HITECH/ARRA
Stage 3: Recommended Changes to Stage 2 Measures and Objectives

Meaningful Use Objectives and Measures: Recommended Changes to Stage 2 Measures and Objectives

Stage 3 raises the bar for what constitutes meaningful use by increasing the thresholds that providers and hospitals must achieve to effectively meet objectives. The committee also expands objectives to improve coordination across providers and hospitals, augment quality and safety at the point of care, reduce disparities, and strengthen patient engagement.  To facilitate these changes, the committee adds certification requirements to ensure that EHRT has the functionality necessary to support its recommendations.

Increase in Threshold Percentages

The HITPC retires several objectives that have “topped out” at 80%. The committee considers 80% the “floor” for meaningful use and suggests that entities who meet this threshold have demonstrated the capability to achieve 100% compliance.4 The committee recommends that the objectives of recording patient demographics, vital signs, and smoking status be retired in Stage 3.  Certification criteria is expanded to include capability to record occupation/industry codes, sexual orientation/gender identity and disability status. The committee also suggests requiring participants to report on the progress of recording vital sign and smoking status as separate clinical quality measures (CQMs). The committee seeks input on whether each measure should be retired, and notes that continuing these measures would necessitate inclusion of an additional number of objectives.

The recommendations increase the threshold percentages of several measures maintained into Stage 3. Stage 2 requires that 60% of medication orders and 30% of both laboratory and radiology orders be created using Computerized Provider Order Entry (CPOE); the committee recommends setting the threshold at 60% for all three order types in Stage 3. Stage 2 requires hospitals to provide electronic lab results to the ordering provider for 20% of electronic lab orders it receives, and requires providers and hospitals to incorporate 55% of lab results into EHRT as structured data; the recommendations for Stage 3 would increase the thresholds for both objectives to 80%. The final Stage 2 rule set the percentage of transitioned or referred patients for whom a summary of care record must be provided at 50%, down from 65% in the proposed rule; in Stage 3, this threshold would be returned to 65%. The committee adds that 30% of such records should be sent electronically, and asks for input on whether this is an appropriate level. Stage 2 requires that 5% of patients use secure e-messaging to communicate with their provider; the recommendations would increase this to 10% for Stage 3, but the committee seeks feedback on the threshold for this objective. Stage 2 expanded the view/download/transmit (VDT) objective, requiring that 50% of patients have online access to their health information, 5% of whom transmit the information to a third party; the recommendations suggest an opportunity to increase either or both of these thresholds based on Stage 2 experiences.

The recommendations also raise the threshold percentages for hospitals’ electronic prescribing (eRx) and use of electronic medication administration records (eMAR) for medication tracking, providers’ sending follow-up/preventive care reminders to patients, and provider and hospital recordation of patient family health history.

Expansion of Objectives, Measures and Certification Criteria

Improving Quality, Safety, and Reducing Disparities

The committee adds a number of features to existing objectives/measures designed to improve the quality and safety of care at the point of delivery. The recommendations would incorporate drug-drug interaction (DDI) checking for “never” combinations into the CPOE requirement for medication orders and expand certification requirements to support this element. Stage 2 requires providers and hospitals to query for a drug formulary before transmitting prescriptions electronically and in Stage 3, providers and hospitals would compare the prescription to at least one drug formulary, including provider review for generic substitutions. The committee seeks input on how to incorporate formulary checking into EHRT. The recommendations would require providers to implement fifteen clinical decision support (CDS) interventions related to five CQMs, compared with just five interventions related to four CQMs in Stage 2, and certification criteria would be expanded to include five broad CDS-related functionalities. Providers must already generate patient lists by specific conditions for use in quality improvement, disparities reduction, research, or outreach reports, and the Stage 3 recommendations would expand this objective by requiring incorporation of near real-time patient-oriented dashboards into the EHRT’s clinical workflow. These dashboards would be used for the same purposes as the patient lists, but would be actionable instead of retrospective.

The committee also recommends more robust certification standards to ensure that EHR products support the provider’s documentation related to problem lists, medication lists, and medication allergy lists, including the ability to reference external lists to make sure that most up-to-date information is utilized at the point of care. The committee seeks feedback on incorporating the expanded criteria for pilot testing.

Patient Engagement and Care Coordination

The recommendations would expand several objectives designed to enhance patient engagement and improve patient outreach. In Stage 3, 80% of the patient-specific education resources that must be provided to 10% of patients in Stage 2 must also be available in at least one of the top five non-English languages spoken nationally. The recommendations would expand the patient reminder objective by requiring providers and hospitals to record communication preferences for 20% of patients. The committee clarifies the objective requiring that clinical summaries be provided to patients by noting that the summary should be pertinent to the office visit, not just an abstract from the medical record. The committee seeks input on what information to include in the summary. The recommendations would also create a menu item within the view/download/transmit objective, wherein 50% of patients must have the ability to designate to whom and when a summary of care document is sent. The committee seeks input on a number of issues related to view/download/transmit.

Care coordination is a primary focus of meaningful use, and is particularly important when transitioning or referring a patient to another setting or provider. The Stage 3 recommendations would require providers to perform reconciliation for medication allergies and problems for 10% of care transitions, in addition to the medication reconciliation they must already perform for 50% of transitions as of Stage 2. The committee requests input on the feasibility of adding other fields for reconciliation. The recommendations would expand the information that providers and hospitals must provide at care transitions to include a care synopsis, setting-specific goals, and instructions for care during the transition.

Population and Public Health

Stage 2 established and strengthened several objectives to improve the population and public health, and Stage 3 broadens these objectives even further. In Stage 2, providers and hospitals must submit electronic data to immunization registries and/or immunization information systems; the Stage 3 recommendations suggest that providers and hospitals should also be able to receive a patient’s immunization history from an external registry/system for use in clinical documentation.  Stage 2 requires providers to identify and report cancer cases to a public health central cancer registry; the committee modifies this objective for Stage 3, so that both providers and hospitals must send reports to a mandated jurisdictional registry, including but not limited to a cancer registry, with an exclusion available when there are no mandated registries, or no capability to receive such reports. Stage 2 requires providers to submit specific case information to specialized registries other than a cancer registry; the Stage 3 recommendations change this objective to require that providers submit reports to an additional registry beyond any prior meaningful use requirements.

The recommendations modify the measures for each expanded objective to include a threshold percentage of patients for whom reports must be submitted and/or received. The committee identifies the need for expanded certification criteria to ensure that EHRT has the requisite functionality and recommends exclusion of certain providers from these requirements.

Transitioning Objectives from MENU to CORE

The committee recommends transitioning several objectives from menu into core. This is significant because in Stage 2, participants were required to satisfy every core objective, but only needed to meet half of the menu objectives of the participants’ choosing.5 The committee recommends designating the following as core objectives; these would no longer be optional for the program participants in Stage 3:

• Accessibility of imaging results through EHRT;
• Recordation of patient family health history;
• Hospital recordation of advance directives for patients 65 and older; and
• Hospital provision of lab results to providers.

The committee requests feedback on the possible barriers that could be encountered in designating the imaging result objective as a core requirement. The committee also recommends making the advance directive objective a menu objective for providers in Stage 3.