1. Meaningful Use Workgroup Improve Quality Safety, Efficiency and Reducing Health Disparities Subgroup 1 Meaningful Use Workgroup Improve Quality Safety, Efficiency and Reducing Health Disparities - Subgroup 1 David Bates, Chair September 2012

2. Guiding Principles Supports new model of care (e.g., team-based, outcomes-oriented, population management) Addresses national health priorities (e.g., NQS, Million Hearts) Broad applicability (since MU is a floor) − Provider specialties (e.g., primary care, specialty care) − Patient health needs − Areas of the country Promotes advancement -- Not "topped out" or not already driven by market forces Achievable -- mature standards widely adopted or could be widely adopted by 2016 Reasonableness/feasibility of products or organizational capacity Reasonableness/feasibility of products or organizational capacity − Prefer to have standards available if not widely adopted − Don’t want standards to be an excuse for not moving forward MU Workgroup Stage 2 Final Rule2

3. Key to reviewing items Red items are changes from Stage 1 to Stage 2 Blue items are changes from Stage 2 to Stage 3 recommendations MU Workgroup Stage 2 Final Rule3

4. IDStage 1 Final RuleStage 2 Final RuleStage 3 RecommendationsStage 4 Placeholder SGRP1 01 Medication only: More than 30% of unique patients seen during the reporting period with at least one medication in their medication list have at least one medication order entered using CPOE EP Objective: Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines EH Objective: Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines EP/EH Measure: More than 60 percent of medication, 30 percent of laboratory, and 30 percent of radiology orders created by the EP or authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using CPOE. Reconcile % after Stage 2 final Objective: Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders directly entered by any licensed healthcare professional who can enter orders into the medical record per State, local and professional guidelines to create the first record of the order. Measure: More than 60% of medication, laboratory, and radiology orders created by the EP or authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using CPOE Improve Quality Safety, Efficiency and Reducing Health Disparities MU Workgroup Stage 2 Final Rule4

5. 5 IDStage 1 Final RuleStage 2 Final RuleStage 3 Recommendations Stage 4 Placeholder SGRP1 30 New for stage 3 Objective: Use computerized provider order entry for referrals/transition of care orders directly entered by any licensed healthcare professional who can enter orders into the medical record per State, local and professional guidelines to create the first record of the order. Measure: More than 20% of referrals/transition of care orders created by the EP or authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded. SGRP1 02 Implement drug- drug and drug- allergy interaction checks Consolidated with CDS Certification: EHRs need to be able to consume external lists of DDIs (e.g., “never” combinations). Seeking externally maintained list of DDIs with higher predictive value Improve Quality Safety, Efficiency and Reducing Health Disparities Coordinate with subgroup 3

6. Improve Quality Safety, Efficiency and Reducing Health Disparities MU Workgroup Stage 2 Final Rule6 ID Stage 1 Final RuleStage 2 Final RuleStage 3 Recommendations Stage 4 Placeholder SGRP1 03 EP only: Generate and transmit more than 40% of all permissible prescriptions electronically EP/EH Objective: Generate and transmit permissible prescriptions electronically (eRx) EP Measure: More than 50% of all permissible, or all permissible and non permissible, prescriptions written by the EP and queried for a drug formulary and transmitted electronically using CEHRT. EH MENU Objective: Generate and transmit permissible discharge prescriptions electronically (eRx) EH MENU Measure: More than 10%of hospital discharge medication orders for permissible prescriptions (for new, changed, and refilled prescriptions) are queried for a drug formulary and transmitted electronically using Certified EHR Technology EP Objective: Generate and transmit permissible prescriptions electronically (eRx) EP Measure: More than 50% of all permissible prescriptions written by the EP are compared to at least one drug formulary (including generic substitutions) transmitted electronically using Certified EHR Technology. EH Objective: Generate and transmit permissible discharge prescriptions electronically (eRx) EH Measure: More than 30% of hospital discharge medication orders for permissible prescriptions (for new or changed prescriptions) are compared to at least one drug formulary and transmitted electronically using Certified EHR Technology

7. Improve Quality Safety, Efficiency and Reducing Health Disparities 7 IDStage 1 Final RuleStage 2 Final RuleStage 3 Recommendations Stage 4 Placeholder SGRP1 04 Record demographics as structured data for more than 50% of all unique patients: Preferred language Gender Race Ethnicity Date of birth (Hospital Only) date and preliminary cause of death in the event of mortality in the eligible hospital or CAH EP Objective: Record the following demographics Preferred language Sex Race Ethnicity Date of birth EH Objective: Record the following demographics Preferred language Sex Race Ethnicity Date of birth Date and preliminary cause of death in the event of mortality in the eligible hospital or CAH Measure: More than 80 percent of all unique patients seen by the EP or admitted to the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) have demographics recorded as structured data Objective: Record the following in structured data: Demographics: Preferred language Gender Race Ethnicity Date of birth Occupation and industry codes Clinical: Sexual orientation, gender identity Disability status Measure: More than 80 percent of all unique patients seen by the EP or admitted to the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) have demographics recorded as structured data (Hospital Only) date and preliminary cause of death in the event of mortality in the eligible hospital or CAH MU Workgroup Stage 2 Final Rule

8. 8 Improve Quality Safety, Efficiency and Reducing Health Disparities ID Stage 1 Final RuleStage 2 Final RuleStage 3 RecommendationsStage 4 Placeholder SGRP1 05 Maintain an up-to-date problem list of current and active diagnoses for more than 80% of all unique patients: have at least one entry or an indication that no problems are known for patient recorded as structured data Consolidated with summary of care New for stage 3 Certification criteria only: EHR systems should provide functionality to help maintain up-to-date, accurate problem list Certification criteria only: Use of lab test results, medications, and vital signs (BP, ht, wt, BMI), to support maintenance of up-to-date accurate problem lists. Vendors utilize rules to help providers improve the problem list (e.g. MAPLE). Stage 4: Patient input to reconciliation of problems SGRP1 06 Maintain active medication list: more than 80% of all unique patients have at least one entry recorded as structured data (or indication that the patient is on no meds) Consolidated with summary of care New for Stage 3 Certification criteria only: Use of problems and lab test results to support maintenance of up-o-date accurate medication lists [this does not mean that the system is going to automatically do something]. Certification criteria: Use other EHR data such as medications filled or dispensed, or free text searching for medications to support maintenance of up-to- date and accurate medication lists. SGRP1 07 Maintain active medication allergy list: More than 80% of all unique patients seen during the reporting period have at least one entry (or indication that the patient has no known medication allergies) recorded as structured data Consolidated with summary of care New for stage 3 Certification criteria only: EHR systems should provide functionality to code medication allergies and link to related drug family, and code related reaction. Stage 4: Contraindications that could include: adverse reactions, procedural intolerance. MU Workgroup Stage 2 Final Rule Did not mean auto-populate, need to re-word.

9. 9 IDStage 1 Final RuleStage 2 Final Rule Stage 3 Recommendations Stage 4 Placeholder SGRP1 08 Record and chart changes in vital signs: more than 50% of all unique patients age 2 and over have vital signs recorded as structured data Height Weight Blood pressure Calculate and display BMI Plot and display growth charts for children 2-20 years, including BMI Objective: Record and chart changes in vital signs: Height/length Weight Blood pressure (age 3 and over) Calculate and display BMI Plot and display growth charts for patients 0-20 years, including BMI Measure: More than 80% of all unique patients seen by the EP or admitted to the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) have blood pressure (for patients age 3 and over only) and height/length and weight (for all ages) recorded as structured data Maintain as is for Stage 3 or retire as topped out measure. SGRP1 09 Record smoking status for patients 13 years old and older: more than 50% of all unique patients seen during the reporting period 13 years or older have smoking status recorded as structured data EP/EH Objective: Record smoking status for patients 13 years old or older Measure: More than 80% of all unique patients 13 years old or older seen by the EP or admitted to the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) have smoking status recorded as structured data Consider retiring or incorporating into CQM Improve Quality Safety, Efficiency and Reducing Health Disparities MU Workgroup Stage 2 Final Rule

10. 10 IDStage 1 Final RuleStage 2 Final RuleStage 3 Recommendations Stage 4 Placeholder SGRP1 10 MENU: Implement drug- formulary checks with access to at least one drug formulary Consolidated (eRX)Consolidated - Moved to eRx objective. SGRP1 11 Report ambulatory and hospital clinical quality measures to CMS or States Objective is incorporated directly into the definition of a meaningful EHR user and eliminated as an objective under §495.6 Removed in Stage 2 SGRP1 12 EH MENU: Record advanced directives for more than 50% patients 65 years old or older EH MENU Objective: Record whether a patient 65 years old or older has an advance directive EH MENU Measure: More than 50 percent of all unique patients 65 years old or older admitted to the eligible hospital's or CAH's inpatient department (POS 21) during the EHR reporting period have an indication of an advance directive status recorded as structured data. Add for EPs if not included in Stage 2 and make core for EH. Ensure standards support in CDA by 2016 Advanced directive listening session to further define? Improve Quality Safety, Efficiency and Reducing Health Disparities MU Workgroup Stage 2 Final Rule

11. 11 IDStage 1 Final RuleStage 2 Final RuleStage 3 Recommendations Stage 4 Placeholder SGRP1 13 EP: Implement one clinical decision support rule relevant to specialty or high clinical priority along with ability to track compliance with that rule EH: Implement one clinical decision support rule related to a high priority hospital condition along with the ability to track compliance with that rule EP/EH Objective: Use clinical decision support to improve performance on high-priority health conditions Measure: 1. Implement five clinical decision support interventions related to four or more clinical quality measures. Absent four clinical quality measures are related to an EP’s scope of practice, the provider may select clinical decision support interventions at a relevant point in patient care related to high-priority health conditions for the entire EHR reporting period. It is suggested that one of the five clinical decision support interventions be related to improving healthcare efficiency. 2. The EP, eligible hospital or CAH has enabled and implemented the functionality for drug-drug and drug-allergy interaction checks for the entre EHR reporting period. Objective: Use clinical decision support to improve performance on high priority health conditions Measure: 1. Implement 15 clinical decision support interventions related to five or more clinical quality measures that are presented at a relevant point in patient care for the entire EHR reporting period. The 15 CDS interventions should include one or more interventions in each of the following areas, as applicable to the EP's specialty: Preventative care (including immunizations) Chronic disease management (e.g., diabetes, hypertension, coronary artery disease) Advanced medication-related decision support* (e.g., renal drug dosing) Appropriateness of lab and radiology orders 2. The EP, eligible hospital, or CAH has enabled the functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period. Certification criteria only: 1. Ability to track CDS triggers and how the provider responded [footnote: this is used to improve the effectiveness of CDS interventions] 2. Ability to flag preference-sensitive conditions, and provide decision support materials for patients. 3. Capability to check for a maximum dose in addition to a weight based calculation. *Kuperman,GJ. (2007). Medication-related clinical decision support in computerized provider order entry systems: a review. Journal of the American Medical Informatics Association: JAMIA, 14(1):29-40. Improve Quality Safety, Efficiency and Reducing Health Disparities Provide an example for CDS interventions to be used to help maintain the accuracy of problems, meds, and allergies Explain that the intent is for vendors to provide ways for clinicians to deal with preventative care and chronic disease – doesn’t need to be hard wired though. Vendor needs to show what kind of interventions. Put in the e.g. utilization

12. Improve Quality Safety, Efficiency and Reducing Health Disparities 12 IDStage 1 Final RuleStage 2 Final RuleStage 3 Recommendations Stage 4 Placeholder SGRP1 14 MENU: Incorporate clinical lab test results into certified EHR technology as structured data for more than 40% of all clinical lab tests results ordered whose results are either in a positive/negative or numerical format EP/EH Objective: Incorporate clinical lab-test results into Certified EHR Technology as structured data Measure: More than 55 percent of all clinical lab tests results ordered by the EP or by authorized providers of the eligible hospital or CAH for patients admitted to its inpatient or emergency department (POS 21 or 23 during the EHR reporting period whose results are either in a positive/negative affirmation or numerical format are incorporated in Certified EHR Technology as structured data Objective: Incorporate clinical lab- test results into EHR as structured data Measure: More than 80% of all clinical lab tests results ordered by the EP or by authorized providers of the eligible hospital or CAH for patients admitted to its inpatient or emergency department (POS 21 or 23) during the EHR reporting period whose results are either in a positive/negative or numerical format are incorporated in Certified EHR Technology as structured data SGRP1 15 MENU: Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach EP CORE Objective: Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach EP CORE Measure: Generate at least one report listing patients of the EP, eligible hospital or CAH with a specific condition. EP Objective: Generate lists of patients for multiple specific conditions and present near real- time patient-oriented dashboards to use for quality improvement, reduction of disparities, research, or outreach reports. MU Workgroup Stage 2 Final Rule Define dashboards better. “Dashboards” are incorporated into the EHR’s clinical workflow, as opposed to retrospective reporting.

13. 13 ID Stage 1 Final Rule Stage 2 Final RuleStage 3 Recommendations Stage 4 Placeholder SGRP1 16 EP MENU: Send preventive or follow-up reminders to more than 20% of all unique patients 65+ years old or 5 years old or younger EP Objective: Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care and send these patients the reminder, per patient preference. Measure: More than 10 percent of all unique patients who have had two or more office visits with the EP within the 24 months before the beginning of the EHR reporting period were sent a reminder, per patient preference when available EP Objective: Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care EP Measure: More than 20% of all unique patients who have had an office visit with the EP within the 24 months prior to the beginning of the EHR reporting period were sent a reminder, per patient preference Exclusion: Specialists may be excluded for prevention reminders (could be more condition specific). SGRP1 17 N/AEH Objective: Automatically track medications from order to administration using assistive technologies in conjunction with an electronic medication administration record (eMAR) Measure: More than 10% of medication orders created by authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are tracked using eMAR. EH Objective: Automatically track medications from order to administration using assistive technologies in conjunction with an electronic medication administration record (eMAR) Measure: 1) More than 10% of medication orders created by authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are tracked using eMAR. 2) Mismatches (situations in which a provider dispenses a medication and/or dosing that is not intended) are tracked and are reported for quality improvement purposes. Improve Quality Safety, Efficiency and Reducing Health Disparities MU Workgroup Stage 2 Final Rule

14. 14 ID Stage 1 Final Rule Stage 2 Final RuleStage 3 Recommendations Stage 4 Placeholder SGRP1 18 N/AEP/EH MENU Objective: Imaging results consisting of the image itself and any explanation or other accompanying information are accessible through Certified EHR Technology. EP/EH MENU Measure: More than 10 percent of all tests whose result is an image ordered by the EP or by an authorized provider of the eligible hospital or CAH for patients admitted to its inpatient or emergency department (POS 21 and 23) during the EHR reporting period are accessible through Certified EHR Technology Move to core, pending Stage 2 Final Rule SGRP1 19 N/AEP/EH MENU Objective: Record patient family health history as structured data EP/EH MENU Measure: More than 20 percent of all unique patients seen by the EP or admitted to the eligible hospital or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period have a structured data entry for one or more first-degree relatives Objective: Record high priority family history data (including colon cancer, breast, glaucoma, MI, diabetes) Measure: Record high priority family history in 40% of patients seen during reporting period Certification criteria: Make sure that every CDS intervention can take into account family history for outreach (need to move that functionality along as part of preventative outreach). Improve Quality Safety, Efficiency and Reducing Health Disparities MU Workgroup Stage 2 Final Rule

15. 15 ID Stage 1 Final Rule Stage 2 Final Rule Stage 3 Recommendations Stage 4 Placeholder SGRP1 20 N/AEP/EH MENU Objective: Record electronic notes in patient records EP MENU Measure: Enter at least one electronic progress note created, edited and signed by an eligible professional for more than 30 percent of unique patient office visits. EH MENU Measure: Enter at least one electronic progress note created, edited and signed by an eligible professional for more than 30 percent of unique patients with at least one office visit during the EHR reporting period. Notes must be text-searchable. Non-searchable scanned notes do not qualify but this does not mean that all of the content has to be character text. Drawings and other content can be included with text notes under this measure. Enter at least one electronic progress note created, edited, and signed by an authorized provider of the eligible hospital’s or CAH’s inpatient or emergency department (POS 21 or 23) for more than 30 percent of unique patients admitted to the eligible hospital or CAH’s inpatient or emergency department during the EHR reporting period. Electronic progress notes must be text-searchable. Non-searchable, scanned notes do not qualify, but this does not mean that all of the content has to be character text. Drawings and other content can be included with text notes under this measure. Record electronic notes in patient records for more than 30% of office visits within four calendar days. Objective Not Included in Stage 2 NPRM - Improve Quality Safety, Efficiency and Reducing Health Disparities

16. MU Workgroup Stage 2 Final Rule 16 IDStage 1 Final RuleStage 2 Final RuleStage 3 Recommendations Stage 4 Placeholder SGRP1 21 N/AEH MENU Objective: Provide structured electronic lab results to ambulatory providers EH MENU Measure: Hospital labs send structured electronic clinical lab results to the ordering provider for more than 20 percent of electronic lab orders received Hospital Objective: Provide structured electronic lab results to eligible professionals. Hospital Measure: Hospital labs send (directly or indirectly) structured electronic clinical lab results to the ordering provider for more than 70% of electronic lab orders received. SGRP1 22 New for stage 3 EH: Explore Timely transition document (elements need to be fleshed out) that is available electronically within four calendar days for when a transition occurs between sites. Improve Quality Safety, Efficiency and Reducing Health Disparities