hit policy committee meaningful use workgroup proposed recommendations on mu notice of proposed rule...

HIT Policy CommitteeHIT Policy Committee

Meaningful Use WorkgroupProposed Recommendations on MU Notice of Proposed Rule Proposed Recommendations on MU Notice of Proposed Rule MakingMaking

Paul Tang, Chair

Palo Alto Medical Foundation

George Hripcsak, Co-Chair

Columbia University

February 17, 2010

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Proposed MU NPRM Recommendations – 1

• Reinstate HITPC recommendation to include progress note documentation for EP Stage 1 MU– Progress notes are key to delivering high quality,

coordinated care (not just a legal requirement):• Legibility – quality & efficiency implications

• Important for documenting complete record (otherwise lost)

• Hybrid systems (part electronic, part paper) causes fragmentation of the record and inefficient workflow

• Paper progress notes impede patients’ access to information (no structured way to provide patients with context to those data)

• Sharing electronic progress notes fundamental to care coordination

• Textual progress notes used to know patient as a human being

– Signal clinical documentation for hospitals in Stage 2

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• Remove “core measures” from Stage 1– Attributes considered:

• Based on the Institute of Medicine’s Six Aims and priorities identified by the National Priorities Partnership

• Have an evidence-based link to improvement in outcomes• Can be measured using coded clinical data in an EHR (to minimize burden)• Is captured as a byproduct of the care process (fits clinician workflow)• Applies to virtually all eligible providers• Measures outcome, to the extent possible

– None of the proposed “core” measures satisfied the criteria (nor did our examples)

– Support use of key HIT-sensitive health priorities drive selection of quality measures

– Will re-explore concept of shared or common measures in future

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• Reinstate HITPC recommendation to stratify quality reports by disparity variables– Providers should produce quality reports stratified by race,

ethnicity, gender, primary language, and insurance type – CMS has stated that an explicit health outcomes policy priority

is to “reduce health disparities”– No assessment of disparity reduction can be made without

stratifying data reports by these variables

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• Providers should maintain up-to-date lists (not just one-time entries)– Maintaining key patient summary information in EHR is critical

for care quality & coordination– Measure: Attestation that the problem lists, medication lists,

and medication allergy lists are up-to-date (CMS audit could be conducted by chart review of a set of randomly selected charts)

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• Reinstate HITPC recommendation to include recording of advanced directives for Stage 1 MU – EPs and hospitals should be expected to record presence or

absence of advance directives for patients > 65 as part of the Stage 1 MU criteria

– Particularly for Medicare providers, recording of advance directives should apply to virtually everybody

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• Reinstate HITPC recommendation to include patient-specific education resources for Stage 1 MU– EHR-enabled links to relevant educational resources critical to

CMS health outcome priority to “engage patients and families”– Provider vetting of consumer educational content represents a

much better than unguided searching of the Internet– Several EHR vendors and health education content providers

have developed partnerships that facilitate EHR-enabled connections to patient-specific content

– EPs & hospitals should report on % of patients for whom they use the EHR to suggest patient-specific education resources

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• Reinstate HITPC recommendation to include clinical efficiency measures for Stage 1 MU– CMS did not include clinical efficiency measures although

“improve efficiency” is a CMS-stated priority– All EPs report % of all medications entered into EHR as a

generic formulation, when generic options exist in relevant drug class

• On page 1987 of the NPRM, CMS cites “prompt providers to prescribe cost-effective generic medications” as one of the key “Benefits to Society” in its impact analysis

– CMS should explicitly require that at least 1 of 5 CDS rules address efficient diagnostic test ordering

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• CMS should create a glidepath for Stage 2 & 3 MU– Vendors need more time to develop appropriate functionality– Providers need more time to integrate it into clinical workflow– Recognize that CMS needs experience from on Stage 1

implementation before finalizing Stage 2 & 3 recommendations – Strong signal of intentions would be very helpful to make the

realization of future expectations more feasible– To extent possible, CMS should consider publishing the Stage

2 MU NPRM earlier than anticipated December 2011

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• CPOE should be done by authorizing provider– CPOE numerator should be number of orders entered directly

by authorizing provider

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• Amend prevention/follow-up reminders criterion to apply to a broader range of the population and allow for provider discretion in targeting reminders– For a chosen/relevant preventive health service or follow-up,

report on the percent of patients who were eligible for that service who were reminded

– Denominator: All patients who were potentially eligible (e.g., meet demographic criteria) and had not received the service

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• Clarify “transitions of care” and “relevant encounters”– Under Care Coordination category– Define “transition of care” to occur when a patient changes

“setting of care” (e.g., hospital, ambulatory primary care practice, ambulatory specialty care practice, long term care, home health, rehabilitation facility)

– Delete “relevant encounter” (not precise)

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• Allow some flexibility in meeting meaningful use criteria– “All-or-nothing” approach may not accommodate legitimate,

unanticipated, local circumstances or constraints– Permit flexibility while preserving a floor– Allow provider to defer fulfillment of a small number of MU criteria

and still receive incentive– Allow EPs & hospitals to qualify for Stage 1 MU incentives if they

defer no more than (mandatory may not be deferred):• 3 of the criteria in the quality domain • 1 of the criteria in the patient/family engagement domain• 1 of the criteria in the care coordination domain• 1 of the criteria in the population/public health domain

– All must meet the privacy & security domain criterion– All must report clinical measures to CMS/state

Priority area # objectives that may be deferred by EP or hospital (all EPs and hospitals must fulfill “mandatory” objectives)

Mandatory objectives (all EPs and hospitals must meet these)

Improving quality, safety, efficiency, and reducing health disparities

3 Have demographics recorded as structured data Report ambulatory/hospital quality measures to

CMS or the States Use CPOE/Use of CPOE for orders (any type)

directly entered by authorizing provider (for example, MD, DO, RN, PA, NP)

Generate and transmit permissible prescriptions electronically (eRx)

Engage patients and families in their health care

1 Patients discharged are provided electronic copy of their instructions and procedures

Improve care coordination 1 Test EHR capacity to electronically exchange key clinical information

Improve population and public health

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Ensure adequate privacy and security protections for personal health information

0 Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities 14


hit policy committee meaningful use workgroup proposed recommendations on mu notice of proposed rule...

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