Giving a patient medications in the ER, having them pop positive on a test, and then withholding further medications because…
Meaningful Use – Final Version Full Text
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We will be adding comments to this post as we find important facts in the long document. Feel free to add your own findings or thoughts.
Hospital and practice CPOE requirement: at least 30% of patients with a med order must have at least one of them entered via CPOE. The denominator is no longer total orders generated, which would have required a manual count of paper orders.
Claims-based clinical quality measures eliminated. The 15 measures (Table 10) are all based on what EHRs can calculate.
Requirement for incorporating lab results into EHR: More than 40% of all clinical lab tests results ordered by the EP or by an authorized provider of the eligible hospital or CAH for patients admitted to its inpatient or emergency department (POS 21 or 23) during the EHR reporting period whose results are either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data.
Each provider can attest that they had no patients that would have allowed them to comply with a particular requirement, i.e. a chiropractor can attest that they are not permitted to prescribe electronically, which would waive the e-prescribing requirement.
Requirement for EPs generating and transmitting e-rx: More than 40% of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology
Re: required clinical quality measures will be limited to only 15 measures for Stage 1 for hospitals and CAHs to the 15 measures
Lab and diagnostic orders eliminated for the CPOE requirement. It’s just med orders. Any licensed professional can enter the orders — i.e. you could hit the CPOE target even if nurses entered all the orders as verbals, at least as I interpret it.
Did ONC also release an updated version of the certification requirements, or does the 12/30/2009 IFR stand?
ED orders count toward the inpatient total for CPOE. That’s a huge change.
A physician who practices at multiple sites, some with and some without an EHR, can qualify if at least 50% of their total encounters across all locations are covered with EHRs.
Re: core measures for EPs. The three required are hypertension, tobacco use, and weight (adults). If measurements are not applicable, then EP will be required to report results of up to three alternate measures including preventative care and screening for influenza, weight (children), and childhood immunization.
Checking of med orders against a drug formulary requires only one formulary to be used and it can either be external or internal.
By what category of diligence were the rules for “meaningful use” finalized on the same date that a NIST conference is being held on “usability” in Maryland (“Usability in Health IT: Technical Strategy, Research, and Implementation”, http://www.nist.gov/itl/usability_hit.cfm), implying there’s a problem — as admitted by HIMSS itself?
http://www.himss.org/content/files/HIMSS_DefiningandTestingEMRUsability.pdf
Defining and Testing EMR Usability: Principles and Proposed Methods of EMR Usability Evaluation and Rating
HIMSS EHR Usability Task Force
June 2009
EXECUTIVE SUMMARY
Electronic medical record (EMR) adoption rates have been slower than expected in the United States, especially in comparison to other industry sectors and other developed countries. A key reason, aside from initial costs and lost productivity during EMR implementation, is lack of efficiency and usability of EMRs currently available. Achieving the healthcare reform goals of broad EMR adoption and “meaningful use” will require that efficiency and usability be effectively addressed at a fundamental level.
Problem list clarified – coding doesn’t have to be done concurrently – the codes can be added later by anyone.
e-prescribing threshold dropped from 75% to 40%, acknowledging that factors outside the provider’s control impact it (non-participating pharmacies, cash patients, controlled substances).
Threshold for recording patient demographics as structured data dropped from 80% to 50%.
Advance directive for hospitals – threshold for recording as structured data dropped from 80% to 50%, also limited only to inpatients (not ED).
For 2011 and 2012, required information on clinical quality measures results will be limited to those that can be automatically calculated by the certified EHR technology.
Hospitals do not have to send patient reminders – clarified that only practices need to do that.
Clinical decision support rule requirement for both hospitals and practices dropped from five to one.
Requirement to file claims and verify eligibility electronically are eliminated, or at least it appears that way.
Requirement to give patients electronic copies of their information when requested dropped from 80% to 50% and time allowed was increased from 48 hours to three business days.
Requirement for practices to provide clinical summaries for 80% of patients dropped to 50%, time frame defined as three business days.
New measure: 10% of practice or hospital patients are given patient-specific educational resources.
Great job on beating the competition to publishing these and for rapid fire analysis!
Once again, Mr. HISTalk and Inga prove they are an important resource to our industry!
Medication reconciliation threshold dropped from 80% to 50%.
An EP is considered hospital-based and ineligible to receive an EHR incentive payment if more than 90% of their services are provided under POS codes inpatient hospital or ER. This is consistent with recent legislation (Continuing Extension Act of 2010.)
Requirement to provide a summary of care record dropped from 80% of transitions of care to 50%.
Most useful is the NEJM summary:
http://content.nejm.org/cgi/reprint/NEJMp1006114.pdf
David Blumenthal provides his summary here:
http://healthcarereform.nejm.org/?p=3732#more-3732
WOW. Great job on this. Thank you.
Do the new rules indicate whether achieving meaningful use is still an all or nothing proposition, or if y can qualify for some of the dollars by achieving some of the metrics?
[From Mr. HIStalk] It was acknowledged that the bar was originally set too high. As a result, they reduced the number of requirements and lowered the thresholds. They said HITECH does not allow partial payments (see Page 56). I need to study the wording more, but it calls for a “core set” and a “menu set” of objectives and providers can skip five objectives of their choosing from the “menu set” and still qualify as a meaningful user.
Core set: CPOE, eRX, demographics, problem list, med list, allergy list, vital signs, smoking status, one CDSS rule, CQM, electronic exchange of clinical information, give patients copies of their information, electronic discharge instructions, clinical summaries, protect information.
Menu set: drug-formulary checks, advance directives, discrete lab results, patient list by condition, reminders, patient access to health information, use EHR to find education resources, medication reconciliation on transition, summary care record on transition, send data to immunization registries, report to public heath agencies, submit surveillance data,
Re: Timing of payments:
For the Medicare program, attestations may be made starting in April 2011 for both EPs and eligible hospitals.
Medicare EHR incentive payments will begin in mid May 2011.
States will be initiating their incentive programs on a rolling basis, subject to CMS approval of the State Medicaid HIT plan, which details how each State will implement and oversee its incentive program.
Further summary of key provisions:
For Stage 1, CMS’s proposed rule called on physicians and other EP to meet 25 objectives (23 for hospitals) in reporting their meaningful use of EHRs. Objectives are divided into a “core” group of required objectives and a “menu set” of procedures from which providers can choose. This “two track” approach ensures that the most basic elements of meaningful EHR use will be met by all providers qualifying for incentive payments, while at the same time allowing latitude in other areas to reflect providers’ varying needs and their individual paths to full EHR use.
In line with recommendations of the HIT Policy Committee, the final rule includes the objective of providing patient-specific educational resources for both EPs and eligible hospitals and the objective of recording advance directives for eligible hospitals.
With respect to defining hospital-based physicians, the final rule conforms to the Continuing Extension Act of 2010. That law addressed provider concerns about hospital-based providers in ambulatory settings being unable to qualify for incentive payments by defining a hospital-based EP as performing substantially all of his or her services in an inpatient hospital setting or emergency room only.
The rule makes final a proposed rule definition that would make individual payments to eligible hospitals identified by their individual CMS Certification Number. The final rule retains the proposed definition of an eligible hospital because that is most consistent with policy precedents in how Medicare has historically applied the statutory definition of a ”subsection (d)” hospital under other hospital payment regulations.
Under Medicaid, the final rule includes critical access hospitals (CAHs) in the definition of acute care hospital for the purpose of incentive program eligibility.
Economic analysis estimates that incentive payments under Medicare and Medicaid EHR programs for 2011 through 2019 will range from $9.7 billion to $27.4 billion.
Great job on posting the final rule – much appreciated! And the associated comments/highlights are terrific.
For MIMT.
“The state or condition of being usable; The degree to which an object, device, software application, etc.
en.wiktionary.org/wiki/usability”
An object, device or software and how usable it is.
Meaningful use relates to how people use this object, device, software, irregardless of its usability.
If it’s not usable and it impedes meaningful use that should be a driver of change and that’s where the conference comes in.
I hope that clears it up any confusion you may have. It’s a good thing 🙂
THE CERTIFICATION REQUIREMENTS RULE ADDED A NEW REQUIRED FEATURE **OUT**OF**NOWHERE**!
§170.302(m)-“Enable a user to electronically identify and provide patient-specific education resources according to, at a minimum, the data elements included in the patient’s: problem list, medication list, and laboratory test results; as well as provide such resources to the patient”
THIS IS A NEW REQUIREMENT THAT WAS NOT IN ANY FORM REPRESENTED IN THE EARLIER IFR.
It would seem to imply that the EHR system will need to be able to automatically select patient education resources based on the patient’s problems, meds, and lab results.
Just thought folks might like to know what their vendors are being asked to pull out of their hats with, oh, 3 months’ notice.
Blah writes:
f it’s not usable and it impedes meaningful use that should be a driver of change and that’s where the conference comes in.
I think you miss my point about putting the cart ahead of the horse.
In any case, it will be interesting to see defendant hospital and HIT executives respond to questions on why they ignored the findings of the National Reseach Council, HIMSS and others.
The meat of the certification requirements are defined in the Federal Register posting below:
http://tinyurl.com/2ffphf9
TPD!
Can you tell me how or where this Problem List criteria was clarified?
Mr. HIStalk Says:
14Problem list clarified – coding doesn’t have to be done concurrently – the codes can be added later by anyone.
July 13th, 2010 at 9:01 am
[From Mr. HIStalk] Page 89: “We did not and do not intend that coding of the diagnosis be done at the point
of care. This coding could be done later and by individuals other than the diagnosing provider. “
MIMD we need general concepts in order to flesh out the details. The horse is right there… in front of the cart, where you would expect it. You don’t go through details to find the concept had been dropped. Now vendors and hospitals know what they will be expected to do, people can design the best ways of achieving it.
Re: Certification requirements. They are fairly basic; I don’t see anybody having any difficulties getting certification. Nice to see SOAP in there. It would have been nice to see some specifics on device integration, abnormal lab result notification; Microbiology formats from external systems, best practice on alerts and decision support. Some of the items that are screaming out for some basic standards. Still, it’s a start.
Hopefully someone reading this is smart enough to explain what in Sam Hill is meant by this rat’s nest of tortured verbiage:
“MU §495.6(d)(1)-“Use computerized provider order entry (CPOE) for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local, and professional guidelines…More than 30 percent of all unique patients with at least one medication in their medication list seen by the EP have at least one medication order entered using CPOE””
What does ONC have in mind when they posit that not all medications on a patient’s medicaation list would have been “entered using CPOE”?
Are they defining “CPOE” as meaning that the provider him/her-self is the one who placed the order/prescription, or…
Are they thinking of the fact that (in most ambulatory EHRs at least) it is possible to add a medication to the med list without creating a prescription (often referred to as “historical” medications)?
Can I give a “shout out” to the folks at ONC who probably haven’t slept much over the last months? No, I don’t work for them directly, but do have a sense of their commitment as I’m employed by one of the RECs.
This is not a “perfect” initiative, but certainly one filled with compassionate and committed people across the country. So to reach today, “R” day, and know how far we’ve come together, is a very proud moment. We have far to go, no doubt. Clearly, the number of posts on HISTalk, and the sense that so many people of “waiting and watching” for every word of this momentous, historic occasion, fills me with even more resolve to do our best to help our end customers….you, the physician! to adopt EHR and use it meaningfully, because that will impact me, your patient!
Does anyone know if the $ will be available for Long Term Care providers (Nursing Homes, Adult Day Care, Assisted Living) and the clinical documentation systems associated with them? Basically, is Meaningful Use and the ARRA $ for any physician or just those who operate in hospitals or clinics?