Are your spidey senses tingling yet? Meaningful Use Stage 2 attestations are right around the corner, and while Stage 2 isn’t the Green Goblin or Doctor Octopus (I promise!), Meaningful Use (MU) can seem like the villian when it comes to remembering what to document, when to document it, and how to document it to get it to count.
So, if Stage 2 is the villian, guess who gets to be the superhero?
Let’s start by taking Uncle Ben’s advice, “With great power comes great responsibility.” And the first responsibility you’ll have as “MU Man” or “MU Woman” is learning everything you can about the requirements for attestation.
We will soon be posting a training presentation (eligible for CME credit) which will detail what and how to document the Stage 2 requirements, but as a quick summary, below are the 17 core measures and 3 menu measures that are required for Stage 2.

Stage 2 Core and Menu Measures

Core Objectives (17 total)
(1) Use computerized provider order entry (CPOE) for medication (>60%), laboratory (>30%) and radiology orders (>30%) directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local, and professional guidelines.

(2) Generate and transmit permissible prescriptions electronically (>50%).

(3) Record the following demographics: preferred language, sex, race, ethnicity, and date of birth (>80%).

(4) Record and chart changes in the following 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 (>80%).

(5) Record smoking status for patients 13 years old or older (>80%).

(6) Use 5 clinical decision support interventions to improve performance on high-priority health conditions (these must be related to Clinical Quality Measures) AND enable and implement drug-drug and drug-allergy checks.

(7) Provide patients the ability to view online, download, and transmit their health information within four business days of the information being available to the EP (>50%).

(8) Provide clinical summaries for patients for each office visit (>50%).

(9) Protect electronic health information created or maintained by the Certified EHR Technology through the implementation of appropriate technical capabilities.

(10) Incorporate clinical lab-test results into Certified EHR Technology as structured data (>55%).

(11) Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach.

(12) Use clinically relevant information to identify pa­tients who should receive reminders for preventive/follow-up care and send these patients the reminders, per patient preference (>10%).

(13) Use clinically relevant information from Certified EHR Technology to identify patient-specific education resources and provide those resources to the patient (>10%).

(14) The EP who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation.

(15) The EP who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide a summary care record for each transition of care or referral (>50%).(16) Capability to submit electronic data to immunization registries or immunization information systems except where prohibited, and in accordance with applicable law and practice (Yes/No).

(17) Use secure electronic messaging to communicate with patients on relevant health information (>5%).

Eligible Professional Menu Objectives (3 of 6)
(1) Record electronic notes in patient records (>30%).

(2) Imaging results consisting of the image itself and any explanation or other accompanying information are acces­sible through CEHRT (>10%).

(3) Record patient family health history (1st degree rela­tive) as structured data (>20%) .

If you’re still learning the ropes on how to use your su­perpowers (a.k.a. EHR documentation skills), this Stage 2 summary may have you rethinking your superhero status, but no one ever promised saving the world was easy.
And I haven’t even mentioned CQMs!

You may have already heard more than you care to about the topic, but like it or not, secure exchange of protected health information is required for HIPAA compliance. Not surprisingly, some of the required measures for achieving Stage 1 and Stage 2 Meaningful Use involve the secure electronic exchange of  patient health information.  Stage 2 Core Measure 17 “Use Secure Electronic Messaging” is a prime example:

The Objective is to use secure electronic messaging to communicate with patients on relevant health information.  A secure message must be sent using the electronic messaging function of the provider’s CEHRT by more than 5 percent of unique patients seen by the eligible provider (EP) during the reporting period. 

A Secure Message is defined as  “Any electronic communication between a provider and patient that ensures only those parties can access the communication. This electronic message could be 1) email, 2) the electronic messaging function of a PHR, 3) an online patient portal, or 4) any other electronic means. An EP or staff member can follow-up with a telephone call or office visit if deemed more appropriate to address the concerns raised in the patient’s e-message. And don’t get too panicking just yet if you’re thinking what a lot of other providers are thinking, “Yikes! Email from patients?!”. . .There isn’t a requirement that the EP must personally respond to electronic messages to the patient. Designated office staff can manage the email under the supervision of the physician.
As Quillen ETSU Physicians prepares to meet the requirements of this measure and to comply with the HIPPA Security Rule, we have started the process of registering our users in the Direct Project.  If you’ve been asked to send us your driver’s license and ETSU ID, then you’re on your way to being registered. The Direct Project offers providers a secure way to send protected health information, including clinical summaries, continuity of care documents (CCDs), and laboratory results, to other providers who also have a Direct address. Presently, we are participating in the most basic implementation of the Direct Project, a secure email system via an email client, which works just like regular email, but with an added level of security required to transport sensitive health information.
Over the next few weeks, some of our users will be receiving an email much like the one you see below. Once you receive it, you’ll be asked in another email by the EHR administrator to forward it to her. She’ll be providing you with additional information for using it later.
Admittedly, there are many changes going on in healthcare right now, which may have you feeling overwhelmed. But, what I keep reminding myself—as I try to muddle through and stay current in serving our users—is that these changes are being implemented for improved quality of patient care and, eventually, to make providing that care to our patients more convenient for everyone.
It wasn’t too long ago that we all heard the chime, “You’ve got mail!” as we logged into our AOL accounts through our dial-up modems (can you remember how slow that connection was?). Now we are blazing across the internet on our smart phones and tablets, with instant access to almost any information we need, including patient health records.
Healthcare technology’s day will soon arrive and all of the changes that are being implemented now will seem routine and outdated as we continue to move forward. Rather than having to leave voicemails, send faxes, call the pharmacy again and again, or wait on a patient’s return call, wait on a fax, or wait on the pharmacy to call you back, the exchange of secure information will be at your fingertips and as fast as you can say, “You’ve Got Secure Mail.”

Perhaps an analogy to cycling and Lance Armstrong may not seem the most appropriate of comparisons, considering the recent news of his steroid abuse, but for some providers, making sense of the different rules, requirements, and stages—and having to manage these in clinics—may seem just as deflating as Armstrong’s stripping of his accolades, and just as tough as having to compete in the Tour de France.

As a multi-specialty, multi-provider practice, Quillen ETSU Physicians will be pursuing stages of meaningful use in various years, and the criteria that must be met is determined by the stage of  the eligible provider’s (EP’s) participation (either Stage 1, Stage 2, or Stage 3). EP’s progress through six years of the program—two payment years in each stage.

Each month, in our newsletter and here on our blog, we provide information and updates  on the EHR Incentive Program, as a “roadmap,” so to speak, as we make this journey together.

The Centers for Medicare and Medicaid Services (CMS) recently updated the criteria for Stage 1 Meaningful Use (MU) for 2013 and beyond. For most of our EPs, these changes will not affect their 2012 attestations.  If an EP is pursuing his or her first or second payment year of Stage 1 in 2013, respectively, the following updates do apply.

Minor Updates
Core Measure 1: More than 30 percent of all unique patients with at least one medication in their medication list seen by the EP have at least one medication order entered using CPOE.

The Update: This particular update (in the form of an alternative measure) took effect in September 2012. EPs have the option to use the alternate measure with a denominator of all medication orders created by the EP during the EHR reporting period.  EPs should choose whichever measure (the original or alternative) works best for them.

How this effects you: As a multi-specialty organization, we often share patients among our providers. Being able to choose the alternate will help the percentages of many of our specialists.

Core Measure 4: More than 40 percent of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology.

The Update: A new exclusion has been added for EPs who qualify. Along with the previous exclusion of  “any EP who writes fewer than 100 prescriptions during the EHR reporting period,” now “any EP who does not have a pharmacy within their organization and there are no pharmacies that accept electronic prescriptions within 10 miles of the EP’s practice location at the start of his/her reporting period” can also be excluded.

How this effects you:  This update will not affect us. We have several pharmacies near our offices.

Core Measure 8: For more than 50 percent of all unique patients age 2 and over seen by the EP, height, weight, and blood pressure are recorded as structured data/ More than 50 percent of all unique patients seen by the EP during the EHR reporting period have blood pressure (for patients age 3 and over) and height and weight (for all ages) recorded as structured data.

The Update: Even Tenncare describes this change as complicated, but basically, in 2013, EPs will have a choice to separate the measure and exclusions. Blood pressure can be separated from height and weight, and EPs can specify an age range of 3 and up for blood pressure.

How this effects you: This change will be particularly welcomed by our pediatricians, as well as specialty providers, for whom these vitals are not applicable to their scope of practice.

Core Measure 10: Successfully report to CMS ambulatory clinical quality measures selected by CMS in the manner specified by CMS.

How this effects you: Core Measure 10 will no longer be listed as a measure. In 2013, providers will simply report the clinical quality measures rather than attest to a separate measure.

Menu Measure 9: Performed at least one test of certified EHR technology’s capacity to submit electronic data to immunization registries and follow up submissions if the test is successful (unless none of the immunization registries to which the EP submits such information has the capacity to receive the information electronically).

The Update:  The verbiage “except where prohibited” was added by CMS for understanding that if EPs are “authorized to submit the data, they should do so even if it is not required by either law or practice.” Technically, this update is not a change but a clarification

How this effects you:  It doesn’t. We are NOT prohibited to submit data and are working with the state of Tennessee to have our immunizations sent directly to their registry.

Menu Measure 10: Performed at least one test of the certifies EHR technology’s capacity to provide electronic syndromic surveillance data to public health agencies and follow-up submission if the test is successful (unless none of the public health agencies to which an EP submits such information has the capacity to receive the information electronically)

How this effects you:  It doesn’t. The change is the same as in Menu Measure 9; however, the Tennessee Office of E-Health Initiatives (TDOH )is not currently participating in testing Syndromic Surveillance messages for Meaningful Use.

Major Update

Core Measure 14: Performed at least one test of certified EHR technology’s capacity to electronically exchange key clinical information.

The Update: Beginning in 2013 and beyond, this objective and measure will not be required for 2013 and beyond. This objective and measure will still be a part of the core set for anyone attesting to Stage 1 MU for 2012, but CMS felt that preparing for Stage 2’s emphasis on exchanging data was incentive enough for EPs to start testing this capability.

How this effects you:  Look for updates and improvements on Quillen’s ability to exchange data, as the beginning of Stage 2 begins in 2014.

I have a “To Do” list of EHR requests, as well as a “To Do” list for all the stuff that needs to be done at home (and both lists can get quite long –with approximately 1200 EHR users and three busy kids!). I’m sure that you also have similar lists.

So, when it comes time to maintain more lists (problem lists, allergy lists, medication lists, etc), I can imagine your response is less than enthusiastic. But lists tend to be generated for a purpose. I know without mine, I would forget many of the things I put on them (and my kids would probably go hungry because I would forget to pay their lunch money). Lists in the EHR, obviously, help us keep up with our patients’ current diagnoses, medical histories, medications, and allergies. With the patient volume many of our clinics handle, keeping lists is essential for providing quality patient care.

That’s why maintaining and reconciling lists is part of the core objectives for Meaningful Use.


Maintain an up-to-date problem list of current and active diagnoses.

Maintain active medication list.

Maintain active medication allergy list.

According to the TennCare website, the up-to-date problem list measure requires that “MORE THAN 80 percent of all unique patients seen by the EP have at least one entry or an indication that no problems are known for the patient as structured data.” So what exactly does this mean? Simply put, active problems need to be entered on the Clinical Desktop (i.e. electronic chart) for your patients, and if by chance they have no active problems? That needs to be recorded as well (For our Allscripst users, ‘No Active Problems’ should be a quick list item in the ACI). And take note of the word CURRENT. If the patient comes back to see you for a follow up or office visit, and the rash associated with poison ivy from the last visit is still listed as an active problem, then resolve it. If the patient is pregnant—and delivers— then resolve it.

Additionally, “more than 80 percent of all unique patients seen by the EP must have at least one entry (or an indication that the patient is not currently prescribed any medication) recorded as structured data.” The same requirement is true for allergies.

The Allscripts system makes it easy enough to reconcile these lists, but when you click on Reconcile, remember that you are stamping the list as up-to-date. You must take the time to review the lists with the patient and make sure that all medications and allergies are accurate. Otherwise, when you click on reconcile and you have not truly “reconciled" it, you are falsely documenting in the chart. We have seen time and time again where duplicate meds and expired meds are still on a list that has been stamped as reconciled.

As I mentioned in my last post, clinics must work on office workflows to ensure that someone is going over these lists with the patient at each visit, whether it’s the nurse or the provider.  We encourage spot checking daily schedules and lists to ensure accuracy. And if you can’t remember this recommendation, how about adding it to your “To-Do” list? 

So far, we have covered the first 10 core objectives for meaningful use. Below are the additional 5 required core objectives:

11.  Implement one clinical decision support rule relevant to specialty or high clinical importance, along with the ability to track compliance with the rule. I was a bit confused by the term ‘clinical decision support’ so I checked the CMS definition. Translation—it’s the ability of the EHR technology to provide healthcare personnel with organized, “intelligently” filtered information that improves patient care. For example, if a patient is due for a flu vaccine, the system alerts the provider that he/she should talk to the patient about getting vaccinated. To meet this objective, providers must decide what clinical decision support rule they want to implement, and then track its effectiveness. A couple of things the EP must keep in mind—the rule must be related to their specialty or of high priority to the clinic, and the rule has to be conditional on patient-specific information (i.e. A reminder to ask about the flu vaccine for every patient doesn’t count; the reminder should be generated based on the patient’s demographics and immunization record).

Examples of a clinical decision support rule that would meet the requirements of this objective: 
--For diabetic patients, an alert to order a hemoglobin A1c test if there hasn’t been one ordered in the past six months.
--For men and women 50 and over who have never had a colonoscopy or haven’t had one in the last 5 years, an alert to remind the provider to discuss ordering one. 

12. Provide patients with an electronic copy of their health information upon request within 3 business days. This objective is often confused with core objective #13 (see below); however, these two objectives are distinctly different. The biggest difference is that this objective applies to requests for the health information, which includes diagnostic test results, problem list, medication lists, and medication allergies. Most offices already have a policy in place for providing this information to patients in a timely manner upon request, as outlined by the HIPAA Privacy Rule.

13. Provide clinical summaries for patients for each office visit within 3 business days. Unlike Core Objective #12, this objective requires that clinical summaries be provided for greater than 50% of all patient visits, and the patient isn’t required to request it—they must be asked if they would like to receive one. One of the challenges related to this objective is determining the workflow for providing the summary. When our Quillen users upgrade to the new version of the EHR, clinical summaries will be automatically generated based on the information charted during the encounter. For the summary to be completely up-to-date, providers will need to finish charting before the patients leaves; otherwise, the summary will need to be mailed, which will increase postage costs for the office. As defined by CMS, the clinical summary most include the following information:

·         patient name
·         provider’s office contact information
·         date and location of visit
·         updated medication list
·         updated vitals
·         reason(s) for visit
·         procedures and other instructions based on clinical discussions that took place during the office visit
·         any updates to a problem list
·         immunizations or medications administered during visit
·         summary of topics covered/considered during visit
·         time and location of next appointment/testing, if scheduled
·         a recommended appointment time if, not scheduled
·         list of other appointments and tests that the patient needs to schedule with contact information
·         recommended patient decision aids
·         laboratory and other diagnostic test orders, test/laboratory results (if received before 24 hours after visit)
·         symptoms

14. Capability to exchange key clinical information among providers of care and patient authorized legal entities electronically. To meet this objective, the only requirement is to perform at least one test of the capability of the EHR system to exchange the information. However, there are two particulars that providers should keep in mind: (1) key clinical information that is “structured data” before it leaves the system should be received as “structured data.” Basically, the information that is received needs to stay formatted if it was sent formatted; and (2) “legal entities” above applies to providers that are not using the same EHR system and that are employed by two separate organizations. For instance, a Quillen doctor exchanging information with another Quillen provider would not count, but a Quillen doctor exchanging information with a HMG provider would count because Quillen and HMG are two different legal entities.

15. Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities. This objective can get a bit technical and is best left to the IT folks to monitor. For the most part, though, protecting security involves controlling access to the system by assigning unique user names and passwords, ensuring that sessions automatically log-off after a predetermined time, encrypting health information, and maintaining audit logs.

So that covers the first 15 required core objectives.
Below is the list of 10 optional or menu objectives from which EPs must choose 5 to meet the meaningful use measures. One of the five must be a public health* objective.

1. Implement drug formulary checks.
2. Incorporate more than 40% of clinical lab-test results into the EHR as structured data.
3. Generate at least one report listing patients of the EP by specific conditions to use for quality improvement, reduction of disparities, research, or outreach.
4.  Send patient reminders per patient preference for preventative/follow-up care. This requires more than 20 % of patients 65 or older or 5 years old or younger.
5.  Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, and allergies) within 4 business days of the information being available to the EP. Think patient portal or personal health record.
6.  Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate (most be more than 10%).
7. The EP who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation. This applies to EPs who are on the receiving end of the transition. The requirement is for more than 50% of patients.
8. The EP who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary care record for each transition of care or referral. Like #8, but applies when the EP transition the patient to someone else. The requirement is for more than 50% of patients.
9. Capability to submit electronic data to immunization registries or immunization information systems and actual submission according to applicable law and practice.*
10. Capability to submit electronic syndromic surveillance data to public health agencies and actual submission according to applicable law and practice.* This objectives applies primarily to Emergency Departments and may be difficult for in-office physicians to implement.

Selecting Menu Objectives

The recommendations for selecting menu objectives are pretty straightforward. Do they apply to your scope of practice? If so, choose the five objectives that already fit into your present workflow, if possible. Some EPs may not qualify for all of the objectives, for which they may be excluded. However, they should still pick five unless they run out of options from which to choose.

As I previously mentioned, there are 15 core objectives that every eligible provider (EP) must report on.  In continuation of my last post, below are the next five objectives:  
 
6. Maintain an active allergy list on more than 80% of all unique patients. See #5. Maintaining an allergy list is a requirement, just as maintaining the medication list is required.  Users will record that the medication list and allergy list has been reviewed by "reconciling" it (i.e. stamping it with a date).
  
7. Record the following demographics: preferred language, gender, race and ethnicity, and date of birth on more than 50% of unique patients. This one is pretty straightforward as well. These demographics are captured by most offices on patient paperwork. The biggest challenge will be making sure that all the information is entered into the computer at each visit.

8. Record and chart vital signs on more than 50% of unique patients age 2 and over. As with #7, most offices already capture this information; however, CMS requires that BMI be calculated and displayed in the chart, as well as the plotting of growth charts (with BMI) for patients ages 2-20.

9. Record smoking status for more than 50% of unique patients 13 and over. Providers must remember to use CMS-acceptable terminology when documenting the smoking status of their patients. These options include
        · Current every day smoker 
        · Current some day smoker 
        · Former smoker 
        · Never smoker
        · Smoker, current status unknown
        · Unknown if ever smoked
Once Quillen users upgrade to the 11.2 version of Allscripts, these will all be designated with MU for acceptable documentation.

10. Report ambulatory clinical quality measures (CQMs) to CMS (or to the State, if Medicaid). These include such measures as adult weight screening, hypertension, and tobacco use intervention. For providers who see pediatric patients, they can choose from immunization status or weight assessment. Another alternate is flu vaccination in patients 50 or older. The list of 38 additional CQMs is available for download at the CMS website. 

In my next post, I'll list the last 5 core objectives, as well as the 10 optional objectives, from which EPs must choose 5.

So exactly how does one define "meaningful use"?
While not everyone who uses EHR may agree on the exact definition, the government hasn't been hesitant to chime in. And why shouldn't they? The whole program has been established to monitor how EHR is improving patient care delivery. 
During each year of participation in the EHR Meaningful Use Incentive Program, eligible providers must report on 20 of 25 specific measures if they want to receive incentive payments for meaningful use of their EHR. These include 15 required core objectives and 5 objectives from a list of 10 optional objectives. They must also report on 6 clinical quality measures from a list of 3 required, 3 alternate, and 38 additional measures.

Confused yet?
This is where meaningful use can get a bit complicated. Some of the measures and objectives can be difficult to understand, and reporting on them is even more complicated. I'll try to explain, but don't be discouraged if they seem a little unclear. Like I mentioned in my previous post, we could all benefit from a class on meaningful use.

Below are the first 5 of 15 core objectives--those that every EP must report on:
1. Use CPOE (computerized physician order entry) for greater than 30% of unique patients with at least one medication in the medication list. So, "CPOE" threw me for a loop. Simply put, the provider should use a computer or mobile device to order a medication or other order (imaging, lab) and record it for more than 30% of his/her patients (and 'unique' means you can't count the patient more than once). It's not exactly the same thing as e-prescribing, which requires sending the script to a pharmacy. See #4.
2. Implement drug-drug and drug-allergy checks. This one's pretty straight forward. Whichever EHR system the provider uses, it must alert the provider regarding drug-to-drug and drug-to-allergy interactions. As long as it's in place for the entire reporting period, then this objective is satisfied.
3. Maintain an up-to-date problem list of current and active diagnoses for more than 80% of unique patients. Basically, this objective requires that the provider enter active and past problems into the patient's medical record. The information can be obtained either from the previous record, a transferred record, the EP's diagnosis, or from asking the patient. Probably the most important thing to remember about this objective is that SOMETHING has to be documented, even if the patient doesn't have any active problems. When our system is upgraded in March, our providers will be able to easily document "no active problems."  Also of note, 'unique', like in #1 above, means a patient can't be counted more than once.
4.  More than 40% of permissible prescriptions written by the provider are generated and transmitted electronically. Very similar to #1, but still unique in that these are actually prescriptions that are sent and received electronically, not just ordered and recorded in the system. Keep in mind, depending on state law, scheduled drugs cannot be sent electronically, so these would not count toward the requirement.
5. Maintain an active medication list on 80% of all unique patients. As with #3, something has to be recorded, even if the patient has no active meds, and remember the definition of 'unique'--CMS isn't talking encounters, they mean individual patients.  

In my next post, I'll list and define the next five objectives...stay tuned.