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HIT Policy Committee. Meaningful Use Workgroup Proposed Recommendations on MU Notice of Proposed Rule Making Paul Tang, Chair Palo Alto Medical Foundation George Hripcsak , Co-Chair Columbia University February 17, 2010. Proposed MU NPRM Recommendations – 1.

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HIT Policy Committee

Meaningful Use Workgroup

Proposed Recommendations on MU Notice of Proposed Rule Making

Paul Tang, Chair

Palo Alto Medical Foundation

George Hripcsak, Co-Chair

Columbia University

February 17, 2010


Proposed MU NPRM Recommendations – 1

  • Reinstate HITPC recommendation to include progress note documentation for EP Stage 1 MU

    • Progress notes are key to delivering high quality, coordinated care (not just a legal requirement):

      • Legibility – quality & efficiency implications

      • Important for documenting complete record (otherwise lost)

      • Hybrid systems (part electronic, part paper) causes fragmentation of the record and inefficient workflow

      • Paper 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 coordination

      • Textual progress notes used to know patient as a human being

    • Signal clinical documentation for hospitals in Stage 2


Proposed MU NPRM Recommendations – 2

  • Remove “core measures” from Stage 1

    • Attributes considered:

      • Based on the Institute of Medicine’s Six Aims and priorities identified by the National Priorities Partnership

      • Have an evidence-based link to improvement in outcomes

      • Can 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 providers

      • Measures outcome, to the extent possible

    • None of the proposed “core” measures satisfied the criteria (nor did our examples)

    • Support use of key HIT-sensitive health priorities drive selection of quality measures

    • Will re-explore concept of shared or common measures in future


Proposed MU NPRM Recommendations – 3

  • Reinstate HITPC recommendation to stratify quality reports by disparity variables

    • Providers should produce quality reports stratified by race, ethnicity, gender, primary language, and insurance type 

    • CMS has stated that an explicit health outcomes policy priority is to “reduce health disparities”

    • No assessment of disparity reduction can be made without stratifying data reports by these variables


Proposed MU NPRM Recommendations – 4

  • Providers should maintain up-to-date lists (not just one-time entries)

    • Maintaining key patient summary information in EHR is critical for care quality & coordination

    • Measure: 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 – 5

  • Reinstate HITPC recommendation to include recording of advanced directives for Stage 1 MU 

    • EPs and hospitals should be expected to record presence or absence of advance directives for patients > 65 as part of the Stage 1 MU criteria

    • Particularly for Medicare providers, recording of advance directives should apply to virtually everybody


Proposed MU NPRM Recommendations – 6

  • Reinstate HITPC recommendation to include patient-specific education resources for Stage 1 MU

    • EHR-enabled links to relevant educational resources critical to CMS health outcome priority to “engage patients and families”

    • Provider vetting of consumer educational content represents a much better than unguided searching of the Internet

    • Several EHR vendors and health education content providers have developed partnerships that facilitate EHR-enabled connections to patient-specific content 

    • EPs & hospitals should report on % of patients for whom they use the EHR to suggest patient-specific education resources


Proposed MU NPRM Recommendations – 7

  • Reinstate HITPC recommendation to include clinical efficiency measures for Stage 1 MU

    • CMS did not include clinical efficiency measures although “improve efficiency” is a CMS-stated priority

    • All EPs report % of all medications entered into EHR as a generic formulation, when generic options exist in relevant drug class

      • On 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 analysis

    • CMS should explicitly require that at least 1 of 5 CDS rules address efficient diagnostic test ordering


Proposed MU NPRM Recommendations – 8

  • CMS should create a glidepath for Stage 2 & 3 MU

    • Vendors need more time to develop appropriate functionality

    • Providers need more time to integrate it into clinical workflow

    • Recognize 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 feasible

    • To extent possible, CMS should consider publishing the Stage 2 MU NPRM earlier than anticipated December 2011


Proposed MU NPRM Recommendations – 9

  • CPOE should be done by authorizing provider

    • CPOE numerator should be number of orders entered directly by authorizing provider


Proposed MU NPRM Recommendations – 10

  • Amend prevention/follow-up reminders criterion to apply to a broader range of the population and allow for provider discretion in targeting reminders

    • For a chosen/relevant preventive health service or follow-up, report on the percent of patients who were eligible for that service who were reminded

    • Denominator: All patients who were potentially eligible (e.g., meet demographic criteria) and had not received the service


Proposed MU NPRM Recommendations – 11

  • Clarify “transitions of care” and “relevant encounters”

    • Under Care Coordination category

    • Define “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 – 12

  • Allow some flexibility in meeting meaningful use criteria

    • “All-or-nothing” approach may not accommodate legitimate, unanticipated, local circumstances or constraints

    • Permit flexibility while preserving a floor

    • Allow provider to defer fulfillment of a small number of MU criteria and still receive incentive

    • Allow 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 domain

      • 1 of the criteria in the care coordination domain

      • 1 of the criteria in the population/public health domain

    • All must meet the privacy & security domain criterion

    • All must report clinical measures to CMS/state


Proposed MU NPRM Recommendations – 12


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