The Proposed Stage 2 and 3 Meaningful Use Recommendations

On January 12, the Health Information Technology Policy Committee published its proposed Stage 2 and 3 Meaningful Use recommendations for public comment.

Robin Raiford from Allscripts created a Quick Guide to the recommendations, making it easy to compare Stage 1, 2 and 3 in a single PDF.

Here's my analysis of the proposed Stage 2 and 3 criteria.

1.  CPOE - Stage 1 requires more than 30% of unique patients with at least one medication in their medication list have at least one medication order entered using CPOE  Stage 2 expands this to 60% of patients for at least one medication, lab or radiology order.  Stage 3 expands this further to 80%.   CPOE orders do not need to be transmitted electronically to pharmacies/labs/radiology departments.   This is a very reasonable rate of CPOE adoption.   The hardest part of implementing CPOE is getting started, which happens in Stage 1.   Adding different types of transactions (without requiring electronic transmission to back end service providers) is more about workflow and behavioral change than technology change.

2.  Drug-drug/drug-allergy interaction checks - Stage 1 requires that interaction technology be enabled.   Stage 2 adds that it will be used for high yield alerts, with metrics for use to be defined.  The idea is that many drug databases contain too many false positive interaction rules, so adoption is slowed by alert fatigue.   If only high yield alerts are required (here's what we've done at BIDMC ), clinicians are more likely to trust drug interaction decision support. Stage 3 adds drug/age checking (such as geriatric and pediatric decision support), drug dose checking, chemotherapy dosing, drug/lab checking, and drug/condition checking.  These are all reasonable goals, but automating chemotherapy protocols is quite challenging.   BIDMC built an Oncology Management System and added a full time research nurse to ensure all chemotherapy protocols are updated and accurate.    It may be asking too much to require chemotherapy dosing decision support nationwide by 2015.

3.  e-Prescribing - Stage 1 requires e-prescribing of 40% of non-controlled substances.  Stage 2 expands this to 50%.  Stage 3 expands it further to 80%.  Electronic faxing is permitted if pharmacies cannot accept e-prescriptions.   These are very reasonable goals and easily achievable if e-prescribing systems are in place, which is required for Stage 1.   E-prescribing of controlled substances, which requires more effort  including two-factor authentication, is not specifically mentioned.

4.  Demographics - Stage 1 requires capture race/ethnicity, primary language, and other demographics for 50% of patients.  Stage 2 expands this to 80%.  Stage 3 expands this further to 90%. Most institutions are already near 100% since they capture this information as part of existing registration and billing processes.

5.  Report quality measures electronically - Stage 2 and 3 will be specified by the Quality Measures Workgroup and CMS.  No further detail is offered at this time.   The hardest part of quality measure reporting is computing the numerators and denominators as is required for Stage 1.  Generating the PQRI XML to send the data to CMS is quite easy.

6.  Maintain problem lists -  Stage 1 requires documentation of at least one problem for 80% of patients.  Stage 2 is unchanged. Stage 3 requires that problem lists be up to date.  This is reasonable.   Clinicians will be motivated to update them because the problem list will be included in clinical summaries sent to the patient after every visit.   I hope that EHR vendors improve the usability of problem list management functions by creating natural language translation into the required SNOMED-CT or ICD9/ICD10 vocabularies.

7.  Maintain active medication lists - Stage 1 requires documentation of at least one medication for 80% of patients.  Stage 2 is unchanged.  Stage 3 requires that medication lists be up to date as part of medication reconciliation, which per requirement 31 below will be a core requirement with 80% compliance in Stage 2 and 90% in stage 3.  In my view, the greatest strength of EHRs should be medication management.

8.  Maintain active medication allergy lists -  Stage 1 requires documentation of at least one allergy for 80% of patients.   Stage 2 is unchanged.  Stage 3 requires that allergy lists be up to date. Clinicians will be motivated to update them because the allergy list will be included in clinical summaries sent to the patient after every visit.  

9.  Vital signs - Stage 1 requires vital sign recording for 50% of patients.   Stage 2 expands this to 80%.  Stage 3 is the same as Stage 2.  This is reasonable.

10.  Smoking status -  Stage 1 requires smoking status documentation for 50% of patients.  Stage 2 expands this to 80%.   Stage 3 expands it to 90%.  This is reasonable.

11.  Use Clinical Decision Support to improve performance on high-priority health conditions -    Implemented properly, decision support can save time while enhancing safety.   Maintaining rules can be challenging and I hope companies evolve to provide cloud-based approaches to decision support.

12.  Formulary checks - In Stage 1, formulary checks are in the menu set with the requirement that clinicians and hospitals have access to at least one internal or external drug formulary for the entire EHR reporting period.  Stage 2 moves this to core.   Stage 3 requires the functionality to be applied to 80% of medication orders.   Formulary checking is generally a part of e-prescribing, so this is reasonable.   The only unknown is how formularies vary in different regions.   Since Massachusetts has only 3 major payers, all regional, formularies have been relatively easy to manage.

13.  Advanced directives - In Stage 1, Advanced Directives are in the menu set with the requirement that 50% of patients 65 and older have advance directive documentation.   Stage 2 moves this to core.  Stage 3 requires 90%.    I believe this is a laudable but a challenging goal to achieve.   My experience is that most hospitals have advanced directives recorded for less than 25% of their patients.

14.  Incorporate lab results as structured data - The Stage 1 menu set requirement is that lab results are incorporated into EHRs as structured data for more than 40% of all clinical lab tests ordered.   Stage 2 moves this to core.  Stage 3 expands the functionality for 90%  of tests ordered and requires they be reconciled with structured orders.   Lab workflow improvement is one of the best ways to save clinicians time and ensure followup of abnormal results.   My only reservation with this requirement is that the standards for content and vocabulary (lab compendiums)  are still a work in process, so reconciliation with electronic orders may be premature.

15.  Generate patient lists - The Stage 1 menu set requirement is to generate at least one report listing patients with a specific condition. Stage 2 moves this to core.  Stage 3 requires such lists are used to manage patients for high priority health conditions.    EHRs must include business intelligence capabilities as part of Stage 1 certification, so these recommendations should be easily achievable.

16.  Send patient reminders - The Stage 1 menu set requirement is to send reminders to more than 20% of all unique patients 65 years/older or 5 years old/younger.   Stage 2 makes this core.   Stage 3 requires 20% of all active patients who prefer to receive reminders electronically receive them.   I'm supportive of this requirement if I can fulfill it by offering all our patients secure web-based reminders via our PHR.   Offering multiple electronic notification options (phone, fax, secure email, PHR, Facebook, Twitter, SMS texting) would be hard to manage.

17. Electronic outpatient notes - Stage 2 adds a new requirement for eligible professionals that 30% of visits have an electronic note.  Stage 3 requires 90%.  This note can be scanned, free text, structured etc.   Offering the option of scanning, dictating, structured and unstructured makes this requirement very reasonable.

18. Electronic inpatient notes - Stage 2 adds a new requirement that 30% of hospital days have at least one electronic note by a physician, NP or PA.   As with outpatient notes, this can be scanned, free text, structured etc.   Very few hospitals have electronic inpatient documentation.   Offering the option of scanning paper notes makes this requirement very reasonable.

19.  Electronic Medication Administration Records - Stage 2 adds a new requirement that 30% of medication orders are tracked via an EMAR.   Stage 3 makes this 80%.   The definition of EMAR will be key.   I think of an electronic medication administration record as positive patient identification of every patient, every drug and every staff member with mobile devices to record all medication events in real time.   Requiring this for the entire country by 2015 is aggressive.

20.  Provide an electronic copy of health information - Stage 1 requires this for 50% of patients who request it.  Stage 2 is unchanged.   Stage 3 requires 90%.   The challenge is implementing the workflow to support this requirement, which has to be done for Stage 1.   Thus Stage 2 and 3 are reasonable.

21.  Provide a copy of discharge instructions -  Stage 1 requires this for 50% of patients who request it. Stage 2 expands this to 80%.  Stage 3 expands it to 90%.  Since printed discharge instructions meet the criteria, this is reasonable.

22.  Patient specific educational resources - Stage 1 requires this for 10% of patients. Stage 2 is unchanged.   Stage 3 expands this to 20% in common specific languages.   This key question is what is a common language?  BIDMC supports 37 different languages.   Offering educational resources in all these languages would be challenging.

23.  Web-based download of inpatient records -  Stage 2 adds the ability to view and download inpatient summaries for 80% of patients.  Stage 3 is the same.   Since BIDMC already has a PHR offered to all its patients, this requirement is actually an easier workflow than providing inpatient record summaries upon demand via a manual process.  This requirement will be challenging for organizations which have not yet widely implemented personal health records.

24.  Provide clinical summaries for each office visit - Stage 1 requires this for 50% of all patients (not just those who ask).  Stage 2 expands this to "view and download" within 24 hours.   Stage 3 is the same.   The challenge is that records may not be completed and signed within 24 hours, especially if dictation or scanning processes are used to generate the electronic record.

25.  Timely electronic access -  The Stage 1 menu set requirement is that more than 10% of all unique patients seen by the clinician are provided timely electronic access to their health information subject to the clinician's discretion to withhold certain information.  Stage 2 and 3 make this core and include the requirement that patients should be able to filter or organize information by date, encounter, etc.   More detail is need about the requirement to organize the data to determine just how difficult this will be.   This requirement will be challenging for practices which have not widely implemented personal health records.

26.  Measures for clinical summaries and timely electronic access - Stage 2 requires that  20% of patients use a web-based portal and Stage 3 expands this to 30%.    It seems a bit odd to measure clinician performance based on patient behavior.  BIDMC has offered comprehensive secure email, timely access to all inpatient/outpatient data, and even full text notes.   After 10 years, no more than 20% of our patients use these functions.   I think a better approach is to require such functions be offered to all patients criteria is that all patients.  Adoption is something beyond clinician control.

27.  Online Secure messaging - Stage 2 and 3 adds a new requirement that online secure messaging be in use.  Our experience with online secure messaging is that it reduces clinician time returning phone calls and enhances both clinician and patient satisfaction.   This is a reasonable requirement.

28.  Patient preference for communication medium - Stage 2 adds a new requirement that patient preference for communication be recorded for 20% of patients.  Stage 3 expands this to 80%.   Per my comment in Timely Electronic Access,  I would prefer offering all patients web-based communications rather than trying to manage multiple communication approaches.

29.  Patient Engagement - Stage 3 includes multiple new patient engagement requirements - electronic self management tools, EHR interfaces to PHRs, patient reporting of care experiences online, and patient generated data incorporation into EHRs.   These need to be defined in much greater detail before their implications can be assessed.

30.  Perform test of HIE - Stage 1 required one test.   Stage 2 expands this to at least three external providers in primary referral networks (but outside the delivery system that uses the same EHR) or a bidirectional connection to at least one health information exchange.   Stage 3 expands this to 30% of external providers or a connection to a health information exchange.   Stage 2 and 3 require the HIE to connect to an entity-level provider directory.   Although some regions with well developed HIE capabilities will find this easy to achieve, many will await the functionality promised by the Direct Project in order to exchange data.

31.  Perform Medication reconciliation - The Stage 1  menu set requirement is medication reconciliation in 50% of care transitions.  Stage 2  moves this to core and expands it to 80%.   Stage 3 expands this to 90%.   Since the Joint Commission required this over 3 years ago, it is very reasonable.  Hard to operationalize, but the right thing to do.

32.  Provide summary of care record - The Stage 1 menu set requirement is a summary of care record for more than 50% of transitions of care and referrals.   Stage 2 makes this core.   Stage 3 expands this to 80%.   The challenge will be defining how this content is transmitted from provider to provider.

33.  List Care members - Stage 2 adds a requirement to provide a list of care team members (including PCP) for 10% of patients.  Stage 3 moves this to 50% via electronic exchange.  Once more details about the electronic exchange are provided, I can better assess this requirement.

34.  Longitudinal care plan - Stage 2 adds a requirement to record a longitudinal care plan for 20% of patients with high-priority health conditions.   Stage 3 expands this to 50%.   Although I'm familiar with pilots in which clinicians and patients jointly develop care plans, I have not seen it widely implemented.  This may be a bit aggressive.

35.   Submit immunization data - The Stage 1 menu set requirement was a single transaction.   Stage 2 moves this to core and requires ongoing submission.  Stage 3 requires query and review of immunization registry data.   The challenge is that many state and local public health departments do not offer the ability to receive and query immunization data.

36.  Submit reportable lab data - The Stage 1 menu set requirement was a single transaction.  Stage 2 moves this to core.   Stage 3 includes the requirement for hospitals to include complete patient contact information in 30% of reports.  As with immunizations, state and local public health departments may find this challenging to support.

37.  Submit syndromic surveillance data - The Stage 1 menu set requirement was a single transaction.  Stage 2 moves this to core.   Stage 3 includes patient self report and something called the Public Health button, which is not defined.  Public Health Departments may find this challenging to support.

38.  Ensure privacy - Nothing new was specified but additional privacy and security objectives are under consideration by the HIT Policy Committee’s Privacy and Security Tiger Team.

Thus my areas of concern are chemotherapy automation, recording patient communication preferences, judging clinician performance based on patient adoption of PHRs, EMAR implementation, maturity of HIE capabilities,  widespread rollout of longitudinal care planning, and public health readiness.

The comment period ends Feb. 25 and the Health IT Policy Committee will consider all of the comments in making its final recommendations this Summer to the Office of the National Coordinator for Health Information Technology at HHS. Here's the work plan as I understand it

Jan, 12, 2011: release draft Meaningful Use criteria and request for comment
Feb-March, 2011: analyze comment submissions and revise Meaningful Use draft criteria
March, 2011: present revised draft Meaningful Use criteria to the HIT Policy Committee
2Q11: CMS report on initial Stage 1 Meaningful Use submissions
3Q11: Final HIT Policy Committee recommendations on Stage 2 Meaningful Use
4Q11: CMS Meaningful Use NPRM

It's great to have a roadmap so we know where we're going between now and 2015.   At present BIDMC is completing its certification inspection tests and is working hard to achieve meaningful use by the end of March so we can attest in April.   Given the challenges of achieving certification and meaningful use for Stage 1,  we welcome a two year window to prepare for Stage 2.