On December 30, 2009, the Office of the National Coordinator (ONC) for health IT released two documents that tried to define “meaningful use of certified EHRs” needed to access stimulus incentive money earmarked in the HITECH section of the American Recovery and Reinvestment Act (ARRA) of 2009.
One of these documents, referred to as the Meaningful Use NPRM (“notice of proposed rule making”), describes the things that a physician or hospital needs to demonstrate beginning in 2011 in order to access ARRA bonuses. Closely tied, the Certification IFR (“interim final rule”) describes the features an EHR product needs to have in order to become Certified.
Both of these documents were opened for a 60-day public comment period, and to date over 5,000 comments have been received and reviewed by the ONC. Half-way through the process, the ONC’s Policy Committee has made recommendations for changes, based on input from multiple stakeholders and the comments received. Granted that the Centers for Medicare and Medicaid Services (CMS) has final say-so over the NPRM, but input from the Policy Committee is certainly very influential.
The changes proposed are significant. There are 12 different recommendations made by the ONC to CMS, which can really change what physicians (and EHR developers) need to do. The recommendations can be summarized as follows:
(1) Reinstate the inclusion of Progress Note documentation for Stage 1 Meaningful Use definitions. The need to demonstrate electronic capture of progress notes was curiously missing from the NPRM, and is a central feature of most EHRs. Inclusion of this is now recommended.
(2) Remove certain core measures from Stage 1. The concept of “core measures” is defined by the National Quality Forum (NQF), but some of these measures (NQF 0013, 0022, 0028) are process measures or lack adequate consensus, and are thus proposed to be dropped.
(3) Reinstate the recommendation to produce Quality Metric reports stratified by race, ethnicity, gender, primary language, and insurance type.
(4) Problem lists, medications and allergies need to be up-to-date.
(5) Reinstate the recommendation to include the recording of Advance Directives as a Stage 1 Meaningful Use for physicians as well as hospitals.
(6) Physicians and hospitals should report on the percentage of patients for whom the EHR was able to suggest patent-specific education resources
(7) Reinstate the recommendation to include measures of “efficiency” for Stage 1 – including capturing the percent of prescriptions that are for generic medications (where generic options exist in the relevant drug class).
(8) CMS should create a glide path for Stage 2 and Stage 3 expectations, and advance the timelines where possible to allow ramp-up time for vendors and providers.
(9) Computerized Physician Order Entry (CPOE) must be entered by the physician directly
(10) Preventive health service reminders requirements should be amended to be more focused – so that reminders relevant to the physician specialty are the only ones expected.
(11) Define more clearly what is meant by “transition of care” – movement of a patient from one setting of care to another (hospital, ambulatory PCP practice, ambulatory specialty practice, long-term care, home health, rehab facility). Medications review needs to happen at each such transition of care.
(12) Most importantly: allow some flexibility in Meaningful Use criteria. This is a move away from the “all or nothing” which we (and others) have criticized in the past. Providers should be “given credit” for movement towards the goal. There are some criteria (e.g. safety and security of data) that are required, regardless. But other criteria can be “deferred.”
Though we are mid-way through the open comment period for the NPRM and IFR documents, it is clear that these represent “moving targets.” Unfortunately, both physicians and EHR developers and vendors will need to adjust their expectations, and their products offered, based on how this all plays out in the end. The open comment period is up March 15, 2010, and finalized rules should be ready by then.
The task is also a challenge for organizations that want to become Certifying Agencies, which will grant HHS Certification to EHR products. As the criteria and the rules shift, how these organizations prepare is also a bit of shifting-sands.
We will keep our eyes closely on these developments, and remain committed to offering an EHR product that is both Certified and easy-to-use, so that physicians can easily document their Meaningful Use in time for 2011 incentive payment availability.
Robert Rowley, MD
Chief Medical Officer, Practice Fusion, Inc.