Attention: Public comments for preliminary Meaningful Use Objectives and Measures for Stages 2 and 3.

February 25, 2011 Meaningful Use Workgroup Health Information Technology Policy Committee (HITPC) U.S. Department of Health and Human Services Attention: Public comments for preliminary Meaningful Use Objectives and Measures for Stages 2 and 3. The Minnesota e-health Initiative is pleased to submit comments on the preliminary Meaningful Use objectives and measures for stages 2 and 3 from the HITPC and its Meaningful Use Workgroup. We appreciate the work done to date by HITPC to continue to develop meaningful use in order to advance health care processes and outcomes and the efforts to seek public comments. Thank you for providing an opportunity to submit comments for your consideration. Should you have questions you may contact: Martin LaVenture, PhD, MPH Director, Minnesota e-health Initiative and Minnesota Office of Health Information Technology PO Box 64882, St. Paul, MN 55164-0882 Phone: (651) 201-5950 Email: martin.laventure@state.mn.us Sincerely, James I. Golden, PhD State Government HIT Coordinator and Director, Division of Health Policy Minnesota Department of Health Marty Witrak, PhD, RN Co-Chair, MN e-health Advisory Committee Professor, Dean, School of Nursing College of St. Scholastica Walter Cooney, MA Co-Chair, MN e-health Advisory Committee Executive Director, Neighborhood Health Care Network CC: Paul Kleeberg, MD, FAAFP, FHIMSS, Clinical Director, Regional Extension Assistance Center for HIT (REACH), Co-Chair, MN e-health Adoption and Meaningful Use Workgroup Bonnie Westra, PhD, RN, FAAN Assistant Professor, University of Minnesota, School of Nursing, Co-Chair, MN e-health Adoption and Meaningful Use Workgroup Page 1 of 20

The Minnesota e-health Initiative Response Preliminary Meaningful Use Objectives and Measures for Stages 2 and 3 Introduction and Approach The Minnesota e-health Initiative ( the Initiative ) is a public-private collaborative whose vision is to accelerate the adoption and use of health information technology in order to improve health care quality, increase patient safety, reduce health care costs and improve public health. A legislatively authorized statewide Advisory Committee guides the Initiative with 25 representatives from interested and affected stakeholders. Details on the Initiative and the Advisory Committee can be found at: http://www.health.state.mn.us/e-health. This statewide coordinated response to the request for public comment was created by inviting and engaging multiple stakeholders from the Minnesota health and healthcare system that are involved in the Minnesota e- Health Initiative, with special participation from members of the Adoption and Meaningful Use workgroup and co-chairs, Bonnie Westra, PhD, RN, FAAN and Paul Kleeberg, MD, FAAFP, FHIMSS. Comments and Recommendations The Minnesota e-health Initiative recognizes that stages 2 and 3 of meaningful use are necessary in making progress towards electronic health records (EHRs) use that will lead to a higher quality, more effective health care system. The preliminary measures are an excellent first step but there is need for more clarity and detail to set the bar at an achievable level while pushing the expectations of the EHR use. To achieve this, the Initiative is providing feedback three ways: general comments and recommendations, feedback on specific measures, and response to specific questions. We strongly encourage consideration of these comments and recommendations. General Comments and Recommendations Providers and hospitals have begun to implement meaningful use clinical quality measures, that may require the development of additional data elements, major workflow changes, system enhancements and code sets beyond what is specified in the core meaningful use objectives and measures. As the Workgroup considers recommending additional quality measures for taking into consideration whether the quality measures complement improved quality of care, efficacy in care practices driven by decision support, and improved patient outcomes. The use of the objectives to categorize the measures leads to measures being split and appearing under multiple objectives. While this is useful to demonstrate that the measure is addressing the four major objectives, consider uncategorizing the measures to reduce to redundancy of the measures and assure consistency for comparable measures. Improve upon the Improve Population and Public Health measures. For more detail see recommendations below and appendices A and B. Increase the detail provided for each to measure including the rationale and value for including the measure. EHRs should be ready out of the box for exchange/interoperability and for use with a health portal. The burden should be place on the certification organizations and vendors to assure that this happens. This is essential for medium to small sized clinics. We recommend defining the numerator and denominator for each measure. It would be ideal if the same process was followed for each measure. The final measures should leverage the extensive work on the CCD and CCR. Page 2 of 20

Comments & Recommendations on Preliminary Meaningful Use Measures All comments and recommendations apply to Stage 2 unless specified otherwise Improving Quality, Safety, Efficiency, & Reducing Health Disparities Measure Comment Recommendation CPOE (by licensed professional) for at least 1 medication, and 1 lab or radiology order for 60% of unique patients who have at least 1 such order (order does not have to be transmitted electronically) Employ drug-drug interaction checking and drug allergy checking on appropriate evidencebased interactions Employ drug-drug interaction checking, drug allergy checking, drug age checking (medications in the elderly), drug dose checking (e.g., pediatric dosing, chemotherapy dosing), drug lab checking, and drug condition checking (including pregnancy and lactation) on appropriate evidencebased interactions. Stage 3 50% of orders (outpatient and hospital discharge) transmitted as erx. Applies to both Stage 2 and 3. 80% of patients have demographics recorded and can use them to produce stratified quality reports Unclear as to if this is a provider based criteria. If not clear, pharmacist could work around this by entering the information themselves. Uncertain as to if this is an AND or an OR when looking at the medication and lab/radiology. How is appropriate evidence-based interactions defined? What are appropriate evidence-based interactions? This term is vague. See comments and recommendations for Stage 2 Measure. Medication and the elderly is challenging. The term elderly needs to be defined. Are legal barriers removed for e- prescribing for controlled substance to support this requirement? How is the mail order pharmacy included in this measure? This will be difficult for rural areas without large pharmacies. How will the EHR be able to track the fact that the pharmacy is unable to take/support e-prescribing? There are many categories relating to race and ethnicity. Are all expected to be an option in the EHR or is it locally relevant choices? Define licensed professional to exclude the pharmacist. Clarify if it is medication AND lab/radiology or medication OR lab/radiology Recommend changing the measure to be provider-based E.g. Each provider must submit 30% of all medication orders via CPOE and 30% of lab orders by CPOE. Define appropriate evidence-based interactions Recommend defining a minimum number of high risk drugs (perhaps 10) to begin with. Define elderly and use same definition in all measures including the measure on advance directives. Define the role of mail order pharmacies in this measure. Identify the method for rural providers to meet with measure if no pharmacy e- prescribes. Recommend using locally relevant choices but identify possible consequences when looking across health settings and states. Page 3 of 20

Continue as per Quality Measures Workgroup and CMS Maintain problem list (80%) / Continue Stage 1 / 80% problem lists are up-to-date. Applies to both Stage 2 and 3. Maintain active med list (80%) // Continue Stage 1 // 80% medication lists are up-to-date. Applies to both Stage 2 and 3. Maintain active medication allergy list (80%) // 80% medication lists are up-to-date. Applies to both Stage 2 and 3. 80% of unique patients have vital signs recorded Reporting of clinical quality measures is of great concern for clinics and hospitals. We are very concerned that given the lack of details at this time () that the required degree of detailed specification for measures will not be provided with enough lead time for vendors to program, test, release, and for healthcare providers to implement. A true patient problem list has all the patient s problems-including those from other providers and care settings. The vendor does not support a interdisciplinary problem list. There is uncertainty about whose care plans / which providers will be involved. Moving from having a problem list to having an updated problem list (stage 1 to stage 3), does not advance the EHR use. This becomes complicated when looking at multiple sources. How does one separate out from difference sources, assure correctness/completeness. Moving from having a med list to having an updated med list (stage 1 to stage 3), does not advance the EHR use. Moving from having a med list allergy to having an updated med allergy list (stage 1 to stage 3), does not advance the EHR use. The measure is unclear and vague. Clarify if it counts if copy forward the information- us the use previous button which pulls old data. Because of the timeframe to identify valid measures, develop and test measures in EHRs, and implement the required clinical workflows that capture necessary information, we advise no additional quality measures in Stage 2, other than those needed to address material deficiencies for specific physician specialties, and that work on additional quality measures be established for Stage 3 so that measures can be implemented efficiently. The development of the 113 proposed emeasures should continue and be connected to the work of the Workgroup and CMS. Clarify which providers will use which list and if the EHR is to be updated by all providers. Identify which sources are to be included and clearly define the expectations of the measure. Explain how up-to-date would be measured? Identify the accepted timeframe (every year, every visit). Also acknowledge that this will vary from patient to patient. (65 year old man compared to 33 year old woman) Page 4 of 20

80% of unique patients have smoking status recorded Use CDS to improve performance on high-priority health conditions. Applies to both Stage 2 and 3. Implement drug formulary checks// Move current measure to core// 80% of medication orders are checked against relevant Formularies Applies to both Stage 2 and 3. Make core requirement. For EP and EH: 50% of patients >=65 years old have recorded in EHR the result of an advance directive discussion and the directive itself if it exists. Stage 2 & 3. Incorporate lab results as structured data (40%)// Move current measure to core, but only where results are available // 90% of lab results electronically ordered by EHR are stored as structured data in the EHR and are reconciled with structured lab orders, where results and structured orders available Applies to Stage 2 & 3. Make core requirement. Generate patient lists for multiple patient-specific parameters This measure occurs across all quality organizations. Proposal is a statement of philosophy and not a benchmark. Is it two rules? Five rules? There are many vague terms defined and would be a huge burden to vendors. For hospitals, this is unclear as to if it applies to both inpatient and outpatient prescriptions. This requires that all payers have readable formularies. How is the measure affected if only 10% of patients have accessible measures? There are questions around how this is implemented at the workflow level. There can be multiple versions of the advanced directives. How do you identify the most up-to-date version? By stage 3 should not be a scanned copy but it is ok for stage 2. How does this impact labs when the answer is not a "yes or no" value? An example is the actual sensitivities of a culture. Do the same qualification on lab results apply for this stage as they for stage 1? The intent and use of the list is unclear. How does one test this function- will it be a paper process/print out? How does this relate to health care homes? Harmonize this measure to other measures collected by quality organizations. Also, recommend moving from smoking status to tobacco use. Recommend developing a measure that has defined terms and is measureable and focuses on expanding the CSD rules for an increasing number of high priority conditions. Also, assure that these can be/are consistent with the providers specialty. Verify how to identify high-priority health conditions The issue of accessible formularies by the payers needs to be addressed before this measure can be truly implemented. For hospitals recommend it apply to both inpatient and discharge medications Specifications need to be defined in such a way to provide for efficient clinical workflow. Also indicate if a POLST form can be used in place of or in addition to the advance directive. POLST is Physician Orders for Life-Sustaining Treatment Provide clarity in the use of standards for LOINC and SnoMed and recording the structured results. Identify the need for this measure including who wants or will use this information. Parameters and certification would need to be defined and incorporated into certified EHRs. It appears to be directed at case management, clarify if this is the intent and its relationship to health care homes (aka medical homes). Page 5 of 20

Patient lists are used to manage patients for high-priority health conditions Send patient reminders (20%) // Make core requirement. 20% of active patients who prefer to receive reminders electronically receive preventive or follow-up reminders. Stage 3. 30% of visits have at least one electronic EP note 30% of EH patient days have at least one electronic note by a physician, NP, or PA 80% of EH inpatient medication orders are automatically tracked via electronic medication administration recording Stage 3. How are the lists used to manage patients for high-priority health conditions? This measure is hard to measure. You can send but cannot track if received. Some EP & EH may not use a certified EHR to do this. Clarify what receive means? How do you track who wants e- reminders? The number remains low. Is this self-identified desire to receive a reminder? Unclear about the time period surrounding the measure. Scanned should not be included. Clarify the intent of this measure. Unclear about the time period surrounding the measure Clarify the intent of the measure This is a big jump from stage 2 30% to 80%. Identify the need for this measure including who wants or will use this information. Clarify is this is beyond the capability and what patients or situations are expected (e.g., routine screening for prevention actions reminders). Need to clarify if crystal reports can be used to meet this measure and if certification is required. Recommend increasing the percent for all those who want reminders. Recommend making this a menu option and defining the time period. Also, recommend eliminating scanned as an option and reducing the percentages. Recommend making this a menu option and defining the time period. Also, recommend eliminating scanned as an option and reducing the percentages. Evaluate progress here and consider a path to achievement of the 80% goal. Recommend reducing 80% to 60% for stage 2. Page 6 of 20

Engage Patient and Family in Their Care Measure Comment Recommendation Uncertain of what information is included in this measure. Is it the discharge summary? More information? Less information? Will a patient portal meet this measure? requirements. Provide electronic copy of health information, upon request (50%)// Continue stage 1 90% of patients have timely access to copy of health information from electronic health record, upon request. Stage 3. Electronic discharge instructions for hospitals (which are given as the patient is leaving the hospital) are offered to at least 80% of patients (patients may elect to receive only a printed copy of the instructions). Stage 2 & 3 20% offered patient-specific educational resources online in the common primary Languages Stage 3 80% of patients offered the ability to view and download via a webbased portal, within 36 hours of discharge, relevant information contained in the record about EH inpatient encounters. Data are available in human-readable and structured forms (HITSC to define). Stage 2 and 3. The term timely access is unclear. This is a big jump as it includes everyone, not just those who are requesting the information. What happens if the patient loses their password or does not have software to read the CCD? The language in this measure changes slightly from stage I and that previously it was only where requested. Now it must be offered to 80%. How is that measured? How is patients reply measured? How is common language defined? How is common language defined? How are we to get these material translated into these common languages if the common language in my neighborhood in an uncommon language? Including all providers (nurses, RT, et al) is very burdensome and will add little value to the patient. The patient knows their gender, race, ethnicity, DOB, et al., there is no need to have them look through that information. It may overwhelm them. There are certain patients that will not want this information in this format and will need to be excluded from the denominator. This measure could require a lot of converting data to layperson readable material. The usefulness of this measure is questionable and should be evaluated. Define the information included in this measure and how to track it. The need to satisfy this capability should be in the EHR certification Define timely access and be aware of how it affects the discharge workflow. Five work days is a realistic for timely access for this measure. Further clarify the role of the EP and EH when it comes to providing TA to patients to access this information. Define common primary languages. Recommend Evaluate progress in this measure and consider a path to achievement of the measure while building on the previous work of HTSP and HL7 using CCD. Define common primary languages Recommend including discharge diagnosis, outpatient medications discontinued, new out patient meds, and contact information for questions. Also, recommend 40% for stage 2 and 80% for stage 3. Recommend that providers be limited to the admitting, major attending, the lead specialty physicians and the lead surgeon. Not nursing and ancillary staff. Page 7 of 20

Patients have the ability to view and download relevant information about a clinical encounter within 24 hours of the encounter. Followup tests that are linked to encounter orders but not ready during the encounter should be included in future summaries of that encounter, within 4 days of becoming available. Data are available in human-readable and structured forms (HITSC to define) Patients have the ability to view and download (on demand) relevant information contained in the longitudinal record, which has been updated within 4 days of the information being available to the practice. Patient should be able to filter or organize information by date, encounter, etc. Data are available in humanreadable and structured forms (HITSC to define). Stage 2 & 3. EPs: 20% of patients use a webbased portal to access their information (for an encounter or for the longitudinal record) at least once. Exclusions: patients without ability to access the Internet EPs: online secure patient messaging is in use Patient preferences for communication medium recorded for 20% of patients There is no percentage indicated. How would you measure follow up tests included in future summaries? Would previous test results always be displayed in future summaries or only if they were not available at the time the last summary was created/ This measure is problematic. It places too much responsibility on the provider. How does one track it? Or the exclusions? How we might change our behavior to get the patient to use the portal? If the system says yes we have a portal, some docs will not take the time to talk about it. There are privacy risks associated with this measure. How is this handled when it deals with access to patient s home computer? What does in use mean? Once the communication medium has been defined, is the intent to that the provider communicate n that medium? Recommend including into the clinical summary the visit diagnosis, medications initiated, and medications discontinued during visit. Also, recommend keeping the percentage at 50% for stage 2 and increasing to 80% for stage 3. Recommend using the HTSP CDA definitions and data elements where they exist care plan includes: The plan of care contains data defining prospective or intended orders, interventions, encounters, services, and procedures for the patient Develop a percent. It is 10% in stage 1 and should be higher for stage 2 and 3. Recommend changing this measure to X% of patients have been instructed /educated on web-based portal. This does not have to occur during the visit, could happen in the waiting room. This measure needs to be assessed for usefulness in hospitalized patients. Recommend moving the measure to a yes/no response. Define communication medium. Page 8 of 20

Offer electronic self-management tools to patients with high priority health conditions Stage 3 EHRs have capability to exchange data with PHRs using standardsbased health data exchange. Stage 3 Patients offered capability to report experience of care measures online Stage 3 Offer capability to upload and incorporate patient- generated data (e.g., electronically collected patient survey data, biometric home monitoring data, patient suggestions of corrections to errors in the record) into EHRs and clinician workflow Stage 3 What are self-management tools? Does this apply to EP or EH or both? Will this require providers to purchase an extra outside resource? Would this be with any PHR? When you say exchange data are you intending that a PHR would be able to upload data to an EHR? How would this traffic be controlled? On admission? Anytime via a portal? Where would the data from a PHR be expected to be stored and identified? Currently these are captured via a contracted vendor and the survey process. Would CMS be creating their own measures? Would this be duplicating or replacing the current process? This is being doing other ways; do we need to add it again as it becomes redundant? Recognize how it fits into the practice setting, workflow. There is benefit to this but how do you operationalize this? What is the intent? How would this information be tagged so that a facility would be able to demonstrate the integrity of their data vs. what is imported from elsewhere? What would a facility have to show in regard to response to a patient suggestion of corrections to errors in the record)? What do you mean by clinical workflow? This information, if uploaded, should be able to be viewed by the provider and either accepted as is, accepted with modifications or not accepted at all. For stage 2, recommend starting by requesting or creating a handful of self-management tool for high priority conditions such as diabetes, asthma, congestive heart failure. Recommend only using PHRs that are certified. If the PHR is not certified the provider is not required to exchange data with it. Although it is important to capture this information, it seems outside the realm of meaningful use of the EHR, recommend removing. Recommend a pilot during stage 2 to see if this is useful/needed. More detail is needed to be able to understand the value and need of this measure. This pushes the boundaries of the EHR. Recommend describing the value of this and the ability of the EHR to handle this data and pilot testing in the ambulatory setting first. For this to be successful, standards to code and exchange home monitoring data is needed. For this measure to be successful, the ability of EHRs to receive and incorporate data should be part of the EHR certification rules. Page 9 of 20

Improve Care Coordination Measure Comments Recommendation The trend to affiliation/ consolidation makes it highly likely that a primary referral network will be using the same network. Terms are vague/not defined. Focus on who are the providers you need to exchange with. Care coordination is the goal- can you perform HIE and is it bi-directional? Connect to at least three external providers in primary referral network (but outside delivery system that uses the same EHR) or establish an ongoing bidirectional connection to at least one health information exchange Medication reconciliation conducted at 80% of care transitions by receiving provider (transitions from another setting of care, or from another provider of care, or the provider believes it is relevant) Provide summary of care record (50%) // Move to Core // Summary care record provided electronically for 80% of transitions and referrals These terms need specificity: Do they include moving from the floor to ICU? Medical patient to surgeon care? How would we determine provider relevance? How is documentation of medication reconciliation recorded to construct this measure? Medication reconciliation done at all visits therefore can be hard to separate out just the transitions of care instances. What if the other provider is not capable of receiving a summary care record electronically? If those providers are to be excluded, how will that be measured? How will I as a provider determine who is capable of receiving information electronically and who is not? This could be a good thing in that it may drive resistant providers to either adopt interoperable electronic health records or see a decrease in referrals. Define primary referral network and connect. Recommend addressing the issue of no place to send the information no exchange partner. Identify how this fits with the 3013 HIE grantees. Also, add bidirection exchange and the data elements to be exchanged. Need clarity on the rationale of this question, is what they want to achieve. Recommend defining/clarifying transitions and relevant. Also, explain how to address information coming from patient and if it differs from the EHR or paper. For EP should be X% of every visit instead of transition of care. Recommend moving to core in stage 3. Page 10 of 20

List of care team members (including PCP) available for 10% of patients in EHR. Applies to stage 2 and 3. Record a longitudinal care plan for 20% of patients with high-priority health conditions How is care team defined? Would it just be a single provider in the primary care clinic and a single provider that each of the specialty clinics, or would be the specialty clinic itself? Could this information be gleaned by listing the providers the patient has seen along with their practice location? Many may be resistant/uncomfortable sharing first and last name of all providers. How does this measure take into account turnover at clinic? The PCP and others are important but not all are necessary. All the terms in this measure are vague. Does this include EH? Recommend clarifying this measure and evaluating usefulness from patient s perspective. Harmonize with Medicare wellness visit requirements of providers. Need to define all terms. Recommend using the HTSP CDA definition: The plan of care contains data defining prospective or intended orders, interventions, encounters, services, and procedures for the patient. Page 11 of 20

Improve Population and Public Health Measure Comment Recommendation See Appendix A EH and EP: Mandatory test. Some immunizations are submitted on an ongoing basis to Immunization Information System (IIS), if accepted and as required by law EH and EP: Mandatory test. Immunizations are submitted to IIS, if accepted and as required by law. During well child/adult visits, providers review IIS via their EHR. Stage 3 EH: move Stage 1 to core EP: lab reporting menu. For EPs, ensure that reportable lab results and conditions are submitted to public health agencies either directly or through their performing labs (if accepted and as required by law). Applies to both stage 2 and 3. Submit syndromic surveillance data Applies to both stage 2 and 3. See Appendix A There was discussion about if this should be core or menu for EP in stage 2 and stage 3. Why does stage III list this as a mandatory test? Is the contact information only relevant for eligible hospitals and not eligible professionals? This has limited value when compared to Minnesota s usual disease reporting. What does syndromic surveillance data include? Change measure to: EH and EP: Move to core. Mandatory test. The EHR should check with each state, city or locality regarding the number of test messages required and the percentage of messages need to pass HL7 conformance testing. All immunizations are submitted within one month of vaccine administration to Immunization Information System (IIS), once test is successful, if accepted and as required by law Change measure to: EH and EP: Mandatory test. The EHR should check with each state, city or locality regarding the number of test messages required and the percentage of messages need to pass HL7 conformance testing. All immunizations are submitted within one month of vaccine administration to IIS, once test is successful, if accepted and as required by law. During well child/adult visits, providers review IIS records, including immunization history and vaccine forecasting (decision support) via their EHR. Clarify that the reporting is electronic. Offer more detail to lead to better understanding if this measure should be core or menu. Recommend not moving to core until syndromic surveillance is better understood. Also must acknowledge that not all data can be accepted by state. Page 12 of 20

Public Health Button for EH and EP: Mandatory test and submit if accepted. Submit notifiable conditions using a reportable public-health submission button. EHR can receive and present public health alerts or follow up requests. Patient-generated data submitted to public health agencies NEW MEASURE NEW MEASURE There is little understanding of how it is suppose to work. This may work better as a constructed decision support rule. If the follow-up request comes after the patient is discharged who is responsible for follow up? This measure does not imply bidirectional communication. There is little understanding of what this is and where it goes. Uncertain if this goes directly to the public health agencies, does the provider get to look at it before it is sent? Public health and population health would greatly benefit from access to de-identified data by sex, age, race/ethnicity, and geography (zip codes). This does no involve collecting more information- just the ability to share with state and local health departments. EHRs should have the ability to submit population health surveillance data to health departments. See Appendix B EHRs should have the ability to submit population health surveillance data to health departments. See Appendix B Recommend a better description and discussion if this goes beyond the boundaries of the EHR. Any concept here must include the need for bidirectional communication. Recommend develop more parameters/description around this measure before determining usefulness and necessity. Data privacy issues associated with this measure need to be identified and addressed. New measures EHRs should submit to health departments de-identified data such as adult and child BMI, chronic diseases, tobacco use, and other important measures of population health. Chronic conditions include asthma, cardiovascular disease, and diabetes This will be much more accurate, timely, completed, and less costly than current methods. New measure: EHRs should report directly/submit to surveillance registry (including but not limited to stroke, cancer, injury, and birth defects). Standards need to be developed in these areas and incorporated in the EHR. Page 13 of 20

Question How can electronic progress notes be defined in order to have adequate specificity? For patient/family access to personal health information, what standards should exist regarding accessibility for people with disabilities (e.g., interoperability with assistive technologies to support those with hearing, visual, speech, or mobile impairments)? What strategies should be used to ensure that barriers to patient access whether secondary to limited internet access, low health literacy, and/or disability are appropriately addressed? What are providers and hospitals experiences with incorporating patient-reported data (e.g., data selfentered into PHRs, electronically collected patient survey data, home monitoring of biometric data, patient suggestions of corrections to errors in the record) into EHRs? For future stages of meaningful use assessment, should CMS provide an alternative way to achieve meaningful use based on demonstration of high performance on clinical quality measures (e.g., can either satisfy utilization measures for recording allergies, conducting CPOE, drug-drug interaction checking, etc, or demonstrate low rates of adverse drug events)? Should Stage 2 allow for a group reporting option to allow group practices to demonstrate meaningful Additional Specific Questions Response Each progress note should have the elements of objective, assessment, and plan. This should be a standardized template. This was seen as an issue that goes beyond the reach of health care as the market needs to step up to improve the software for the patient to read documents. We did acknowledge that documents presented to the patient should not be scanned documents or images, but instead be text documents, which can be read by the computer of the blind patient. Images can be provided if they have text attached to them, which can define what is in the image. It is important to reach out the community to ask these questions. This is a big challenge with nobody (in healthcare) willing to pay for it. The FCC is working on making Internet access more broadly available and we would support that plan. For low health literacy, it is important that there is access to a definition of terms inpatient information so they do not understand something they can research it and understand it better in simple lay language. And for the disabled patient is important that personal health records and documents presented to them can be readily navigated. Again, it would be best to ask those who currently advocate for these groups what they see as the barriers first. Not everyone can have internet access in there home so increased access in public areas will need to be pursued. Costs will have to be evaluated carefully: how can we assist those with low health literacy in the least expensive way? The first time we see a patient we are including patient reported information. It is just that we, as the intermediary, modify that information and put it into our terminology. The same can be done with patient reported data. As a provider, I need to remain the intermediary (or in some instances, my delegate) for any data that is put in my patient s record. This is a good idea but how do we implement it. Capturing the clinical quality measures is already the most difficult part of meaningful use as it is a workflow issue. Since quality is the ultimate goal this may be reasonable but smaller providers may be at a disadvantage. This was seen as a slippery slope. It could lead to some low users being hidden by those in compliance. Group standards should be no lower than individual standards. And if the group standards are not met, who is Page 14 of 20

use at the group level for all EPs in that group? In stage 1, as an optional menu objective, the presence of an advance directive should be recorded for over 50% of patients 65 years of age or older. We propose making this objective required and to include the results of the advance-directive discussion, if available. We invite public comment on this proposal, or to offer suggestions for alternative criteria in this area. What are the reasonable elements that should make up a care plan, clinical summary, and discharge summary? What additional meaningful-use criteria could be applied to stimulate robust information exchange? There are some new objectives being considered for stage 3 where there is no precursor objective being proposed for stage 2 in the current matrix. We invite suggestions on appropriate stage 2 objectives that would be meaningful stepping-stone criteria for the new stage 3 objectives. punished? If the group standards are met, who was rewarded? This has implications for the incentives. The incentives would need to go in the same direction as the reporting, either to the individual or the group. This document can change frequently in various care locations, clinic, hospital, and social worker that can be problematic as how to have or know that you have the updated version. Why has CMS chosen to remove from annual wellness visit but required in EHR? CCD and CCR should be interdisciplinary and should be focused on one to three major areas but should be kept in the clinic arena. Hospital care plans tend to be episode focused. Focus on achieving the current exchange activities and becoming more closely linked to the goals related to the 3013 HIE grantees. The 3013 grantees are the entities charged with developing robust exchange capacity. Consider adding the proposed population measures. See the specific recommendations for each measure. Page 15 of 20

Appendix A Rationale for Recommendations to Submit Immunization Data Measures Stage 2 & 3 Page 16 of 20

Minnesota Department of Health, Minnesota Immunization Information Connection (MIIC): Comments on Meaningful Use for Stage 2 Background The Minnesota Immunization Information Connection (MIIC) is a program among health care providers, parents, public health agencies, and schools aimed at preventing disease through immunization. MIIC uses a confidential, computerized information system, also known as an immunization registry, which contains a complete and accurate record of a person's immunizations, no matter where they got those shots. Comments & Response The immunization components of Meaningful Use Stage 2 should be moved to Core and not Menu. The majority of the Immunization Information Systems (IIS) community are ready to participate or will be shortly. This should be an easy win. Based on experience responding to Stage 1 of the Meaningful Use efforts, it is important to clarify the measures, especially around the current text regarding a mandatory test of messaging capabilities. Currently it is too vague to allow IIS be prepared to be good partners. In addition, it may allow different testing approaches by different IIS, confounding standardization efforts. Tests should be described more explicitly, suggested characteristics: The test messages shall be generated by the local instance of the EHR being tested based on data in that system. This should be the actual sending system that will connect when actual data exchange occurs. There should be enough test messages to adequately demonstrate the capacity to create well-formed messages. The messages shall be compliant with the applicable Implementation Guides published on the CDC website, including state specific Implementation Guides. Not all messages must pass HL7 conformance testing, but a reasonable proportion should pass. The EHR should check with each state, city, or locality regarding the number of test messages required and the percentage of messages need to pass HL7 conformance testing. Another area needing clarification is what it means to support ongoing submission of immunization records. First, we recommend that ALL immunizations are submitted following a successful test. We assume that this means that an EHR can actually successfully submit real immunization histories to an IIS and that the IIS can process these messages. Thus, we recommend that immunizations are submitted within at least one month of vaccine administration date. With the above comments and recommendations, recommend changing stage 2 and stage 3 to: Stage 2: EH and EP: Move to core. Mandatory test. The EHR should check with each state, city, or locality regarding the number of test messages required and the percentage of messages need to pass HL7 conformance testing. All immunizations are submitted within one month of vaccine administration to Immunization Information System (IIS), once test is successful, if accepted and as required by law Stage 3: EH and EP: Mandatory test. The EHR should check with each state, city or locality regarding the number of test messages required and the percentage of messages need to pass HL7 conformance testing. All immunizations are submitted within one month of vaccine administration to IIS, once test is successful, if accepted and as required by law. During well child/adult visits, providers review IIS records, including immunization history and vaccine forecasting (decision support) via their EHR. Page 17 of 20

Appendix B Rationale for Additional Improve Population and Public Health Measures Page 18 of 20

Introduction Minnesota Department of Health, Office of State Health Improvement Initiatives: Comments on Meaningful Use for Stage 2 Minnesota Department of Health (MDH) Office of State Health Improvement Initiatives (OSHII) integrates state-level surveillance data on chronic disease risk factors and community-based initiatives with the goal of reducing health care costs through prevention of chronic disease. To achieve this, OSHII uses the State Health Improvement Program (SHIP) to facilitate implementation of evidence-based strategies designed to prevent chronic disease through policy, systems and environmental change. The Effectiveness of SHIP Programs Depends on Surveillance Data SHIP programs focus on tobacco use, exposure to second-hand smoke and obesity as areas of prevention that address the three top preventable causes of mortality in the U.S. Implementation of these programs takes place at the local level through community health boards and tribal governments. Implementation activities under SHIP are currently underway in all 87 Minnesota counties and at 9 of the 11 American Indian tribes in the state. MDH depends on surveillance data to track the progress of these programs and assess the burden of obesity and tobacco use on Minnesota. Minnesota surveillance data related to tobacco use, exposure to second-hand smoke and obesity comprises the feedback system used to measure the effectiveness of SHIP strategies on population health improvement and provides the information needed to make adjustments to evidence-based strategies and target resources in prevention areas where needs are the greatest. Data currently available to Minnesota is provided by the Behavioral Risk Factor Surveillance System (BRFSS), Minnesota Student Survey (MSS), Minnesota Adult Tobacco Survey (MATS), and Minnesota Youth Tobacco Survey (MYTS). Minnesota lacks a surveillance system for childhood overweight and obesity rates. It is our belief that sharing of Electronic Health Record (EHR) data at the state level for use as surveillance for public health will improve the outcomes stemming from SHIP and fill important data gaps. As a result, we strongly recommend the sharing of the obesity measure Body Mass Index (BMI) and tobacco use data should be included as a requirement of meaningful use (MU) under stage 2 of the Medicare and Medicaid Programs Electronic Health Record Incentive Program. Sharing of EHR Information will fill surveillance gaps and improve MDH measurement of SHIP outcomes and impact on health in Minnesota Access to EHR data will significantly improve the timeliness and quality of BMI and tobacco use data available to our state. Minnesota data currently available on tobacco use and BMI have limitations in the ability to guide the targeting and evaluation of SHIP implementation. BRFSS data is a based on an annual random sample survey, which represents the state but has insufficient sample size to provide data at the local level where SHIP programs operate. Further, the validity of this data is based on self-reporting which has limitations that are not inherent with the measurement in a clinical setting. The data provided by MSS, MATS and MYTS also have limitations in validity due to self-reporting, and they are conducted every three years limiting their effectiveness in providing data needed to make timely adjustments to SHIP programs. In terms of providing local level data needed to evaluate SHIP, MATS and MYTS have the same limitation as BRFSS due to insufficient sample size. Page 19 of 20

In addition, a major concern is the gap in BMI data available for children. BRFSS does not provide BMI for children. In addition, although MSS does collect BMI data for 9 th and 12 th grade students, it does not provide data for children in 1 st grade through 8 th grade. Another concern is a limitation in the ability of MSS to precisely determine whether a child with a given BMI is overweight or obese. That determination is done by percentile ranking of a child s BMI using the date of birth and the date height and weight measurements were done. MSS does not gather that data and must use approximations for its calculations. However, vital signs data required for EHR systems under the final rules for stage 1 includes calculation of child BMI percentile ranking using date of birth and date of measurement data available in the medical record. Sharing of EHR child BMI data for public health use would provide childhood obesity data of a magnitude and accuracy that is not currently available from current sources. Sharing EHR data offers a unique and cost-effective source of valuable data The current methods for collection of statewide public health data for use in obesity prevention and tobacco use depend on the expenditure of major resources in terms of staff and budgets. At a time when budgets are tight and resources to create new surveillance systems scarce, sharing the EHR data discussed will provide a major step forward in prevention of chronic disease that States may not be able to undertake themselves. For this as well as the reasons previously stated, we reaffirm our recommendation to share the obesity measure BMI and tobacco use data as a requirement of MU under stage 2 of the Medicare and Medicaid Programs Electronic Health Record Incentive Program. Page 20 of 20