Recently, the Meaningful Use Workgroup of the Health IT Policy Committee (a federal advisory committee responsible for recommendations to the Office of the National Coordinator) requested public comment on their proposed Stage Two and Three meaningful use objectives and measures. As the Commission developed its response, in order to better represent the diverse group of health IT stakeholders with whom we work, we fielded a survey requesting that respondents rate the objectives and measures with respect to the ease of implementation – both from the clinical workflow perspective and any technological challenges. Our 468 responders included different types of providers (36%), EHR vendors (29%), and others (29%).
The following measures and objectives were considered to be too aggressive by at least one third of the respondents. Several were considered too aggressive by most of the respondents. Note that all nine are enhancements of existing Stage One objectives and measures, and reflect current experience in the field.
§ Syndromic Surveillance. Over 50% of providers and 40% of vendors and others felt that this was not ready to be a core measure for Stage Two. Public Health agencies, facing budget cuts now, do not have an infrastructure to accept and analyze data; there is no infrastructure to support information exchange from technical and policy perspectives; and the standards and implementation guidance are not sufficiently constrained. The remaining respondents felt that this would require significant investment of resources and effort if it became a core measure.
§ Drug Formulary Checks will require that a large percent of patients seen have formularies available in the system. This will be difficult for certain providers who see patients with a large variety of insurance plans and separate formularies, or who see patients whose formularies are not readily available. A target of 80% was not considered reasonable, even for providers who are using an e-prescribing network to retrieve formulary information. Availability of this information is dependent on making an accurate insurance eligibility match with the patient and insurance companies publishing their formulary through Surescripts and/or a Pharmacy Benefit Manager. There is wide variance in the degree to which both of these conditions are met.
§ Medication Reconciliation. Few settings are actually doing this as part of Meaningful Use Stage One and responders recommended making it core in Stage Two, but not increasing the percent of patients to which it applies (from 50% to 80%) until Stage Three. Limited by lack of good standardized data and HIE, much of the input necessary to perform medication reconciliation is currently manual, even if data are generated elsewhere electronically.
§ Patient Access to Health Information within 4 days. This objective has progressed from providing a “copy of the patient summary” to a “timely access” requirement to the ability of patients to “view on demand.” Any change of this degree which anticipates a final rule in the second quarter 2012, with users live on Stage Two just six months later, is fraught with significant risk. Since the HIT Standards Committee still needs to define standards, there is lack of clarity about what constitutes “relevant” information. The objective will require major workflow change at the provider level and a change of this magnitude at the national level could become a patient safety issue. Respondents recommend staying at Stage One level until this can be further evaluated.
§ Submission of Immunization Data. Ongoing submission of immunization data to state registries is premature given the lack of transmission mechanisms and state systems that can accept these data. Bidirectional flow will require sustainable health information exchange (HIE) models which are in the very early stages of planning and will likely not be ready nationwide by 2014. Respondents recommended no expansion beyond Stage One.
§ Capability to Exchange Key Clinical Information. This measure is similar to the above in that anything beyond using an EHR with the capability to submit data requires significant technological and policy work far beyond the scope of clinical practice and individual providers. Most states have not yet addressed either the policy or technical challenges necessary to create the supporting infrastructure to meet these objectives in either Stage Two or Three.
§ Clinical Decision Support. This is another area where respondents felt that it was premature to go beyond Stage One at this point because a supporting infrastructure is not yet built beyond a few simple decision support rules. Full implementation of sound and reliable clinical decision support (CDS) will need a designated set of evidence based rules that can be incorporated into a decision support structure that integrates with multiple data sources within the EHR. While this may be possible by Stage Three, until this infrastructure can be built, providers should not be held accountable to any CDS beyond what is currently available.
§ Submission of Reportable Lab Data (and reconciliation with orders). Respondents believe that this measure is not appropriate until we have more standardized lab results coding (beyond numerical values), transmission and implementation guidance.
§ Drug Allergy/Etc Checks. Respondents registered minimal concern with this becoming a core requirement in Stage Two. There was, however, significant concern about the Stage Three proposal. Commentary identified that there is no consistent library of evidence- based interactions for more complex interactions and the field is more dynamic than existing technology can accommodate. Basic alert fatigue is a problem must be solved first. Lastly, chemotherapy should not be included in a measure that would be applicable to all providers because of its highly specialized nature.
It is important to note that, in general, respondents believed that the proposed new Stage Two objectives and measures could be accomplished by 2012. Many of the features necessary to meet some of these new objectives and measures were already included in EHRs as part of the pre- HITECH EHR certification process. Concerns were registered, however, with respect to one of the Stage Three enhancements of these measures and objectives: providing educational materials in a common primary language. These could be made available in multiple other ways than through the physician of record and have the potential for errors using current translational technologies.
We also received numerous comments with respect to proposed Stage Three objectives and measures for which Stage Two had not yet been determined. Virtually all reflected the need for further maturation that would take longer than the implementation timeline necessary to have them included in EHR technology by 2014.
Lastly, we received numerous comments about the importance of assuring that finally adopted objectives and measures reflect those processes that are, in fact, in the providers’ control. While many of the objectives, and measures proposed by the Workgroup are laudable in their own right, putting individual providers financially at risk for results beyond their control is counterproductive to the overall goal of widespread provider adoption of HIT that is used in a meaningful manner.
Karen M. Bell, MD, MMS
Chair, Certification Commission
Chair, Certification Commission