Tuesday, February 23, 2010

HIT Policy Committee Meaningful Use Revisions

On February 17, the HIT Policy Committee held an important meeting to discuss its recommended revisions to meaningful use.

The handouts are

The important summary to read is the NPRM recommendations, but here's my Cliffs Notes version:

Recommendation 1.0: Include “Document a progress note for each encounter” for Stage 1 EP MU definition. This highlights the importance of unstructured text to communicate the thought process used when developing a treatment plan.

Recommendation 1.1: Signal clinical documentation as a required MU criterion in Stage 2 for hospitals. Today few hospitals have fully electronic progress notes, but eventually they will be needed to eliminate the inefficiencies of hybrid electronic/paper workflows.

Recommendation 2.0: Remove three proposed quality measures (inquiry regarding tobacco use, blood pressure measurement, drugs to be avoided in the elderly) from Stage 1 criteria. Since these are process measures not outcome measures they do not meet the quality measurement criteria specified by the Policy Committee.

Recommendation 3.0: Providers should produce quality reports stratified by race, ethnicity, gender, primary language, and insurance type. To meet the ARRA goal of reducing disparities in care, there needs to be measurement and feedback to providers.

Recommendation 4.0: EPs and hospitals should report the percentage of patients with up-to-date problem lists, medication lists, and medication allergy lists. Rather than just record the presence of a list, it is more important to ensure these lists are up to date.

Recommendation 5.0: EPs and hospitals should record whether the patient has an advance directive as part of the Stage 1 MU criteria. Given that ARRA focuses on the Medicare population, it is especially important that all patients over 65 have recorded their advance directive preferences.

Recommendation 6.0: EPs and hospitals should report on the percentage of patients for whom they use the EHR to suggest patient-specific education resources. Physician vetted education resources, such as those that a clinician personalizes in an EHR are more valuable than internet sourced resources a patient discovers by random searching.

Recommendation 7.0: All EPs should report to CMS the percentage of all medication, entered into the EHR as a generic formulation, when generic options exist in the relevant drug class. Such a measure would encourage efficiency in drug prescribing.

Recommendation 7.1: CMS should explicitly require that at least one of the five clinical decision support rules address efficient diagnostic test ordering. Such a measure would encourage efficiency in high cost radiology test ordering.

Recommendation 8.0: CMS should advance its timetable for the release of future MU NPRMs in order to allow adequate ramp-up time for vendors and providers. Without a glide path, vendors will struggle to create multi-year product plans.

Recommendation 9.0: The numerator for the CPOE measure should define a qualifying CPOE order as one that is directly entered by the authorizing provider for the order. It's not appropriate for nurses, clerks, or other extenders to enter orders on behalf of the clinician.

Recommendation 10.0: Change the measure to read, “For a chosen preventive health service or follow up (the EP chooses a relevant preventive or follow up service for their specialty), report on the percent of patients who were eligible for that service who were reminded.” This enables the reminder criteria to apply to all patients in practice, not just a subset over 50 as stated in the NPRM.

Recommendation 11.0: Delete “relevant encounter” from the medication reconciliation measure

Recommendation 11.1: Define “transition of care” to be the movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another. This ensures that the timing of medication reconciliation is clear - when the patient goes from one care setting to another.

Recommendation 12.0: Eligible professionals and hospitals should be given the flexibility to defer up to 6 meaningful-use criteria as described in the table below, but must meet all mandatory objectives. This is the partial credit recommendation, that uses the chart pictured above. It enables local variation in implementation, because it is hard to know which aspects of meaningful use will be hard to achieve in each locality.

I agree with these recommendations - they provide clarity, restore some important criteria, and enable an easier glide path by removing some requirements and allowing partial credit on others.

Well done!


Steven Waldren MD, MS said...

Re: Recommendation 1.0 - Documentation

I think this is wrong on multiple fronts. (1) documentation is required for current payment, so it just adds a reporting burden on physicians, (2) there is no concrete definition of "progress notes.". (3) we need to move beyond documentation and get to data exchange. Physicians complain all the time about 5-6 page "notes" from an EHR on a routine visit that say nothing of clinical importance or the signal to noise ratio is so low it is not worth the read; (4) the administrative burden for MU as proposed is already to high without adding more.

Michelle W said...

Great summary of the committee meeting; I often wish the workgroups and committees would publish a transcript along with the audio recording. But as for Recommendation 9, there's a bit more to it, since a big part of the committee's discussion concerned teaching hospitals and shared responsibilities between supervising providers and other "licensed professionals." I think we'll hear even more clarification on CPOE when the Meaningful Use workgroup meets again in March.

Ahmad Rais Johari said...

hi John...i just exploring your blog. Very informative blog..that my comment.FYI, currently my university (UiTM - www.uitm.edu.my) on progress to deploy Total Healthcare Information System for our own Clinical Training Center at Sg. Buluh and Selayang Malaysia. I'm the project manager for this project. Hope u can share your experiences with me....tq

jrlandau said...

+1 for Steven Waldren's comment

Alex I said...

John, Can I infer from the Proposed MU NPRM Recommendations chart that ePrescribing is now a requirement for Hospitals? It was only a requirement for Eligible Providers in the MU Grid previously published.
I'm hoping it's a mistake in not delineating ePrescribing in the Mandatory Objectives column and assigning it to EPs only.

Regards. Alex

John Halamka said...

You are correct - eRx is for eligible professionals. Inpatient CPOE is for hospitals.