A first glance at the stage 1 core and menu set objectives makes sense for primary care, but what about specialists? Not too many ophthalmologists perform immunizations. Probably not many psychiatrists are routinely obtaining vital signs on their patients. What about radiologists,chiropractors, or urologists? How will these potential eligible professionals, or EPs, meet the requirements of meaningful use? This is one area that the rules and regulations have been modified based on comments from stakeholders. Specialists can claim exceptions to meaningful use criteria that don't apply to their specialty as well as enjoy great flexibility in the reporting requirements for quality measures. EPs that are specialists can still achieve the CMS incentives based on the flexibility that is incorporated into two primary areas: menu exclusions and quality measures.
Core and menu set exclusions
There are numerous exclusions and provisions that will allow specialists to meet meaningful use guidelines without having to change the way they practice health care. If EPs cannot meet a specific meaningful use objective because it is outside the scope of their practice, they may be allowed to exclude that objective. Even better, an objective that is excluded can count the same as if that objective was met. In the menu set, where the EP must choose five of the 10 objectives, if two of the objectives don't apply, that EP would then only have to meet three of the remaining menu set objectives.
- Computerized Provider Order Entry (CPOE): Any EP who writes fewer than 100 prescriptions during the EHR reporting period;
- Generate and transmit permissible prescriptions electronically (eRx): Any EP who writes fewer than 100 prescriptions during the EHR reporting period;
- Record and chart vital signs: Any EP who sees only patients 2 years old or younger. Any EP who believes that all three vital signs of height, weight and blood pressure have no relevance to their scope of practice may attest and be excluded;
- Record smoking status for patients 13 years or older: Any EP who sees no patients 13 years or older;
- Provide patients with an electronic copy of their health information: Any EP that has no requests from patients or their agents for an electronic copy of patient health information during the EHR reporting period;
- Clinical summaries provided to patients for all office visits: Any EPs who have no office visits during the EHR reporting period;
- Implement drug-formulary checks: Any EP who writes fewer than 100 prescriptions during the EHR reporting period;
- Lab results: Any EP who orders no lab tests whose results are either in a positive/negative or negative numeric format during the EHR reporting period;
- Send reminders to patients based on patient preferences and selected by specific criteria: Any EP who has no patients 65 years old or older or 5 years old or younger;
- Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, medication allergies) within 4 business days of the information being available to the EP: Any EP who neither orders nor creates any of the information listed in the ONC Final Rule 45 CFR 170.304 (g). (lab test results, problem list, medication list and medication allergy list);
- Perform medication reconciliation: Any EP who was not the recipient of any transitions of care during the EHR reporting period;
- Provide summary care record for each transition of care: Any EP who does not transfer a patient to another setting or refer a patient to another provider during the EHR reporting period;
- Capability to submit electronic data to immunization registries: Any EP who has not given any immunizations during the EHR reporting period;
- Capability to submit electronic syndromic surveillance data to public health agencies: Any EP who does not collect any reportable syndromic information on their patients during the EHR reporting period.
Is it OK to report zero for all [quality] measures if no measures apply? The answer is yes and is clearly defined in the CMS guidance.
This is an area that has generated concern for all EPs and specialists in particular. The requirements are clear that the quality measures objective cannot be excluded and must be reported. But what if the required core, alternate core, or other measures do not encompass the type of patients that an EP typically sees? Is it OK to report a zero? Is it OK to report zero for all measures if no measures apply? The answer is yes and is clearly defined in the CMS guidance.
The definition of what constitutes a "patient encounter" is critical to the ability of many specialists to develop a strategy to successfully meet meaningful use and receive the CMS EHR incentives. Much of the documentation and attestation of "meaningful use" is based on "patient encounters." A patient encounter for an internist or general practitioner is obvious. But it is not so obvious for some specialists. If a patient is referred to an ambulatory surgical center and a gastroenterologist performs a colonoscopy, is that a patient encounter? If a radiologist reviews and provides an impression of an image should that be counted as a "unique patient seen?" If a cardiologist reviews an EKG but never sees the actual patient, is that an encounter? If these events are classified as patient encounters that could be very problematic for specialists because in these scenarios it might be difficult to meet numerous MU measures simply because they might not have access to the type of data required for these patients to document meaningful use. Such EP measures as vitals, problem list and medication allergy list might be impossible to meet for these patients because the specialist would not have access to that type of information. If these patients must be included in the denominator of meaningful use calculations, that would spell failure for many attempts by specialists to obtain the CMS incentives. CMS has weighed in on this issue and the news is good for specialists. In response to a request for clarification CMS has stated:
A patient seen through telemedicine would still count as a patient "seen by the EP." However, in cases where the EP and the patient do not have an actual physical or telemedicine encounter, but the EP renders a minimal consultative service for the patient (like reading an EKG), the EP may choose whether to include the patient in the denominator as "seen by the EP" provided the choice is consistent for the entire EHR reporting period and for all relevant meaningful use measures. For example, a cardiologist may choose to exclude patients for whom they provide a one-time reading of an EKG sent to them from another provider, but include more involved consultative services as long as the policy is consistent for the entire EHR reporting period and for all meaningful use measures that include patients "seen by the EP." EPs who never have a physical or telemedicine interaction with patients must adopt a policy that classifies as least some of the services they render for patients as "seen by the EP" and this policy must be consistent for the entire EHR reporting period and across meaningful use measures that involve patients "seen by the EP" -- otherwise, these EPs would not be able to satisfy meaningful use, as they would have denominators of zero for some measures.
Let us know what you think about the book excerpt; email Anne Steciw, Associate Editor.