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Parsing Stage 2 Meaningful Use — Part 2

Two weeks ago, I reviewed the Basic and Intermediate core metrics for Stage 2 of Meaningful Use with the perspective of ambulatory care. As a refresher, I defined the categories as follows:

  1. Basic: requirements that should be standard processes for most practices
  2. Intermediate: requirements that require additional work, new processes, but are probably reasonable expectations of a well-organized and efficient office
  3. Advanced: requirements that could pose significant challenges due to required changes in workflow, additional costs, or are less in the control of the practice

For this post, I comment on the Advanced category.


  • Implement 5 clinical decision support interventions related to four or more clinical quality measures(CQMs): This metric requires considerable thought as the practice must select clinical quality measures relevant for the office for which there are already existing clinical decision support in the certified EHR. Further, beginning in 2014, EPs must report on 9 of the available 64 CQMs. Three (3) of these 9 must be CQMs that are associated with one of the following 6 domains from the National Quality Strategy:
  1. Patient & Family Engagement
  2. Patient Safety
  3. Care Coordination
  4. Population & Public Health
  5. Efficient Use of Healthcare Resources
  6. Clinical Processes/Effectiveness

A list of the CQMs is part of the final rule — see Table 8 beginning on page 54069 of the Federal Register, 9/4/12. Will CDS be ready? Here’s the response in the Final Rule to that question from CMS:

We recognize commenters’ concerns regarding the maturity of CDS systems. Closely linked to the development of EHRs, there are multiple factors impacting the evolution of CDS systems including; the increasing availability and sophistication of information technology in clinical settings, the increasing pace of publication of new evidence-based guidelines for clinical practice and the continual evaluation and improvements of CDS.2 We clarify that all CEHRT includes CDS interventions. The companion ONC standards and certification criteria final rule published elsewhere in this issue of the Federal Register includes further information regarding the criteria necessary to implement CDS in CEHRT for Stage 2 of meaningful use. With each incremental phase of meaningful use, CDS systems progress in their level of sophistication and ability to support patient care. For Stage 2 of meaningful use, it is our expectation that at a minimum, providers will select clinical decision support interventions to drive improvements in the delivery of care for the high-priority health conditions relevant to their patient population.

So, for the reasons above, this metric falls into the “advanced” category.

  • More than 50% of all unique patients seen by the EP are provided timely (within four business days) online access to their health information subject to the EP’s discretion; more than 5% of patients view, download, or transmit to a third party their health information: These metrics will necessarily involve significant changes to workflow and a concerted effort to encourage patients to access their records to count as a “view, download or transmit” in the metric’s numerator. In addition, this functionality will likely incur additional costs to the practice. CMS defines providing access:

    … as having been given when the patient possesses all of the necessary information needed to view, download, or transmit their information. This could include providing patients with instructions on how to access their health information, the Website address they must visit for online access, a unique and registered username or password, instructions on how to create a login, or any other instructions, tools, or materials that patients need in order to view, download, or transmit their information.

    Several stakeholders expressed considerable concern about the fact that practices will be dependent on 5% of their patients to view/download/transmit in order to qualify for the EHR incentive. The proposed rule had a requirement of 10%. Here is part of CMS’ response to this concern:

    While we recognize that EPs cannot directly control whether patients access their health information online, we continue to believe that EPs are in a unique position to strongly influence the technologies patients use to improve their own care, including viewing, downloading, and transmitting their health information online. We believe that EPs’ ability to influence patients coupled with the low threshold of more than 10 percent of patients having viewed online, downloaded, or transmitted to a third party the patient’s health information make this measure achievable for all EPs.

    From the patient perspective, it’s conceivable that a patient with several physicians participating in the EHR Incentive Program will receive overtures from each of his/her physicians to view/download/transmit. What will patients do? Will they prefer to access their subspecialty records or their primary care records?

    Note that by 2014, even those EPs who are attempting to meet Stage 1 criteria will need to provide view/download/transmit capability — but will not be held to the 5% usage threshold for patients. Here is the language from the final rule re: changes to Stage 1:

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

    EP Measure: More than 50 percent of all unique patients seen by the EP during the EHR reporting period are provided timely (within four 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 information.

    I think it’s clear why I placed this metric in the “Advanced” category.

  • More than 5% of all unique patients (or their authorized representatives) send a secure message using the electronic messaging function of CEHRT: Similar to the view/download/transmit measure, this one also requires action by patients for the practice to achieve success. In response to the same concerns as for the view/download/transmit objective regarding dependency on patient actions, CMS responded with similar language — that EPs can strongly influence the technologies that patients use for their care. The final rule lowered the threshold from 10% to 5%. CMS also clarified that the EP does not have to personally respond to each secure message. CMS does expect someone in the practice to respond on behalf of the physician just as if they received a telephone message. The workflow changes and potential costs (direct and indirect) justify placing this in the Advanced category for Stage 2.
  • The EP that transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 10% of such transitions and referrals either: a) electronically transmitted using CEHRT to a recipient, or b) where the recipient receives the the summary of care record via exchange facilitated by an organization that is a NwHIN Exchange participant or in a manner consistent with the ONC-established guidance on the nationwide health information network: The main challenge with this metric is that it isn’t routinely done now and must be introduced, tested, and improved. Ultimately, this is the type of objective that should positively affect patient care once used regularly. Transitions in care are associated with a significant number of patient safety issues and morbidity/mortality. Implementation involves both the technical issues and culture change. However, given the clinical importance, hopefully practices will find this less difficult than I expect.
  • Successful ongoing submission of electronic immunization data from CEHRT to an immunization registry or immunization information system: Unlike Stage 1 of MU, unsuccessful transmission will not satisfy this measure. “An eligible provider must either have successful ongoing submission or meet an exclusion criterion.” However, “If the PHA [Public Health Agency] does not have the capacity to accept reporting (including situations when the PHA accepts electronic data but states it lacks capacity to enroll the EP, eligible hospital or CAH during that reporting period), the EP or hospital can claim an exclusion for this measure related to the data that cannot be accepted.” I’d encourage readers to review the comments in the final rule about this objective which you can find in the final rule, page 54021, published in the Federal Register on September 4, 2012. There are questions about multiple transport mechanisms, registries, the definition of “ongoing,” and other technical details. Because this is new territory for Stage 2 and now a core measure, I’ve included it in the Advanced category.

Do you agree with this categorization? What challenges did I leave out? What have you learned about your certified EHR and the potential costs associated with meeting Stage 2 of MU?

This post is the personal opinion of the author and does not necessarily reflect the official policy or position of the American College of Physicians (ACP).

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