Monday, July 19, 2010

A Meaningful Use and Standards Rule FAQ

Since the Final Meaningful Use and Standards Rules were released last week, many people have emailed me questions, which I'd like to share generally. My blog is not reviewed by ONC or CMS, so these answers are my own opinion.

1. The Meaningful Use Rule identifies 15 Core Set required criteria and 10 Menu Set optional criteria (from which eligible professionals and hospitals must choose 5). Can they choose any 5?

You cannot choose any 5. Page 59 of the Meaningful Use final rule notes "all EPs and hospitals must choose at least one of the population and public health measures to demonstrate as part of the menu set. This is the only limitation placed on which five objectives can be deferred from the menu set."

This means that eligible professionals (EPs) must submit data to immunization registries or syndromic surveillance registries. Hospitals must submit data to immunization, syndromic surveillance or reportable lab registries. If such registries do not exist in your state/city (i.e. there is no repository to receive the data), CMS will not penalize the EP or Hospital.

2. The patient engagement aspects of the Meaningful Use Rule seem challenging to operationalize. Can I provide a paper copy of the visit summary or discharge summary to the patient? If not, how do I deliver a summary to the patient electronically? Can it be a PDF?

Patient engagement is probably the most complex area of the Meaningful Use and Standards Rule. Here's my understanding:

a. EHRs and Hospital Information Systems must have the capability of producing a human readable summary AND a computable summary that adheres to the Standards Final Rule (CCR or CCD). For some organizations, that would be two documents (a human readable PDF and a computable CCD, for example), or they could produce one electronic copy with an XSL style sheet that makes the CCD human readable. Thus, the Standards Rule requires a CCR/CCD at a minimum plus optional human readable PDF, Text, DOC etc. Here's the Standards Rule text:

Electronic copy of health information. Enable a user to create an electronic copy of a patient’s clinical information, including, at a minimum, diagnostic test results, problem list, medication list, and medication allergy list in:
(1) Human readable format; and
(2) On electronic media or through some other electronic means in accordance with:
(i) The standard (and applicable implementation specifications) specified in §170.205(a)(1) or §170.205(a)(2); and
(ii) For the following data elements the applicable standard must be used:
(A) Problems. The standard specified in §170.207(a)(1) or, at a minimum, the version of the standard specified in §170.207(a)(2);
(B)Laboratory test results. At a minimum, the version of the standard specified in §170.207(c); and
(C) Medications. The standard specified in §170.207(d)."

b. To achieve Meaningful Use, you must give an encounter summary to 50% of outpatients and 50% of ED/Inpatients who ask —and that summary can be electronic or printed. Even though the EHR must be certified to produce a CCR or CCD, meaningful use does not require that the patient actually receive their information in these formats. Paper is fine. In fact, even if you were to provide a CCR or CCD, the patient still has the option of requesting paper and you must provide paper if asked.

c. If you do want to deliver summaries to the patient electronically. how can you do it? The answer - anyway you want per Page 179 of the Meaningful Use Final Rule:
"Comment: Several commenters requested changes to the media through which this information could be provided. Differing commenters recommended eliminating the paper option, while others recommended only the paper option.

Response: We believe that more options give the EP needed flexibility. The EP could choose any of the listed means from the proposed rule of PHR, patient portal on a web site, secure email, electronic media such as CD or USB fob, or printed copy. If the EP chooses an electronic media, they would be required to provide the patient a paper copy upon request. Both forms can be and should be produced by certified EHR technology."

3. Do Emergency Department Systems need to be certified?

The Final Meaningful Use Rule clarifies that Emergency Department professionals are part of hospital staff and hospital meaningful use. Specifically, the Emergency Department is mentioned as part of the patient summary and CPOE requirements. For example:

"* More than 50% of all patients who are discharged from an inpatient or ED of a hospital who request an electronic copy of their discharge instructions must be provided with it."

Thus, ED information systems are likely going to be certified as to their ability to export an electronic copy of discharge instructions/clinical summaries. I suspect that ordering and medication management will also be included in certification of ED systems. We'll know more over the next few months at the Authorized Testing and Certification Bodies begin their work.

4. At what points in care does Medication Reconciliation have to be done?

If patient is transitioned from the ED to the ICU to the inpatient ward of the same hospital, does medication reconciliation have to be done 3 times per the Meaningful Use Rule?

At BIDMC, our Joint Commission mandate for medication reconciliation has led us to verify medications at every external and internal care transition. However, Meaningful Use does not. Per Page 193:
"Comment: Commenters requested additional clarity of the term “transition of care.” A few suggestions were provided by commenters including expanding the description to include all transfers to different settings within a hospital or revising the definition to “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”.
Response: In the proposed rule we clarified “transition of care” as the transfer of a patient from one clinical setting (inpatient, outpatient, physician office, home health, rehab, longterm care facility, etc) to another or from one EP, eligible hospital, or CAH (as defined by CCN) to another. We believe that different settings within one hospital using certified EHR technology would have access to the same information so reconciliation would not be necessary. We modify our clarification to account for some of the revisions provided. We clarify 'transition of care' as 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. We also clarify that the receiving eligible hospital or EP would conduct the medication reconciliation."

5. Can I use multiple software applications to achieve Meaningful Use?

Meaningful Use can be achieved using any combination of systems. However, every application and module used to achieve meaningful use must be certified (or the combination of systems in use at the site must achieve site certification).

At BIDMC, we're doing a site certification of our EHR, CPOE, Lab/Pharmacy/Radiology, decision support and data warehousing systems, since all will be used to achieve Meaningful Use.

Commercial vendors will certify their products, but in my opinion, many hospitals will end up doing site certification because they have numerous built and bought applications that will be used to achieve Meaningful Use.

I hope these answers are useful. I also hope they are correct. Each time I'm asked a question, I forward it to CMS and ONC to include in their internal FAQ database, so there will eventually be official answers!


Michelle W said...

Thanks for that first answer on which options could be dropped, I missed that qualifier about which ones in my initial flyover of this rule.

Anonymous said...

Though a bit tangential to the latest rules, I wonder if you would comment about metadata (audit and system logging) implications of the rules.

Anonymous said...

Could a radiologist meet the standard of Meaningful Use, if so, how?

Anonymous said...

John - thanks for the information. I would like your thoughts on this scenario. If a EH has a certified EHR for Inpatients and a seperate certified EHR for ED (both from different vendors). How would they report their metrics for CPOE? Example: IP CPOE is only 10% but ED CPOE is at 80% but combined they would reach the 30% threshold.

Would the facility report the two seperate numbers or combine the two numbers manually?

Would the facility need a "Site Certification" even though both vendors were certified?


Joe Weber said...

How does free text play into meaningful use? If a physician dictates all or part of a note, can this qualify? The text could be generated by front- or back-end speech recognition, by traditional transcription, or by physician typing. It would seem that deploying natural language processing, to extract the clinical facts and convert them to EHR-field-populating codes, might be required in order to qualify as meaningful use.

Anonymous said...

Thanks for your take on the various requirements. One question, per your comment about what BIDMC is doing. I understand you have built your own patient portal. Do you foresee needing to have that "certified" as well or is the patient portal just a means in which to "display" information to patients from your certified EMR, etc.? Just trying to get a sense if a patient portal would need to be certified as well.

Thanks again!

kentB said...

Radiologists are eligible to receive Meaningful Use incentive payments. Many of the measures of meaningful use include "patients seen by the EP" in their definition of denominator. In a large multi-specialty group practice, radiologists are rarely face to face with a patient. Patients who are scheduled for diagnostic imaging studies are not scheduled to see an individual radiologist. With no appointments or office visit charges to look at to figure out who was "seen by" the Radiologist, what data could on claim implies the patient was "seen by" the Radiologist?

Unknown said...

It seems a little silly that you only have to give half of your patients who ask, access to their medical records.

Does this mean that you can tell the other half sorry, we don't feel like giving you a copy today?

Or perhaps, sorry, we've hit our quota for today, come back tomorrow ....

Alfred Harding
CL Medical Consulting
Lubbock, TX

Anonymous said...

I would like to know more about the "site" certification process. CCHIT hasn't posted their certification process but Drummond has. Drummond doesnt have any information about "site" certification in their Testing Guide. Can anyone tell me more about what it is and who is providing that certification?

Anonymous said...

I would appreciate if you could should some light on the recent CMS notification, on their website, which suggests that an ED patient in observation would count in the CPOE denominator. I thought observation patients were out.

Here’s the link to the CMS notice: