The good, the bad and the ugly of Stage 3 MU

An analysis of the many facets of Stage 3's 700-plus pages, co-written with Massachusetts eHealth Collaborative CEO Micky Tripathi
By John Halamka
10:40 AM
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On Friday, March 20, CMS released the Electronic Health Record Incentive Program-Stage 3, and ONC released the 2015 Edition Health Information Technology Certification Criteria, 2015 Edition Base Electronic Health Record Definition, and ONC Health IT Certification Program Modifications.
Perhaps the most important statement in the entire 700+ pages is the following from the CMS rule: "Stage 3 of meaningful use is expected to be the final stage and would incorporate portions of the prior stages into its requirements."
Providers and vendors alike were all hoping for something lean and clean. The CMS Stage 3 rule weighs in at 301 pages, but the ONC certification rule takes the cake at 431 pages. The JASON Task Force, whose recommendations were unanimously approved by the HIT Standards and Policy Committees, recommended that ONC and CMS make an explicit trade-off: Decrease the breadth and complexity of the MU program, and in return, increase the expectations in a few key areas, such as interoperability. The CMS MU Stage 3 rule, for the most part, has adopted this philosophy. Unfortunately, the same can't be said for the ONC certification rule.
We provide a brief synopsis of the MU and certification rules below, followed by our analysis of these proposals.
CMS Stage 3 MU Rule Synposis
The CMS meaningful use rule is focused and narrowed to eight objectives.
There is some fine-print though. Contained within many of the objectives are multiple measures.  Depending on which options one chooses, and whether you are a provider or a hospital, the total number of MU measures could range from 15 to 20, and that's NOT INCLUDING the clinical quality measures, which have always been like a MU menu all of their own, and which are now going to be determined through a different process and won't be defined until later in 2015.
Here is a synopsis of the MU Stage 3 requirements:
Provider-facing EHR functions:
*ePrescribing: The thresholds have increased to 80 percent for EPs and 25 percent for EHs, but overall this is just asking for more of the same. Of note is that controlled substance prescriptions can now be optionally included in states where it is allowed electronically.
*Clinical decision support: There are two measures: 1) implement five CDS interventions tied to four quality measures; and 2) turn on drug-drug and drug-allergy interaction alerts for the entire EHR reporting period. This is aligned with the past trajectory from earlier stages.
*CPOE: There are three measures: Use CPOE on at least 80 percent of medication orders, 60 percent of lab orders, and 60 percent of diagnostic imaging orders. CMS has given a little flexibility here by now counting entry by "scribes" (personnel with at least a medical assistant credential), excluding standing orders, and including a broader array of imaging such as ultrasound, MRIs, and computed tomography.
Patient-facing EHR functions:
*Patient access to information: There are two measures: 1) 80 percent of patients must be able to access their records either through the View/Download/Transmit function or through an ONC-certified API; and 2) give 35 percent of patients access to patient-specific educational resources. Note, this objective just requires that access is provided to patients. No patient action is required in order to meet these objectives
*Active patient engagement: There are three measures: 1) 25 percent of patients must access their records either through View/Download/Transmit or through an ONC-certified API; 2) 35 percent of patients must receive a clinically-relevant secure message; and 3) provider must incorporate information from patients or "non-clinical" settings for 15 percent of patients. These measures do require patient action, though there is some flexibility because provider-initiated messages now count toward the secure messaging measure, for example. The most challenging measure will be the last one, which requires patient-generated data or data from non-clinical settings such as home health, physical therapy, etc.
*Health information exchange: There are three measures: 1) Send electronic summary for 50 percent of TOCs and referrals; 2) Get electronic summary for 40 percent of TOCs and referrals; and 3) Perform med/allergy/problem reconciliation for 80 percent of TOCs and referrals.
*Public health and clinical data registry reporting: There are six measures. "Active engagement" is required for: 1) immunizations; 2) syndromic surveillance; 3) reportable conditions case reporting; 4) public health registries; 5) non-public health registries; 6) electronic lab reporting. EPs need to choose three out of 1-5, and EHs need to choose four out of 1-6. Having witnessed that that there is wide variability in public health capacity across the country, CMS has provided some flexibility here by defining "active engagement" broadly to include either registering, testing or transacting. In short, you'll get credit even if you're not actively transacting as long as you are on the path and making a good faith effort.
The CMS rule is laid out logically and pretty easy to follow. (That is, for a 300+ page federal regulation.)

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