Today at the HIT Policy Committee meeting, the Meaningful Use Workgroup will present its recommendations as part of the process leading to a final rule in 2015:
Feb 2014: Draft stage 3 recommendations reviewed with HITPC
March 2014: HITPC approval of stage 3 recommendations
Fall 2014: NPRM for stage 3
1st half 2015: Final Rule for stage 3
Effective: 2017
I presume the regulation writing will follow previous approaches with ONC writing the certification rule and CMS writing the attestation rule.
As I've written about recently, I think it is important to evaluate Meaningful Use Stage 3 from several perspectives including workflow impact, standards readiness, and the tension that such regulations create by prescribing functionality in products, reducing the ability of organizations and vendors to set their own priorities.
The certification criteria noted in the Meaningful Use Workgroup slides are enumerated below and I've added my own discussion questions. It’s important to assess not only the merits of each of the criteria, but their cumulative effect. Each hospital and physician office will have to trade-off meeting these requirements instead of doing something else, because few if any providers have the bandwidth to take on more.
In addition to the detailed discussion points below, I suggest that each of the criteria meet a three-part test before being considered for Meaningful Use Stage 3: 1) is there evidence that the specific technology function, if used, would substantially improve the quality, safety, efficiency, or affordability of care? 2) do we believe that the market will not adequately address the requirement on its own 3) will there be sufficient, uniformly available state-level and industry infrastructure in place to make the required technology achievable?
When I write about such topics, I have to select my words very carefully. Throughout much of my life, I've been viewed as an edgy innovator. At this period in my career, some view me as the status quo, resistant to change. When I propose discussion questions below, I am not taking a position for or against a policy goal. I'm trying to weigh the cost/benefit of regulation at a time when many stakeholders in healthcare are resource constrained, time bankrupt, and struggling to comply with existing regulations.
I look forward to the open debate of these issues.
1. Clinical Decision Support (CDS)
Ability to track CDS interventions and user responses
Perform age-appropriate maximum daily-dose weight based calculation
Consume external CDS rules
Discussion questions:
a. Will tracking every intervention and user response, a technically challenging activity, substantially impact healthcare quality/safety, research, or efficiency?
b. Are standards sufficiently well described/mature to author and exchange externally authored rules?
c. Must we require that all rules be transmitted or might we allow options such as decision support services in which rules reside in external modules and only questions/answers are exchanged?
2. Advance Directives
CEHRT has the functionality to store the document in the record and/or include more information about the document (e.g., link to document or instructions regarding where to find the document or where to find more information about it).
Discussion questions:
a. Given variations in state regulations for advance directives, will we require structured data standards or accept free text/pointers to free text?
b. Can we eliminate the "OR" since such criteria become an "AND" for developers
3. EMAR
CEHRT provides the ability to generate and report on discrepancies between what was ordered and what/when/how the medication was actually administered to use for quality improvement.
Discussion questions:
a. Is tracking every variation/override, a technically challenging activity, a high priority for healthcare quality departments?
b. Do discrepancies commonly occur and if so, are these discrepancies clinically relevant?
4. Imaging
For both EPs (menu) and EHs (core) imaging results should be included in the EHR. Access to the images themselves should be available through the EHR (e.g., via a link).
Discussion questions:
a. To clarify, does this imply a certification criteria to receive electronic radiology results, analogous to electronic lab results?
b. If so, are the standards for receiving radiology results (including vocabularies for naming radiology tests/procedures) sufficiently mature to support such functionality?
5. Clinical Documentation
Help the reader understand the origin of any copied text and identify relevant changes made to the original text. Example method: provide functionality analogous to “track changes” in Microsoft Word to make the original source of copied text clear and any subsequent changes made.
Discussion questions:
a. Today, many organizations address copy/paste with policy. Must we enforce policy with technology?
b. Given that many applications are web-based and not a "thick client" such as Microsoft Word, there may be significant technical challenges in distinguishing between typing and pasting. Does the technology exist to support this requirement?
