A guidebook to MU stage 3's 8 objectives

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CMS released its proposed meaningful use stage 3 requirements on March 20. The rules outline the final stage of the meaningful use program, focusing on improving patient outcomes and facilitating the exchange of patient data.

Although there are many other changes made in the final rule, including an adjustment of the EHR reporting period to more closely align with the calendar year and other quality measure reporting periods, CMS lists a set of 8 objectives eligible providers, eligible hospitals and critical access hospitals must meet to attest stage 3.

Here is a brief guide to the meaningful use stage 3 objectives.

1. Protect patient health information
This objective is an expansion on the privacy rules established in meaningful use stages 1 and 2. Stage 2 required entities to conduct a security risk analysis and address the security of data stored in a certified EHR system. Stage 3 adds language to the security requirements for the implementation of technical, administrative and physical safeguards for patient information.

Security risk analyses will be required to report vulnerabilities by the end of each calendar year, as stage 3 adjusts the reporting period to align with the calendar year. Eligible professionals, eligible hospitals and critical access hospitals must conduct a security risk analysis upon the installation of an EHR system or upon upgrade, which can begin prior to the beginning of the first EHR reporting period of using the new system. Every year after that, a provider must review the security risk analysis at least once per reporting period.

2. Electronic prescribing
Eligible professionals will be required to generate and transmit permissible prescriptions electronically and eligible hospitals and critical access hospitals must generate and transmit permissible discharge prescriptions electronically.

Stage 2 included a list of discharge medications eligible for electronic prescription, and stage 3 proposes to include that list. The requirements differ for eligible professionals and hospitals on this objective.

For EPs, 80 percent of all permissible prescriptions must be queried for a drug formulary and transmitted electronically using an EHR. The requirement gradually climbed from 40 percent in stage 1 to 50 percent in stage 2, but because 92 percent of EPs who attested stage 2 met that threshold, CMS expressed confidence in raising it to 80 percent.

For eligible hospitals and CAHs, 25 percent of hospital discharge medication orders for permissible prescriptions must be queried for a drug formulary and transmitted electronically using an EHR. Stage 2 set a 10 percent threshold, and because stage 2 hospitals and CAHs performed at 53 percent levels at the median, CMS expressed confidence in the new requirement. Stage 3 will also remove the requirement for refill prescriptions, requiring e-prescription only for new and changed prescriptions.

3. Clinical decision support
The clinical decision support objective contains two sub-measures. The first is to implement five clinical decision support interventions related to four or more clinical quality measurements at a relevant point in patient care for the entire EHR reporting period. The second is to implement technology for drug interaction and drug-allergy interaction for an entire EHR reporting period.

This objective offers a little more flexibility, allowing EPs, eligible hospitals and CAHs the freedom to choose whichever clinical decision support tools best fit their patient population and practice. CMS recommends providers choose tools related to preventive care, chronic condition management, heart disease and hypertension, appropriateness of diagnostic orders or procedures and advanced medication-related decision support.

CMS will not require providers to report change in each CQM, but rather to set internal goals for improved performance. The requirements heavily recommend providers choose tools supporting CQMs related to improving patient outcomes and proposed no exceptions to the rule.

4. Computerized physician order entries
The new CPOE measure includes three sub-measures. First, 80 percent of medication orders created by an EP or authorized provider in a hospital or CAH's inpatient or emergency department must be recorded in a CPOE. Second, more than 60 percent of lab orders must be created using a CPOE. Third, more than 60 percent of diagnostic imaging orders must be created using a CPOE.

This objective expands only slightly upon the requirements of stages 1 and 2, in which providers were required to make medication, laboratory and radiology requests electronically. Stage 3 expands the objective to include any licensed healthcare professional or credentialed medical assistant.

EPs may also credential staff to input orders electronically, but CMS leaves it up to the discretion of the EP based on workflow, appropriate credentialing, analysis of the staff member's duty and compliance with all applicable federal, state and local laws and professional guidelines. CMS says it will seek comment on whether an exclusion would ever apply to this rule.

5. Patient access
One of the most extensive objectives, the patient access objective aims to expand physicians' communication with patients through technology. Stage 3 requires the EP, eligible hospital or CAH to provide access for patients to view online, download or transmit their health information or retrieve it through an application program interface within 24 hours of its availability.

The provider is only required to provide access; the patient is not required to take action for the provider to meet the objective's goals. CMS says providing patients with access "should not require the provider to make extraordinary efforts to assist patients in use or access of information, but the provider must inform patients of these options and provide sufficient guidance so that all patients could leverage this access."

The objective contains two sub-measures. First, more than 80 percent of all unique patients seen by the EP or discharged from the eligible hospital or CAH inpatient or ED should be provided access to view, download or transmit health information within 24 hours of its availability or access to an online ONC-certified API that can be use by third-party applications or devices to provide access. Second, the EP, eligible hospital or CAH must use clinically relevant information from the EHR to identify patient-specific educational resources and provide access to those materials to more than 35 percent of patients.

Stage 3 increases the threshold from 50 percent to 80 percent and to decrease the delay period of access to 24 hours based on the continued automation process and faster response time. Exceptions apply to EPs, eligible hospitals or CAHs in counties where less than 50 percent of households have access to 4Mbps broadband.

CMS is also seeking alternate proposals for this objective because the use of APIs could potentially replace direct access.

6. Coordination of care through patient engagement
This objective has three sub-measures. First, more than 25 percent of all unique patients seen by the EP or discharged from the eligible hospital or CAH inpatient or ED must actively engage with the EHR made accessible by the provider. EPs, hospitals and CAHs can meet the objective by either reporting 25 percent of their unique patients viewed, downloaded or transmitted their information to a third party during an EHR reporting period through the portal or through an ONC-certified API.

Second, a secure message must be sent to 35 percent of patients seen by an EP or discharged from an eligible hospital or CAH through the practice's EHR.

Third, patient-generated data or data from a non-clinical setting is incorporated into the EHR technology for more than 15 percent of all unique patients.

CMS acknowledges the challenges in measuring patient access through third-party applications that use an API, and it will modify the requirement based on comments it receives.

For the third requirement, CMS defines a non-clinical setting as any provider or setting of care that is not an EP, eligible hospital or CAH and does not have a certified EHR. This includes nutritionists, physical therapists, occupational therapists, psychologists and home health providers as well as data generated by the patients themselves. CMS acknowledges that this definition of data is broad and seeks comment on how it should be defined and incorporated into practice.

7. Exchange of health information
EPs, eligible hospitals and CAHs must provide a summary of care record when transitioning or referring their patient to another setting of care, retrieve a summary of care document upon the first encounter with a patient and incorporate summary of care information from other providers into their EHR.

This objective includes three sub-measures. First, more than 50 percent of transitions of care and referrals from an EP, eligible hospital or CAH must create a summary of care record using an EHR and exchange the record. Second, summary of care documents for more than 40 percent of transitions or referrals received and new patient encounters must be incorporated into the provider's EHR. Third, for more than 80 percent of new patient encounters, the EP, eligible hospital or CAH must implement clinical information reconciliation for medication, medication allergy and a current problem list.

The ONC issued a common clinical data set to encourage data exchange, and CMS has included the list in its stage 3 requirements. CMS will seek comment on whether alerts received by EPs from hospitals when a patient is admitted, seen in the ED or discharged should be included as a separate measure because the landscape of how providers use alerts is changing so rapidly.

8. Public health and clinical data registry reporting 
This objective requires EPs, eligible hospitals and or CAHs to be actively engaged in submitting data to public health agencies or clinical data registries through an EHR. Stage 3 will remove the "ongoing submission" requirement from stage 2 and replace it with "active engagement" to more accurately reflect the nature of communication between providers and a public health agency or clinical data regisitry. EPs, eligible hospitals or CAHs must contribute to three of six listed measures.

The measures include immunization registry reporting, syndromic surveillance reporting, case reporting, public health registry reporting, clinical data registry reporting and electronic reportable lab result reporting.

This objective provides flexibility through three active engagement options. First, EPs, eligible hospitals or CAHs can demonstrate active engagement by completing registration to submit data within 60 days after the start of the EHR reporting period. Second, the EP, eligible hospital or CAH can demonstrate active engagement by being in the process of testing and validating the electronic submission of data. They must respond to the requests from a public health agency or clinical data registry within 30 days; failure to respond twice constitutes not meeting the measure. Third, the EP, eligible hospital or CAH can demonstrate active engagement by submitting data to the public health agency or clinical data registry.

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