Meaningful Use Panel: Stage 3 Update

Arthur Davidson, MD, MSPHDenver Public Health

Council of State and Territorial Epidemiologists Annual Conference

Pasadena, CAJune 10, 2013

1

Agenda

• Overview of Stage 3 policy perspectives– Review of HIT Policy Committee progress

• Consolidation and Deeming

• Public health agency opportunities: on-boarding

• CSTE and member role during this phase

2

Stages of Meaningful Use (MU)

Improving Outcomes

Stage 12011-13

Stage 22014-15

Stage 32016-17

3

Original Principles for Stage 3 Recommendations

• New model of care: support team-based, outcomes-oriented, population management

• National health priorities: address National Prevention/Quality Strategies, Partnerships for Patients, and Million Hearts Campaign

• Broad applicability (since MU is a floor)– Provider specialties (e.g., primary care, specialty care)– Patient health needs– Areas of the country

• Not "topped out" or not already driven by market forces• Mature standards widely adopted or could be widely adopted

by 2016 (for stage 3)4

Lessons from Stages 1Implications for Stage 3

5

Stage 1 Experience Implications for Stage 3

Substantial increase in adoption rates and effective use

Creating critical mass of users and data in electronic form

Mandatory floor creating network effects Rising tide is floating boats (e.g., setup for patient engagement, HIE)

Thresholds consistently exceeded Once MU functionality is implemented, it is used

Consistent use across the years Gains from stage 1 (and 2) will persist

Reporting requirements have considerable costs and burden

Simplify and reduce reporting requirements

Prescriptive, “forced march” impacts available resources for innovation or to address local priorities

Rely more heavily on market pull (e.g., new payment incentives); promote innovative approaches i.e., reward good behavior

Additional Goals for Stage 3

• Address key gaps (e.g., interoperability, patient engagement, reducing disparities) in EHR functionality that the market will not drive alone, but are essential for all providers:– to create level playing field– to create network effects– to fulfill need for a public good

• Consolidation: combine MU objectives where higher level objective implies compliance with subsumed process objectives

• Deeming: consider alternative pathways to meet performance and/or improvement thresholds; satisfaction of subset of relevant MU functionality implicitly required to achieve performance/improvement

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Proposed Stage 3 Population and Public Health MU Objectives/Criteria

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No. Stage 3 Recommendations Method Target*104 Occupation and industry codes Certification EP/EH

401a Immunization registries Measure EP/EH

401b Immunization Clinical Decision Support (CDS)

Measure EP/EH

402a Electronic lab reporting Measure EH

402b Case reports to public health Future EP

403 Syndromic surveillance Measure EH

404 Cancer registry Measure EH/EP

405 Additional (e.g., specialty) registry Measure EH/EP

407 Healthcare acquired infection Measure EH

408 Adverse event reporting Future EH/EP*EH= eligible hospital; EP=eligible Provider

Consolidation Summary

• 43 MU Workgroup objectives proposed in stage 3 Request for Comment (RFC)

• Consolidated to 25 objectives• Assumptions

– Full MU Workgroup will consider RFC feedback and update criteria

– All criteria will be included in certification• Focus on advanced uses

– e.g., recording data vs. use data• Give credit for MU objectives that should be standard of practice once

passed stages 1 and 2 • Identify what needs to be “used” and certified

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Types of Consolidation

• Advanced within concept of another objective– (no current PH example)

• Duplicative concepts -objective becomes certification only– immunization forecasting -> clinical decision support

• Demonstrated use and can trust that it will continue – patient lists, population management, ACO and

quality reporting

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Consolidation Overview

Reconciliation

eRx – formulary

CDS

Pt list/dashboard

Reminders

EH: eMAR

EH: Lab results EP

PGHD

Clinical summary

Patient education

Secure MessagingNotify of health event

Care plan*

Immunization registry

Adverse event*

Case reports to PHA

VDT ToC – Care summary

Advanced directive

Registries

Syndromic Surveillance

Electronic Lab Reproting

Identify clinical trials

Quality, safety, reducing health disparities

Referral loop

Test tracking

Imaging results

Electronic notes

Engaging patients & families

Improving care coordination

Population & public health

eRx transmission

Certification Criteria

Maintained Objective

Key:

* Proposed for future stage of MU

Demographics

CPOE - meds

CDS for immun

Comm preference

CPOE - rad

CPOE - lab

Amendment

Family Hx

Prob, med, allg list

Structured lab

VitalsSmoking status

Comm preference

Comm preference

Cancer registry

Specialty registry

HAI reportsDemographics

Amendment

Family Hx

Prob, med, allg list

Structured lab

VitalsSmoking status

CPOE - referrals

Inter prob list*

RxHx PDMP*

CPOE - meds

Deemed MU Objectives

Deemed in Satisfaction of:• Clinical decision support• e-Prescribing – formulary, generic subs• Reminders• Electronic notes• Test tracking• Clinical summary• Patient education• Reconcile problems, meds, allergies

• *View, download, transmit (VDT), consider adding if stage 2 reports good uptake

• *Secure patient messaging, consider adding if stage 2 reports good uptake

Remaining Items:• Advance directive• E- medication administration record• Imaging results• EH: provide lab results• Patient generated data• *View/download/transfer• *Secure patient messaging• Care summary • Care plan• Referral loop• Notification of health event• Immunization registry• Electronic laboratory reporting• Case reports to public health agency• Syndromic surveillance• Reporting to 2 registries• Adverse event reporting

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Stage 2 MU: On-Boarding

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EP/EHRegistration of

intent

PH requests provider action

PH on-boards EP/EH

PH capable?

Provider acts?

MU objective

met?

1st Time Failure? EP/EH fails

EP/EH passes:Letter for

attestation

No

No

Yes

Yes

Provider must: •register intent by the deadline•participate in on-boarding process •respond to PHA written requests for action within 30 days on two separate occasions.

Yes

NoYesEP/EH exclusion

No

Yes

CMS Final Rule: http://www.gpo.gov/fdsys/pkg/FR-2012-09-04/pdf/2012-21050.pdf

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Formed to discuss and develop consensus around standardization of the new processes across domains and across jurisdictions

Representatives from: •ASTHO, NACCHO, AIRA, ISDS, CSTE, JPHIT, NAACCR, state PHAs, ONC, CDC, PHII, others

Stage 2 MU Public Health Reporting Requirements Task Force

SecurePortal

Eligible ProviderEligible Hospital

Eligible ProviderEligible Hospital

Registries

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Standard DataWarehouse

Query Service

Standard DataWarehouse

Secure federated

query

Secure federated

query

• BMI• CVD risk• Tobacco• Mental health

Query Health Pilots

Pilot Description Focus Owners

NYC/NYS: Primary Care Information Project of the NYC Dept of Health and Mental Hygiene and the NYS Dept of Health

Chronic disease, reportable, syndromic

M Buck

FDA Mini-Sentinel: with 17 large data providers with 126M covered lives, Harvard Pilgrim and HMO research network.

Diagnoses, drugs, procedures

J Brown

MDPHnet: MA Dept of Public Health, MA Leagues of Community Health Centers and Atrius Health

ILI, DM surveillance

J Brown, K Benson

BioSense 2: Cloud based system Syndromic surveillance

T Kass-Hout, M Alletto

Clinical Quality Measures: Allscripts and MITRE Group using Health Quality Measure Format (HQMF) for Stage 2 CQM reporting.

Clinical quality measures in EHR

P Rao

15http://wiki.siframework.org/Query+Health+Pilots+Team

CSTE Position Statements

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Area 2010 2011 2012 2013Infectious Diseases 28 14 9 15Surveillance/Informatics 5 5 1 3Cross Cutting 1 1Occupational 1 1Environmental 1 1Chronic Disease 2 1TOTAL 34 21 13 21

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Conclusions

• Stage 3 MU will push for improved outcomes with greater emphasis on health information exchange

• Public health agencies will demonstrate their capacity/desire to participate through on-boarding in Stage 2

• CSTE can provide new data regarding functionality and standards to influence policy decisions

• CSTE and its members have a unique opportunity to be more strategic, with cross-cutting approaches to informatics investments