Briefing

Briefing: Meaningful use criteria, stages 2 and 3

In January the Centers for Medicare & Medicaid Services (CMS) released the proposed Stage 2 and Stage 3 meaningful use criteria in the form of a request for comments. The Health IT Policy Committee

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advising the CMS hopes to finalize the new meaningful use criteria this summer. In addition to a public comment period that ended Feb. 25, the committee intends to host a series of public meetings this spring. (Comments on the Stage 3 criteria will be taken at a later date.)

The meaningful use of electronic health record (EHR) technology was defined in 2009's Health Information Technology for Economic and Clinical Health, or HITECH Act, and the Stage 1 meaningful use criteria were finalized in July 2010.

Some of the Stage 2 meaningful use criteria are continuations of Stage 1, and require hospitals and eligible providers (EPs) to increase the percentage of electronic transactions they conduct. In addition, CMS has proposed moving several criteria from the menu, or optional set of Stage 1 criteria to the core, or required Stage 2 meaningful use criteria. Finally, stages 2 and 3 introduce numerous new requirements.

The chart below lists the proposed Stage 2 and Stage 3 meaningful use criteria. All differences in requirements for hospitals and EPs are indicated. It should be noted that the breakdown of core versus menu meaningful use criteria is subject to change for stages 2 and 3.

This guide is part of SearchHealthIT.com's Briefings series, which is designed to give IT leaders strategic guidance and advice that addresses the management and decision-making aspects of timely topics.

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Core meaningful use criteria

Criterion Stage 1 Stage 2 Stage 3
Implement drug-drug and drug-allergy checks. Enable this feature. Use in appropriate, evidence-based patient interactions. In addition to drug-drug and drug-allergy checking, use drug-age, drug-dose, drug-lab and drug-condition checking in appropriate, evidence-based patient interactions.
Implement one clinical decision support (CDS) rule, including diagnostic test ordering, along with the ability to track compliance with that rule. EPs: Implement rule relevant to specialty or high clinical priority. Hospitals: Implement rule related to a high-priority hospital condition. Use CDS to improve performance on high-priority health conditions. Establish eight CDS attributes for the purposes of certification. (1) Same as Stage 2.
Use a computerized physician order entry (CPOE) system. EPs: Use CPOE for at least 30% of all orders. Hospitals: Use CPOE for 30% of any type of order directly entered by authorizing provider. (2) Use for 60% of all orders. Use for 80% of all orders.
Maintain an up-to-date problem list of current and active diagnoses. (3) Record at least one entry (or an indication of none) as structured data (4) for at least 80% of all unique patients. Same as Stage 1. Same as Stage 1.
Generate and transmit permissible prescriptions electronically (e-prescribing). EPs: Using certified EHR technology, write and transmit electronically at least 40% of all permissible prescriptions. (5) Hospitals: N/A At least 50% of all prescriptions. At least 80% of all prescriptions.
Maintain active medication list. (6) Record at least one entry (or none) for at least 80% of all unique patients. Same as Stage 1. Same as Stage 1.
Maintain active medication allergy list. (3) Record at least one entry (or none) for at least 80% of all unique patients. Same as Stage 1. Same as Stage 1.
Record demographic information. EPs: Record demographic information (preferred language, insurance type, gender, race, ethnicity and date of birth) for at least 50% of unique patients. Hospitals: Record same information required of EPs, as well as date and cause of death if the patient has died. Record for at least 80% of patients. Use data to produce stratified quality reports. Record for at least 90% of patients. Include Institute of Medicine categories. Use data to produce stratified quality reports.
Record and chart changes in vital signs. For at least 50% of all unique patients 2 years of age and older, record height, weight and blood pressure; calculate and display body mass index, and plot and display growth charts for patients 2 years old to 20 years old, including BMI. Record for at least 80% of patients. Record for at least 90% of patients.
Record smoking status for patients 13 years old or older. Record for at least 50% of all unique patients. Record for at least 80% of patients. Record for at least 90% of patients.
Report quality measures to the CMS or to the states. For 2011, submit summary information for clinical quality measures or hospital quality measures to CMS based on the attestation methodology of reporting clinical data. For 2012, submit the measures electronically. (7) Continue this process. Continue this process.
Provide patients with an electronic copy of their personal health information upon request. (8) EPs: Provide information (including diagnostic test results, problem list, medication lists, allergies) to at least 50% of all patients within three business days. Hospitals: Provide the same information required of EPs, as well as discharge summary and procedures. Same as Stage 1. Provide information to at least 90% of patients.
Provide patients with an electronic copy of their discharge instructions and procedures at time of discharge, upon request. (9) EPs: N/A. Hospitals: Provide information to at least 50% of all patients who are discharged and request an electronic copy of their discharge instructions and procedures. EPs: N/A. Hospitals: Provide to at least 80% of patients. EPs: N/A. Hospitals: Provide to at least 90% of patients in the facility's common primary languages. (10)
Provide clinical summaries (11) for patients for each office visit. EPs: Provide clinical summaries for at least 50% of all office visits within three business days. Hospitals: N/A. EPs: Make information relevant to the patient encounter available for viewing and downloading within 24 hours. Follow-up tests should be included in future clinical summaries within four business days. Data should be available in human-readable and structured formats. (12) Hospitals: N/A. Same as Stage 2.
Exchange key clinical information among providers of care and patient-authorized entities electronically. EPs: Test the capacity of a certified EHR system to exchange key clinical information (for example, problem list, medication list, allergies and diagnostic test results) electronically. Hospitals: Key clinical information can include discharge summary, procedures, problem list, medication list, allergies and diagnostic test results. Connect to at least three external providers in one's primary referral network but outside the delivery system that uses the same EHR system; or establish an ongoing, bidirectional connection to at least one health information exchange (HIE). (13) Connect to at least three external providers in one's primary referral network or establish an ongoing, bidirectional connection to at least one HIE.
Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities. Conduct or review a security risk analysis and implement security updates as necessary. (14) Same as Stage 1. Same as Stage 1.

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Proposed core meaningful use criteria

Criterion Stage 1 Stage 2 Stage 3
Implement drug-formulary checks. Enable this function and access at least one internal or external drug formulary. Move to core requirements. Otherwise, same as Stage 1. Check 80% of medication orders against relevant formularies. (15)
Record advance directives for patients 65 years of age or older. EPs: N/A. Hospitals: Do so for at least 50% of patients 65 years of age or older. Move to core requirements and apply to EPs as well as hospitals. Record for 90% of patients. (16)
Incorporate clinical lab-test results into EHR systems as structured data. Incorporate into certified EHR technology more than 40% of all clinical lab-test results that are given in a positive/negative or numerical format. Move to core requirements, but only where results are available. Incorporate 90% of clinical lab-test results, store them as structured data within the EHR system and reconcile them with structured lab orders.
Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, and outreach. Generate at least one report listing patients with a specific condition. Move to core requirements and generate patient lists for more than one condition. Use lists to manage patients with high-priority health conditions.
Send electronic reminders to patients per patient preference for preventive or follow-up care. EPs: Send reminders to at least 20% of all unique patients seen by the EP who are 5 years of age or less, or 65 years of age or older. Hospitals: N/A. Move to core requirements. Otherwise, same as Stage 1. Send preventive or follow-up reminders to 20% of the active patients (17) who prefer to receive their reminders electronically.
Provide summary care record for each transition of care and referral. Do so for at least 50% of transitions and referrals. Move to core requirements. Otherwise, same as Stage 1. Do so for at least 80% of transitions and referrals.
Provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice. Test the EHR system's capacity to provide electronic syndromic surveillance data to public health agencies unless none have the capacity to receive the information electronically. Move to core requirements. Otherwise, same as Stage 1. Testing is mandatory. Results must be submitted if the test is accepted.
Provide electronic submission of reportable lab-test results (as required by state or local law) to public health agencies, and actual submission where it can be received. EPs: N/A. Hospitals: Test the EHR system's capacity to electronically submit reportable lab-test results to public health agencies (unless no agency to which a hospital submits such information can receive the information electronically). EPs: Covered below. Hospitals: Move to core requirements. Otherwise, same as Stage 1. EPs: Covered below. Hospitals: Conduct test.Submit reportable lab-test results and conditions, if accepted electronically. In 30% of reports, include complete contact information for the patient. (18)

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Menu meaningful use criteria

Criterion Stage 1 Stage 2 Stage 3
Use EHR technology to identify patient-specific education resources, and provide those to the patient as appropriate. Provide to more than 10% of patients. Same as Stage 1. Provide to more than 20% of patients as online resources available in the facility's common primary languages. (10)
Provide patients with timely electronic access to their health information. (11) EPs: Provide electronic access to the health information of at least 10% of all unique patients within four business days of that information being made available to the EP. Hospitals: N/A EPs: Make information relevant to the patient encounter available for viewing and downloading within 24 hours. Follow-up tests should be included in future summaries within four business days. Give patients the ability to filter information by such criteria as date and encounter. Data should be available in human-readable and structured formats. (12) Hospitals: N/A. Same as Stage 2.
Perform medication reconciliation at relevant encounters and at each transition of care. Do so for at least 50% of encounters and transitions. Do so for at least 80% of encounters and transitions. Do so for at least 90% of encounters and transitions.
Submit electronic data to immunization registries, and actual submission where required and accepted. Test the EHR system's capacity to submit electronic data to immunization registries. Conduct test. Submit some immunizations on an ongoing basis to the Immunization Information System (IIS), if accepted and as required by law. (19) Conduct test. In addition, submit all immunizations to IIS, if accepted and as required by law. Review IIS records via EHR system.

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Meaningful use criteria new to Stage 2

Criterion Stage 2 Stage 3
Include at least one electronic note (20) per patient visit. EPs: Record for at least 30% of visits. Hospitals: Have a physician, nurse practitioner or physician's assistant record for at least 30% of hospital patient days. EPs: Record for at least 90% of visits. Hospitals: Record for at least 80% of hospital patient days.
Track medication orders using electronic medication administration recording. EPs: N/A. Hospitals: Track 30% of medication orders. EPs: N/A. Hospitals: Track 80% of inpatient medication orders.
Let patients view and download inpatient summary information (21) through a Web portal. EPs: N/A. Hospitals: Offer this feature to 80% of patients within 36 hours of discharge. Make data available in human-readable and structured formats. (12) Same as Stage 2.
Provide clinical summaries for patients for each office visit. Provide patients with timely electronic access to their health information. (22) EPs: Get 20% of patients to use a Web portal to access their information at least once. Hospitals: N/A. EPs: Get 30% of patients to use a Web portal to access their information at least once. Hospitals: N/A.
Provide online, secure patient messaging. EPs: Use this technology. Hospitals: N/A. Same as Stage 2.
Record a patient's preferred way to be contacted. Record preferred communication medium (17) for 20% of patients. Record preferred communication medium for 80% of patients.
Provide a list of a patient's care team members, including his or her primary care physician. Do so for at least 10% of patients. Make list available in EHR system. Do so for at least 50% of patients. Make list available via electronic exchange.
Provide a longitudinal care plan (23) for patients with high-priority health conditions. Do so for 20% of such patients. Do so for 50% of such patients. Make list available via electronic exchange.
Provide electronic submission of reportable lab-test results (as required by state or local law) to public health agencies, and actual submission where it can be received. EPs: Create a lab reporting menu. Ensure that reportable lab-test results and conditions are submitted, either directly or through lab reporting systems, if accepted electronically. Hospitals: Covered above. EPs: Conduct system test. Ensure that reportable lab-test results and conditions are submitted. Hospitals: Covered above.

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Meaningful use criteria new to Stage 3

The following six meaningful use criteria have been proposed for Stage 3. In each case, CMS is seeking comments on what will be needed in Stage 2 to make the Stage 3 objective possible. All six apply to hospitals and EPs.

  • Offer electronic self-management tools to patients with high-priority health conditions.
  • Give EHR systems the capability to exchange data with personal health record services using standards-based health data exchange.
  • Give patients the ability to report online their experiences based on set care measures.
  • Incorporate into EHR systems and clinical workflows such patient-generated data as home monitoring data and suggestions for error corrections.
  • Test the EHR system's ability to receive and present public health alerts and follow-up requests. Submit, if accepted electronically, notifiable conditions using a reportable "public health button."
  • Submit patient-generated data to public health agencies.

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Public comments on the new meaningful use criteria

CMS accepted public comments on the meaningful use criteria for stages 2 and 3 until Feb. 25. In those comments, health IT professionals are urging policymakers to move forward with Stage 2 slowly.

Among the main concerns, EHR vendors, such as those represented by the Electronic Health Record Association, are asking for clarifications in the standards that accompany the second round of meaningful use requirements.

Providers and the organizations that represent them also are suggesting they have more time to see whether Stage 1 was successful before they dive into Stage 2.

  • "The current meaningful use Stage 2 regulatory timeline provides an inadequate amount of time for eligible hospitals to follow an implementation and testing schedule," the eHealth Initiative wrote in its comments. "A rushed process could potentially affect patient care."
  • The American Medical Association cautioned CMS against implementing "unrealistic" Stage 2 meaningful use criteria, such as high reporting thresholds and those that do not apply to a physician's routine practice.
  • A recent survey by the Certification Commission for Healthcare Information Technology, or CCHIT, pointed to nine Stage 2 meaningful use criteria that at least one-third of respondents had deemed "too aggressive." These criteria -- all of which are extensions of Stage 1 measures -- include syndromic surveillance, medication reconciliation, submission of immunization data and clinical decision support.

In addition, several regulatory processes, such as the ICD-10 conversion, affect the health care industry's ability to comply with meaningful use. Stakeholders are asking the Health IT Policy Committee to take those into consideration when it develops timelines for the final two stages of meaningful use.

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Additional resources

Stage 1 meaningful use criteria (SearchHealthIT.com)

How EHR standards align with meaningful use criteria (SearchHealthIT.com)

Briefing: The meaningful use final rule (SearchHealthIT.com)

Flow chart for EPs to determine meaningful use eligibility (CMS)

Briefing: Getting meaningful use money in five steps (SearchHealthIT.com)

Certified health IT product list (ONC)

Register for the EHR Incentive Programs (CMS)

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Footnotes

(1)   The CDS attributes are authentication, evidence-based credibility, patient-context sensitivity, invocation of relevant knowledge, timeliness, efficiency of workflow, integration with EHR system and presentation to the appropriate party.

(2)   Authorizing providers include doctors of medicine, doctors of osteopathic medicine, registered nurses, physician assistants and nurse practitioners.

(3)   CMS recommends that these lists can be kept up to date easily if they are made part of the patient visit summary and patient care plans.

(4)   Defined as "hav[ing] specified data type and response categories within an electronic record or file."

(5)   If the receiving pharmacy cannot accept electronic prescriptions, automatic generation of an electronic fax is permissible.

(6)   CMS recommends that these can be kept up to date easily through the process of medication reconciliation.

(7)   The Quality Measures Workgroup of the Health IT Policy Committee will consider new measures after the review of public comments.

(8)   This requirement applies only to information already stored in the EHR system.

(9)   Electronic discharge instructions should include a statement of a patient's condition, medication, activity and dietary restrictions, follow-up appointments or tests, pending test results, and referrals. CMS seeks additional comments on these elements.

(10)  According to the Office of Civil Rights, a primary language is one spoken by 5% of the total population eligible to be served by a hospital or by 1,000 people in that population, whichever is less.

(11)  This information includes the date, location and reason for the visit, the provider's name, medical lists, medication allergies, procedures and immunizations administered, vital signs, test results, clinical instructions, follow-up tests or appointments, and patient demographic information. CMS seeks additional comments on these elements.

(12)  The Health IT Standards Committee will define these formats.

(13)  According to CMS, successful HIE will require the development and use of infrastructure, such as an entry-level provider directory.

(14)  The Health IT Policy Committee's Privacy & Security Tiger Team is considering additional privacy and security objectives.

(15)  CMS must determine to what extent formularies are available to EPs.

(16)  CMS has identified several potential issues, including existing state statutes, the challenges this would present to outpatient facilities and specialists, privacy, and the need to define a standard for recording advance directives.

(17)  CMS intends to define this term at a later date.

(18)  Complete contact information includes a patient's address, city and state, and phone number.

(19)  Hospitals and EPs may choose not to send certain data through IIS. The goal of Stage 2 for this criterion, CMS said, is to get EHR users into the habit of reviewing IIS recommendations.

(20)  This note could be scanned into the EHR system or directly entered into the system in a narrative or structured format.

(21)  This information includes the date of admission to and discharge from the hospital, the reason for hospitalization, problem lists, medical lists, medication allergies, procedures and immunizations administered, vital signs at discharge, discharge and care transition instructions, and patient demographic information. CMS seeks additional comments on these elements.

(22)  This requirement, new to Stage 2, sets measures for two meaningful use criteria defined in Stage 1.

(23)  CMS seeks input on what such a plan will entail. Its suggestions include a list of care team members, diagnoses, medications, allergies and the overall goals of a care program.

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Let us know what you think about the briefing; email Brian Eastwood, Site Editor.

This was first published in March 2011

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