care, which we believe will ensure a high level of compliance in maintaining an up-to-date problem list, active medication list, and active medication allergy list for patients.
By making the problem, allergy, and medication lists part of the Summary of Care Record, CMS has not relaxed their existing Stage 1 standards. Providers will still need to keep these lists in a structured format so that the lists can populate the Summary of Care Record. Mandating a 10% threshold for electronic transmission of the Summary of Care Record insures the government’s goal of increased electronic communication between providers — especially providers of disparate EHR systems. The ONC has recommended standards for the electronic communication of files between providers and patients, which we will cover in a future blog post.
- Capability to identify and report specific cases to a specialized registry (other than a cancer registry), except where prohibited, and in accordance with applicable law and practice. (Menu Measure)
Per CMS: This is the capability to identify and report specific cases to a specialized registry (other than a cancer registry), except where prohibited, and in accordance with applicable law and practice. We believe that reporting to registries is an integral part of improving population and public health. The benefits of this reporting are not limited to cancer reporting. We include cancer registry reporting as a separate objective because it is more mature in its development than other registry types, not because other reporting is excluded from Meaningful Use. We have included this objective to provide more flexibility in the menu objectives that EPs can choose. We believe that specialized registry reporting could provide many EPs with Meaningful Use menu option that is more aligned with their scope of practice.
Does anyone know who, what, and where these registries are? If they do exist, are they ready to work with thousands of providers? What public health issues will they hope to advance? The government pretty much acknowledges that this measure is not based on any existing infrastructure. What hope do providers have that in the next year or so there will be registries to report “public health” findings that are not cancer related? We expect the government to make this measure much more specific, and confirm for providers that there is an existing infrastructure to support it; if not, we hope they remove it and replace it with one of the 17 core measures. If this measure makes it to the final rule, the current format for data exchange would be the CDA.
- The CCD and CCR PHRs are going to be replaced with the new CDA Summary of Care Record in Stage 2 of Meaningful Use.
- The Summary Care Record will include the structured allergy, medication, and problem lists, and there won’t be individual measures for those lists in Stage 2 of Meaningful Use.
- There are 4-5 measures that will depend on the use of the CDA (those measures are captioned above).
- The government has proposed data transfer methods to exchange CDA documents between providers that do not use the same EHR.
- Many of the workflows related to the measures discussed above will only require MediTouch EHR programmers to perform minor tweaks to comply with Stage 2 of Meaningful Use.
- The CDA may prove to be a better solution than the current CCD and CCR for providers as well as patients (this will be discussed in our next blog post).
Summary of Care Records in the CDA format are the cornerstone of several Meaningful Use Stage 2 measures. MediTouch EHR through its patient portal, YourHealthFile, and state of the art interface has already made great strides in accomplishing much of what is going to be required in most of the Meaningful Use Stage 2 measures. We remain skeptical about certain parts of the measures that are coupled to the new CDA standard, but not about the standard itself. In fact, we believe that the new CDA Summary of Care Record method to exchange patient information will be a great improvement for patients and providers; we will explain why in the next blog post of our series.