HITPC: MU workgroup previews Stage 3 recommendations

Clinical decision support (CDS), patient engagement, care coordination and population management are the four areas of special emphasis reflected so far in Meaningful Use (MU) Stage 3 draft recommendations, Paul Tang, MD, MS, Palo Alto Medical Foundation and chair of the MU workgroup, said at the Health IT Policy Committee meeting on Feb. 4.

As a prelude to seeking committee endorsement of recommendations at the next meeting on March 11, the workgroup unveiled the latest work to date. The draft recommendations thus far culminate from 112 MU workgroup and subgroup public phone calls, Tang said. “This is only one step in the whole process. We’ve had a lot of opportunity for public and official comment, and we still have more to go.”

Along with George Hripcsak, assistant professor, department of medical informatics at Columbia University and co-chair, Tang reviewed overall recommended changes and clarifications to MU Stage 2 objectives for Stage 3.

Changes under the "improving quality of care and safety" priority include:

• CDS: Interventions would apply to clinical quality measures (CQMs) in at least four of the six National Quality Strategy priorities, including preventative care, chronic disease management, appropriateness of lab/rad orders, advanced medication-related decision support and improving problems, medication and allergy lists. Certification criteria would include ability to track CDS interventions and user responses; perform age‐appropriate maximum daily‐dose weight-based calculation; and consume external CDS rules.
• Care planning: Eligible hospitals (EHs), as a core objective, and eligible providers (EPs), as a menu objective, would be required to record whether a patient over 65 has an advance directive. Certification criteria would include storing the document in the record itself.
• Electronic medication administration record (eMAR): Would require EHs (core) to automatically track medications using assistive technologies in conjunction with eMAR. Certification criteria would require the reporting on discrepancies between what was ordered and how the medication actually was administered.
• Imaging: For both EPs (menu) and EHs (core), imaging results would be required in the EHR, including access to images themselves. (Threshold: Low)
• Electronic notes: EPs (core) would have to record electronic progress notes, authored by eligible professionals. For EHs (core), these notes must be authored by an authorized provider. Criteria would require ability for the reader to understand the origin of copied text and modifications. (Threshold:Low)
• Order tracking: A new menu objective for EPs to assist with follow-up orders to improve management of results. For certification, system must display abnormal tests, date completed, notify when available or incomplete and match results with the order. (Threshold: Low)
• Unique device identifier (UDI): EPs and EHs would be required to record the UDI for newly implanted devices. (Threshold: High)
• Medication adherence: Certification criteria would require access to pharmacy medication fill information and the prescription drug monitoring program.

Under the "reducing health disparities" priority, changes include:

• Demographics: Certification criteria would require systems to capture patient preferred method of communication, occupation and industry codes, sex orientation and gender identity and disability status. Communication preferences would be applied to clinical summary, reminders and patient education objectives.

Changes under the "engaging patients and families in their care" priority include the following:

• View, download and transmit: EPs and EHs must provide patients with the ability to VDT their health data within 24 hours if generated during the course of a visit (instead of four days). Family history data is required through VDT. (Threshold: High)
• Amendments: A new objective, certification criteria would require systems to allow patients to easily request an amendment to their online records.
• Patient general heath data: A new functional objective, would recommend getting patient data from structured or semi-structured questionnaires or secure messaging. (Threshold: Low)
• Visit summary/clinical summary: EPs must provide office-visit summaries to patients with “relevant, actionable information, and instructions pertaining to the visit.” Certification criteria would require systems to allow configuration of summary reports to serve this purpose. (Threshold: Medium)
• Patient education: EPs and EHs that use certified EHRs would be required to provide educational material in patient’s preferred language in the preferred form.

Under the "improving care coordination" priority:

• Summary of care: EPs, EHs and critical access hospitals (CAHs) would be required to provide summary of care for transfers; consult requests; and consult request notes.
• Notifications: As a new objective, EHs and CAHs would be required to send electronic notifications of significant healthcare events—such as arrival at an emergency department, hospital admission, discharge or death—in a timely manner to the patient’s care team with patient consent. (Threshold: Low)

As lastly, under the "improving population and public health" priority:

• Immunization history: Certification criteria would require systems to provide ability to receive and present a standard set of structured, externally-generated immunization history and capture the act and date of review within EP/EH practice. (Threshold: Low)
• Case reports: New certification criteria would require that certified EHR is capable of using external knowledge to prompt end user when criteria are met for case reporting; capable of recording and maintaining an audit of date and time of prompt, and using external knowledge to collect standardized case reports.
• Registries: Reuse certified EHR data to electronically submit data reports to one registry

Tang also told the committee that although “popular”, the workgroup took the “deeming concept”—which would allow high-performing providers pursue an optional pathway to certification—off the table. Tang said it is difficult to implement before the development of outcomes-oriented CQMs.

Many committee members, while lauding the workgroup’s work, expressed concern about the ability of providers to achieve these objectives, both clinically and financially.

“I’m still concerned about timing. If we can’t get to Stage 2, getting to Stage 3 will be a big pull,” said Marc Probst, vice president and CIO of Intermountain Healthcare.

Others raised concerns about the unintended consequences of recording gender identity; the ability for patients to VDT within 24 hours of appointment; and usability issues.