HIT Policy Committee Meaningful Use Workgroup Proposed Recommendations on MU Notice of Proposed Rule Making Paul Tang, Chair Palo Alto Medical Foundation

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  • HIT Policy Committee

    Meaningful Use WorkgroupProposed Recommendations on MU Notice of Proposed Rule Making

    Paul Tang, ChairPalo Alto Medical FoundationGeorge Hripcsak, Co-ChairColumbia University

    February 17, 2010

  • *Proposed MU NPRM Recommendations 1Reinstate HITPC recommendation to include progress note documentation for EP Stage 1 MUProgress notes are key to delivering high quality, coordinated care (not just a legal requirement):Legibility quality & efficiency implicationsImportant for documenting complete record (otherwise lost)Hybrid systems (part electronic, part paper) causes fragmentation of the record and inefficient workflowPaper progress notes impede patients access to information (no structured way to provide patients with context to those data)Sharing electronic progress notes fundamental to care coordinationTextual progress notes used to know patient as a human beingSignal clinical documentation for hospitals in Stage 2

  • *Proposed MU NPRM Recommendations 2Remove core measures from Stage 1Attributes considered:Based on the Institute of Medicines Six Aims and priorities identified by the National Priorities PartnershipHave an evidence-based link to improvement in outcomesCan be measured using coded clinical data in an EHR (to minimize burden)Is captured as a byproduct of the care process (fits clinician workflow)Applies to virtually all eligible providersMeasures outcome, to the extent possibleNone of the proposed core measures satisfied the criteria (nor did our examples)Support use of key HIT-sensitive health priorities drive selection of quality measuresWill re-explore concept of shared or common measures in future

  • *Proposed MU NPRM Recommendations 3Reinstate HITPC recommendation to stratify quality reports by disparity variablesProviders should produce quality reports stratified by race, ethnicity, gender, primary language, and insurance typeCMS has stated that an explicit health outcomes policy priority is to reduce health disparitiesNo assessment of disparity reduction can be made without stratifying data reports by these variables

  • *Proposed MU NPRM Recommendations 4Providers should maintain up-to-date lists (not just one-time entries)Maintaining key patient summary information in EHR is critical for care quality & coordinationMeasure: Attestation that the problem lists, medication lists, and medication allergy lists are up-to-date (CMS audit could be conducted by chart review of a set of randomly selected charts)

  • *Proposed MU NPRM Recommendations 5Reinstate HITPC recommendation to include recording of advanced directives for Stage 1 MUEPs and hospitals should be expected to record presence or absence of advance directives for patients > 65 as part of the Stage 1 MU criteriaParticularly for Medicare providers, recording of advance directives should apply to virtually everybody

  • *Proposed MU NPRM Recommendations 6Reinstate HITPC recommendation to include patient-specific education resources for Stage 1 MUEHR-enabled links to relevant educational resources critical to CMS health outcome priority to engage patients and familiesProvider vetting of consumer educational content represents a much better than unguided searching of the InternetSeveral EHR vendors and health education content providers have developed partnerships that facilitate EHR-enabled connections to patient-specific contentEPs & hospitals should report on % of patients for whom they use the EHR to suggest patient-specific education resources

  • *Proposed MU NPRM Recommendations 7Reinstate HITPC recommendation to include clinical efficiency measures for Stage 1 MUCMS did not include clinical efficiency measures although improve efficiency is a CMS-stated priorityAll EPs report % of all medications entered into EHR as a generic formulation, when generic options exist in relevant drug classOn page 1987 of the NPRM, CMS cites prompt providers to prescribe cost-effective generic medications as one of the key Benefits to Society in its impact analysisCMS should explicitly require that at least 1 of 5 CDS rules address efficient diagnostic test ordering

  • *Proposed MU NPRM Recommendations 8CMS should create a glidepath for Stage 2 & 3 MUVendors need more time to develop appropriate functionalityProviders need more time to integrate it into clinical workflowRecognize that CMS needs experience from on Stage 1 implementation before finalizing Stage 2 & 3 recommendations Strong signal of intentions would be very helpful to make the realization of future expectations more feasibleTo extent possible, CMS should consider publishing the Stage 2 MU NPRM earlier than anticipated December 2011

  • *Proposed MU NPRM Recommendations 9CPOE should be done by authorizing providerCPOE numerator should be number of orders entered directly by authorizing provider

  • *Proposed MU NPRM Recommendations 10Amend prevention/follow-up reminders criterion to apply to a broader range of the population and allow for provider discretion in targeting remindersFor a chosen/relevant preventive health service or follow-up, report on the percent of patients who were eligible for that service who were remindedDenominator: All patients who were potentially eligible (e.g., meet demographic criteria) and had not received the service

  • *Proposed MU NPRM Recommendations 11Clarify transitions of care and relevant encountersUnder Care Coordination categoryDefine transition of care to occur when a patient changes setting of care (e.g., hospital, ambulatory primary care practice, ambulatory specialty care practice, long term care, home health, rehabilitation facility)Delete relevant encounter (not precise)

  • *Proposed MU NPRM Recommendations 12Allow some flexibility in meeting meaningful use criteriaAll-or-nothing approach may not accommodate legitimate, unanticipated, local circumstances or constraintsPermit flexibility while preserving a floorAllow provider to defer fulfillment of a small number of MU criteria and still receive incentiveAllow EPs & hospitals to qualify for Stage 1 MU incentives if they defer no more than (mandatory may not be deferred):3 of the criteria in the quality domain 1 of the criteria in the patient/family engagement domain1 of the criteria in the care coordination domain1 of the criteria in the population/public health domainAll must meet the privacy & security domain criterionAll must report clinical measures to CMS/state

  • *Proposed MU NPRM Recommendations 12

    Priority area# objectives that may be deferred by EP or hospital (all EPs and hospitals must fulfill mandatory objectives)Mandatory objectives (all EPs and hospitals must meet these)Improving quality, safety, efficiency, and reducing health disparities3Have demographics recorded as structured dataReport ambulatory/hospital quality measures to CMS or the StatesUse CPOE/Use of CPOE for orders (any type) directly entered by authorizing provider (for example, MD, DO, RN, PA, NP)Generate and transmit permissible prescriptions electronically (eRx)Engage patients and families in their health care1Patients discharged are provided electronic copy of their instructions and proceduresImprove care coordination1Test EHR capacity to electronically exchange key clinical informationImprove population and public health1Ensure adequate privacy and security protections for personal health information0Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities