HIT Policy Committee

1. 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

2. 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

3. 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

4. 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

5. 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)

6. 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

7. 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

8. 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

9. 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

10. Proposed MU NPRM Recommendations – 9 • CPOE should be done by authorizing provider • CPOE numerator should be number of orders entered directly by authorizing provider

11. 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

12. 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)

13. 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

14. Proposed MU NPRM Recommendations – 12