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Meaningful Use Workgroup New Pathways for Meaningful Use Stage 3

April 3, 2013Paul Tang, MDGeorge Hripcsak, MDChristine Bechtel

1Stages of Meaningful UseImproving OutcomesStage 12011-13Stage 22014-15Stage 32016-172Stages of Meaningful UseImproving OutcomesStage 12011-13Stage 22014-15Stage 32016-173Original Principles for Stage 3 RecommendationsSupports new model of care (e.g., team-based, outcomes-oriented, population management)Addresses national health priorities (e.g., NQS, prevention, Partnerships for Patients, Million Hearts)Broad applicability (since MU is a floor)Provider specialties (e.g., primary care, specialty care)Patient health needsAreas of the countryNot "topped out" or not already driven by market forcesMature standards widely adopted or could be widely adopted by 2016 (for stage 3)

4Lessons from Stages 1Implications for Stage 3Stage 1 ExperienceSubstantial increase in adoption rates and effective useMandatory floor creating network effectsThresholds consistently exceeded

Consistent use across the years

Reporting requirements have considerable costs and burdenPrescriptive, forced march impacts available resources for innovation or to address local priorities

Implications for Stage 3Creating critical mass of users and data in electronic formRising tide is floating boats (e.g., setup for patient engagement, HIE)Once MU functionality is implemented, it is usedGains from stage 1 (and 2) will persistStage 3: Simplify and reduce reporting requirementsStage 3: Rely more heavily on market pull (e.g., new payment incentives); promote innovative approaches ie., reward good behavior5Additional Principles Explored for Stage 3 Address key gaps (e.g., interoperability, patient engagement, reducing disparities) in EHR functionality that the market will not drive alone, but are essential for all providers:to create level playing fieldto create network effectsto fulfill need for a public goodConsolidate MU objectives where higher level objective implies compliance with subsumed process objectivesConsider alternative pathway where meeting performance and/or improvement thresholds deems satisfaction of subset of relevant MU functionality implicitly required to achieve performance/improvement6Consolidation SubgroupChristine Bechtel, Chair7Consolidation Summary43 MUWG objectives proposed in stage 3 RFC Consolidated to 25 objectivesAssumptionsThe full WG will consider RFC feedback and update criteriaAll criteria will be included in certificationFocus on advanced usesex: recording data vs. use dataGive credit for MU objectives that should be standard of practice once passed stages 1 and 2 Identify what needs to be used and certified

8Types of ConsolidationAdvanced within concept of another objectiveDuplicative conceptsobjective becomes certification onlyDemonstrated use and can trust that it will continue9Advanced within Concept of Another ObjectivePatient preferred means of communication (SGRP208)

DemographicsAdded as an additional element

Patient education, per patient preference

Clinical Summary, per patient preference

Certification CriteriaMaintained ObjectiveKey:Reminders, per patient preference

10Duplicative ConceptsImmunization intervention (SGRP401B)

CDS (113)Interventions include preventative care for immunizations

Certification CriteriaMaintained ObjectiveKey:11Structured lab results (SGRP114)

Included in care summary (303)

Included in view, download, transmit (204A)

Demonstrated UsePatient lists and dashboards (SGRP115)Needed for population management and quality measurementHow to measure use?Existing external drivers that will drive use (new models of care)PQRS, value based purchasing, ACOs12CPOE - Advanced within concept of another objective, duplicative concept, demonstrated use13

CPOE for Medication Orders

Needed to provide meds within care summary (303)Needed to provide meds within VDT (204A)Needed for eRx formulary and generic substitutionsCertification CriteriaMaintained ObjectiveKey:Consolidation at a Glance14

Consolidation OverviewReconciliation

eRx formulary


Pt list/dashboardReminders

EH: eMAREH: Lab results EPPGHDClinical summary

Patient education

Secure MessagingNotify of health eventCare plan*Immunization registryAdverse event*Case reports to PHAVDT

ToC Care summary

Advanced directiveRegistries

Synd SurveillanceELRIdentify clinical trialsQuality, safety, reducing health disparitiesReferral loopTest tracking

Imaging results

Electronic notesEngaging patients & familiesImproving care coordinationPopulation & public healtheRx transmissionCertification CriteriaMaintained ObjectiveKey:* Proposed for future stage of MUDemographics15CPOE - medsCDS for immunComm preferenceCPOE - radCPOE - labAmendmentFamily HxProb, med, allg listStructured labVitalsSmoking statusComm preferenceComm preferenceCancer registrySpecialty registryHAI reportsDemographicsAmendmentFamily HxProb, med, allg listStructured labVitalsSmoking statusCPOE - referralsInter prob list*RxHx PDMP*CPOE - medsDeeming SubgroupPaul Tang, Chair16Deeming AssumptionsCannot reliably achieve good performance (or significantly improve) without effective use of HITTherefore: in order to promote innovation, reduce burden, and reward good performance, deem high performers (or significant improvers) in satisfaction of a subset of MU objectives as an optional pathway to qualifying for MU

1717Example Criteria for Deeming for EPsDemonstrate high (top 30 %ile) or improved performance (20% reduction of gap between last year's performance and top quartile). Select two items from each of the categories below: Prevention of high priority diseases (pick 2 from)Breast cancer (mammography screening)Colon cancer (colonoscopy screening)Influenza (flu vax)Pneumonia (pneumococcal vaccine)Obesity (BMI screening and follow up)Cardiovascular disease (LDL screen)HTN (BP screen and follow up)Control of high priority chronic health conditions (pick 2 from)HTN (BP control or improvement)Diabetes (A1c control)Heart attack (LDL control)Asthma (controller med)CHF (ACEI or ARB meds)MI (beta blocker)18Example Criteria for Deeming for EHsDemonstrate high (top 30 %ile) or improved performance (20% reduction of gap between last year's performance and top quartile) for all of the below:Patient safety (pick 2 from)Clostridium difficile Infection (outcome measure)Catheter-Associated Urinary Tract Infection (outcome measure)Central Line-Associated Blood Stream Infection (outcome measure)MRSA (outcome measure)Specific Surgical Site Infection (SSI) Outcome MeasureSevere sepsis and septic shock: Management bundleLate sepsis or meningitis in very low birth weight (VLBW) neonates (risk-adjusted)Measure of pressure ulcersCare coordination (pick 2 from)Experience of care (from HCAHPS)?Hospital-wide-all-cause unplanned readmission measure (HWR)CTM-3, 3-item care transition19Additional RequirementDisparitiesStratify all four population reports by disparity variables

20Deemed MU ObjectivesDeemed in Satisfaction of:CDSeRx formulary, generic subsRemindersElectronic notesTest trackingClinical summaryPatient educationReconcile problems, meds, allergies

*View, download, transmit (VDT), consider adding if stage 2 reports good uptake*Secure patient messaging, consider adding if stage 2 reports good uptakeRemaining Items:Advance directiveReminderseMARImaging resultsEH: provide lab resultsPatient generated data*VDT*Secure patient messagingCare summary Care planReferral loopNotification of health eventImmunization registryELRCase reports to PHASyndromic surveillanceReporting to 2 registriesAdverse event reporting21Additional ConsiderationsOffer both absolute threshold (e.g., 70+%ile) and significant improvement (e.g., reduce gap between last year's performance and full performance by 20%) options for deemingPropose performance reporting period to be 6 months vs. 1-year MU reporting period to give providers a chance to deem yet still have time to resort to functional objectives qualification if not meeting deeming thresholdsSpecialists may have fewer options for deeming as determined by available NQF QMs. If not able to report on at least 4 performance measures, then may not be eligible for the deeming pathway



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