EHR Association: Detailed Commentary on Specific Objectives and Questions

Transcription

1 EHR Association: Detailed Commentary on Specific Objectives and Questions CPOE Stage 1 Final Rule CPOE for medication orders (30%) EHRA Applause: 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 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 electronically) 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) 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. : 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: HITPC January/February 2011 Request for Comment on Stage 2 Meaningful Use, Feedback from EHRA: Page 1 of 44

2 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 Stage 1 Final Rule Drug-drug/drug-allergy interaction checks Employ drug-drug interaction checking and drug allergy checking on appropriate evidencebased interactions Employ drug-drug interaction checking, drug allergy checking, drug age checking (medications in the elderly), drug dose checking (e.g., pediatric dosing, chemotherapy dosing), drug lab checking, and drug condition checking (including pregnancy and lactation) on appropriate evidence-based interactions Reporting of drug interaction checks to be defined by quality measures workgroup EHRA 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. HITPC January/February 2011 Request for Comment on Stage 2 Meaningful Use, Feedback from EHRA: Page 2 of 44

3 E Prescribing (ERx) Stage 1 Final Rule E-prescribing (ERX) (EP) (40%) 50% of orders (outpatient and hospital discharge) transmitted as erx 80% of orders (outpatient and hospital discharge) transmitted as erx If receiving pharmacy cannot accept erx, automatically generating electronic fax to pharmacy OK EHRA 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. HITPC January/February 2011 Request for Comment on Stage 2 Meaningful Use, Feedback from EHRA: Page 3 of 44

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 Stage 1 Final Rule Record demographics (50%) 80% of patients have demographics recorded and can use them to produce stratified quality reports EHRA 90% of patients have demographics recorded (including IOM categories) and can use them to produce stratified quality reports IOM categories as defined in: Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement Institute of Medicine report, Of note, these categories are proposed to be used for stage 3, and are not required in proposed stage 2. 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 ve encountered industry confusion regarding the Stage 1 requirement to capture race and ethnicity according 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? HITPC January/February 2011 Request for Comment on Stage 2 Meaningful Use, Feedback from EHRA: Page 4 of 44

5 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 Stage 1 Final Rule Report CQM electronically Continue as per Quality Measures Workgroup and CMS EHRA Continue as per Quality Measures Workgroup and CMS 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 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. HITPC January/February 2011 Request for Comment on Stage 2 Meaningful Use, Feedback from EHRA: Page 5 of 44

6 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 Stage 1 Final Rule Maintain problem list (80%) Continue Stage 1 EHRA Applause: 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 plans 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 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. HITPC January/February 2011 Request for Comment on Stage 2 Meaningful Use, Feedback from EHRA: Page 6 of 44

7 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 Stage 1 Final Rule Maintain active med list (80%) Continue Stage 1 80% medication lists are up-to-date Expect to drive list to be up-to-date via medication reconciliation EHRA 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. HITPC January/February 2011 Request for Comment on Stage 2 Meaningful Use, Feedback from EHRA: Page 7 of 44

8 Medication Allergy List Stage 1 Final Rule Maintain active med-allergy list (80%) Continue Stage 1 80% medication allergy lists are up-to-date Expect to drive the list to be up-to-date by making it part of visit summary EHRA 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. HITPC January/February 2011 Request for Comment on Stage 2 Meaningful Use, Feedback from EHRA: Page 8 of 44

9 Vital Signs Stage 1 Final Rule Record vital signs (50%) 80% of patients have vital signs recorded 80% of patients have vital signs recorded NA EHRA 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 Stage 1 Final Rule Record smoking status (50%) 80% of patients have smoking status recorded 90% of patients have smoking status recorded NA EHRA 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 HITPC January/February 2011 Request for Comment on Stage 2 Meaningful Use, Feedback from EHRA: Page 9 of 44

10 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 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: 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: 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. NA EHRA 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: HITPC January/February 2011 Request for Comment on Stage 2 Meaningful Use, Feedback from EHRA: Page 10 of 44

11 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 Stage 1 Final Rule Implement drug formulary checks Move current measure to core 80% of medication orders are checked against relevant formularies What is the availability of formularies for eligible professionals? EHRA 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 HITPC January/February 2011 Request for Comment on Stage 2 Meaningful Use, Feedback from EHRA: Page 11 of 44

12 will be very difficult for certain providers who see patients with a large variety of insurance plans and separate formularies, or who see patients whose formularies are not readily available. It is inappropriate to penalize providers for some of these circumstances beyond their control. For eligible professionals, we recommend that the objective for Stage 3 be a percentage of medication orders are checked against relevant formularies when the formulary is available for the patient via the e-prescribing hub the provider uses. 80% might not be reasonable even for providers who are using an e-prescribing networking to retrieve formulary information, such as Surescripts Payer. The availability of formulary information is dependent on (1) making an insurance eligibility match with the patient and (2) that insurance company publishing their formulary through Surescripts and a PBM. There is wide variance in the match rates for both of these criterion based on location in the country and insurance plan inclusion. Also, though we do not necessarily know how this would be implemented, we suggest you allow for use of hospital formularies and for Stage 3, focus on formularies that are practical to use (not just relevant). Advance Directive Stage 1 Final Rule Record existence of advance directives (EH) (50%) Make core requirement. For EP and EH: 50% of patients >=65 years old have recorded in the EHR the result of an advance directive discussion and the directive itself if it exists For EP and EH: 90% of patients >=65 have recorded in EHR the result of an advance directive discussion and the directive itself if it exists Potential issues include: state statutes; challenges in outpatient settings; age; privacy; specialists; needs to be accessible and certifiable; need to define a standard EHRA Define the standards to be used in the EHR for the discussion result and the directive with enough lead time for vendors to program, test, release, and for healthcare providers to implement.* In a non-urgent setting, many patients and physicians might feel that it is most appropriate for a patient to discuss their advance directive decisions with his or her primary care physician, since that physician is most familiar with the patient s medical history. Because of this, we recommend that specialists be allowed to attest that it is inappropriate to their practice and to be able to claim an exclusion. HITPC January/February 2011 Request for Comment on Stage 2 Meaningful Use, Feedback from EHRA: Page 12 of 44

13 A reasonable step for Stage 2 would be to focus on scanning, filing, linking, or referencing advance directives into the EHR so they are available to care providers. We suggest that this step be the focus of Stage 2, not recording a coded result of an advance directive discussion. We suggest that undefined language (without a corresponding standard) be removed from the objective. Lab Results Stage 1 Final Rule Incorporate lab results as structured data (40%) EHRA Move current measure to core, but only where results are available 90% of lab results electronically ordered by EHR are stored as structured data in the EHR and are reconciled with structured lab orders, where results and structured orders available NA It is unclear what but only where results are available means in Stage 2. This phrase must be clearly defined to ensure accurate reporting across sites. Is this a necessary distinction for eligible hospitals? Be careful to require only numerators and denominators to be reported that can be measured. For example, if a lab order and result are inappropriately written in an EHR in an unstructured format, it is not possible to report that they are not structured because the lack of structure means the EHR is not aware that this information is supposed to be a lab order and result. Define exactly how this will be measured with enough lead time for vendors to program, test, release, and for healthcare providers to implement.* Also, for Stage 3, the volume of unsolicited results could complicate reconciliation and measurement. We suggest only measuring orders that have associated results available. HITPC January/February 2011 Request for Comment on Stage 2 Meaningful Use, Feedback from EHRA: Page 13 of 44

14 Patient Lists Stage 1 Final Rule EHRA Generate patient lists for specific conditions Make core requirement. Generate patient lists for multiple patient-specific parameters Patient lists are used to manage patients for high-priority health conditions Driven by quality measures The terms patient-specific parameters and high-priority health conditions are unclear. For patient-specific parameters, it is unclear whether a single list must be generated based on multiple parameters, such as a diagnosis and a medication, or whether multiple lists for a single parameter are allowed, such as one list for patients with a specific diagnosis and another list for patients on a specific medication. We suggest that this objective align with data already captured in earlier requirements such as "Record demographics." The language on generating lists should be correspondingly removed from the demographics objective. It is also unclear how an EP or hospital will be required to report on whether a list was used to manage patient care. Without further clarification, we suggest that this objective remain attestation only. Definitions for these terms and details on how this objective will be measured (if it is not attestation only) should be provided with enough lead time for vendors to program, test, release, and for healthcare providers to implement.* Patient Reminders Stage 1 Final Rule Send patient reminders (20%) Make core requirement. 20% of active patients who prefer to receive reminders electronically receive preventive or follow up reminders How should active patient be defined? HITPC January/February 2011 Request for Comment on Stage 2 Meaningful Use, Feedback from EHRA: Page 14 of 44

15 EHRA Please clarify that the age restriction that is part of Stage 1 will remain in Stage 2 and 3 and that this remains an EP measure only. Consider removing this requirement in Stage 3 as we move to outcomes-based measurement and further use of CDS to manage high priority health conditions, as specific tools like patient reminders will be needed for managing high priority conditions as required by other objectives and quality measures. If this requirement is not removed in Stage 3, we have the following concerns: Define active patients and exactly how this will be measured with enough lead time for vendors to program, test, release, and for healthcare providers to implement.* We suggest that EPs have discretion here, but are also concerned about consistent measurement across systems. Another concern about defining active patients is the need to send reminders to patients who have not necessarily been seen during the reporting period, though most MU reporting is based on the patient population that had encounters during the reporting period. What does "electronically" mean? We suggest that this definition be left open for innovation, to include portals, PHRs, texting, , and others. In Stage 1, there is some confusion in the marketplace about what is intended by "reminders." For example, are appointment reminders (you have an appointment tomorrow) included? Need to define "preventive or follow-up care reminders" but we suggest that EPs are given discretion in this area. We suggest it be clarified that if one provider or the staff of a clinic send reminders to patients, that these reminders being sent count for all providers who have seen the patient during the reporting period. Electronic Notes for Visits Stage 1 Final Rule (NEW) 30% of visits have at least one electronic EP note 90% of visits have at least one electronic EP note Can be scanned, narrative, structured, etc. HITPC January/February 2011 Request for Comment on Stage 2 Meaningful Use, Feedback from EHRA: Page 15 of 44

16 EHRA Applause: We agree with the addition of this objective and measure for Stage 2, as it is key to moving to a paperless record and to providing rich clinical context in the EHR. Suggestions: We recommend that scanned notes not be counted for this measure. Scanned notes introduce potential handwriting illegibility and errors. At least notes that are entered as free-text can still be searched by an EHR for a specific detail written in the note. Scanned notes do not, in most cases, provide such search capabilities. It would also be helpful to further define "narrative" and "structured." We want to clarify that the narrative notes are searchable. The note needs to be precisely defined, which may be mean clarity and precision on the range of permissible formats. The definition should not be overly prescriptive, but vendors and providers need to be clear on what is a note and what should not be counted as a note. We suggest that notes be defined by the author and note type. Finally, the jump from 30% to 90% is too large. We recommend 30% for Stage 2 and 60% for Stage 3. Electronic Notes for Hospital Days Stage 1 Final Rule (NEW) 30% of EH patient days have at least one electronic note by a physician, NP, or PA 80% of EH patient days have at least one electronic note by a physician, NP, or PA Can be scanned, narrative, structured, etc. EHRA Applause: We agree with the addition of this objective and measure for Stage 2, as it is key to moving to a paperless record and to providing rich clinical context in the EHR. HITPC January/February 2011 Request for Comment on Stage 2 Meaningful Use, Feedback from EHRA: Page 16 of 44

17 Suggestions: We recommend that scanned notes not be counted for this measure. Scanned notes introduce potential handwriting illegibility and errors. At least notes that are entered as free-text can still be searched by an EHR for a specific detail written in the note. Scanned notes do not, in most cases, provide such search capabilities. It would also be helpful to further define "narrative" and "structured." We want to clarify that the narrative notes are searchable. The note needs to be precisely defined, which may be clarity and precision on the range of permissible formats. The definition should not be overly prescriptive, but vendors and providers need to be clear on what is a note and what should not be counted as a note. We suggest that notes be defined by the author and note type. For example - - is a discharge summary a note? Finally, the jump from 30% to 80% is too large. We recommend 30% for Stage 2 and 60% for Stage 3. Electronic Medication Administration Stage 1 Final Rule (NEW) 30% of EH medication orders automatically tracked via electronic medication administration recording 80% of EH inpatient medication orders are automatically tracked via electronic medication administration recording NA EHRA The jump from 30% to 80% is too large. We recommend 30% for Stage 2 and 60% for Stage 3. The measure for Stage 3 includes the clarification that this applies only to inpatient medication orders. We feel that it would be helpful to specify this detail for Stage 2 as well to explicitly exclude any interpretation that discharge prescriptions would be counted. Please clarify what "automatically" means, as well as that the intention of this objective and measure could include bar-coding, RFID, or similar technologies used for medication administration. We believe all varieties of technology should be considered appropriate, but that the language in the proposal as written might not necessarily imply the use of these technologies and might be accomplished through more basic functionality such as an HITPC January/February 2011 Request for Comment on Stage 2 Meaningful Use, Feedback from EHRA: Page 17 of 44

18 electronic record of administered medications. It is difficult to evaluate the feasibility of this objective while this remains confused. We need specific clarification on which technologies are acceptable and healthcare providers and hospitals require specific signaling in order to properly invest in new technologies in preparation for Stage 2. Electronic Copy of Health Information Stage 1 Final Rule Provide electronic copy of health information, upon request (50%) Continue Stage 1 90% of patients have timely access to copy of health information from electronic health record, upon request EHRA Only applies to information already stored in the EHR Suggestions: We assume that the definition of health information in this objective will remain the same as in Stage 1 in Stage 2 and 3, and that the ONC standard of the Continuity of Care Document would also be the same. In Stage 1 we have had issues with the conflicting guidance between the CMS rule (which indicates that all available health information should be provided to the patient) and the ONC standards specified (which only provide for certain subsets of coded information). These discrepancies need to be aligned, and we suggest that they be aligned with the standards available. For reasons discussed earlier, we suggest thresholds never rise above 80% due to the difficulty of accounting for all fringe cases in regulation. Therefore, if this objective is maintained independently, we suggest that the Stage 3 threshold not be higher than 80%. HITPC January/February 2011 Request for Comment on Stage 2 Meaningful Use, Feedback from EHRA: Page 18 of 44

19 Electronic Copy of Discharge Instructions Stage 1 Final Rule Provide electronic copy of discharge instructions (EH) at discharge (50%) EHRA Electronic discharge instructions for hospitals (which are given as the patient is leaving the hospital) are offered to at least 80% of patients. (Patients may elect to receive a printed copy of the instructions.) Electronic discharge instructions for hospitals (which are given as the patient is leaving the hospital) are offered to at least 90% of patients in the common primary languages. (Patients may elect to receive a printed copy of the instructions.) Electronic discharge instructions should include a statement of the patient s condition, discharge medications, activities and diet, follow-up appointments, pending tests that require follow up, referrals, scheduled tests [we invite comments on the elements listed above] From the Office of Civil Rights: in a given region, a primary language defined as any language spoken by five (5%) percent of the total population eligible to be served or one thousand (1000) persons in that population, whichever is less Clarify that this requirement can be met through portal access where the portal provides timely access to discharge instructions. One important learning from Stage 1 on this objective is that the issue for providers is not typically the EHR, which has this capability, but rather, the hardware and training requirements to provide as the patient is leaving. Computers in discharge departments must be equipped with a method to save the information to a CD (CD burner) or flash drive (available USB port) as well as with encryption tools. Users who are not used to providing patients with electronic information must be trained on how to use these tools. Given those barriers, 80% or 90% is an inappropriately high percentage for this objective. ly, requiring clinicians to document that an electronic copy was offered and declined places an additional documentation requirement that serves no clinical purpose. It is challenging to report on the patients who were "offered" electronic instructions without adding unnecessary additional documentation of that question. Clarify that a hospital can choose one electronic means and that this is sufficient, and that while a hospital has a choice of possible means to deliver the electronic copy, and that the hospital does not have to offer the patient a choice of electronic methods. Regarding the point on common languages, we appreciate the definition offered by the Office of Civil Rights. However, we are still unclear on several points relating to this definition: HITPC January/February 2011 Request for Comment on Stage 2 Meaningful Use, Feedback from EHRA: Page 19 of 44

20 The clarification does not define a region. Given population fluctuations, we are concerned that an EP or hospital be allowed a certain period of time after a population reaches the required threshold before the clinician is required to provide instructions in that language. For example, the population at the beginning of the reporting period. This requirement might be burdensome for hospitals located in exceptionally diverse areas. We recommend capping the requirement at the top 3 languages documented for the patient population. Is sufficient clinically-reviewed discharge instructions content available in languages to meet this objective? Patient Education Stage 1 Final Rule EHR-enabled patient-specific educational resources (10%) Continue Stage 1 EHRA Applause: 20% offered patient-specific educational resources online in the common primary languages From the Office of Civil Rights: in a given region, a primary language defined as any language spoken by five (5%) percent of the total population eligible to be served or one thousand (1000) persons in that population, whichever is less. We agree with continuing Stage 1 for Stage 2. Concerns: Regarding the point on common languages for Stage 3, we appreciate the definition offered by the Office of Civil Rights. However, we are still unclear on several points relating to this definition: The clarification does not define a region. Given population fluctuations, we are concerned that an EP or hospital be allowed a certain period of time after a population reaches the required threshold before the clinician is required to provide instructions in that language. For example, the population at the beginning of the reporting period. This requirement might be burdensome for EPs and hospitals located in exceptionally diverse areas. We recommend capping the requirement at the top 3 languages documented for the patient population. Is sufficient clinically-reviewed patient education content available in languages to meet this objective? We suggest that another option for this objective would be to nationally define 3 specific languages as a starting point to allow content vendors to focus their efforts in the time allowed. HITPC January/February 2011 Request for Comment on Stage 2 Meaningful Use, Feedback from EHRA: Page 20 of 44

21 View and Download Inpatient Information Stage 1 Final Rule EHRA Applause: (NEW for EH) 80% of patients offered the ability to view and download via a web-based portal, within 36 hours of discharge, relevant information contained in the record about EH inpatient encounters. Data are available in human-readable and structured forms (HITSC to define). 80% of patients offered the ability to view and download via a web-based portal, within 36 hours of discharge, relevant information contained in the record about EH inpatient encounters. Data are available in human readable and structured forms (HITSC to define). Inpatient summaries include: hospitalization admit and discharge date and location; reason for hospitalization; providers; problem list; medication lists; medication allergies; procedures; immunizations; vital signs at discharge; diagnostic test results (when available); discharge instructions; care transitions summary and plan; discharge summary (when available); gender, race, ethnicity, date of birth; preferred language; advance directives; smoking status. [we invite comments on the elements listed above] A web portal as defined as online access to health information. Therefore all web portals defined as such are subject to HIPPA rules and regulations. We agree with making available both human readable and structured data for Stage 2, building off of the Stage 1 approach. Concerns: Clarify that 80% means that 80% could have this access if they want it (would be able to sign up for a patient portal) and not that 80% must actually sign up, which would be unreasonable. Also, consider an exception for children s hospitals. Offering patient portals to teenage patients can be complicated by the concerns of what information can be shared with the patient versus the guardian. Given this concern, it might make sense to include a minimum age of 18 years for offering patient portal access in the measure. For patients discharged to a nursing home, it might also make sense to have the portal be available to a caretaker. Clarify that only information from the most recent discharge is expected to be included. HITPC January/February 2011 Request for Comment on Stage 2 Meaningful Use, Feedback from EHRA: Page 21 of 44

22 36 hours is not sufficient for the complexity of the hospital data to be included. The hospital information department might need to review information prior to making it available and may not be able to review all information within 36 hours. We suggest removing the 36 hour requirement and considering four to six business days as a more appropriate time period. We suggest that the data set be narrowed to be consistent with the information available in the earlier objective to provide an electronic copy of discharge instructions. The information that was given to the patient in printed discharge instructions should be able to be available in a shorter time frame than other information, which often takes longer to be made available. Information that is part of the discharge instructions should be made available at discharge. Also, clarify "relevant information" and "uniformly readable". We are concerned about the lack of standards for the care transitions and plan. What specifically is intended to be used for the standard? Is the discharge summary appropriate to be shared with the patient? Isn't this intended for other physicians? Timely Electronic Access Stage 1 Final Rule Provide timely electronic access (EP)* (10%) Patients have the ability to view and download (on demand) relevant information contained in the longitudinal record, which has been updated within 4 days of the information being available to the practice. Patient should be able to filter or organize information by date, encounter, etc. Data are available in human-readable and structured forms (HITSC to define). Patients have the ability to view and download (on demand) relevant information contained in the longitudinal record, which has been updated within 4 days of the information being available to the practice. Patient should be able to filter or organize information by date, encounter, etc. Data are available in human-readable and structured forms (HITSC to define). The following data elements are included: encounter dates and locations; reasons for encounters; providers; problem list; medication list; medication allergies; procedures; immunizations; vital signs; diagnostic test results; clinical instructions; orders; longitudinal care plan; gender, race, ethnicity, date of birth; preferred language; advance directives; smoking status. [we invite comments on the elements listed above] HITPC January/February 2011 Request for Comment on Stage 2 Meaningful Use, Feedback from EHRA: Page 22 of 44

23 EHRA There is not an industry standard for what is contained in a "longitudinal care plan." We suggest that this item be removed from the requirement until there is an accepted industry standard. Clarify that the ability to download lab results does not prohibit the provider from reviewing the lab and procedure results prior to releasing them to the patient online. What is intended by "longitudinal" -- this term must be carefully defined. We suggest clarifying that encounters older than one year do not need to be displayed (though they could be displayed optionally). The level of patient ad-hoc reporting described is a large development functionality addition that requires sufficient time for development. We suggest deferring the entire objective to Stage 3. If the entire objective is not deferred, we suggest deferring the sorting and filtering elements as requiring too much development, as well as reviewing the data elements required to see whether they are currently captured. Also, the timing standard should be four business days. HITPC January/February 2011 Request for Comment on Stage 2 Meaningful Use, Feedback from EHRA: Page 23 of 44

24 Clinical Summaries for Office Visits Stage 1 Final Rule Provide clinical summaries each office visit (EP)* (50%) EHRA Patients have the ability to view and download relevant information about a clinical encounter within 24 hours of the encounter. Follow-up tests that are linked to encounter orders but not ready during the encounter should be included in future summaries of that encounter, within 4 days of becoming available. Data are available in human-readable and structured forms (HITSC to define). Patients have the ability to view and download relevant information about a clinical encounter within 24 hours of the encounter. Follow-up tests that are linked to encounter orders but not ready during the encounter should be included in future summaries of that encounter, within 4 days of becoming available. Data are available in human-readable and structured forms (HITSC to define). The following encounter data are included (where relevant): encounter date and location; reasons for encounter; provider; problem list; medication list; medication allergies; procedures; immunizations; vital signs; diagnostic test results; clinical instructions; orders: future appointment requests, referrals, scheduled tests; gender, race, ethnicity, date of birth; preferred language; advance directives; smoking status. [we invite comments on the elements listed above] We are concerned with the description of the clinical summary, which implies that the summary is a snapshot in time but is also continually updated with future information (such as follow-up test results) as they become available. Clarify that the clinical summary is always providing information that is current at the time it is generated, or that it is a snapshot in time that is not subsequently updated. Clarify which encounters are intended so that there is not confusion that encounters that happened 10 years ago should be reflected in the portal. Also, clarify "relevant information" and "uniformly readable". 24 hours is not sufficient for providing the information. This is not a technology issue so much as allowing sufficient time for clinical review. We suggest continuing with the Stage 1 requirement of 3 business days. Business days are the appropriate time measurement for EP requirements. We suggest that the physician be given discretion to not share information they deem better shared with patients in other ways. Some of the information in the data elements to be included might be information stored in a registration system rather than in an EHR, we suggest these be excluded. HITPC January/February 2011 Request for Comment on Stage 2 Meaningful Use, Feedback from EHRA: Page 24 of 44

25 When measuring this objective, are vendors expected to validate that information is available within 24 hours, or is this established by provider attestation? If the vendor is expected to validate that all information is available in 24 hours, this requirement might require significant development. Timely Access and Clinical Summaries Stage 1 Final Rule EHRA This objective sets the measures for Provide timely electronic access (EP) and for Provide clinical summaries for each office visit (EP) EPs: 20% of patients use a web-based portal to access their information (for an encounter or for the longitudinal record) at least once. Exclusions: patients without ability to access the Internet EPs: 30% of patients use a web-based portal to access their information (for an encounter or for the longitudinal record) at least once. Exclusions: patients without ability to access the Internet NA It is inappropriate for an EP to be held accountable for criteria beyond his/her immediate control, and we have concerns that this objective is measured based on patient behavior. We prefer the measure proposed for the hospital equivalent of this objective that the measure be based on a percentage of patients offered access. ly, such an approach would eliminate the need to provide an exclusion for this objective since a patient who declines because of lack of Internet access can still be counted as having been offered access. If the exclusion criterion for this measure is maintained, we are concerned about the ability of an EHR to accurately determine whether a patient has access. The only way to report on such information would be to require clinicians to document this information, which places an additional documentation requirement on the clinician, which serves no clinical value. Also, patients who do not have internet access are really not different than any patients who decline access to a portal for any reasons. We suggest that all patients who decline be excluded. Also, are studies of current portal usage reflective of use in all geographic regions? We suggest that an alternative measure for these objectives would be to include information about the availability of the patient portal in the visit summary given to the patient after the visit. The presence of this information could be established during certification. HITPC January/February 2011 Request for Comment on Stage 2 Meaningful Use, Feedback from EHRA: Page 25 of 44