CHIME Concordance Analysis of Stage 2 Meaningful Use Final Rule - Objectives & Measures Stage 2 MU Objectives and Measures for EHs - Core More than 60 percent of medication, 1. Use CPOE for medication, laboratory, and laboratory, and radiology More than 60 percent of medication, 30 radiology orders orders entered by any licensed percent of laboratory, and 30 percent of created by authorized We believe the threshold is more healthcare professional who radiology orders created by the EP or providers of the appropriately set at 50 percent with can enter orders into the authorized providers of the eligible hospital's hospital s inpatient or the denominator of patients with at medical record per State, local, or CAH's inpatient or emergency department emergency department least one type of order. and professional guidelines to (POS 21 or 23) during the EHR reporting (POS 21 or 23) during create the first record of the period are recorded using CPOE. +0 the EHR reporting order. period are recorded using CPOE. 2. Record all of the following demographics: (A) Preferred language; (B) Gender; (C) Race; (D) Ethnicity; (E) Date of birth; and (F) Date and preliminary cause of death in the event of mortality in the hospital. More than 80 percent of all unique patients admitted to the hospital s inpatient or emergency department during the EHR reporting period have demographics recorded as structured data. We believe the additional questions of disability, gender identity and sexual orientation would be problematic. More than 80 percent of all unique patients seen by the EP or admitted to the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period have demographics recorded as structured data. +1 1
3. Record and chart changes in the following vital signs: (A) Height/Length; (B) Weight; (C) Blood pressure (ages 3 and over); (D) Calculate and display BMI; (E) Plot and display growth charts for patients 0-20 years, including BMI. 4. Record smoking status for patients 13 years old or older. More than 80 percent of all unique patients admitted to the hospital s inpatient or emergency department during the EHR reporting period have blood pressure (for patients age 3 and over only) and height/length and weight (for all ages) recorded as structured data. More than 80 percent of all unique patients 13 years old or older admitted to the hospital s inpatient or emergency department during the EHR reporting period have smoking status recorded as structured data. We have no comments or concerns regarding this measure. We have no comments or concerns regarding this measure. More than 80 percent of all unique patients seen by the EP or admitted to the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period have blood pressure (for patients age 3 and over only) and height/length and weight (for all ages) recorded as structured data. +1 More than 80 percent of all unique patients 13 years old or older seen by the EP or admitted to the eligible hospital's or CAH's inpatient or emergency departments (POS 21 or 23) during the EHR reporting period have smoking status recorded as structured data. +1 2
5. Use clinical decision support to improve performance on high priority health conditions. (A) Implement five clinical decision support interventions related to five or more clinical quality measures, if applicable, at a relevant point in patient care for the entire EHR reporting period; and (B) The hospital has enabled the functionality for drug-drug and drugallergy interaction checks for the duration of the EHR reporting period. We are largely in support of this proposed objective and measure and believe it strikes an appropriate balance between giving flexibility to the provider and urging integration with clinical quality measures. 1. Implement five clinical decision support interventions related to four or more clinical quality measures at a relevant point in patient care for the entire EHR reporting period. Absent four clinical quality measures related to an EP, eligible hospital or CAH's scope of practice or patient population, the clinical decision support interventions must be related to high-priority health conditions. It is suggested that one of the five clinical decision support interventions be related to improving healthcare efficiency. 2. The EP, eligible hospital, or CAH has enabled and implemented the functionality for drug-drug and drug allergy interaction checks for the entire EHR reporting period. +1 3
6. Incorporate clinical lab-test results into CEHRT as structured data. More than 55 percent of all clinical lab tests results ordered by authorized providers of the hospital for patients admitted to its inpatient or emergency department during the EHR reporting period whose results are either in a positive/negative or numerical format are incorporated in CEHRT as structured data. While we have no concerns regarding this proposed hospital measure, we wish to take this opportunity to note that it would probably never be possible to expect that anything approaching 100 percent of the relevant clinical lab test results could be incorporated as structured data due to the fact that some, relatively rare tests performed by reference labs would not lend themselves to such incorporation. More than 55 percent of all clinical lab tests results ordered by the EP or by authorized providers of the eligible hospital or CAH for patients admitted to its inpatient or emergency department (POS 21 or 23) during the EHR reporting period whose results are either in a positive/negative affirmation or numerical format are incorporated in Certified EHR Technology as structured data. +1 7. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach. Generate at least one report listing patients of the hospital with a specific condition. We urge CMS to maintain its single list policy for this objective, as an increase in the required number of lists will not do more than create extra boxes to check. Further, we presume that EPs would retain the flexibility of deciding what specific lists should be generated, taking into account their individual patient care goals and circumstances. Generate at least one report listing patients of the EP, eligible hospital or CAH with a specific condition. +1 4
8. Provide patients the ability to view online, download and transmit information about a hospital admission. (A) More than 50 percent of all patients who are discharged from the inpatient or emergency department of the hospital have their information available online within 36 hours of discharge; and (B) More than 10 percent of all patients who are discharged from the inpatient or emergency department of a hospital view, download or transmit to a third party their information during the EHR reporting period. 1. We believe giant strides in patient engagement can begin by making online access of information available to the patient, within 4 business days. 2. We oppose measure (B) because we believe it is premature, at best, to adopt measures not completely under the control of EPs. 3. If CMS is confident that download and transmit options are widely used by patients, we believe measure (B) could simply require the capability for patients to view online, download and transmit their health information, but not make providers liable for patient use of these capabilities. 4. The exclusion relating to broadband availability needs to be revised to account for situations where a specific EP s office location does not have such access. 1. More than 50 percent of all patients who are discharged from the inpatient or emergency department (POS 21 or 23) of an eligible hospital or CAH have their information available online within 36 hours of discharge 2. More than 5 percent of all patients (or their authorized representatives) who are discharged from the inpatient or emergency department (POS 21 or 23) of an eligible hospital or CAH view, download or transmit to a third party their information during the reporting period. Therefore, after consideration of the public comments received, we are finalizing the broadband exclusion as proposed. Pg. 274 (access defined 268) +1 5
9. Use clinically relevant information from CEHRT to identify patient-specific education resources and provide those resources to the patient. More than 10 percent of all unique patients admitted to the hospital s inpatient or emergency department are provided patientspecific education resources identified by CEHRT. Largely support this objective and add, in response to CMS invitation for comment, we do not believe that patient-specific education resources at appropriate literacy levels and with appropriate cultural competencies could be successfully identified at this time through the use of CEHRT. Patient-specific education resources identified by CEHRT are provided to patients for more than 10 percent of all unique patients with office visits seen by the EP during the EHR reporting period. More than 10 percent of all unique patients admitted to the eligible hospital's or CAH's inpatient or emergency departments (POS 21 or 23) are provided patient- specific education resources identified by Certified EHR Technology. +1 6
10. The hospital that receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation. The hospital performs medication reconciliation for more than 65 percent of transitions of care in which the patient is admitted to the hospital s inpatient or emergency department. While we support moving this measure to the core set for Stage 2, we do not support the proposed 65 percent threshold. We believe it would be more reasonable to leave the threshold at 50 percent. The EP, eligible hospital or CAH performs medication reconciliation for more than 50 percent of transitions of care in which the patient is transitioned into the care of the EP or admitted to the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23). +1 11. The hospital that transitions their patient to another setting of care or provider of care or refers their (A) The hospital that transitions or refers their patient to another setting of care or In terms of measure (A), we note that the expectation is that the summary care record would be formatted according to the content (Preamble 187-204) 1. The EP, eligible hospital, or CAH that transitions or refers their patient to another 7
patient to another provider of care should provide summary care record for each transition of care or referral. provider of care provides a summary of care record for more than 65 percent of transitions of care and referrals; and (B) The hospital that transitions or refers their patient to another setting of care or provider of care electronically transmits using CEHRT to a recipient with no organizational affiliation and using a different CEHRT vendor than the sender a summary of care record for more than 10 percent of transitions of care and referrals. exchange standard Consolidated Clinical Document Architecture (CDA), not the Continuity of Care Document (CCD). 1. We believe the 65 percent threshold in measure (A) is too ambitious and should be reduced to 50 percent. 2. We oppose measure (B) based on potential workflow issues, patient safety issues and a general question of feasibility. 3. We believe a simpler approach would allow EPs to voluntarily report when they experience interoperability problems when attempting to send a summary care record for transition of care. 4. We believe that short of striking the measure in its entirety, an alternative approach would be to make measure (B) a menu option wherein EPs would be allowed to attest to having captured the requisite information. setting of care or provider of care provides a summary of care record for more than 50 percent of transitions of care and referrals. +1 2. The EP, eligible hospital or CAH that transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 10% of such transitions and referrals either-- (a) electronically transmitted using CEHRT to a recipient or (b) where the recipient receives the summary of care record via exchange facilitated by an organization that is a NwHIN Exchange participant or in a manner that is consistent with the governance mechanism ONC establishes for the nationwide health information network. +1 3. An EP, eligible hospital or CAH must satisfy one of the two following criteria: (A) Conducts one or more successful electronic exchanges of a summary of care document, as part of which is counted in "measure 2" (for EPs the measure at 495.6(j)(14)(ii)(B) and for eligible hospitals and CAHs the measure at 495.6(l)(11)(ii)(B)) with a recipient who has EHR technology that was developed designed by a different EHR technology developer than the sender's EHR technology certified to 45 CFR 170.314(b)(2); 8
12. Capability to submit electronic data to immunization registries or immunization information systems except where prohibited, and in accordance with applicable law and practice. 13. Capability to submit electronic reportable laboratory results to public health agencies, except where prohibited, and in accordance with applicable law and practice. Successful ongoing submission of electronic immunization data from CEHRT to an immunization registry or immunization information system for the entire EHR reporting period. Successful ongoing submission of electronic reportable laboratory results from CEHRT to a public health agency for the entire EHR reporting period as authorized, and in accordance with applicable State law and practice. The final rule needs to address this issue and make clear that an EH would be eligible for the above exclusions if all local jurisdictions (i.e. city, county or State) were not capable of receiving electronic immunization data from EHs. CDC s capabilities should not be a factor. The final rule needs to address this issue and make clear that an EH would be eligible for the above exclusions if all local jurisdictions (i.e. city, county or State) were not capable of receiving electronic immunization data from EHs. CDC s capabilities should not be a factor. or (B) Conducts one or more successful tests with the CMS designated test EHR during the EHR reporting period. Successful ongoing submission of electronic immunization data from Certified EHR Technology to an immunization registry or immunization information system for the entire EHR reporting period. +1 Successful ongoing submission of electronic reportable laboratory results from Certified EHR Technology to public health agencies for the entire EHR reporting period. +1 9
14. Capability to submit electronic syndromic surveillance data to public health agencies, except where prohibited, and in accordance with applicable law and practice. Successful ongoing submission of electronic syndromic surveillance data from CEHRT to a public health agency for the entire EHR reporting period. The final rule needs to address this issue and make clear that an EH would be eligible for the above exclusions if all local jurisdictions (i.e. city, county or State) were not capable of receiving electronic immunization data from EHs. CDC s capabilities should not be a factor. Successful ongoing submission of electronic syndromic surveillance data from Certified EHR Technology to a public health agency for the entire EHR reporting period. +1 10
15. Protect electronic health information created or maintained by the CEHRT through the implementation of appropriate technical capabilities. Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308(a)(1), including addressing the encryption/security of data at rest in accordance with requirements under 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the hospital s risk management process. We believe this measure should be simplified to refer only to compliance with applicable HIPAA privacy and security rules. Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308(a)(1), including addressing the encryption/security of data stored in CEHRT in accordance with requirements under 45 CFR 164.312 (a)(2)(iv) and 45 CFR 164.306(d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the provider's risk management process. +0 11
16. Automatically track medications from order to administration using assistive technologies in conjunction with an electronic medical administration record (emar). emar is implemented and in use for the entire EHR reporting period in at least one ward/unit of the hospital. [regulation text] We strongly support the addition of this new objective and measure to the core set. More than 10 percent of medication orders created by authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period for which all doses are tracked using emar. +1 Stage 2 MU Objectives and Measures for EHs - Menu 12
1. Record whether a patient 65 years old or older has an advance directive. 2. Imaging results and information are accessible through CEHRT. More than 50 percent of all unique patients 65 years old or older admitted to the hospital s inpatient department (POS 21) during the EHR reporting period have an indication of an advance directive status recorded as structured data. More than 40 percent of all scans and tests whose result is an image ordered by an authorized provider of the hospital for patients admitted to its inpatient or emergency department during the EHR reporting period are accessible through CEHRT. We support CMS in its decision to keep this part of the menu set. We are concerned that the proposed measure wording is ambiguous and that the measure, as proposed, would be impossible to meet. More than 50 percent of all unique patients 65 years old or older admitted to the eligible hospital's or CAH's inpatient department (POS 21) during the EHR reporting period have an indication of an advance directive status recorded as structured data +1 More than 10 percent of all tests whose result is one or more images ordered by the EP or by an authorized provider of the eligible hospital or CAH for patients admitted to its inpatient or emergency department (POS 21 and 23) during the EHR reporting period are accessible through Certified EHR Technology. 0 13
3. Record patient family health history as structured data. More than 20 percent of all unique patients admitted to the hospital s inpatient or emergency department during the EHR reporting period have a structured data entry for one or more firstdegree relatives. We do not believe that available standards that would allow for the collection of structured data for this measure are sufficiently mature. Finally, even if hospitals could meet this measure, we are not persuaded that this would be a meaningful exercise. More than 20 percent of all unique patients seen by the EP or admitted to the eligible hospital or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period have a structured data entry for one or more first-degree relatives. 0 4. Generate and transmit permissible discharge prescriptions electronically (erx). More than 10 percent of hospital discharge medication orders for permissible prescriptions (for new or changed prescriptions) are compared against at least one drug formulary and transmitted electronically using CEHRT. This measure is reasonable as a menu set item. However, even as a menu set item, the proposed percentage threshold should not be increased for stage 2. More than 10 percent of hospital discharge medication orders for permissible prescriptions (for new, changed, and refilled prescriptions) are queried for a drug formulary and transmitted electronically using Certified EHR Technology. +1 14
Record electronic notes in patient records New Menu Item New Menu Item Enter at least one electronic progress note created, edited and signed by an eligible professional for more than 30 percent of unique patients with at least one office visit during the EHR reporting period. Enter at least one electronic progress note created, edited and signed by an authorized provider of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) for more than 30 percent of unique patients admitted to the eligible hospital or CAH's inpatient or emergency department during the EHR reporting period. Electronic progress notes must be text-searchable. Nonsearchable notes do not qualify, but this does not mean that all of the content has to be character text. Drawings and other content can be included with searchable text notes under this measure. +1 Provide structured electronic lab results to ambulatory providers New Menu Item New Menu Item Hospital labs send structured electronic clinical lab results to the ordering provider for more than 20 percent of electronic lab orders received. +1 Grand Total = 19 / 28 = 68% (September 2012) 15