Article

Getting a handle on Stage 2 Requirements

Even if you’ve had success with Stage 1 meaningful use requirements, pay attention to the changes included in Stage 2.

Meaningful Use

Getting a handle on Stage 2 Requirements

Even if you’ve had success with Stage 1 meaningful use requirements, pay attention to the changes included in Stage 2.

Darla Shewmaker, Villa Hills, KY

Regardless of their stage of meaningful use, all providers are required to demonstrate meaningful use for a three-month EHR reporting period in 2014. That is the good news. The bad news is practices, providers and many EHR vendors are not ready for the complex 2014 requirements and the clock is ticking.

To help consolidate and simplify the information needed to comply with Stage 2, I have included both a core measure matrix and a menu measure matrix (see below). Each lists the measure, the exclusion (if one exists) and a comparison to the Stage 1 requirement. Stage 2 requires all 17 core measures and your choice of 3 of the 6 menu set measures.

Core measures you should recognize from Stage 1 are CPOE (expanded), eRx, Demographics, Vital Signs, Smoking Status, Clinical Decision Support, Clinical Summaries and Security Risk Analysis. Stage 1 menu set items that were elevated to core measures for Stage 1 are Labs, Patient Lists, Preventative Care, Education Resources, Medication Reconciliation, Summary of Care for Transition of Care and Immunization Registries. Let’s look at what’s new and some new twists on old measures.

New: Patient Engagement Measures – Patient Participation Required

View, Download and Transmit (core measure #7). To qualify for this measure, first, you must provide more than 50% of the patients seen during the reporting period with the ability to view online, download and transmit their health information within four business days. Second, more than 5% of these patients must view, download, or transmit to a third party their health information.

Secure Messaging (core measure #17). More than 5% of unique patients (or their authorized representatives) seen during the reporting period must send your practice a secure message (any electronic provider/patient communication that ensures only those parties can access the communication). The message, sent using the electronic messaging function of certified electronic health record technology (CEHRT), could be e-mail or the electronic messaging function of a patient health record (PHR), an online patient portal, or any other electronic means. The response does not need to be electronic. An EP or staff member could address concerns raised in the message by follow-up phone call or office visit. Also, there is not an expectation that the EP must personally respond to electronic messages to the patient.

Both of these measures will most likely be accomplished utilizing an Internet portal. (The May/June issue of OP will cover patient portals, including their part in achieving meaningful use.)

New: Menu Set Measures

Electronic Notes (menu set measure #2). To qualify, you must send an electronic note, which CMS defines as an electronic progress note, to more than 30% of the patients seen during the reporting period. CMS will rely on providers own determinations and guidelines defining when progress notes are necessary to communicate individual patient circumstances and for coordination with previous documentation of patient observations, treatments and/or results in the electronic health record.

Image Results (menu set measure #3). EPs must make accessible through the CEHRT more than 10% of all tests (performed during the reporting period) whose result is one or more images ordered by the EP. Included are images from devices that emit “any ionizing or nonionizing electromagnetic or particulate radiation, or any sonic, infrasonic, or ultrasonic wave.” Providers may include other types of imaging as long as the policy is consistent over the entire reporting period. Based on this definition, providers could choose to count their images (such as OCT) or could select other options in the menu set.

Image results must be accessible through your EHR, either by incorporating the image and accompanying information into CEHRT or if located in another technology, by linking the image and accompanying information to CEHRT, along with an indication that the image and information are available elsewhere. Basically, the information should be available with one click. The images won’t count if they require a secondary search in a separate system.

Family History (menu set #4) More than 20% of unique patients seen during the reporting period must have a structured data entry for one or more first-degree relatives (parents, offspring or siblings). To qualify, these entries must be coded to SNOMED CT or HL7 Pedigree. A structured entry recorded as “unknown” is also valid.

Specialized Registries (menu set measure #6) Specialized registries are sponsored by national specialty societies or maintained by public health agencies. The AAO is sponsoring the IRIS (Intelligent Research in Sight) Registry. This registry is the nation’s first comprehensive eye disease clinical registry. EPs must attest “yes” to successfully submitting specific case information from CEHRT to a specialized registry for the entire reporting period to meet this measure.

A New Twist: An Expanded Measure

Clinical Summaries (core measure #8). While not a new measure, these after-visit summaries, which provide “relevant and actionable information and instructions” for the patient, must now include:

■ Patient name

■ Provider’s name/office contact information

■ Date and location of the visit

■ Reason for the office visit

■ Current problem list

■ Current medication list

■ Current medication allergy list

■ Procedures performed during the visit

■ Immunizations or medications administered during the visit

■ Vital signs taken during the visit (or other recent vital signs)

■ Laboratory test results

■ List of diagnostic tests pending

■ Clinical instructions

■ Future appointments

■ Referrals to other providers

■ Future scheduled tests

■ Demographic information (sex, race, ethnicity, date of birth, preferred language)

■ Smoking status

■ Care plan fields, must include at minimum: problem (the focus of the care plan), goal (the target outcome) and any instructions that the provider has given the patient. A goal is a defined target or measure to be achieved in the process of patient care (an expected outcome).

■ Recommended patient decision aids (if applicable to the visit)

This summary, which must be provided to more than 50% of the patients in the reporting period, can be sent through a PHR, patient portal on the website, secure e-mail, electronic media such as CD or USB fob, or printed copy. Regardless of the electronic medium used, EPs must provide the patient with a paper copy upon request. Or, if the EP provides paper copies, an electronic form of the EP’s choice would need to be provided upon request. If an EP believes that substantial harm may arise from the disclosure of particular information, that information may be withheld from the clinical summary. Providers may not charge patients a fee to provide this information. In the event that a clinical summary is offered to and subsequently declined by the patient, that patient may still be included in the numerator of the measure. OP

STAGE 2: 17 CORE MEASURES

CORE OBJECTIVE

MEASURE DESCRIPTION

EXCLUSIONS

STAGE 1 COMPARISON

1. CPOE

Use computerized provider order entry (CPOE) for more than 60% of medication orders, 30% of laboratory orders, and 30% of radiology orders

Write fewer than 100 prescriptions during the reporting period or if there are no pharmacies that accept electronic prescriptions within 10 miles

Stage 1 only required 30% of medication orders

Laboratory and radiology are NEW!

2. eRx

More than 50% of all permissible prescriptions, or all prescriptions, written by the EP are queried for a drug formulary and transmitted electronically

Write fewer than 100 prescriptions during the reporting period or if there are no pharmacies that accept electronic prescriptions within 10 miles

Stage 1 only required 40% of prescriptions

Drug Formulary was a menu set choice in Stage 1.

3. Demographics

Record demographics (preferred language, sex, race, ethnicity, date of birth) for more than 80% of unique patients

NONE

Increase from 50%

4. Vital Signs

Record vital signs: height/length and weight (no age limit); blood pressure (ages 3 and over); calculate and display body mass index (BMI); and plot and display growth charts for patients 0-20 years, including BMI

More than 80% of all unique patients seen by the EP have blood pressure (for patients age 3 and over only) and/or height and weight (for all ages) recorded as structured data

Sees no patients 3 years or older is excluded from recording blood pressure.

Believes that all 3 vital signs of height/length, weight, and blood pressure have no relevance to their scope of practice is excluded from recording them.

Believes that height/length and weight are relevant to their scope of practice, but blood pressure is not, is excluded from recording blood pressure.

Believes that blood pressure is relevant to their scope of practice, but height/length and weight are not, is excluded from recording height/length and weight.

Increase from 50%

5. Smoking Status

Record smoking status for patients 13 years or older for more than 80% of unique patients

Any EP that neither sees nor admits any patients 13 years old or older.

Increase from 50%

EHR must use SNOMED CT for smoking status

6. Clinical Decision Support

Implement 5 clinical decision support interventions related to four or more clinical quality measures. Absent four clinical quality measures related to an EP’s scope of practice or patient population, the clinical decision support interventions must be related to high-priority health conditions.

Implement drug/drug and drug/allergy checks for entire reporting period

For the second measure, any EP who writes fewer than 100 medication orders during the EHR reporting period.

Stage 1 required only 1 clinical decision support rule.

Drug allergy checks were a separate measure in Stage 1. This was combined into a single measure and is now part of clinical decision support for Stage 2.

7. View, Download and Transmit

Provide patients the ability to view online, download and transmit their health information within four business days.

More than 50% of all unique patients are provided online access to their health information.

More than 5% of all unique patients view, download, or transmit to a third party their health information.

EP neither orders nor creates any of the information listed for inclusion as part of both measures, except for “Patient name” and “Provider’s name and office contact information, may exclude both measures.

EP conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 3Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may exclude only the second measure.

Stage 1 required more than 50% of all patients of the EP who request an electronic copy of their health information are provided it within 3 business days.

Ability to Download is NEW!

Ability to Transmit is NEW!

Stage 1 was triggered by a request and stage 2 requires the information available to 50% of unique patients.

8. Clinical Summaries

Clinical summaries provided to patients or patient-authorized representatives within one business day for more than 50% of office visits.

Any EP who has no office visits during the EHR reporting period

Stage 1 required the same percentage, but scope has expanded to include patient representatives

9. Security Risk Analysis

Conduct or review a security risk analysis, including addressing the encryption/security of data at rest and implement security updates as necessary and correct identified security deficiencies as part of its risk management process

NONE

Specific identification for encryption and security of data at rest is NEW!

EHR to record amendments is NEW!

10. Labs

More than 55% of all clinical lab tests results ordered by the EP during the EHR reporting period whose results are either in a positive/negative or numerical format are incorporated in as structured data

Any EP who orders no lab tests where results are either in a positive/negative affirmation or numeric format during the EHR reporting period

Increase from 40%

Menu set for Stage 1 and Core for Stage 2

11. Patient Lists

Generate at least one patient list by specific condition per provider

NONE

Menu set for Stage 1 and Core for Stage 2

12. Preventive Care

Use EHR to identify and provide reminders for preventive/follow-up care for more than 10% of patients with two or more office visits in the last 2 years

Any EP who has had no office visits in the 24 months before the EHR reporting period

Menu set for Stage 1 and Core for Stage 2 Stage 1 was 20%

13. Education Resources

Use EHR to identify and provide education resources more than 10% of unique patients

Any EP who has had no office visits in the 24 months before the EHR reporting period

Menu set for Stage 1 and Core for Stage 2, Stage 1 was same 10%

14. Medication Reconciliation

Medication reconciliation at more than 50% of transitions of care

Any EP who was not the recipient of any transitions of care during the EHR reporting period

Menu set for Stage 1 and Core for Stage 2, Stage 1 was same 50%

15. Summary of Care for Transition of Care

Provide summary of care document for more than 50% of transitions of care and referrals with 10% sent electronically and at least one sent to a recipient with a different EHR vendor or successfully testing with CMS test EHR

Any EP who transfers a patient to another setting or refers a patient to another provider less than 100 times during the EHR reporting period is excluded from all three measures.

Menu set for Stage 1 and Core for Stage 2, Stage 1 was same 50%

10% electronic as well as successful test requirement is NEW!

16. Immunization Registries

Successful ongoing transmission of immunization data

There are 4 exclusions but this one should apply for most:

The EP does not administer any of the immunizations to any of the populations for which data is collected by their jurisdiction’s immunization registry or immunization information system during the EHR reporting period

Menu set for Stage 1 and Core for Stage 2

Stage 1 was a test where Stage 2 is on-going submission

17. Secure Messaging

A secure message was sent using the electronic messaging function of CEHRT by more than 5% of unique patients (or their authorized representatives) seen by the EP during the EHR reporting period

Any EP who has no office visits during the EHR reporting period, or any EP who conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 3Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period

NEW!


STAGE 2 - 6 MENU SET MEASURES (CHOOSE 3)

Menu Objective

Measure Description

Exclusions

Stage 1 Comparison

1. Syndromic Surveillance

Successful ongoing transmission of syndromic surveillance data

EP is not in a category of providers that collect ambulatory syndromic surveillance information on their patients during the EHR reporting period;

EP operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data in the specific standards required by CEHRT at the start of their EHR reporting period;

EP operates in a jurisdiction where no public health agency provides information timely on capability to receive syndromic surveillance data; or

EP operates in a jurisdiction for which no public health agency that is capable of accepting the specific standards required by CEHRT at the start of their EHR reporting period can enroll additional EPs

Menu set for Stage 1 and Stage 2

Stage 1 was a test where Stage 2 is on-going submission

2. Electronic Notes

Enter at least one electronic progress note created, edited and signed by an EP for more than 30% of unique patients with at least one office visit during the EHR reporting period.

NONE

NEW!

3. Imaging Results

More than 10% of all tests whose result is one or more images ordered by the EP during the EHR reporting period are accessible through CEHRT

Any EP who orders less than 100 tests whose result is an image during the EHR reporting period; or any EP who has no access to electronic imaging results at the start of the EHR reporting period

NEW!

4. Family History

More than 20% of all unique patients seen by the EP during the EHR reporting period have a structured data entry for one or more first-degree relatives

Any EP who has no office visits during the EHR reporting period

NEW!

EHR must use SNOMED CT or HL7 Pedigree for family history

5. Cancer Registries

Successful ongoing transmission of cancer case information

There are several exclusions but this may be the most common:

EP does not diagnose or directly treat cancer

Note: if you do diagnose and/ or treat cancer check with your state registry for more information

NEW!

6. Specialized Registry

Successful ongoing transmission of data to a specialized registry

There are several available exclusions, but the AAO IRIS registry is a specialized registry available to meet this measure.

NEW!

Ms. Shewmaker has spent 17 years on the front lines of electronic health record design and implementation. She recently left her position as VP of product development and is focusing on ophthalmic practice consultations, education and compliance. Contact Darla at Darla@destinationsconsulting.com.