Giving a patient medications in the ER, having them pop positive on a test, and then withholding further medications because…
Inga Compares the Preliminary Meaningful Use Rule to the Final
This is a first pass at trying to catalog the changes in the final rule. Your comments and observations are welcome!
CPOE
Preliminary rule
- Practices: use CPOE for orders involving medications, laboratory, radiology, and referrals.
Hospitals: medications, laboratory, radiology, blood bank, PT, OT, RT, rehab, dialysis, consults, and discharge and transfer.
Orders do not have to be sent electronically to the fulfilling department (lab, pharmacy, etc.)
Practices must enter 80% of their total orders directly by the clinician into the CPOE system. Hospitals must have 10% of all orders entered by CPOE.
Final rule
- For practices and hospitals: more than 30% of unique patients with at least one medication in the medication list have at least one medication ordered through CPOE. The denominator is no longer total orders generated. Lab and diagnostic orders eliminated from the CPOE requirement. Any licensed professional can enter the order. ED orders count toward the inpatient total for CPOE.
Clinical Checking of Orders
Preliminary rule
- Real-time screening (drug-drug interactions and drug-allergy contraindications), formulary check, user ability to maintain screening rules, track user responses to alerts.
Final rule
- The EP/eligible hospital/CAH has enabled the drug-drug, drug-allergy, and drug-formulary check functionality for the entire reporting period. Any EP who writes fewer than 100 prescriptions during the EHR reporting period is exempt.
Problem List
Preliminary rule
- Longitudinal current and active diagnoses coded in ICD-9-CM or SNOMED CT.
80% of unique patients must have at least one coded problem/diagnosis, with “none” being an allowed entry (hospitals and practices).
Final rule
- At least 80% of patients have at least one entry or an indication that no problems are known. Data must be recorded as structured data . Coding doesn’t have to be done concurrently – the codes can be added later by anyone.
E-Prescribing
Preliminary rule
- Practices only.
Must send 75% of non-controlled substance prescriptions electronically.
Final rule
- Threshold dropped from 75% to 40%
Active Medication List
Preliminary rule
- 80% of unique patients must have at least one coded entry, with “none” being an allowed entry (hospitals and practices).
Final rule
- Unchanged.
Medication Allergy List
Preliminary rule
- Longitudinal with allergy history.
80% of unique patients must have at least one coded entry, with “none” being an allowed entry (hospitals and practices).
Final rule
- Unchanged.
Demographics
Preliminary rule
- Practices: preferred language, insurance type, gender, race, ethnicity, and data of birth.
Hospitals: all of the above plus date and cause of death if applicable.
80% of patients must have demographics recorded as structured data.
Final rule
- Threshold dropped from 80% to 50% .
Vital Signs
Preliminary rule
- Height, weight, BP, BMI, growth charts for patients 2-20 years old, temperature, pulse.
80% of patients aged 2 and over must have blood pressure and BMI entered.
Children 2-20 must have a growth chart.
Final rule
- More than 50% of patients 2 years and older must have height, weight, and blood pressure recorded as structure data. EPs who believe that measuring and recording height, weight and blood pressure of their patients has no relevance to their scope of practice can be excluded. For MU purposes, providers do not have to maintain BMI and growth charts, although certified EMRs are required to do the BMI calculation and display growth charts with structured data.
Smoking Status
Preliminary rule
- Record if current smoker, former smoker, or never smoked.
Must be recorded for 80% of patients.
Final rule
- Must record at least 50% of patients 13 and older for smoking status.
Clinical Decision Support Rule
Preliminary rule
- Included five measures beyond drug screening, based on demographics: diagnoses, lab results, or medication list. Real-time alerts and suggestions based on evidence. Track response to alerts.
Final Rule
- Implement one clinical decision support rule relevant to specialty or high clinical priority for EPs, or one clinical decision support rule related to a high priority hospital condition for hospitals. Also must track compliance with that rule.
Record Advanced Directives
- This is a new one not included in the preliminary rules to prove meaningful use. Hospitals must record at least 50% of inpatients 65 years old or older an indication of an advance directive status.
Structured lab results
Preliminary rule
- Display results, translate LOINC codes, allow maintenance based on new results.
Must record as structured EHR data 50% of all results that are delivered in positive/negative or numeric format.
Final rule
- Threshold reduced to 40% of clinical lab test results.
Patient Lists
Preliminary rule
- Allow user to select, sort, retrieve, and output patient lists based on demographics, medications, and conditions.
Final rule
- Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach.
Report Quality Measures to CMS and States
Preliminary rule
- Calculate, display, and submit quality measure results.
Final rule
- Clarification: this is for hospital quality measurements. For 2011, provide aggregate numerator, denominator, and exclusions through attestation. For 2012, measures must be electronically submitted.
Patient Reminders
Preliminary rule
- Practices only: issue based on patient preferences, demographics, conditions, and medication list.
Final rule
- Reminders must be sent to at least 50% of patients age 50 or over that are seen by the EP.
Insurance Eligibility
Preliminary rule
- Allow user to record and display based on eligibility response from insurer.
Must cover 80% of unique patients.
Final rule
- Requirement withdrawn for Stage 1 but look for it in Stage 2.
Submit Claims
Preliminary rule
- Must submit 80% of all claims filed electronically.
Final rule
- Requirement withdrawn for Stage 1 but look for it in Stage 2.
Electronic Copy of Health Information to Patients
Preliminary rule
- Allow user to create an electronic copy of test results, problem list, medication list, medication allergy list, immunizations, and procedures. Hospitals must also provide a discharge summary, but not procedures. Must provide an electronic copy of health information to requesting patients within 48 hours.
Final rule
- Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies,
discharge summary, procedures), upon request. Discharge summary and procedures are for hospitals only. Must provide to at least 50% of requesting patients within three business days.
Electronic Copy of Discharge Instructions
Preliminary rule
- Hospitals only. Must provide electronically to 80% of discharged patients who request them.
Final rule
- Threshold reduced to 50%.
Timely Patient Access to Health Information
Preliminary rule
- Practices only: diagnostic results, problem list, medication list, medication allergy list, immunizations, and procedures. Within 96 hours of availability.
Must provide to 10% of unique patients.
Final rule
- Practices must to 10% of its patients within four business days of being updated in the EHR, subject to the EP’s discretion to withhold certain information.
Clinical Summary of Each Office Visit
Preliminary rule
- Practices only: diagnostic results, medication list, procedures, problem list, immunizations. Must provide for 80% of office visits.
Final rule
- Provide clinical summaries provided to patients for more than 50% of all office visits within three business days.
Access to patient-specific education resources
- Another new item that was not in the preliminary rules. Use EHRs to identify patient-specific education resources and provide those resources to the patient if appropriate. Both EPs and hospitals must provide patient-specific education resources to at least 10% of patients.
Information Exchange
Preliminary rule
- Enable electronic sending and receiving of diagnostic test results, problem list, medication list, medication allergy list, immunizations, and procedures. Hospital requirements also include a discharge summary. Must conduct at least one test of information exchange.
Final rule
- Exchange key clinical information among providers of care and patient authorized entities electronically. Both practices and hospitals should exchange problem list, medication list, medication allergies, and diagnostic test results; hospitals should also exchange discharge summary and procedures.
Medication Reconciliation
Preliminary Rule
- Compare and merge two or more medication lists into a single list that can be displayed in real time. Must be performed in 80% of encounters and care transitions.
Final Rule:
- Threshold is reduced to 50%.
Submit Data to Immunization Registries
Preliminary rule
- Must conduct at least one test of submitting information.
Final rule
- Perform at least one test of certified EHR technology’s capacity to submit electronic data to immunization registries and follow up submission if the test is successful (unless none of the immunization registries to which the EP, hospital, or CAH submits such information have the capacity to receive the information electronically).
Submit Lab Results to Public Health Agencies
Preliminary rule
- Hospitals only. Must conduct at least one test of submitting information.
Final rule
- Perform at least one test and follow up submission.
Submit Syndrome Surveillance Data to Public Health Agencies
Preliminary rule
- Must conduct at least one test of submitting information.
Final rule
- Perform at least one test and follow up submission.
Protect Electronic Patient Information
Preliminary rule
- Unique identifier, emergency access for authorized users, session timeout, encryption where preferred, encryption when exchanging information, maintain audit logs, provide integrity check for recipient of electronically transmitted information, verify user identities and access privileges, record PHI disclosures.
Must conduct a security risk analysis and implement security updates.
Final rule
- Conduct or review a security risk analysis, implement security updates as necessary, and correct identified security deficiencies.
Nice summary, thanks.
Just saw two glaring changes…Insurance Eligibility & Electronic Claims – why did they remove these from Stage 1 when this is something that most hospitals are doing today? I am sure many hospitals who were looking to have a check mark on this long list just did a collective roll of their eyes.
What is everyone’s thoughts on the required list and this new optional list? Some of the items on the optional list I know are not adopted by many states and if I read this 800+ page document correctly, could go against the 5 they get to “omit”. So instead of just choosing 5 to omit, they have to include the 2 or 3 that are not even required by their state into the 5 they omit instead of just ignoring them as impossible to meet & still getting to choose 5 to not meet at this time (if they so choose…).
Thanks for the summary…
RE: Eligibility and Electronic Claims – The comments in the standards final rule basically said that this is often performed outside of an EHR system (and sometimes by a third party); EHR vendors who might otherwise function as a Complete EHR would fail on this point. Also, as Pez points out, most already do this, so there was not need to provide incentives.
Inga, you might want to highlight which objectives are part of the core set of required definitions of MU and which are the optional ones. I would be interested in seeing a vote of folks on which ones they think their practices or hospitals will likely pursue from the optional list.
RE: Eligibility and Electronic Claims – agree with Dr. HITECH. However…
“However, we do believe that inclusion of a robust system to check insurance eligibility electronically is an important long term policy goal for meaningful use of certified EHR technology and we intend to include this objective as well as electronic claims submission Stage 2.” (p. 155)
Great Summary thank you.
Two changes – Summary of care record is for both Hospitals and EPs. Drug/Formulary checking was split to its own menu objective.
Many of the measures now include the Emergency Department. This was likely done since many organizations were concerned about meeting 10% CPOE without the ED. The unintended consequence of adding ED to the denominator of the other objectives is the ED systems need to be certified. Also, these ED systems now need to perform many of the same functions as the core clinical system to meet the measurement across the hospital population. i.e. Drug/Drug and Drug/Allergy Checking, Problem Lists, Vitals, Smoking etc.
Any licensed professional is specified as the following: ‘Use CPOE for medication orders directly entered by any licensed professional who can enter orders into the medical record per state, local & professional.’
I have questions regarding the “Preliminary Cause of death” portion of the Patient Demographics Meaningful Use Measure: Does this have to be documented by a physician, Is there a time factor in documentation or may the physician do it later when he/she does the discharge summary? Also, when I looked on CMS.com, it appeared to only apply to IP or EP Emergency patients – is that so?
Thank you!