Friday, July 17, 2009

An Update to Meaningful Use

On June 16, I wrote about the release of the draft definition of meaningful use.

Today, at the HIT Policy Committee meeting, the final definition of meaningful use was released and adopted. What was changed?

1. For inpatient CPOE, only 10% of orders must be entered electronically
2. For problem lists, ICD9 or SNOMED must be used
3. Advanced directives must be recorded
4. Smoking status must be recorded
5. Quality measures must be reported to CMS
6. Clinicians and Hospitals must implement at least one clinical decision rule relevant to a high clinical priority
7. Administrative transactions, including eligibility and claims, must be completed electronically

Also, the timing of meaningful use was clarified in this presentation on Slide 12 and 13

The Meaningful Use Workgroup recommended use of an 'adoption year' timeframe (i.e., '2011 measures' applies to first adoption year even if HIT adopted in 2013; '2013 measures' applies to 3rd adoption year.

Thus, clinicians can still receive partial stimulus funds if they implement 2013-2015 instead of 2011-2013, and they can follow the same path as early adopters instead of an increasingly difficult set of criteria.

The Committee also discussed options for certification which I encourage you to read.

A very important meeting today. Now that meaningful use has been defined and approved, the HIT Standards Committee can complete its initial standards and certification criteria recommendations, which will be delivered next Tuesday.


Ahier said...

Thanks for sharing these insights John and for the work on the Standards Committee. It looks like we are making good progress now...
For those who may be interested, I have posted the rough draft transcript of the HIT Policy meeting here:

David said...

John, thanks as always for your timely posts.
How "final" do you think these MU criteria are? Especially the "adoption year" principle which is a significant change. Will CMS agree to it? If the HIT PC is just "recommending" these criteria, how will the final final decisions be made? It might be helpful to have a timeline or chart of the overall HHS process from proposals to final rules, showing where HIT PC recommendations fit in the big picture.

Unknown said...


It still sounded to me like ONC and then CMS will take the input of the group and it has not "been defined or approved yet."

According to David, "We’re going to hopefully — we may be able to come back to the committee in August with some additional questions or some thinking from the national coordinator’s office. We’ll see. We’re going to talk to our General Counsel about that. There will be some period of time where we’re going to be heads down writing our regulations and working on our process internally and like I said there will be comments, opportunities again on these topics in December. "

And Jody said, "I just want to clarify these are recommendations of an advisory committee, and "CMS will come up with a proposed rule on the incentives including the definition of meaningful use and get comments, and then go to a final rule. ONC will be developing an interim final rule as set forth in our statute on the standards and certification criteria which we will also get comment on and come up with a final rule after comment.

BTW - Thanks Brain for serving as the aggregator of public resources and speaking up for those with speech and language disorders by posting the transcript that HHS created for everyone during the meeting.

geekgoalie said...

There is a 2015 Objective that reads "Multimedia support (e.g., x-rays)"

What does this mean? Does this require the use of clinical images (DICOM) or the exchange of them?

DK MD said...

There is an issue with respect to MU vis-à-vis Hospitals that remains unclear, and perhaps unsettled. Whether the HIT Standards Committee can/should address this you might consider.
The issue revolves around a hospital (its IT framework notwithstanding) as a system-of-systems. No matter how one cuts it, the ED functions entirely differently than an inpatient floor, or the OR, and so on. As an example, CPOE which is instituted in the ED module/system, but not yet on some floors, may account for 100% of ED orders, but 5% of overall hospital orders. How does one resolve these with respect to 2011 and beyond? Do they remain separate, harmonize, or blur? Does the ED exhibit MU, but not the floor? Does the hospital? How do they fit into the evolving dialogue about certification of systems and modules vis-à-vis interoperability?
Questions, questions! Yes. Nevertheless there is a fundamental issue within regarding the hospital setting, its departments, and the IT-adoption endeavor.
Thanks for your work, John.

Don Kamens

Unknown said...

The slide show was very helpful to see. I think most of the outpatient criteria are clear and resaonable, but I am curious to the value of two of them.

1) % meds entered into EMR as generic. I am all for generics, and in fact tell my patients that I am an early adopter of technology, but a late adopter of meds. But with mandated interchange at the pharmacy level and an EMR that lists brand name and generic name, is there much value in making docs comb through their EMRs and change all those patients whose med lists say Norvasc (amlodipine) to just amlodipine? I don't think there is.

2) % patients >50 with annual colorectal cancer screening. Annual?? That does not seem in line with current clinical practice. If colonoscopy completely normal at 50, USPSTF says you don't have to do anything until 60. I am curious to see further info around this.

-Michael Coffey, MD

JGF said...

John, you've got a spam comment from 7/19. I'm afraid only moderation will stop those.

There are so many interesting issues that will arise. Consider the problem list.

When the standard says "SNOMED", do they mean SNOMED concepts, or SNOMED terms? Do they mean pre-coordinated or is coordination allowed? If coordination is not allowed, then how should we deal with 'missing' pre-coordinated concepts? Any extension would be neither SNOMED nor ICD.

Can we mix and match SNOMED and ICD, or must it be one or the other? If it must only be one, I am fairly sure vendors will only implemente ICD-9, which will be vast step backwards (as I think you have learned).

What about the SNOMED terms? Some of them are less than ideal, or quite unfamiliar (ex: scabies) to most clinicians. Can vendors supply their own synonyms as long as their are associated SNOMED concepts?

Can customers change the terms for ICD or SNOMED? Most vendors actually implement a hacked version of ICD-9 ...

Speaking of which, since there's no elecronic version of ICD-9 (really, there isn't), what's the standard for ICD-9 problem lists?

Oh, and what's a problem list? Should it include smoking status? Procedure codes (ICD-9 procedures?, SNOMED procedures) or procedure STATUS (s/p hyesterectomy), any SNOMED code (including those for religion), Psycho-social issues? Inability to pay? Persnickitiness?

This will be interesting.

BlogRdr said...

Thanks for your post. Can you explain why ICD-10 isn't mentioned on the Meaningful use chart, even though it goes out to 2015? Did I miss it?


JGF said...

Yes, the ICD-10 omission was indeed curious.

John Halamka said...

You'll find ICD-10 listed in the work the HIT Standards Committee is doing.

I'm posting the details of the National Library SNOMED-CT problem list subset in my blog right now!