Thursday, February 23, 2012

Moving Up the Escalator to Stage 2

The eagerly awaited Notice of Proposed Rule Making (NPRM) on Meaningful Use Stage 2 has been finally released in a sprawling 455 pages document. If you followed the discussions of the Federal Advisory Committees over the last year or so, you would know that Meaningful Use Stage 2 is just another small step towards an overarching goal of utilizing health information technology to support current policies aimed at providing better care for individuals, better health for populations and lower the costs of health care. We can agree or disagree on the wisdom of those policies, but if you are using electronic health records or just contemplating a move to computerized records, and have an interest in obtaining Meaningful Use incentives or avoiding penalties, you should have a basic understanding of what the next step on the technology escalator consists of.

Meaningful Use Stage 2 distinguishes itself from Stage 1 mainly by proposing a major push to health information exchange. It also brings a new level of complexity to the assembly of various data sets that are intended to be exchanged with other care providers and/or patients. It would probably be a bit simpler to define one superset of information and use it for all information exchange measures. The other notable feature of Stage 2 is that a couple of measures are completely dependent on patients’ willingness and ability to engage in Internet based communications.

Basically everything that was required for Stage 1 is also required for Stage 2, although some measures have higher thresholds, and others have been consolidated in one measure, or are just implied in other measures. For physicians, Meaningful Use Stage 1 had 25 measures, of which 20 needed to be met. Stage 2 has 22 measures, of which 20 need to be fulfilled in order to qualify for incentives starting in 2014 (yes, 2014). There is still a bit of wiggle room, but not as much as in the past. Finally, just like in Stage 1, there are several exclusions available for measures that do not apply to your practice.
The following is an (almost) objective summary of the newly proposed measures.

The Departed
The following Stage 1 measures have been removed from the Stage 2 list for various reasons as described below,
  • Maintain problem lists – incorporated into summary of care measure
  • Maintain medication lists  – incorporated into summary of care measure
  • Maintain drug allergy lists – incorporated into summary of care measure
  • Perform drug formulary checks – incorporated into the electronic prescribing measure
  • Drug-drug and drug-allergy interaction alerts – incorporated into the Clinical Decision Support measure
Golden Oldies
The following measures have not changed from Stage 1 to Stage 2, but those that were optional are now mandatory.
  • Generate one list of patients with a specific condition
  • Send reminders to 10% of patients (slight change: patients of all ages not seen in over two years)
  • Provide patient education materials to patients stays at 10%
Wee Bit Harder
  • Recording patient demographics increased to 80%
  • Recording vitals increased to 80%
  • Recording smoking status increased to 80%
  • Electronic prescribing threshold up to 65% for ambulatory practice and newly added for hospital discharge medications at 10%
  • Incorporate structured lab results into the EHR is up to 55%
  • Medications reconciliation upon transition of care increased to 65%
  • Recording existence of Advanced Directives has increased to more than 50% for hospitals only.
Full Step up the Escalator
  • Computerized Physician Order Entry (CPOE) is now required for 60% of Medication orders, Laboratory orders and Radiology orders. Just to clarify, this is NOT a requirement to send orders out electronically. It is only a requirement to document the orders in the EHR.
  • Clinical Decision Support (CDS) is increased to the implementation of 5 distinct rules, related to 5 or more CQM. This should not be a major problem for most EHRs, unless the final CQM are very different than what was offered in Stage 1. Enabling drug-drug and drug-allergy alerts are in addition to the above.
  • Clinical summaries need to be made available to more than 50% of patients within 24 hours now, down from 3 days in Stage 1. Huge problem for those who don’t finish their charts on the same day. Clinical summaries should include at least the following items:
    • Patient Name.
    • Provider's name and office contact information.
    • Date and location of the visit.
    • Reason for the office visit.
    • Current problem list and any updates to it.
    • Current medication list and any updates to it.
    • Current medication allergy list and any updates to it.
    • Procedures performed during the visit.
    • Immunizations or medications administered during the visit.
    • Vital signs and any updates.
    • Laboratory test results.
    • List of diagnostic tests pending.
    • Clinical instructions.
    • Future appointments.
    • Referrals to other providers.
    • Future scheduled tests.
    • Demographics (gender, race, ethnicity, date of birth, preferred language). (New requirement for Stage 2.)
    • Smoking status (New requirement for Stage 2.)
    • Care plan field, including goals and instructions. (New requirement for Stage 2.)
    • Recommended patient decision aids (if applicable to the visit). (New requirement for Stage 2.)
  • Submission of data to immunizations registries is no longer just a test. Stage 2 requires ongoing submission to a registry. Hopefully by Stage 2 the current mess, where hundreds of fully certified EHRs are incapable of connecting to registries in reality, will be resolved.
  • Hospitals also need to have a working interface for lab results to public health entities, instead of just performing a test.
  • Menu Item (ambulatory): Syndromic Surveillance interfaces need to be operational for Stage 2. For hospitals this is mandatory.
  • Perform security risk assessment and remediation of deficiencies has not changed, but there is an explicit requirement to address “the encryption/security of data at rest”. So if you have your EHR server in your office, you will need your IT guy to pitch in a few hours here.
  • Reporting clinical quality measures to CMS increased from 6 to 12 for ambulatory physicians and is up to 24 for hospitals. There are extensive lists of measures and a couple of choices on how to pick them. Note that there are several new measures and that CMS is expecting to be able to receive these reports electronically by 2014 and therefore CQM reporting will be separate from Meaningful Use attestation for Stage 2. Unlike Stage 1, physicians would be able to elect group reporting for CQM.
New and Noteworthy
  • Hospitals must attest that 10% of medications are automatically tracked via an electronic medication administration record (eMAR).
  • View/Download/Transmit – First, more than 50% of patients must have timely online access to their health information 4 days after it is received by physicians (36 hours after discharge for hospitals). Second, over 10% of your patients must view or download or transmit their information to a third party. This will require a Patient Portal that can log visits and an upgrade to most portals to allow transmission of records to somewhere. You will need to have over half of your patients registered for the Portal, which may be a problem if most of your patients don’t have email accounts, since most EHR supplied Patient Portals require an email for registration. Note that you must somehow ensure that 1 in 10 patients actually logs into their Patient Portal account and looks at the records. The Portal must make available the following items at the very least:
    • Patient name.
    • Provider's name and office contact information.
    • Problem list.
    • Procedures.
    • Laboratory test results.
    • Medication list.
    • Medication allergy list.
    • Vital signs (height, weight, blood pressure, BMI, growth charts).
    • Smoking status.
    • Demographic information (preferred language, gender, race, ethnicity, date of birth).
    • Care plan field, including goals and instructions, and any additional known care team members beyond the referring or transitioning provider and the receiving provider.
  • Secure messaging with over 10% of patients online is another new measure that can be satisfied by having a Patient Portal. The language for this new measure indicates that the secure messages must be sent by the patients, so as with the above measure, you will have to somehow ensure that your patients send you online messages.
  • Summaries of care need to be transmitted for more than 65% of transitions or referrals. Of those over 10% must be transmitted electronically to someone not organizationally affiliated with you, AND that someone must use an EHR that is different than the one you are using. Choose your referrals wisely and make sure you inquire in advance about the EHR situation at the receiving end. You will probably have to type it in your EHR for record keeping purposes. If you work for a Kaiser-like organization, you may have a serious problem here.  Required data elements for these summaries are as follows (not sure why Meds and Allergies are excluded):
    • Patient name.
    • Referring or transitioning provider's name and office contact information (ambulatory only).
    • Procedures.
    • Relevant past diagnoses.
    • Laboratory test results.
    • Vital signs (height, weight, blood pressure, BMI, growth charts).
    • Smoking status.
    • Demographic information (preferred language, gender, race, ethnicity, date of birth).
    • Care plan field, including goals and instructions, and any additional known care team members beyond the referring or transitioning provider and the receiving provider.
    • Discharge instructions for hospitals.
  • Menu Item: Availability of images in the EHR is required for over 40% of orders for all scans and tests whose result is an image. Many EHRs will need some retooling for this and you will need some expensive interfaces to hit the 40% threshold, particularly if you order imaging tests at multiple facilities, assuming those facilities have the ability (and willingness) to provide you access to their systems. The last thing you want to do here is to have those images travel over the network. It will kill your bandwidth and your server.
  • Menu Item: Record Family History as structured data for over 20% of patients. This one is a walk in the park for practically all EHRs. Be sure to pick this one.
  • Menu Item (ambulatory): Reporting to a Cancer Registry. This will require an operational interface for the entire reporting period.
  • Menu Item (ambulatory): Reporting to a Specialized Registry (other than cancer). Here too a fully operational interface is needed. This is probably not much of a choice in most states.
If you managed to read to this point without falling asleep or suffering an anxiety attack, please note that this is just an NPRM and public comment is requested. Go ahead and make your opinions heard. CMS and ONC have listened to comments in the past and showed willingness to adjust. I would suspect that just like Meaningful Use Stage 1, these regulations will be much relaxed by the time the final rule is issued later this year, and further accommodations will be made as work in the field actually begins.

Note: Public comments can be posted here.


  1. Hi Margalit, very well written summary! You read and write faster than I do. I like the clever categories of "escalation" you created.

    But wrt your question about why meds and allergies were not included in the summary of care record, actually the ARE. Take a look at the lower part of p. 109 where it says "In addition, all summary of care documents used to meet this objective must include the following:
    ● An up-to-date problem list of current and active diagnoses.
    ● An active medication list, and
    ● An active medication allergy list.”
    For some strange reason, they didn't put those in the main list of required data, but afterwards, separated by an intervening paragraph.

    I agree that your commentary was (almost) objective, but your advice to physicians was helpful.


  2. Good catch, David. I missed that one.
    I am pretty sure I will reread and write some more on this subject with absolutely no pretense of objectivity :-)