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Meaningful Use Workgroup Stage 3 – Preliminary Recommendations Paul Tang, Palo Alto Medical Foundation, Chair George Hripcsak, Columbia University, Co-Chair

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Page 1: Meaningful Use Workgroup Stage 3 – Preliminary Recommendations Paul Tang, Palo Alto Medical Foundation, Chair George Hripcsak, Columbia University, Co-Chair

Meaningful Use Workgroup Stage 3 – Preliminary Recommendations

Paul Tang, Palo Alto Medical Foundation, ChairGeorge Hripcsak, Columbia University, Co-Chair

Page 2: Meaningful Use Workgroup Stage 3 – Preliminary Recommendations Paul Tang, Palo Alto Medical Foundation, Chair George Hripcsak, Columbia University, Co-Chair

HITPC: MU Workgroup Stage 3 Recommendations 2

Workgroup Membership

Co-Chairs:Paul Tang Palo Alto Medical FoundationGeorge Hripcsak Columbia University

Members:• David Bates Brigham & Women’s Hospital• Michael Barr American College of Physicians• Christine Bechtel National Partnership/Women & Families• Neil Calman Institute for Family Health• Tim Cromwell Department of Veterans Affairs• Art Davidson Denver Public Health• Marty Fattig Nemaha County Hospital• James Figge NY State Dept. of Health• Joe Francis Veterans Administration• Leslie Kelly Hall Healthwise• Yael Harris HRSA• David Lansky Pacific Business Group/Health• Deven McGraw Center/Democracy & Technology• Latanya Sweeney Carnegie Mellon University• Greg Pace Social Security Administration• Robert Tagalicod CMS/HHS• Karen Trudel CMS• Charlene Underwood Siemens• Amy Zimmerman Rhode Island Department of Health and Human Services

Page 3: Meaningful Use Workgroup Stage 3 – Preliminary Recommendations Paul Tang, Palo Alto Medical Foundation, Chair George Hripcsak, Columbia University, Co-Chair

HITPC: MU Workgroup Stage 3 Recommendations 3

HITPC Stage 3 MU Timeline

• Oct, 2012 – present pre-RFC preliminary stage 3 recs• Nov, 2012 – RFC distributed• Dec 21, 2012 – RFC deadline• Jan, 2013 – ONC synthesizes RFC comments for WGs review• Feb, 2013 – WGs reconcile RFC comments• Mar, 2013 – present revised draft stage 3 recs• Apr, 2013 – approve final stage 3 recs• May, 2013 – transmit final stage 3 recommendations to HHS

Page 4: Meaningful Use Workgroup Stage 3 – Preliminary Recommendations Paul Tang, Palo Alto Medical Foundation, Chair George Hripcsak, Columbia University, Co-Chair

4

Guiding Principles

• Supports new model of care (e.g., team-based, outcomes-oriented, population management)

• Addresses national health priorities (e.g., NQS, Million Hearts) • Broad applicability (since MU is a floor)

−Provider specialties (e.g., primary care, specialty care)−Patient health needs−Areas of the country

• Promotes advancement -- Not "topped out" or not already driven by market forces

• Achievable -- mature standards widely adopted or could be widely adopted by 2016

• Reasonableness/feasibility of products or organizational capacity−Prefer to have standards available if not widely adopted−Don’t want standards to be an excuse for not moving forward

MU Workgroup Stage 3 Recommendations

Page 5: Meaningful Use Workgroup Stage 3 – Preliminary Recommendations Paul Tang, Palo Alto Medical Foundation, Chair George Hripcsak, Columbia University, Co-Chair

5

Key to reviewing items

• Red items are changes from Stage 1 to Stage 2• Blue items are changes from Stage 2 to Stage

3 recommendations• Green items are updates made following the

August 1, 2012 HITPC

MU Workgroup Stage 3 Recommendations

Page 6: Meaningful Use Workgroup Stage 3 – Preliminary Recommendations Paul Tang, Palo Alto Medical Foundation, Chair George Hripcsak, Columbia University, Co-Chair

Improve Quality Safety, Efficiency and Reducing Health Disparities - Subgroup 1

MU Workgroup Stage 3 Recommendations 6

Page 7: Meaningful Use Workgroup Stage 3 – Preliminary Recommendations Paul Tang, Palo Alto Medical Foundation, Chair George Hripcsak, Columbia University, Co-Chair

ID Stage 1 Final Rule Stage 2 Final Rule Stage 3 Recommendations Stage 4 Placeholder

SGRP101

Medication only: More than 30% of unique patients seen during the reporting period with at least one medication in their medication list have at least one medication order entered using CPOE

EP Objective: Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines

EH Objective: Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines

EP/EH Measure: More than 60 percent of medication, 30 percent of laboratory, and 30 percent of radiology orders created by the EP or authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using CPOE.

Objective: Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders directly entered by any licensed healthcare professional who can enter orders into the medical record per State, local and professional guidelines to create the first record of the order.CPOE for medications includes DDI checking for “never” combinations as determined by an externally vetted list.Measure: More than 60% of medication, laboratory, and radiology orders created by the EP or authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using CPOE Certification Criteria: EHR must be able to consume an externally supplied list of “never” DDIs, using RxNorm and NDF-RT standards along with a TBD DDI reactions value set.

Seeking externally maintained list of DDIs with higher predictive value

Improve Quality Safety, Efficiency and Reducing Health Disparities

MU Workgroup Stage 3 Recommendations 7

Page 8: Meaningful Use Workgroup Stage 3 – Preliminary Recommendations Paul Tang, Palo Alto Medical Foundation, Chair George Hripcsak, Columbia University, Co-Chair

8MU Workgroup Stage 3 Recommendations

ID Stage 1 Final Rule Stage 2 Final Rule Stage 3 Recommendations Stage 4 Placeholder

SGRP130

New for stage 3 New for stage 3 Objective: Use computerized provider order entry for referrals/transition of care orders directly entered by any licensed healthcare professional who can enter orders into the medical record per State, local and professional guidelines to create the first record of the order.

Measure: More than 20% of referrals/transition of care orders created by the EP or authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded.

SGRP102

Implement drug-drug and drug-allergy interaction checks

Consolidated with CDS Objective: EHRs need to include the “never” list of drug-drug interactionsMeasure: Enable list of “never” combinations

Ability to consume other listsCertification: EHRs need to be able to consume and act on external lists of DDIs (e.g., “never” combinations).

Seeking externally maintained list of DDIs with higher predictive value

Improve Quality Safety, Efficiency and Reducing Health Disparities

Coordinate with subgroup 3

Moved to SGRP101

Page 9: Meaningful Use Workgroup Stage 3 – Preliminary Recommendations Paul Tang, Palo Alto Medical Foundation, Chair George Hripcsak, Columbia University, Co-Chair

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Improve Quality Safety, Efficiency and Reducing Health Disparities

MU Workgroup Stage 3 Recommendations

ID Stage 1 Final Rule Stage 2 Final Rule Stage 3 Recommendations Stage 4 Placeholder

SGRP103

EP only: Generate and transmit more than 40% of all permissible prescriptions electronically

EP/EH Objective: Generate and transmit permissible prescriptions electronically (eRx)

EP Measure: More than 50% of all permissible, or all permissible and non permissible, prescriptions written by the EP and queried for a drug formulary and transmitted electronically using CEHRT.

EH MENU Objective: Generate and transmit permissible discharge prescriptions electronically (eRx)

EH MENU Measure: More than 10%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

EP Objective: Generate and transmit permissible prescriptions electronically (eRx)EP Measure: More than 50% of all permissible prescriptions written by the EP are compared to at least one drug formulary (reviewed for generic substitutions) transmitted electronically using Certified EHR Technology.

EH Objective: Generate and transmit permissible discharge prescriptions electronically (eRx)EH Measure: More than 30% of hospital discharge medication orders for permissible prescriptions (for new or changed prescriptions) are compared to at least one drug formulary and transmitted electronically using Certified EHR Technology

Page 10: Meaningful Use Workgroup Stage 3 – Preliminary Recommendations Paul Tang, Palo Alto Medical Foundation, Chair George Hripcsak, Columbia University, Co-Chair

Improve Quality Safety, Efficiency and Reducing Health Disparities

10

ID Stage 1 Final Rule Stage 2 Final Rule Stage 3 Recommendations Stage 4 Placeholder

SGRP104

Record demographics as structured data for more than 50% of all unique patients:• Preferred language• Gender• Race• Ethnicity• Date of birth

(Hospital Only) date and preliminary cause of death in the event of mortality in the eligible hospital or CAH

EP Objective: Record the following demographics• Preferred language• Sex• Race• Ethnicity• Date of birth

EH Objective: Record the following demographics• Preferred language• Sex• Race• Ethnicity• Date of birth• Date and preliminary cause of death in the event of mortality in the eligible hospital or CAH

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) have demographics recorded as structured data

Objective: Record the following in structured data:Demographics:• Preferred language• Sex• Race• Ethnicity• Date of birth• Occupation and industry codesClinical:• Sexual orientation, gender identity• Disability status

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) have demographics recorded as structured data• (Hospital Only) date and preliminary cause of death in the event of mortality in the eligible hospital or CAH

MU Workgroup Stage 3 Recommendations

Ensure SOGI and disability status are included in

certification and remove?

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Improve Quality Safety, Efficiency and Reducing Health DisparitiesID Stage 1 Final Rule Stage 2 Final Rule Stage 3 Recommendations Stage 4 Placeholder

SGRP105

Maintain an up-to-date problem list of current and active diagnoses for more than 80% of all unique patients: have at least one entry or an indication that no problems are known for patient recorded as structured data

Consolidated with summary of care

New for stage 3Certification criteria only: EHR systems should provide functionality to help maintain up-to-date, accurate problem list

Certification criteria only: Use of lab test results, medications, and vital signs (BP, ht, wt, BMI), to support maintenance of up-to-date accurate problem lists. Vendors utilize rules to help providers improve the problem list (e.g. MAPLE). System provides prompts about additions, edits, and deletions for clinicians review and action.

Stage 4: Patient input to reconciliation of problems

SGRP106

Maintain active medication list: more than 80% of all unique patients have at least one entry recorded as structured data (or indication that the patient is on no meds)

Consolidated with summary of care

New for Stage 3Certification criteria only:Use of problems and lab test results to support maintenance of up-to-date accurate medication lists by clinicians. System provides prompts about additions, edits, and deletions for clinicians review and action. [this does not mean that the system is going to automatically do something].

Certification criteria: Use other EHR data such as medications filled or dispensed, or free text searching for medications to support maintenance of up-to-date and accurate medication lists.

SGRP107

Maintain active medication allergy list: More than 80% of all unique patients seen during the reporting period have at least one entry (or indication that the patient has no known medication allergies) recorded as structured data

Consolidated with summary of care

New for stage 3Certification criteria only: EHR systems should provide functionality to code medication allergies and link to related drug family, and code related reaction. System provides prompts about additions, edits, and deletions for clinicians review and action.

Stage 4: Contraindications that could include: adverse reactions, procedural intolerance.

MU Workgroup Stage 3 Recommendations 11

Page 12: Meaningful Use Workgroup Stage 3 – Preliminary Recommendations Paul Tang, Palo Alto Medical Foundation, Chair George Hripcsak, Columbia University, Co-Chair

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ID Stage 1 Final Rule Stage 2 Final Rule Stage 3 Recommendations

Stage 4 Placeholder

SGRP108

Record and chart changes in vital signs: more than 50% of all unique patients age 2 and over have vital signs recorded as structured data• Height• Weight• Blood pressure• Calculate and display BMI• Plot and display growth charts for children 2-20 years, including BMI

Objective: Record and chart changes in vital signs:• Height/length• Weight• Blood pressure (age 3 and over)• Calculate and display BMI• Plot and display growth charts for patients 0-20 years, including BMI

Measure: More than 80% 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) have blood pressure (for patients age 3 and over only) and height/length and weight (for all ages) recorded as structured data

Retire as topped out measure?

SGRP109

Record smoking status for patients 13 years old and older: more than 50% of all unique patients seen during the reporting period 13 years or older have smoking status recorded as structured data

EP/EH Objective: Record smoking status for patients 13 years old or older

Measure: More than 80% 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 department (POS 21 or 23) have smoking status recorded as structured data

Incorporate into CQM?

Improve Quality Safety, Efficiency and Reducing Health Disparities

MU Workgroup Stage 3 Recommendations

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ID Stage 1 Final Rule Stage 2 Final Rule Stage 3 Recommendations Stage 4 Placeholder

SGRP110

MENU: Implement drug-formulary checks with access to at least one drug formulary

Consolidated (eRX) Consolidated - Moved to eRx objective.

SGRP111

Report ambulatory and hospital clinical quality measures to CMS or States

Objective is incorporated directly into the definition of a meaningful EHR user and eliminated as an objective under §495.6

Removed in Stage 2

SGRP112

EH MENU: Record whether an advance directives for more than 50% patients 65 years old or older

EH MENU Objective: Record whether a patient 65 years old or older has an advance directive

EH MENU Measure: 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.

Ensure standards support in CDA by 2016

EP MENU/EH Core Objective: Record whether a patient 65 years old or older has an advance directive

EP MENU/EH Core Measure: 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.

Improve Quality Safety, Efficiency and Reducing Health Disparities

MU Workgroup Stage 3 Recommendations

Page 14: Meaningful Use Workgroup Stage 3 – Preliminary Recommendations Paul Tang, Palo Alto Medical Foundation, Chair George Hripcsak, Columbia University, Co-Chair

ID Stage 1 Final Rule Stage 2 Final Rule Stage 3 Recommendations Stage 4 Placeholder

SGRP113

EP: Implement one clinical decision support rule relevant to specialty or high clinical priority along with ability to track compliance with that rule

EH: Implement one clinical decision support rule related to a high priority hospital condition along with the ability to track compliance with that rule

EP/EH Objective: Use clinical decision support to improve performance on high-priority health conditions

Measure: 1. Implement five clinical decision support interventions related to four or more clinical quality measures. Absent four clinical quality measures are related to an EP’s scope of practice, the provider may select clinical decision support interventions at a relevant point in patient care related to high-priority health conditions for the entire EHR reporting period. 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 entre EHR reporting period.

Objective: Use clinical decision support to improve performance on high priority health conditionsMeasure: 1. Implement 15 clinical decision support interventions related to five or more clinical quality measures that are presented at a relevant point in patient care for the entire EHR reporting period. The 15 CDS interventions should include one or more interventions in each of the following areas, as applicable to the EP's specialty: • Preventative care (including immunizations) • Chronic disease management (e.g., diabetes, hypertension, coronary artery disease) • Advanced medication-related decision support* (e.g., renal drug dosing) • Appropriateness of lab and radiology orders 2. The EP, eligible hospital, or CAH has enabled the functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period.

Certification criteria only:1. Ability to track CDS triggers and how the provider responded **2. Ability to flag preference-sensitive conditions, and provide decision support materials for patients.3. Capability to check for a maximum dose in addition to a weight based calculation.

*Kuperman,GJ. (2007). Medication-related clinical decision support in computerized provider order entry

systems: a review. Journal of the American Medical Informatics Association: JAMIA, 14(1):29-40.

**this is used to improve the effectiveness of CDS interventions

MU Workgroup Stage 3 Recommendations 14

Improve Quality Safety, Efficiency and Reducing Health DisparitiesMove to stage 4?• Advanced medication related decision support • Capability to check for maximum dose in

addition to a weight based calculation

Page 15: Meaningful Use Workgroup Stage 3 – Preliminary Recommendations Paul Tang, Palo Alto Medical Foundation, Chair George Hripcsak, Columbia University, Co-Chair

Improve Quality Safety, Efficiency and Reducing Health Disparities

15

ID Stage 1 Final Rule Stage 2 Final Rule Stage 3 Recommendations Stage 4 Placeholder

SGRP114

MENU: Incorporate clinical lab test results into certified EHR technology as structured data for more than 40% of all clinical lab tests results ordered whose results are either in a positive/negative or numerical format

EP/EH Objective: Incorporate clinical lab-test results into Certified EHR Technology as structured data

Measure: 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

Objective: Incorporate clinical lab-test results into EHR as structured data

Measure: More than 80% 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 or numerical format are incorporated in Certified EHR Technology as structured data

SGRP115

MENU: Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach

EP CORE Objective: Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach

EP CORE Measure: Generate at least one report listing patients of the EP, eligible hospital or CAH with a specific condition.

EP Objective: Generate lists of patients for multiple specific conditions and present near real-time patient-oriented dashboards to use for quality improvement, reduction of disparities, research, or outreach reports. Dashboards are incorporated into the EHR’s clinical workflow for the care coordinator or the provider. It is actionable and not a retrospective report.

MU Workgroup Stage 3 Recommendations 15

Page 16: Meaningful Use Workgroup Stage 3 – Preliminary Recommendations Paul Tang, Palo Alto Medical Foundation, Chair George Hripcsak, Columbia University, Co-Chair

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ID Stage 1 Final Rule Stage 2 Final Rule Stage 3 Recommendations Stage 4

Placeholder

SGRP116

EP MENU: Send preventive or follow-up reminders to more than 20% of all unique patients 65+ years old or 5 years old or younger

EP Objective: Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care and send these patients the reminder, per patient preference.

Measure: More than 10% of all unique patients who have had two or more office visits with the EP within the 24 months before the beginning of the EHR reporting period were sent a reminder, per patient preference when available

EP Objective: Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care and send these patients the reminder, per patient preference.

EP Measure: More than 20% of all unique patients who have had an office visit with the EP within the 24 months prior to the beginning of the EHR reporting period were sent a reminder, per patient preference

Exclusion: Specialists may be excluded for prevention reminders (could be more condition specific).

SGRP117

N/A EH Objective: Automatically track medications from order to administration using assistive technologies in conjunction with an electronic medication administration record (eMAR)

Measure: More than 10% 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 are tracked using eMAR.

EH Objective: Automatically track medications from order to administration using assistive technologies in conjunction with an electronic medication administration record (eMAR)

Measure: 1) More than 30% 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 are tracked using eMAR.2) Mismatches (situations in which a provider dispenses a medication and/or dosing that is not intended) are tracked and are reported for quality improvement purposes.

Improve Quality Safety, Efficiency and Reducing Health Disparities

MU Workgroup Stage 3 Recommendations

Page 17: Meaningful Use Workgroup Stage 3 – Preliminary Recommendations Paul Tang, Palo Alto Medical Foundation, Chair George Hripcsak, Columbia University, Co-Chair

17

ID Stage 1 Final Rule Stage 2 Final Rule Stage 3 Recommendations Stage 4

Placeholder

SGRP118

N/A MENU Objective: Imaging results consisting of the image itself and any explanation or other accompanying information are accessible through Certified EHR Technology.

MENU Measure: More than 10 percent of all tests whose result is an image 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

CORE Objective: Imaging results consisting of the image itself and any explanation or other accompanying information are accessible through Certified EHR Technology.

CORE Measure: More than 10 percent of all tests whose result is an image 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

SGRP119

N/A MENU Objective: Record patient family health history as structured data

MENU Measure: 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

CORE Objective: Record high priority family history data (including colon cancer, breast, glaucoma, MI, diabetes)

CORE Measure: Record high priority family history in 40% of patients seen during reporting period

Certification criteria: Make sure that every CDS intervention can take into account family history for outreach (need to move that functionality along as part of preventative outreach).

Improve Quality Safety, Efficiency and Reducing Health Disparities

MU Workgroup Stage 3 Recommendations

RFC: What are the barriers to moving this forward?

Page 18: Meaningful Use Workgroup Stage 3 – Preliminary Recommendations Paul Tang, Palo Alto Medical Foundation, Chair George Hripcsak, Columbia University, Co-Chair

18MU Workgroup Stage 3 Recommendations

ID Stage 1 Final Rule Stage 2 Final Rule Stage 3

RecommendationsStage 4

Placeholder

SGRP120

N/A EP/EH MENU Objective: Record electronic notes in patient records

EP MENU Measure: Enter at least one electronic progress note created, edited and signed by an eligible professional for more than 30 percent of unique patient office visits. Notes must be text-searchable. Non-searchable scanned 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 text notes under this measure.

EP MENU Measure: 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. Non-searchable, scanned 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 text notes under this measure.

Record electronic notes in patient records for more than 30% of office visits within four calendar days.

Improve Quality Safety, Efficiency and Reducing Health Disparities

Page 19: Meaningful Use Workgroup Stage 3 – Preliminary Recommendations Paul Tang, Palo Alto Medical Foundation, Chair George Hripcsak, Columbia University, Co-Chair

19MU Workgroup Stage 3 Recommendations 19

ID Stage 1 Final Rule Stage 2 Final Rule Stage 3 Recommendations Stage 4 Placeholder

SGRP121

N/A EH MENU Objective: Provide structured electronic lab results to ambulatory providers

EH MENU Measure: Hospital labs send structured electronic clinical lab results to the ordering provider for more than 20 percent of electronic lab orders received

Hospital Objective: Provide structured electronic lab results to eligible professionals.

Hospital Measure: Hospital labs send (directly or indirectly) structured electronic clinical lab results to the ordering provider for more than 80% of electronic lab orders received.

SGRP122

New for stage 3 New for stage 3 EH: Explore Timely transition document (elements need to be fleshed out) that is available electronically within four calendar days from when a transition occurs between sites.

Improve Quality Safety, Efficiency and Reducing Health Disparities

Removed for subgroup 3 objective

Page 20: Meaningful Use Workgroup Stage 3 – Preliminary Recommendations Paul Tang, Palo Alto Medical Foundation, Chair George Hripcsak, Columbia University, Co-Chair

Engaging Patients and Families – Subgroup 2

MU Workgroup Stage 3 Recommendations 20

Page 21: Meaningful Use Workgroup Stage 3 – Preliminary Recommendations Paul Tang, Palo Alto Medical Foundation, Chair George Hripcsak, Columbia University, Co-Chair

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ID Stage 1 FR Stage 2 Final Rule Stage 3 Recommendations Stage 4

SGRP204A

N/A EP Objective: Provide patients the ability to view online, download, and transmit their health information within 4 business days of the information being available to the EP.

EP Measure: 1. More than 50% of all unique patients seen by the EP during the EHR reporting period are provided timely (within 4 business days after the information is available to the EP) online access to their health information subject to the EP's discretion to withhold certain information2. More than 5% of all unique patients seen by the EP during the EHR reporting period (or their authorized representatives) view, download , or transmit to a third party their health information

EH Objective: Provide patients the ability to view online, download, and transmit information about a hospital admission

EH Measure: 1. More than 50% 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 discharge2. More than 5% 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

• EPs should make info available within 24 hours if generated during course of visit

• For labs or other types of info not generated within course of visit, it is made available to pts within four business days of info becoming available to EPs

• Signal potential for increasing both thresholds (% offer and % use) based on experience in Stage 2

Updated required elements:• Laboratory or other test results, such as radiology results.

•Note: Depending on experience in Stage 2, CMS may want to give credit to some providers for view/download/transmit where the patient has specified that they prefer info to be sent to a location they specify (such as provider portal or PHR), rather than only making available information on the provider’s portal.

MENU item: Automated Transmit: (builds on “Automated Blue Button Project”): Provide 50% of patients the ability to designate to whom and when (i.e. pre-set automated & on-demand) a summary of care document is sent to patient-identified care team members.

Building on Automated Transmit: 1a. Create the ability for providers to review patient-transmitted information and accept updates into EHR.

1b. Related certification criteria: Standards needed for provider directories in order to facilitate more automated transmissions per patients’ designations.

MU Workgroup Stage 3 Recommendations

Engage Patients and Families

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MU Workgroup Stage 2 Final Rule 22

Engage Patients and FamiliesID Stage 1 Final

Rule Stage 2 Final Rule Stage 3 Recommendations Stage 4 Placeholder

SGRP204B

New for Stage 3

New for Stage 3

Option 1: Provide 10% of patients with ability to submit information (provider chooses one or more of these information types according to what is most appropriate to their practice) such as: 1. Family Health History [as per Surgeon General] 2. ODLs [as per How's Your Health ]3. Caregiver status and role [as per DECAF]4. Functional status [as per PROMIS 10]5. Patient-created health goals (needs a standard, also in care summary and plan)6. Medical device: Glucose level*7. Medical device: Blood Pressure*8. Medical device: Weight**[SNOMED/LOINC]

Option 2: Provide 10% of patients with ability to submit information using:1) A generic semi-structured questionnaire platform and 2) capability to receive uploads from home devices (e.g., glucometer, BP device, scale) that accommodate the data above.

MENU: Provide 10% of patients with the ability to submit patient-generated health information to improve performance on high priority health conditions, and/or to improve patient engagement in care (e.g. patient experience, pre-visit information, patient created health goals, etc.).

Based upon feedback from HITSC this can be a MENU item.

Need RFC language to describe the rational for this function (contributes health outcomes improvement, QI goals and care efficiency).

Page 23: Meaningful Use Workgroup Stage 3 – Preliminary Recommendations Paul Tang, Palo Alto Medical Foundation, Chair George Hripcsak, Columbia University, Co-Chair

23MU Workgroup Stage 3 Recommendations

Engage Patients and Families

ID Stage 1 Final Rule

Stage 2 Final Rule Stage 3 Recommendations Stage 4

Placeholder

SGRP204C

New for Stage 3

New for Stage 3

Certification criteria only: Create capability to accept pre-visit prep tools into the EHR (e.g., the ability to consent to treatment, fill out administrative forms) (and also could send to other EHRs)

SGRP204D

New for Stage 3

New for Stage 3

Objective: Offer 10% of patients the ability to amend information (e.g., offer correction, addition or update to the record)

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ID Stage 1 Final Rule Stage 2 Final Rule Stage 3 Recommendations

Stage 4 Placeholder

SGRP205

Provide clinical summaries for >50% of all office visits within 3 business days

EP Objective: Provide clinical summaries for patients for each office visit

EP Measure: Clinical summaries provided to patients or patient-authorized representatives within 1 business day for more than 50 percent of office visits.

Required elements:● Patient name.● Provider's name and office contact information.● Date and location of the visit.● Reason for the office visit.● Current problem list.● Current medication list.● Current medication allergy list.● Procedures performed during the visit.● Immunizations or medications administered during the visit.● Vital signs taken during the visit (or other recent vital signs). ● Laboratory test results.● List of diagnostic tests pending.● Clinical instructions.● Future appointments.● Referrals to other providers.● Future scheduled tests. ● Demographic information maintained within CEHRT (sex, race, ethnicity, date of birth, preferred language).● Smoking status ● Care plan field(s), including goals and instructions. ● Recommended patient decision aids (if applicable to the visit).

The intent is that the information provided is intended to be relevant to the office visit. Edits to the type of information required should be made accordingly.

Engage Patients and Families

MU Workgroup Stage 3 Recommendations

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ID Stage 1 Final Rule Stage 2 Final Rule Stage 3 Recommendations Stage 4 Placeholder

SGRP206

MENU: Use certified EHR to identify patient-specific educational resources for >10% of all patients

EP/EH Objective: Use Certified EHR Technology to identify patient-specific education resources and provide those resources to the patient

EP CORE Measure: 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

EH CORE Measure: 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

Add language support:For the top 5 non-English languages spoken nationally, and based on a list of the EP or EH’s most prevalent non-English speaking population, provide 80% of patient-specific education materials in at least one of those languages.

Engage Patients and Families

MU Workgroup Stage 3 Recommendations

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ID Stage 1 Final Rule Stage 2 Final Rule Stage 3 Recommendations Stage 4 Placeholder

SGRP207

N/A EP Objective: Use secure electronic messaging to communicate with patients on relevant health information

EP Measure: A secure message was sent using the electronic messaging function of Certified EHR Technology by more than 5 percent of unique patients (or their authorized representatives) seen by the EP during the EHR reporting period

Measure: More than 10% of patients use secure electronic messaging to communicate with EPs

Stage 4: Create capacity for electronic episodes of care (telemetry devices, etc) and to do e-referrals and e-consults

SGRP208

N/A N/A [Communication Preferences] EP and EH Measure: Record communication preferences for 20% of patients, based on how (e.g., the medium) patients would like to receive information for certain purposes (including appointment reminders, reminders for follow up and preventive care, referrals, after visit summaries and test results).

Engage Patients and Families

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ID Stage 1 Final Rule Stage 2 Final Rule Stage 3 Recommendations Stage 4 Placeholder

SGRP209

New for Stage 3 New for stage 3 Explore For Certification Rule Only: Capability for EHR to query research enrollment systems to identify available clinical trials.

No use requirements until Stage 4.

Engage Patients and Families

MU Workgroup Stage 3 Recommendations

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Improving Care Coordination – Subgroup 3

MU Workgroup Stage 3 Recommendations 28

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MU Workgroup Stage 2 Final Rule29

ID Stage 1 Final Rule Stage 2 Final Rule Stage 3 Recommendations Stage 4 Placeholder

SGRP302

MENU: Perform medication reconciliation for >50% of transitions of care in which the patient is transitioned into the care of the EP, eligible hospital, or CAH

EP/EH CORE Objective: The EP who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation.

EP/EH CORE Measure: The EP, eligible hospital or CAH performs medication reconciliation for more than 50% 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)

EP / EH / CAH Objective: The EP, eligible hospital or CAH who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform reconciliation for: - medications- medication allergies- problems

EP / EH / CAH Measure: The EP, EH, or CAH performs reconciliation for medications for more than 50% of transitions of care, and it performs reconciliation for medication allergies, and problems for more than 10% 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).

SC&C Recommendation: Standards work needs to be done to adapt and further develop existing standards to define the nature of reactions for allergies (i.e. severity).

Reconciliation of contraindications (any medical reason for not performing a particular therapy; any condition, clinical symptom, or circumstance indicating that the use of an otherwise advisable intervention in some particular line of treatment is improper, undesirable, or inappropriate)SC&C Recommendation: Standards work needs to be done to support the valuing and coding of contraindications.IE Recommendation: Advance medication reconciliation to check for formulary compliance.

Medication formulary compliance v.1: prescriber electronically prescribes, EMR reconciles against relevant formulary, if formulary-compliant, prescription transmitted to pharmacy

Medication formulary compliance v.2: prescriber electronically prescribes, EMR reconciles against relevant formulary, if NOT formulary-compliant, prescription rejected, prescriber alerted to non-compliance, opportunity given via structured data prior-auth form to document medical necessity for non-formulary med, prior auth electronically and automatically granted in real-time if required prior auth requirements are fulfilled; this entire transaction could be done with structured data

Improve Care Coordination

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Im p ro ve C are C o o rd in ati o n

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ID Stage 1 Final Rule Stage 2 Final Rule Stage 3 Recommendations

SGRP303

MENU: Provide a summary of care record for >50% of all transitions and referrals of care

EP CORE Objective: The EP who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care provides summary care record for each transition of care or referral.

EH CORE Objective: The eligible hospital or CAH who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care provides summary care record for each transition of care or referral.

CORE Measure: 1. 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 50 percent of transitions of care and referrals.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 (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 network3. An EP, eligible hospital or CAH must satisfy one of the following criteria: (1) one (or more) successful electronic exchanges of a summary of care document as part of "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 developed by a different EHR developer than the sender’s EHR technology certified to 45 CFR 170.314(b)(2); or (2) conducts one or more successful tests with the CMS designated test EHR during the EHR reporting period.

Include the following information if the provider knows it:● Patient name.● Referring or transitioning provider's name & office contact information (EP only).● Procedures.● Immunizations● Laboratory test results.● Vital signs (height, weight, blood pressure, BMI).● Smoking status.● Functional status, including activities of daily living, cognitive and disability status● Demographic information (preferred language, sex, race, ethnicity, date of birth).● Care plan field, including goals and instructions.● Care team including the primary care provider of record and any additional known care team members beyond the referring or transitioning provider and the receiving provider.● Discharge instructions (Hospital Only)● Reason for referral (EP only)

EP/ EH / CAH Objective: EP/EH/CAH who transitions their patient to another setting of care or refers their patient to another provider of care - Provide a summary of care record for each site transition or referral when transition or referral occurs with available information

Measure: The EP, eligible hospital, or CAH that site transitions or refers their patient to another setting of care (including home) or provider of care provides a summary of care record for 65% of transitions of care and referrals (and at least 30% electronically).

Certification Criteria: EHR is able to set aside a concise narrative section in the summary of care document that allows the provider to prioritize clinically relevant information such as reason for transition and/or referral.

Must include the following four for transitions of site of care, and the first for referrals (with the others as clinically relevant): 1. Concise narrative in support of care transitions (free text that captures reason for referral or transition)2. Setting-specific goals3. Instructions for care during transition and for 48 hours afterwards4. Care team members, including primary care provider and caregiver name, role and contact info (using DECAF)

Certification Criteria: Consider inclusion of data sets being defined by S&I Longitudinal Coordination of Care WG, which and are expected to complete HL7 balloting for inclusion in the C-CDA by Summer 2013:

1) Consultation Request (Referral to a consultant or the ED)2) Transfer of Care (Permanent or long-term transfer to a different facility, different care team, or Home Health Agency)

Improve Care Coordination

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Improve Care Coordination

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ID Stage 1 Final Rule

Stage 2 Final Rule

Stage 3 Recommendations Stage 4 Placeholder

SGRP304

New New New EP/ EH / CAH Objective: EP/ EH/CAH who transitions their patient to another site of care or refers their patient to another provider of careFor each transition of site of care, provide the care plan information, including the following elements as applicable:•Medical diagnoses and stages •Functional status, including ADLs•Relevant social and financial information (free text)•Relevant environmental factors impacting patient’s health (free text)•Most likely course of illness or condition, in broad terms (free text)•Cross-setting care team member list, including the primary contact from each active provider setting, including primary care, relevant specialists, and caregiver•The patient’s long-term goal(s) for care, including time frame (not specific to setting) and initial steps toward meeting these goals•Specific advance care plan (POLST) and the care setting in which it was executed

For each referral, provide a care plan if one exists

Measure: The EP, eligible hospital, or CAH that transitions or refers their patient to another site of care or provider of care provides the electronic care plan information for 10% of transitions of care to receiving provider and patient/caregiver.

Certification Criteria: Develop, pilot test, and ballot standards for a shared care plan, as being defined by S&I Longitudinal Coordination of Care WG. Some of the data elements in the shared care plan overlap content represented in the CDA. Consider adopting standards for the structured recording of other data elements, such as patient goals and related interventions.

Improve Care Coordination

MU Workgroup Stage 3 Recommendations

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ID Stage 1 Final Rule

Stage 2 Final Rule Stage 3 Recommendations Stage 4 Placeholder

SGRP305

New for Stage 3

New for Stage 3

EP / EH / CAH Objective (new): EP/EH/CAH to whom a patient is referred acknowledges receipt of external information and provides referral results to the requesting provider, thereby beginning to close the loop. Measure: For 10% of patients referred during an EHR reporting period, referral results generated from the EHR are returned to the requestor (e.g. via scan, printout, fax, electronic CDA Care Summary and Consult Report).

Certification Criteria: Consider inclusion of data set defined by S&I Longitudinal Coordination of Care WG and expected to complete HL7 balloting for inclusion in the C-CDA by Summer 2013:Shared Care Encounter Summary (Consultation Summary, Return from the ED to the referring facility, Office Visit)

Continue working to close the loop with an acknowledgement of order receipt and tracking for completion.

In addition, consider standards for referral requests that require authorizations (or pre-certifications) for procedure, surgery, lab, radiology, test orders.

Procedure/Surgery/lab/radiology/test prior authorization v.A: for those procedures/surgeries/lab/radiology /test with clear and objective prior authorization requirements and a structured data prior authorization form is available, clinician fill out the prior authorization form using structured data fields and prior authorization can be granted electronically and in real-time by the payor.

Procedure/Surgery/lab/radiology /test prior authorization v.B: for those procedures/surgeries/lab/radiology/test, for which prior authorization is non-standardized and is highly individualized, a standardized form is created that collects from the clinician text fields answering an agreed upon set of medical necessity questions, standardized form is sent electronically to insurer for review, insurer responds with Approval/Denial (with rationale if denied) using a standardized format text document back to clinician with either approval and/or denial with rationale.

MU Workgroup Stage 3 Recommendations

Improve Care Coordination

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Objectives not included

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ID Stage 1 Final Rule Stage 2 Final Rule Stage 3 Stage Undetermined

SGRP127

New New New Ability to maintain an up-to-date interdisciplinary problem list inclusive of versioning in support of collaborative care

SGRP125

New New New Medication reconciliation: create ability to accept data feed from PBM (Retrieve external medication fill history for medication adherence monitoring)

SGRP308

NEW NEW NEW IE workgroup recommendation:EH OBJECTIVE: The EH/CAH will send electronic notification of a significant healthcare event in a timely manner to key members of the patient’s care team, such as the primary care provider, referring provider or care coordinator, with the patient’s consent if required.

EH MEASURE: For 10% of patients with a significant healthcare event (arrival at an Emergency Department (ED), admission to a hospital, discharge from an ED or hospital, or death) , EH/CAH will send an electronic notification to at least one key member of the patient’s care team, such as the primary care provider, referring provider or care coordinator, with the patient’s consent if required, within 2 hours of when the event occurs.

Improve Care Coordination

MU Workgroup Stage 3 Recommendations

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Population and Public Health – Subgroup 4

MU Workgroup Stage 3 Recommendations 34

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ID Stage 1 Final Rule Stage 2 Final Rule Stage 3 Recommendations Stage 4 Placeholder

SGRP401A

MENU: Perform at least one test of the capability to submit electronic data to immunization registries

EP/EH Objective: Capability to submit electronic data to immunization registries or immunization information systems except where prohibited, and in accordance with applicable law and practice

EP/EH Measure: 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

EP/ EH Objective (New): Capability to receive a patient’s immunization history supplied by an immunization registry or immunization information system, and to enable healthcare professionals to use structured historical immunization events in the clinical workflow, except where prohibited, and in accordance with applicable law and practice.

Measure: Documentation of timely and successful electronic receipt by the Certified EHR Technology of vaccine history (including null results) from an immunization registry or immunization information system for 30% of patients who received immunizations from the EP/EH during the entire EHR reporting period.

Exclusion: EPs and EHs that administer no immunizations or jurisdictions where immunization registries/immunization information systems cannot provide electronic immunization histories.

Certification criteria: EHR is able to receive and present a standard set of structured, externally-generated, immunization history and capture the act and date of review within the EP/EH practice.

Stage 4 EP/EH Objective: Add submission of vaccine contraindication(s) and reason(s) for substance refusal to the current objective of successful ongoing immunization data submission to registry or immunization information systems.

Improve Population and Public Health

MU Workgroup Stage 3 Recommendations

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Improve Population and Public Health

MU Workgroup Stage 3 Recommendations

ID Stage 1 Final Rule Stage 2 Final Rule Stage 3 Recommendations Stage 4 Placeholder

SGRP401B

New for Stage 3 New for Stage 3 EP/EH Objective (New): Capability to receive, generate or access appropriate age-, gender- and immunization history-based recommendations (including immunization events from immunization registries or immunization information systems) as applicable by local or state policy.

Measure: Implement an immunization recommendation system that: 1) establishes baseline recommendations (e.g., Advisory Committee on Immunization Practices), and 2) allows for local/state variations. For 10% of patients receiving an immunization, the EP/EH practice receives the recommendation before giving an immunization.

Exclusion: EPs and EHs that administer no immunizations.

Certification criteria: EHR uses a standard (e.g., national, state and/or local) rule set, plus patient age, gender, and prior immunization history to recommend administration of immunizations; capture the act and date/time of recommendation review.

Changed threshold to 10% from 20% for

consistency

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ID Stage 1 Final Rule Stage 2 Final Rule Stage 3 Recommendations Stage 4 Placeholder

SGRP402A

Perform at least one test of the capability to submit electronic data on reportable lab results to public health agencies and actual submission in accordance with applicable law and practice

EH Objective: Capability to submit electronic reportable laboratory results to public health agencies, except where prohibited, and in accordance with applicable law and practice

Measure: Successful ongoing submission of electronic reportable laboratory results from Certified EHR Technology to public health agencies for the entire EHR reporting period as authorized.

EH Objective (unchanged): No change from current requirement for electronic lab reporting which generally is sent from the laboratory information system

Improve Population and Public Health

MU Workgroup Stage 3 Recommendations

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Improve Population and Public Health

MU Workgroup Stage 3 Recommendations

ID Stage 1 Final Rule Stage 2 Final Rule Stage 3 Recommendations Undetermined

SGRP402B

More information from RFC - New

More information from RFC - New

More information from RFC - New

RFC ONLY (Stage undetermined):EP Objective (new): Capability to use externally accessed or received knowledge (e.g. reporting criteria) to determine when a case report should be reported and then submit the initial report to a public health agency, except where prohibited, and in accordance with applicable law and practice.

Measure: Attestation of submission of standardized initial case reports to public health agencies on 10% of all reportable disease or conditions during the entire EHR reporting period as authorized, and in accordance with applicable state/local law and practice.

Certification criteria: The EHR uses external data to prompt the end-user when criteria are met for case reporting. The date and time of prompt is available for audit. Standardized (e.g., consolidated CDA) case reports are submitted to the state/local jurisdiction and the data/time of submission is available for audit

RFC ONLYChanged threshold to

10% from 20% for consistency

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ID Stage 1 Final Rule Stage 2 Final Rule Stage 3 Recommendations Stage 4 Placeholder

SGRP403

Perform at least one test of the capability to submit electronic syndromic surveillance data to public health agencies and actual submission in accordance with applicable law and practice

EP MENU Objective: Capability to submit electronic syndromic surveillance data to public health agencies, except where prohibited, and in accordance with applicable law and practice

EH Objective: Capability to submit electronic syndromic surveillance data to public health agencies, except where prohibited, and in accordance with applicable law and practice

EP/EH Measure: Successful ongoing submission of electronic syndromic surveillance data from Certified EHR Technology to a public health agency for the entire EHR reporting period

No change from current requirements.

Improve Population and Public Health

MU Workgroup Stage 3 Recommendations

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Improve Population and Public Health

MU Workgroup Stage 3 Recommendations

ID Stage 1 Final Rule Stage 2 Final Rule Stage 3 Recommendations Stage 4 Placeholder

SGRP404

N/A EP MENU Objective: Capability to identify and report cancer cases to a public health central cancer registry, except where prohibited, and in accordance with applicable law and practice.

EP MENU Measure: Successful ongoing submission of cancer case information from CEHRT to a public health central cancer registry for the entire EHR reporting period

EH/EP Objective: Capability to electronically participate and send standardized (i.e. data elements and transport mechanisms), commonly formatted reports to a mandated jurisdictional registry (e.g., cancer, children with special needs, and/or early hearing detection and intervention) from Certified EHR to either local/state health departments, except where prohibited, and in accordance with applicable law and practice. This objective is in addition to prior requirements for submission to an immunization registry.

Measure: Documentation of ongoing successful electronic transmission of standardized reports from the Certified EHR Technology to the jurisdictional registry. Attestation of submission for at least 10% of all patients who meet registry inclusion criteria during the entire EHR reporting period as authorized, and in accordance with applicable State law and practice.

Certification criteria: EHR is able to build and then send a standardized report (e.g., standard message format) to an external mandated registry, maintain an audit of those reports, and track total number of reports sent.

Exclusion: where local or state health departments have no mandated registries or are incapable of receiving these standardized reports

Changed threshold to 10% from 20% for

consistency

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ID Stage 1 Final Rule Stage 2 Final Rule Stage 3 Recommendations Stage 4 Placeholder

SGRP405

N/A EP MENU Objective: Capability to identify and report specific cases to a specialized registry (other than a cancer registry), except where prohibited, and in accordance with applicable law and practice.

EP MENU Measure: Successful ongoing submission of specific case information from Certified EHR Technology to a specialized registry for the entire EHR reporting period

EP Objective: Capability to electronically submit standardized reports to an additional registry beyond any prior meaningful use requirements (e.g., immunizations, cancer, early hearing detection and intervention, and/or children with special needs). Registry examples include hypertension, diabetes, body mass index, devices, and/or other diagnoses/conditions) from the Certified EHR to a jurisdictional, professional or other aggregating resources (e.g., HIE, ACO), except where prohibited, and in accordance with applicable law and practice.

Measure: Documentation of successful ongoing electronic transmission of standardized (e.g., consolidated CDA) reports from the Certified EHR Technology to a jurisdictional, professional or other aggregating resource. Attestation of submission for at least 10% of all patients who meet registry inclusion criteria during the entire EHR reporting period as authorized, and in accordance with applicable state/local law and practice.

Certification criteria: EHR is able to build and send a standardized message report format to an external registry, maintain an audit of those reports, and track total number of reports sent.

Improve Population and Public Health

MU Workgroup Stage 3 Recommendations

• Changed threshold to 10% from 20% for consistency.

• Changed from undetermined to stage 3.

Note: This objective is the same as the previous, but adds a second registry and

does not need to be jurisdictional.

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Improve Population and Public Health

MU Workgroup Stage 3 Recommendations

ID Stage 1 Final Rule Stage 2 Final Rule Stage 3 Recommendations Stage 4 Placeholder

SGRP407

New for Stage 3 New for Stage 3 EH Objective: Capability to electronically send standardized Healthcare Associated Infection (HAI) reports to the National Healthcare Safety Network (NHSN) using a common format from the Certified EHR, except where prohibited, and in accordance with applicable law and practice.

Measure: Documentation of successful electronic transmission of standardized healthcare acquired infection reports to the NHSN from the Certified EHR Technology. Total numeric count of HAI in the hospital and attestation of Certified EHR electronic submission of at least 20% of all reports during the entire EHR reporting period as authorized, and in accordance with applicable State law and practice.

Certification criteria: EHR is able to sending a standard HAI message to NHSN, maintain an audit and track total number of reports sent.

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43MU Workgroup Stage 3 Recommendations

ID Stage 1 Final Rule Stage 2 Final Rule

Stage 3 Recommendations Undetermined

SGRP408

RFC ONLY RFC ONLY RFC ONLY RFC ONLY (Stage undetermined):EH/EP Objective (new): Capability to electronically send adverse event reports (e.g., vaccines, devices, EHR, drugs or biologics) to the Federal Drug Administration (FDA) and/or Centers for Disease Control and Prevention (CDC) from the Certified EHR, except where prohibited, and in accordance with applicable law and practice.

Measure: Attestation of successful electronic transmission of standardized adverse event reports to the FDA/CDC from the Certified EHR Technology. Total numeric count (null is acceptable) of adverse event reports from the EH/EP submitted electronically during the entire EHR reporting period as authorized, and in accordance with applicable State law and practice.

Certification criteria: EHR is able to build and send a standardized adverse event report message to FDA/CDC and maintain an audit of those reports sent to track number of reports sent

Improve Population and Public Health

RFC ONLY

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Information Exchange Workgroup

Micky Tripathi, Chair

MU Workgroup Stage 3 Recommendations 44

Page 45: Meaningful Use Workgroup Stage 3 – Preliminary Recommendations Paul Tang, Palo Alto Medical Foundation, Chair George Hripcsak, Columbia University, Co-Chair

Lab Orders (EHR Certification Criteria)

• Certification Only for EPs: The EHR must have the ability to issue an electronic order of laboratory test within a providers workflow. The capability should be compatible with the Lab Order Interface and Lab Results Interface guidelines produced by the S&I Framework Initiative.

• Request for Comment for Meaningful Use with these additional questions:– Are the existing standards for laboratory orders

adequate to support including this certification criterion?

45

May want to reword as standards are available.

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E-Rx of Controlled Substances (modify existing objective)

• MU objective: Controlled substance prescriptions should count towards the e-prescribing numerator, but not the denominator.

• Certification criterion: The EHR system must be able to support the e-prescribing of controlled substances.

• This approach provides an extra credit incentive for providers to e-prescribing controlled substances by counting towards their achievement of the e-prescribing numerator but not towards the denominator. This approach also obviates the need to include exemptions around state law restrictions and the capabilities of trading partners.

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Query for Patient Information (EHR Certification Criteria)

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Stage 2 of Meaningful Use requires EPs, EHs & CAHs to send care summaries when patients are transitioned to another setting, with more than 10% of those summaries required to be sent digitally using certified EHR technology. The 2014 EHR Certification criteria require EHRs to have the capability to perform this function. Those criteria will help EPs, EHs & CAHs digitally transmit care summaries in circumstances where the recipient is known (or can be located through a provider directory). But these criteria will not help providers locate patient records in circumstances where the source of those records are unknown. The most common use case where this occurs is when a patient arrives in an emergency room; but there could be other circumstances where providers have a need to query a patient’s record in order to provide optimal treatment. Certified EHRs should have the capability to enable EPs, EHs & CAHs to query for a patient’s record and request that records relevant to treatment be sent. Proposed Criteria for the next phase of EHR Certification:1. The EHR must be able to query another entity* for outside records and respond to such queries . This query may consist of three transactions:• Patient query based on demographics and other available identifiers• Query for a document list based for an identified patient• Request a specific set of documents from the returned document list*the outside entity may be another EHR system, a health information exchange, or an entity on the NwHIN, for example. 2. When receiving in inbound patient query, the EHR must be able to tell the querying system whether patient authorization is required to retrieve the patient’s records. (E.g. if authorization is already on file at the record-holding institution it may not be required). 3. The EHR initiating the query must be able to query an outside entity* for the authorization language to be presented to and signed by the patient or her proxy in order to retrieve the patient’s records. Upon the patient signing the form, the EHR must be able to either:• Send a copy of the signed form to the entity requesting it• Send an electronic notification attesting to the collection of the patient’s signature Note: The authorization text may come from the record-holding EHR system, or, at the direction of the patient or the record-holding EHR, could be located in a directory separate from the record-holding EHR system, and so a query for authorization language would need to be directable to the correct endpoint. Are we also establishing certification criteria for the response? For example, a response that a record for that patient does exist and the document list? Also a capability for record-holding EHR to be able to respond to such a request (e.g., release upon authorization from the record-holding EHR). Potentially also enable providers to program providers on identified on the patient’s care team to be able to receive responses automatically? Not sure the EHR should be able to program for only one of these options – record holding EHRs should be permitted to get a copy of the signed form if they don’t want to rely on the attestation

1. Are we also establishing certification criteria for the response? For example, a response that a record for that patient does exist and the document list? Also a capability for record-holding EHR to be able to respond to such a request (e.g., release upon authorization from the record-holding EHR). Potentially also enable providers to program providers on identified on the patient’s care team to be able to receive responses automatically?

3. Not sure the EHR should be able to program for only one of these options – record holding EHRs should be permitted to get a copy of the signed form if they don’t want to rely on the attestation

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Query Provider Directory (EHR Certification Criteria)

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Request for Comment for Meaningful Use with these additional questions:• Are there sufficiently mature standards in place to support this criteria? What implementation of these standards are in place and what has the experience been?

Priorities supported by a provider directory query which facilitates Direct messaging and queries:

– Improved care coordination– Reduces readmission, redundant testing– Improves patient safety– Facilitates “hassle-free” health information exchange

Certification criterion: The EHR must be able to query aProvider Directory external to the EHR to obtain entity-leveladdressing information (e.g. push or pull addresses).

Page 49: Meaningful Use Workgroup Stage 3 – Preliminary Recommendations Paul Tang, Palo Alto Medical Foundation, Chair George Hripcsak, Columbia University, Co-Chair

Data Portability Between EHR Vendors (RFC)Request for Comment for EHR Certification:ONC’s HIT Policy Committee recognizes the importance of enabling healthcare providers to switch from using one EHR to another vendor’s EHR. It also recognizes that not all data can be migrated from one EHR to another. For instance, it is unreasonable to expect audit trails to be able to be imported from one EHR into another vendor’s EHR because EHR audit trails are so intimately tied to the EHR’s internal data structure and function. In the MU2 Certification Rule, ONC required at a minimum the capability to export C-CDA summaries on all patients which includes their most recent clinical information. It was recognized that this core clinical dataset was merely a first step towards the goal of seamless data portability. ONC also encouraged, although did not require, including historical laboratory test results, immunizations, and procedures.ONC’s HIT Policy Committee wishes to advance data portability further, and thus seeks comment to help identify reasonable actions that may further facilitate data portability.• What are the most important current and historical data elements that should be included in the exported

data? Should this included data that was saved in the EHR as an image or waveform?• What associated metadata should be exported to provide context to these historical data elements?• Should there be different standards for EP versus EH EHRs with regards to which data elements to export and

how far back historically to include?• ONC’s HIT Policy Committee recognizes that some data elements do not need to be transferred into the new EHR

but instead need to be archived and made available through some other non-EHR mechanism. What non-EHR mechanisms for storing, retrieving and displaying these archived data are available? Are there standards and services available to accomplish this?

• What are the risks and harms of requiring EHR vendors to provide data portability beyond C-CDA summaries?• What are the risks and harms of not advancing the current state of data portability beyond C-CDA summaries?

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Page 50: Meaningful Use Workgroup Stage 3 – Preliminary Recommendations Paul Tang, Palo Alto Medical Foundation, Chair George Hripcsak, Columbia University, Co-Chair

Exchange of electrocardiograms (RFC)Request for Comment for EHR Certification:ONC’s HIT Policy Committee recognizes the importance of enabling healthcare providers to exchange electrocardiograms (EKGs). It also recognizes that there is limited experience with exchange of EKGs between healthcare providers.ONC’s HIT Policy Committee wishes to advance the exchange of EKGs between healthcare providers, and thus seeks comment to help identify reasonable actions that may promote this exchange.• How useful is the exchange of electrocardiograms (EKGs). What is the incremental value of exchanging

the actual image or waveform instead of just the textual EKG reading?• What technologies and standards are available for exchange of EKGs, and how mature are they? What

vendors support these standards and to what extent are they supported? Should EKGs be exchanged as waveforms or images and why?

• Are current EKG systems designed for sending and receiving EKGs? If yes, by what means and using which standards?

• Are current EHR systems designed for sending and receiving EKGs? If yes, by what means and using which standards?

• What examples of successful and unsuccessful exchange of EKGs are available?• What are the barriers to the exchange of EKGs? Are these barriers universal or unique to certain EKG

vendors?

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Include in images? Include wave forms – EKGs. Question for RFC.