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Parsing Stage 2 of Meaningful Use

In case you haven’t noticed, the final rule for Stage 2 Meaningful Use was published August 23, 2012. While most people using Certified EHR Technology are still working through Stage 1, and we’re just getting reports from the Regional Extension Centers about challenges from the field, health IT users need to consider the expectations set forth for 2014 when Stage 2 begins.

I will only address the core elements for eligible professionals in the ambulatory care setting and suggest that they be separated into three categories:

  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 will deal with the first two categories (Basic and Intermediate) and will follow up with comments on the Advanced category in my next blog.

See if you agree with my categorization — or not.


  • >80% of all unique patients seen by the EP have demographics recorded as structured data (e.g., preferred language, sex, race, ethnicity, date of birth): These data are essential elements to help define the population being served and are most often collected by office staff requiring no significant input by the EP other than to set the policies in place to guide support staff.
  • >80% of all unique patients seen by the EP have vital signs recorded (e.g., height/length, blood pressure, body mass index (BMI), growth charts): Again, these data are typically collected and entered by support staff at the direction of the EPs. BMI is calculated by entering height/weight. As an internist taking care of adults, I have never used growth charts, but I presume that systems could generate them (up to the age of 20 years old) based on standard data collected.
  • The EP 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 as an inpatient or to the emergency department: This is just good practice and should be the routine for all transitions in care. Medication errors cause significant morbidity and mortality. Assuring that patients are taking the correct medication at the right dosage should be a priority.
  • >80% of all unique patients 13 years old or older have smoking status recorded as structured data: Even though smoking rates among middle school students have been dropping, I suggest that EPs treating this population don’t limit the questions to those over 13. This is not a difficult question to ask and is so important for assessing risks to people not matter what the specialty of the EP.
  • >50% of all permissible prescriptions are transmitted electronically using Certified EHR Technology (CEHRT): If a practice has adopted CEHRT, e-prescribing should be among the first elements of the technology implemented. Once it is use, there are few reasons for not using it to generate prescriptions.
  • Generate at least one report listing patients of the EP with a specific condition: If structured data are entered including diagnosis codes, it should be relatively easy to pull one list to meet this objective. Consider a list of patients with diabetes mellitus who might need a pneumococcal vaccine or influenza vaccine or children with asthma to make sure they’ve had the influenza vaccine.


  • More than 60% of medication, 30% of laboratory, and 30% of radiology orders are recorded using computerized physician order entry: This is a more complicated objective because it is a compound measure. To achieve the measure, all three thresholds need to be met or exceeded. Further, the final rule includes the following statement: “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.” Therefore, this metric could have significant work flow implications for practices that have historically had ancillary staff enter orders based on verbal directions, written protocols, or team-based collaboration and scribing arrangements. The rule does clarify that, “…nurses who are licensed and can enter orders into the medical record per state, local and professional guidelines may enter the order into CEHRT and have it count as CPOE.” There is also language related to credentialed healthcare professionals/medical assistants. Per the rule, “We believe that this expansion is warranted and protects the concept that the CDS interventions will be presented to someone with medical knowledge as opposed to a layperson. The concept of credentialed healthcare professionals is over broad and could include an untold number of people with varying qualifications. Therefore, we finalize the more limited description of including credentialed medical assistants. The credentialing would have to be obtained from an organization other than the employing organization.” Note that scribes without such credentialing could not act on behalf of EPs to enter orders. For these and other reasons, this objective could have been placed in the Advanced category, but because structured data for medications, laboratory and radiology orders is important and central to good patient care and ordering these tests is commonplace, I’ve kept it in the Intermediate category.
  • More than 55% of all clinical lab tests results ordered by the EP which are reported as either a positive/negative affirmation or numerical format are incorporated into CEHRT as structured data: There are two main issues with this objective: 1) Some labs do not provide results in a common structured format; and 2) the cost associated with the laboratory interfaces. However, the final rule included the following statement indicating that the 55% threshold should be reasonable: “Stage 1 attestation data shows that 91.5% of EPs and 95% of eligible hospitals and CAHs were able to successfully demonstrate meaningful use for this measure.” Once established, the flow of information to the CEHRT should almost be routine.
  • 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 for preventive/follow-up care, per patient preference when available: For most practices, identifying 10% of the patients seen who require a preventive visit or reminder should be fairly straightforward based on the age of the patient (i.e., vaccination), clinical condition, or a medication requiring monitoring. Note that these reminders cannot be for something that the patient is already scheduled to receive. For example, a reminder to a woman that she’s due for a mammogram is okay but a reminder about the appointment for that same mammogram wouldn’t count.
  • Clinical summaries are provided to patients or patient-authorized representatives within 1 business day for more than 50% of office visits: The final rule clarifies that, “It is the intention of this objective that clinical summaries be automatically given to patients within 1 business day of an office visit. However, we do recognize that some patients may decline a physical copy of their clinical summary. In the event that a clinical summary is offered to and subsequently declined by the patient, that patient may still be included in the numerator of the measure.” The rule also notes that offering the clinical summary can’t be passive (as in posting a sign that the summary is available upon request). Because this is an extra step in the work flow process, may require new templates in the EHR to formulate an appropriate summary, and has a specific time within which it needs to be accomplished, I’ve placed this in the Intermediate category. However, once the process is established, the routine of completing a note and offering a summary of the visit should not take much additional effort.
  • The EP that transitions or refers their patient to another setting of care or provider provides a summary of care record for more than 50% of transitions of care and referrals (see associated metric under “Advanced”): Again, this is good clinical practice and should help with transitions in care/referrals. One of key attributes of the Patient-Centered Medical Home (PCMH) and PCMH-Neighbor models is the professional obligation to provide adequate information to support seamless delivery of care. The essential elements of the summary of care record include:

    Patient name, Referring or transitioning provider’s name and office contact information (EP only), Procedures, Encounter diagnosis, 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).

    Critical to the successful meeting of this metric is the capture of the relevant data in the appropriate EHR fields so that it can be assembled for the summary. That could be a challenge, but once in place, the generation of such a summary should become fairly routine.

  • Conduct or review a security risk analysis in accordance with the requirements (see Code of Federal Regulations) and implement security update as necessary and correct identified security deficiencies: While this may seem onerous, CMS developed a guide to support this assessment. The Department of Health & Human Services also produced a Cybersecure Your Practice game aimed at educating the whole practice about HIPAA and security risks. Additional, more detailed (and longer) guidance is available from the National Institute of Standards and Technology (NIST) and the Office of Civil Rights (in part, based on NIST publications). While conducting the risk assessment and mitigating concerns identified might be time-consuming, it shouldn’t be too challenging and could help the practice avoid inadvertent security breaches and HIPAA violations.

Advanced: I’ll address the following objectives in an upcoming post.

  • Implement 5 clinical decision support interventions related to four or more clinical quality measures
  • More than 50% of all unique patients seen by the EP are provided timely (within 4 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
  • More than 5% of all unique patients (or their authorized representatives) send a secure message using the electronic messaging function of CEHRT
  • 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
  • Successful ongoing submission of electronic immunization data from CEHRT to an immunization registry or immunization information system

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). ACP does not endorse a specific EHR brand or product and ACP makes no representations, warranties, or assurances as to the accuracy or completeness of the information provided herein.

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