Meaningful Use Initial Stage 2 and 3 Request for Comment Feedback

Meaningful Use Initial Stage 2 and 3 Request for Comment Feedback

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EHR Association:   Detailed Commentary on Specific Objectives and Questions  CPOE Proposal from the HITPC Request for Comment CPOE for medication orders (30%) Stage 1 Final Rule CPOE (by licensed professional) for at least 1 medication, and 1 lab or radiology order for 60% of unique patients who have at least 1 such order (order does not have to be Proposed Stage 2 transmitted electronically) CPOE (by licensed professional) for at least 1 medication, and 1 lab or radiology order on 80% of patients who have at least 1 such order (order does not have to be transmitted Proposed Stage 3 electronically) Stages 2 and 3, order can be transmitted electronically or on paper, except as noted in Additional Comments  other objectives (allows market forces to push electronic transmission) EHRA Comments Applause:  We agree with the expansion of order types. We agree that it is appropriate to maintain the Stage 1 metric of measuring by patient (and not by orders) given the burden of counting paper orders to assemble an “all orders” denominator. If the “unique patient” denominator is maintained, we feel that the percentages given are appropriate. Comments: In Stage 1, there has been confusion about the unclear and repeatedly modified definition of “licensed professionals.” We request a clear and consistent definition. We do not suggest changing the denominator to all orders due to the reporting burden of counting paper orders. If the denominator is changed to ...

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Ajouté le 24 septembre 2011
Nombre de lectures 24
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EHR toicisas:Aon   
Detailed Commentary on Specific Objectives and Questions 
CPOE 
Proposal from the HITPC Request for Comment Stage 1 Final Rule CPOE for medication orders(30%)CPOE (by licensed professional) for at least 1 medication, and 1 lab or radiology order for Proposed Stage 2 of unique patients who have at least 1 such order (order does not have to be 60% transmitted electronically)
CPOE (by licensed professional) for at least 1 medication, and 1 lab or radiology order on Proposed Stage 3 80% of patients who have at least 1 such order (order does not have to be transmitted electronically)
Comments 
Stages 2 and 3, order can be transmitted electronically or on paper, except as noted in other objectives (allows market forces to push electronic transmission)
Applause:  We agree with the expansion of order types. We agree that it is appropriate to maintain the Stage 1 metric of measuring by patient (and not by orders) given the burden of counting paper orders to assemble an all orders denominator. If the unique patient denominator is maintained, we feel that the percentages given are appropriate.
Comments: In Stage 1, there has been confusion about the unclear and repeatedly modified definition of licensed professionals. We request a clear and consistent definition.
We do not suggest changing the denominator to all orders due to the reporting burden of counting paper orders. If the denominator is changed to all orders, we suggest the percentages be lowered to 30% in Stage 2 and 50% in Stage 3 to account for:
 *The necessary timeframe depends on the definition, but we recommend at least 18 months of notice in advance of required compliance).
 
 HITPC January/February 2011 Request for Comment oSntage 2 Meaningful Use, Feedback from EHRAP:age 1 of 4 4
1. Stepping stones between Stages 1, 2, and 3
2. Appropriate non-CPOE situations such as verbal orders during surgery, nurse-administered protocol-based orders, etc.
We agree with not changing the denominator to all orders due to the reporting burden of counting paper orders.
Also, it is important to be clear on how transmission of orders is defined, especially in hospitals.
Drug Interaction Checks 
Proposal from the HITPC Request for Comment Stage 1 Final Rule interaction checks Drug-drug/drug-allergy on checkin cking on appropriate evidence-Proposed Stage 2oisnartcnietesdbagandrdguallreygcehEmoyplrudrd-giguretnitca Employ drug-drug interaction checking, drug allergy checking, drug age checking (medications in the elderly), drug dose checking (e.g., pediatric dosing, chemotherapy Proposed Stage 3 drug lab checking, and drug condition checking (including pregnancy and dosing), lactation) on appropriate evidence-based interactions
Comments 
Reporting of drug interaction checks to be defined by quality measures workgroup
EHRA Comments 
We believe that this objective and measure should remain at Stage 1 levels. We are concerned about the vagueness of the word appropriate, specifically with regards to who is determining the appropriateness of an alert. We strongly believe that appropriateness should be determined by the eligible professional or hospital and request that this point be clarified in the proposal.
If there is to be a standard definition (which we do not suggest), we are concerned that a definition of appropriate might not be available with enough lead time for vendors to program, test, and release corresponding features, and for healthcare providers to implement those features.*
What is intended by evidence-based? Are there non-evidence-based drug interactions? We suggest the language be clarified.
For Stage 3, some of the proposed items may not be appropriate. Look to what is in 2011 CCHIT certification criteria for some guidance.
 *The necessary timeframe depends on the definition, but we recommend at least 18 months of notice in advance of required compliance).
 
 HITPC January/February 2011 Request for Comment oSntage 2 Meaningful Use, Feedback from EHRAP:age 2 of 4 4
EPrescribing (ERx) 
Proposal from the HITPC Request for Comment Stage 1 Final Rule E-prescribing (ERX) (EP) (40%) 50% o Proposed Stage 2orders (outpatient and hospital discharge) transmitted as eRx  f Proposed Stage 3 80% of orders (outpatient and hospital discharge) transmitted as eRx
If receiving pharmacy cannot accept eRx, automatically generating electronic fax to Comments pharmacy OK
EHRA Comments 
Applause:  We are glad that the ONC and CMS recently clarified that the use of an integrated EHR and pharmacy system can be counted as e-prescribing. This clarification should be maintained, as the use of an integrated system achieves the same goals and offers more information to both the pharmacy and ordering physician than a simple interface allows.
We also agree with the ONC and CMS clarifications that use of an interface to an internal pharmacy is also appropriately counted as e-prescribing. This clarification should be maintained, as the use of an electronic interface to an internal pharmacy achieves the same goals whether it uses the ONC NCPDP standard or an alternate standard.
We also feel that it is appropriate that e-prescribing requirements for Meaningful Use align with other requirements for e-prescribing, such as DEA regulations on e-prescribing of controlled substances. We suggest that e-prescribing of controlled substances become part of Meaningful Use only at such time that the industry has been safely able to implement the new requirements. It does not seem appropriate for Stage 2 given the current state.
Concerns: Given the difficulty of effectively addressing all edge cases, we agree that the Stage 3 proposed threshold be no higher than 80%.
Also, 60% is a high threshold for hospitals just implementing this functionality. The new requirement to e-prescribe discharge orders should begin with a threshold of 30% and move to 60% in Stage 3.
The denominator of this measure is currently all permissible prescriptions written by the EP, which burdens EPs with having to count paper prescriptions for reporting (even though alternate denominators were chosen for other measures to avoid this situation). We suggest clarifying this objective to include only orders available in the EHR.  *The necessary timeframe depends on the definition, but we recommend at least 18 months of notice in advance of required compliance).
 
 HITPC January/February 2011 Request for Comment oSntage 2 Meaningful Use, Feedback from EHRAP:age 3 of 4 4
Regarding e-prescribing of hospital discharge medications, this criterion will require an implementation of a new interface for every hospital that is intending to be a meaningful user. Is there sufficient time for implementation? We are also concerned that existing e-prescribing networks might not be able to handle such a volume of implementations and prescriptions.
We encourage the HITPC, CMS, and ONC to align Surescripts criteria and Meaningful Use and certification criteria to avoid some of the unnecessary confusion caused by this misalignment in Stage 1.
Demographics 
Proposal from the HITPC Request for Comment Stage 1 Final Rule Record demographics (50%) Proposed Stage 2tyreportsrocerscihpargomeusncadanddecuerpdotohtmeualiedqtifistra8%0ofhavedepatients Proposed Stage 3MacgOIirseetoged(cordudininclmecadan)theusn09%medargocihperspofieatsntvehareportsqauilytaritifde to produce st IOM categories as defined in: Race, Ethnicity, and Language Data: Standardization for Comments Quality Improvement Institute of Medicine report, 2009. Of note, theseHealth Care categories are proposed to be used for stage 3, and are not required in proposed stage 2.
EHRA Comments 
Applause:  We agree with what we understand to be your intent to maintain the Stage 1 demographics categories for Stage 2, focusing on an increase in the percentage.
Concerns: We unt red industry confusion regarding the Stage 1 requirement to capture race and ethnicity according ve enco e to OMB guidelines. Some organizations capture both race and ethnicity in one field and are unsure if that is acceptable. Alternately, they can capture both in separate fields but using more granular terms than are specified by OMB, and they are unsure whether this is acceptable, whether they must capture with OMB specific terms as well, or whether they must map the terms. If mapping is acceptable, they are uncertain if they need to have the capability to do the mapping, or if they actually have to do the mapping for Meaningful Use. We suggest that you work with ONC and CMS to define these requirements in a way that avoids such industry swirl and confusion.
We are concerned that the proposal for Stage 3 is vague but could represent a large development effort. When will sufficient clarification be available with standards and specifications that development will be able to begin?
 *The necessary timeframe depends on the definition, but we recommend at least 18 months of notice in advance of required compliance).
 
 HITPC January/February 2011 Request for Comment oSntage 2 Meaningful Use, Feedback from EHRAP:age 4 of 4 4
Sufficient detail must be available with enough lead time for vendors to program, test, and release corresponding features, and for healthcare providers to implement those features.*
Finally, how is the requirement can use them to produce stratified quality reports to be measured? This item must be defined with enough lead time for vendors to program, test, release, and for healthcare providers to implement.* Alternately, if this language was intended as an example, it should be removed from the objective.
Clinical Quality Measures 
Proposal from the HITPC Request for Comment Stage 1 Final Rule CQM electronically Report Proposed Stage 2 as per Quality Measures Workgroup and CMS Continue Proposed Stage 3 Continue as per Quality Measures Workgroup and CMS
Comments 
The HIT Policy Committees Quality Measures Workgroup issued a request for comment in December; new measures will be considered after review of public comments
EHRA Comments 
The reporting of clinical quality measures is one of our greatest areas of concern for Meaningful Use Stage 2 and 3. We provided feedback in response to the workgroups request for input in December, but we strongly feel that it is not possible to evaluate HIT sensitivity for many of the categories until further detail and specifications are provided. Evaluation for HIT sensitivity once that degree of detail is known is essential.
We are very concerned that given the lack of details at this time (January 2011) given that the required degree of detailed specification will not be provided with enough lead time for vendors to program, test, release, and for healthcare providers to implement.*
Because of the timeframe to identify valid measures, develop and test measures in EHRs, and implement the required clinical workflows that capture necessary information, we advise no additional quality measures in Stage 2, other than a very small set needed to address material deficiencies for specific physician specialties, and that work on additional quality measures be established for Stage 3 so that measures can be implemented efficiently. Rushed implementation of additional quality measures in Stage 2 would be a hardship on healthcare organizations that are still trying to gain base adoption.
In Stage 1, we have heard a great deal of feedback from users that quality measures are not applicable to all patient populations. For example, children's hospitals are expected to report on the same stroke and VTE measures as adult hospitals, but these are not high priority areas for these institutions. We do encourage the committee to address the needs of specialists regarding quality reporting while ensuring that any new measures are introduced with enough time for development and implementation as described above.
 *The necessary timeframe depends on the definition, but we recommend at least 18 months of notice in advance of required compliance).
 
 HITPC January/February 2011 Request for Comment oSntage 2 Meaningful Use, Feedback from EHRAP:age 5 of 4 4
Also, taking into account our concern with adding new measures given the available timing, we strongly believe that quality measures should be aligned across CMS and ONC programs, such as PQRI, value-based purchasing, accountable care organizations, and Core measures reporting.
Problem List 
Proposal from the HITPC Request for Comment Stage 1 Final Rule problem list (80%) Maintain Proposed Stage 2 Stage 1 Continue Proposed Stage 3 80% problem lists are up-to-date Expect to drive list to be up-to-date by making it part of patient visit summary and care Comments plans
Applause:  Our early Meaningful Use adopters have found that the problem list 80% threshold is one of the most difficult to achieve in Meaningful Use Stage 1. Therefore, we agree with the proposal to not raise the threshold or change the method of measurement in Stage 2.
We think it is likely and appropriate that, while providers enter clinical problem list items, coding might happen later by another professional. We suggest that the ability for such coding after the clinical encounter be clearly permissible in all stages if Meaningful Use.
Suggestions: For Stage 3, define up-to-date with enough lead time for vendors to program, test, release, and for healthcare providers to implement.*
We suggest the following options for determining "up-to-date."
1. To avoid measurement burden, rely on indicators like providing the patient with an after visit summary, which will help ensure that the problem list is kept current; or
2. Counting whether the problem list is up-to-date by whether it was  k d as reviewed during the reporting mar e period.
Your option for determining "up-to-date" should be signaled as soon as possible to help the development community understand if additional work is required.
 *The necessary timeframe depends on the definition, but we recommend at least 18 months of notice in advance of required compliance).
 
 HITPC January/February 2011 Request for Comment oSntage 2 Meaningful Use, Feedback from EHRAP:age 6 of 4 4
We also request further detail on your mention of care plans for Stage 3. What is meant by this term; it must be clearly defined.
Medication List 
Proposal from the HITPC Request for Comment Stage 1 Final Rule Maintain active med list(80%)Proposed Stage 2Continue Stage 1 Proposed Stage 3 medication lists are up-to-date 80%
Comments 
Expect to drive list to be up-to-date via medication reconciliation
EHRA Comments 
Applause:  We agree with using Stage 1 levels for Stage 2.
Suggestions: For Stage 3, define up-to-date with enough lead time for vendors to program, test, release, and for healthcare providers to implement.*
We suggest the following options for determining "up-to-date."
1. To avoid measurement burden, rely on indicators like providing the patient with an after visit summary to ensure that the list is kept current; or.
2. Counting whether the list is up-to-date by whether it was marked as reviewed during the reporting period.
Your option for determining "up-to-date" should be signaled as soon as possible to help the development community understand if additional work is required.
 *The necessary timeframe depends on the definition, but we recommend at least 18 months of notice in advance of required compliance).
 
 HITPC January/February 2011 Request for Comment oSntage 2 Meaningful Use, Feedback from EHRAP:age 7 of 4 4
Medication Allergy List 
Proposal from the HITPC Request for Comment Stage 1 Final Rule active med-allergy list Maintain(80%)C Proposed Stage 2 Stage 1 ontinue
Proposed Stage 3 80% medication allergy lists are up-to-date
Comments 
Expect to drive the list to be up-to-date by making it part of visit summary
EHRA Comments 
Applause:  We agree with using Stage 1 levels for Stage 2.
Suggestions: We suggest expanding this objective to include more than just medication allergies.
For Stage 3, define up-to-date with enough lead time for vendors to program, test, release, and for healthcare providers to implement.*
We suggest the following options for determining "up-to-date " .
1. To avoid measurement burden, rely on indicators like providing the patient with an after visit summary to ensure that the list is kept current; or
2. Counting whether the list is up-to-date by whether it was marked as reviewed during the reporting period.
Your option for determining "up-to-date" should be signaled as soon as possible to help the development community understand if additional work is required.
 *The necessary timeframe depends on the definition, but we recommend at least 18 months of notice in advance of required compliance).
 
 HITPC January/February 2011 Request for Comment oSntage 2 Meaningful Use, Feedback from EHRAP:age 8 of 4 4
Vital Signs 
Proposal from the HITPC Request for Comment Stage 1 Final Rule Record vital signs(50%)Proposed Stage 2 80% of patients have vital signs recorded Proposed Stage 3 80% of patients have vital signs recorded
Comments 
NA
EHRA Comments 
Suggestions: Please clarify that the vital signs that must be captured are the same as those in Stage 1 (height, weight, and blood pressure) but also reconcile the objective and measure to avoid any confusion.
If new vital signs are to be introduced, they should be defined with enough lead time for vendors to program, test, release, and for healthcare providers to implement.*
Also, this is an objective that may not necessarily need to be applied to every specialty (for example, dermatology) and an exclusion should be allowed.
Smoking Status 
Proposal from the HITPC Request for Comment Stage 1 Final Rule Record smoking status(50%)Proposed Stage 2 of patients have smoking status recorded 80% P ed Stage 3 90% of patients have smoking status recorded ropos
Comments 
NA
EHRA Comments 
Clarify that smoking status is intended to be captured using the same standards and measurement metrics as specified in Stage 1 and that new standards are not to be introduced. If new standards are to be introduced, they
 *The necessary timeframe depends on the definition, but we recommend at least 18 months of notice in advance of required compliance).
 
 HITPC January/February 2011 Request for Comment oSntage 2 Meaningful Use, Feedback from EHRAP:age 9 of 4 4
should be defined with enough lead time for vendors to program, test, release, and for healthcare providers to implement.*
Given the difficulty of effectively addressing all edge cases, we suggest that thresholds not be set higher than 80% in general, and that the Stage 3 proposed threshold be changed from 90% to 80%.
Also, this is an objective that may not necessarily need to be applied to every specialty (for example, dermatology) and an exclusion should be allowed.
Clinical Decision Support 
Proposal from the HITPC Request for Comment Stage 1 Final Rule Implement 1 CDS rule Use CDS to improve performance on high priority health conditions. Establish CDS attributes for purposes of certification: Proposed Stage 2 1. Authenticated (source cited); 2. Credible, evidence-based; 3. Patient-context sensitive; 4. Invokes relevant knowledge; 5. Timely; 6. Efficient workflow; 7. Integrated with EHR; 8. Presented to the appropriate party who can take action. Use CDS to improve performance on high priority health conditions. Establish CDS attributes for purposes of certification: Proposed Stage 3 Authenticated (source cited); 2. Credible, evidence-based; 3. Patient-context sensitive; 1. 4. Invokes relevant knowledge; 5. Timely; 6. Efficient workflow; 7. Integrated with EHR; 8. Presented to the appropriate party who can take action.
Comments 
NA
EHRA Comments 
We are very concerned that your proposed CDS EHR requirements go well beyond what an EHR should be programmed to do. We feel that CDS features with an EHR should allow EPs and hospitals as much flexibility in designing CDS as possible. By allowing them to customize their own CDS alerts and advisories, they can create specific and targeted decision support based on criteria specific to their patient population. It would be inefficient for an EHR vendor to hard-code specific CDS rules into the system and should instead be designed to provide a framework that allows EPs and hospitals to quickly create their own clinical decision support rules.
Within such a context, it would be impossible for an EHR to control whether a CDS is authenticated or evidence-based. Such information would come from the entity creating the CDS rule. The EHR could, however provide a method of displaying a source to a clinician. We suggest rewording the proposed CDS criteria as follows:
 *The necessary timeframe depends on the definition, but we recommend at least 18 months of notice in advance of required compliance).
 
 HITPC January/February 2011 Request for Comment oSntage 2 Meaningful Use, Feedback from EHRAP:age 10 of 44
1. EHR provides a method of displaying to the provider the source/citation of the CDS. (revision of 1 and 2)
2. EHR allows rules to be configured to enable decision support based on the patients context (clinic visit, currently admitted). (revision of 3)
3. EHR rules respond to information in the chart about the patients problems, allergies, medications, demographics, and vitals. (revision of 4)
4. EHR allows rules to be configured to present decision support at a specific point during the clinical workflow. (revision of 5)
5. EHR allows rules to be configured to present decision support to users of certain roles. (revision of 8)
6. CDS can be integrated with other with other applicable EHR functionality (Revision of 7).
We are also concerned with the vagueness of the term high-priority health conditions. Because we feel that CDS should be flexible, we suggest that this point be clarified to indicate the specific conditions and other CDS criteria be left to the discretion of the EP or hospital and be determined by CMS or other federal or state government body.
If you do elect to define high priority health conditions as a specific list of conditions or other clarifying criteria, we request that such a clarification be published with enough lead time for vendors to program, test, release, and for healthcare providers to implement.*
Consider stepping up CDS use by number of rules or conditions addressed and consider linkage to quality measures used by the provider.
Drug Formulary Checks 
Proposal from the HITPC Request for Comment Stage 1 Final Rule drug formulary checks Implement Proposed Stage 2 Move current measure to core Proposed Stage 3 of medication orders are checked against relevant formularies 80% ents What is the availability of formularies for eligible professionals? Comm
Importing and maintaining formulary information can be very time consuming, depending on the way the formulary information is provided to the provider. When moving to an aggressive percentage for Stage 3 (80% of all orders) you are requiring that a large percentage of patients have formularies available in the system. This level  *The necessary timeframe depends on the definition, but we recommend at least 18 months of notice in advance of required compliance).
 
 HITPC January/February 2011 Request for Comment oSntage 2 Meaningful Use, Feedback from EHRAP:age 11 of 44