Wednesday, September 19, 2012

The September HIT Standards Committee Meeting

We began the meeting by noting this was the 40th meeting of the HIT Standards Committee and the bulk of the meeting was spent thoroughly reviewing the Stage 2 ONC and CMS rules so that all members can evangelize about the accomplishments of the past 3 years, ensuring every stakeholder understands the amount of work done to specify content, vocabulary and transport standards for healthcare.   Given the hundreds of pages of detailed regulations outlining very specific standards developed by hundreds of people working thousands of hours, we were confused by yesterday's Wall Street Journal article which noted:

"The industry could not agree on data standards - for instance on how to record blood pressure or list patients' problems"

Those standards were finished and included in the Stage 2 Standards and Certification Final Rule

"Instead of demanding unified standards, the government has largely left it to vendors who declined to cooperate, thereby ensuring years of non communication and non coordination"

For Stage 2, interoperability testing will be done by government authorized bodies using standards mandating by government.

Armed with the details of the Stage 2 rules, the members will ensure such mis-information is not promulgated.

Travis Broome from CMS began the meeting with an overview of the Stage 2 CMS rule.   He noted that the schedule is highly customizable such that a clinician begins and proceeds at a pace that works for his/her practice.  He noted the 2014 reporting period was changed to 90 days instead of a year to enable more flexibility in implementation of Stage 2 technologies.

He outlined the 17 eligible professional core measures

Use CPOE for more than 60% of medication, 30% of laboratory, and 30% of radiology

E-Rx for more than 50% - controlled substances are optional

Record demographics for more than 80%

Record vital signs for more than 80%

Record smoking status for more than 80%

Implement 5 clinical decision support interventions + drug/drug and drug/allergy

Incorporate lab results for more than 55%

Generate patient list by specific condition

Use EHR to identify and provide reminders for preventive/follow-up care for more than 10% of patients with two or more office visits in the last 2 years

Provide online access to health information for more than 50% with more than 5% actually accessing

Provide office visit summaries for more than 50% of office visits

Use EHR to identify and provide education resources more than 10%

More than 5% of patients send secure messages to their EP

Medication reconciliation at more than 50% of transitions of care

Provide summary of care document for more than 50% of transitions of care and referrals with 10% sent electronically and at least one sent to a recipient with a different EHR vendor or successfully testing with CMS test EHR

Successful ongoing transmission of immunization data

Conduct or review security analysis and incorporate in risk management process

The eligible professional menu set measures (pick 3 of 6) are:

More than 10% of imaging results are accessible through Certified EHR Technology

Record family health history for more than 20%

Successful ongoing transmission of syndromic surveillance data

Successful ongoing transmission of cancer case information

Successful ongoing transmission of data to a specialized registry

Enter an electronic progress note for more than 30% of unique patients

The Hospital Core objectives are:

Use CPOE for more than 60% of medication, 30% of laboratory, and 30% of radiology

Record demographics for more than 80%

Record vital signs for more than 80%

Record smoking status for more than 80%

Implement 5 clinical decision support interventions + drug/drug and drug/allergy

Incorporate lab results for more than 55%

Generate patient list by specific condition

eMAR is implemented and used for more than 10% of medication orders

Provide online access to health information for more than 50% with more than 5% actually accessing

Use EHR to identify and provide education resources more than 10%

Medication reconciliation at more than 50% of transitions of care

Provide summary of care document for more than 50% of transitions of care and referrals with 10% sent electronically and at least one sent to a recipient with a different EHR vendor or successfully testing with CMS test EHR

Successful ongoing transmission of immunization data

Successful ongoing submission of reportable laboratory results

Successful ongoing submission of electronic syndromic surveillance data

Conduct or review security analysis and incorporate in risk management process


The hospital menu set measures (pick 3 of 6) are:


Enter an electronic progress note for more than 30% of unique patients

More than 10% electronic prescribing (eRx) of discharge medication orders

More than 10% of imaging results are accessible through Certified EHR Technology

Record family health history for more than 20%

Record advanced directives for more than 50% of patients 65 years or older

Provide structured electronic lab results to EPs for more than 20%

He highlighted the patient engagement and electronic exchange requirements that ensure EHRs must actively share data among payers, providers, and patients before stimulus payments are made to hospitals or professionals.

We discussed the fact that lab results transmission only includes those ordered electronically and this could be challenging because many hospitals receive orders manually and return results electronically.   We also discussed the hardship exceptions for Pathologists, Radiologists,  and Anesthesiologists.

Steve Posnack then reviewed the standards rule, noting that it includes 5 major themes - enhancing standards-based exchange, promoting EHR technolog/safety, enabling greater patient engagement, introducing greater transparency, and reducing regulatory burden.

There are 50 certification criteria - 17 clinical, 7 care coordination, 3 clinical quality measures, 9 privacy/security, 3 patient engagement, 6 public health, and 4 utilization

Standards include a common MU Data set - including standards for Problems and Vital signs, which were two items called "without standard" in the Wall Street Journal article referenced above.

slides 16-18 in his presentation nicely summarize these standards

Certification can be "right sized" to align vendor capabilities with customer needs.  For example, BIDMC could elect not to do advance directives, progress notes, or lab transmissions (since it requires receiving incoming electronic orders to qualify and EHRs in the community may not be able to send them), BIDMC would not have to create or certify technologies for menu set items it does not plan to use in attestation

Farzad noted that based on very valuable feedback on the Governance RFI, there will be more focused work on certificate management, provider directories, and helpful convening instead of writing regulation for the NwHIN.   All concurred that this was a good approach.

Liz Johnson and Cris Ross presented an Implementation Workgroup Update on Testing Methods.
They highlighted the notion of scenario based testing - a workflow that requires the execution of multiple related actions.  Chris Brancato presented a medication management example  illustrating how building blocks of unit testing can be assembled into a single logical progression that aligns with workflow.  Carol Bean noted that the next wave of testing procedures, test data , and test tools will be released this Friday.

Finally, Doug Fridsma, provided an update on ONC Standards Activities, highlighting the new Health eDecisions and Automate Blue Button Initiative.

A great meeting demonstrating very important progress.   It's clear to me that Meaningful Use Stage 2 and its associated testing criteria accelerate interoperability more than any previous initiative.


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