Final MU Objectives: Medication and Allergy Lists, Demographics, Vital Signs, Smoking Status, and Advanced Directives
This is the third in a series of hospital-focused summaries of the final Stage 1 meaningful use objectives and measures. The goal of these entries is to support rural community hospital personnel in their efforts to meet specific meaningful use objectives. Notations marked “implications…” are my interpretations, which may or may not be correct.
Objectives # 1-5 were covered in previous blogs.
Objective #6: Maintain Active Medication List (Core Set)
The proposed medication list objective for EPs and hospitals was: “Maintain active medication list.”
The final medication list objective is: No change: finalized as proposed.
The objective must be achieved using certified EHR technology as defined in the final certification rule. The definition of active medication list in the final certification rule is: “Enable a user to electronically record, modify, and retrieve a patient’s active medication list as well as medication history for longitudinal care.”
ONC supporting language: “We also take this opportunity, in the context of our response regarding “longitudinal care” above, to clarify that “medication history” is intended to include a record of prior modifications to a patient’s medications.” Additionally: “We have removed from this certification criterion the requirement to use (RxNorm).”
Implications of the above: Community hospital information systems (HIS) generally have medication list functions accessible through the pharmacy, provider ordering, and other modules. Providers should verify that existing vendors can (or at least are working to) meet the certification requirements as defined. Given the emphasis on longitudinal care, the vendor’s capability to “pull forward” the patient’s medication history through multiple encounters or care transitions may be an issue.
The proposed medication list measure for EPs and hospitals was: “At least 80% of all unique patients seen by the EP or admitted by the eligible hospital have at least one entry (or an indication of “none” if the patient is not currently prescribed any medication) recorded as structured data.”
The final medication list measure is: “More than 80% of all unique patients seen by the EP or admitted to the eligible hospital’s or CAH’s inpatient or emergency departments (POS 21 or 23) have at least one entry (or an indication that the patient is not currently prescribed any medication) recorded as structured data.”
“Unique patient” means that if the patient is seen more than once during the reporting period, he or she only counts once in the denominator, which means that the objective has been met if the medication list is maintained during at least one of the patient encounters.
“Structured data is not fully dependent on an established standard. Established standards facilitate the exchange of the information across providers by ensuring data is structured in the same way. However, structured data within certified EHR technology merely requires the system be able to identify the data as providing specific information.”
The ability to calculate the measure will be included in the certified EHR technology as a certification requirement.
The Denominator is: “Number of unique patients seen by the EP or admitted to an eligible hospital’s or CAH’s inpatient or emergency departments (POS 21 or 23) during the EHR reporting period.”
The Numerator is: “The number of patients in the denominator who have a medication (or an indication that the patient is not currently prescribed any medication) recorded as structured data.”
The Threshold is: “The resulting percentage must be more than 80% in order for an EP, eligible hospital, or CAH to meet this measure.”
Exclusion: There are no exclusions.
Objective #7: Maintain Active Allergy List (Core Set)
The proposed allergy list objective for EPs and hospitals was: “Maintain active medication allergy lists.”
The final allergy list objective is: No change: finalized as proposed.
The objective must be achieved using certified EHR technology as defined in the final certification rule. The definition of active allergy list in the final certification rule is: “Enable a user to electronically record, modify, and retrieve a patient’s active medication allergy list as well as medication allergy history for longitudinal care.”
Implications of the above: Community hospital information systems (HIS) generally have medication allergy list functions accessible through the pharmacy, provider ordering, and other modules. Providers should verify that existing vendors can (or at least are working to) meet the certification requirements as defined. Given the emphasis on longitudinal care, the vendor’s capability to “pull forward” the patient’s medication allergy history through multiple encounters or care transitions may be an issue.
The proposed medication list measure for EPs and hospitals was: “At least 80% of all unique patients seen by the EP or admitted by the eligible hospital have at least one entry (or an indication of “none” if the patient has no medication allergies) recorded as structured data.”
The final medication list measure is: “More than 80% of all unique patients seen by the EP or admitted to the eligible hospital’s or CAH’s inpatient or emergency departments (POS 21 or 23) have at least one entry (or an indication that the patient has no known medication allergies) recorded as structured data.”
“Unique patient” means that if the patient is seen more than once during the reporting period, he or she only counts once in the denominator, which means that the objective has been met if the medication allergy list is maintained during at least one of the patient encounters.
“Structured data is not fully dependent on an established standard. Established standards facilitate the exchange of the information across providers by ensuring data is structured in the same way. However, structured data within certified EHR technology merely requires the system be able to identify the data as providing specific information.”
The ability to calculate the measure will be included in the certified EHR technology as a certification requirement.
The Denominator is: “Number of unique patients seen by the EP or admitted to an eligible hospital’s or CAH’s inpatient or emergency departments (POS 21 or 23) during the EHR reporting period.”
The Numerator is: “The number of patients in the denominator who have at least one entry (or an indication that the patient has no known medication allergies) recorded as structured data.”
The Threshold is: “The resulting percentage must be more than 80% in order for an EP, eligible hospital, or CAH to meet this measure.”
Exclusion: There are no exclusions.
Objective #8: Record Demographics (Core Set)
The proposed record demographics objective for EPs was: “Record the following demographics: preferred language, insurance type, gender, race and ethnicity, and date of birth.” And for hospitals was: “Record the following demographics: preferred language, insurance type, gender, race and ethnicity, date of birth, and date and cause of death in the event of mortality.”
The final record demographic objective for EPs is: “Record the following demographics: preferred language, gender, race and ethnicity, and date of birth.” And for hospitals is: Record the following demographics: preferred language, gender, race and ethnicity, date of birth, and date and preliminary cause of death in the even of mortality in the eligible hospital or CAH.”
CMS supporting language: “If a patient declines to provide the information or if capturing the patient’s ethnicity or race is prohibited by state law, such a notation entered as structured data would count as an entry for purposes of meeting the measure.” Additionally, “Given the complexity of defining insurance type and attributing it to patients in an agreed upon way, we are eliminating insurance type from this meaningful use objective.”
The objective must be achieved using certified EHR technology as defined in the final certification rule. The definition of record demographics functionality in the final certification rule is: For EPs, “Enable a user to electronically record, modify, and retrieve patient demographic data including preferred language, gender, race, ethnicity, and date of birth. Enable race and ethnicity to be recorded in accordance with the standard specified at 170.207(f).” And for hospitals, “Enable a user to electronically record, modify, and retrieve patient demographic data including preferred language, gender, race, ethnicity, date of birth, and date and preliminary cause of death in the event of mortality. Enable race and ethnicity to be recorded in accordance with the standard specified at §170.207(f).”
ONC supporting language on the standard: “We note that the OMB race and ethnicity codes constitute a government unique standard for the purposes of the National Technology Transfer and Advancement Act of 1995 (NTTAA). We have adopted this standard because it provides an easily understood structure and format for electronically transmitting the data elements identified in the meaningful use Stage 1 objective.”
Implications of the above: Community hospital information systems (HIS) generally have patient demographic information entry functions through the registration and other modules. Providers should verify that existing vendors can (or at least are working to) meet the certification requirements (including the ability to record preliminary cause of death and to utilize the OMB standards) as defined.
The proposed record demographics measure for EPs and hospitals was: “At least 80% of unique patients seen by the EP or admitted to the eligible hospital have demographics recorded as structured data.”
The final record demographics measure is: “More than 50% of all unique patients seen by the EP or admitted to the eligible hospital’s or CAH’s inpatient or emergency departments (POS 21 or 23) have demographics recorded as structured data.”
“Unique patient” means that if the patient is seen more than once during the reporting period, he or she only counts once in the denominator, which means that the objective has been met if the demographics have been recorded during at least one of the patient encounters.
“Structured data is not fully dependent on an established standard. Established standards facilitate the exchange of the information across providers by ensuring data is structured in the same way. However, structured data within certified EHR technology merely requires the system be able to identify the data as providing specific information.”
The ability to calculate the measure will be included in the certified EHR technology as a certification requirement.
The Denominator is: “Number of unique patients seen by the EP or admitted to an eligible hospital’s or CAH’s inpatient or emergency department (POS 21 or 23) during the EHR reporting period.”
The Numerator is: “The number of patients in the denominator who have all the elements of demographics (or a specific exclusion if the patient declined to provide one or more elements or if recording an element is contrary to state law) recorded as structured data.”
The Threshold is: “The resulting percentage must be more than 50% in order for an EP, eligible hospital, or CAH to meet this measure.”
Exclusion: There are no exclusions.
Objective #9: Record Vital Signs (Core Set)
The proposed record vital sign objective (for EPs and hospitals) was: “Record and chart changes in the following vital signs: height, weight, and blood pressure and calculate and display body mass index (BMI) for ages 2 and over; plot and display growth charts for children 2-20 years, including BMI.”
The final record vital sign objective is: No change: finalized as proposed.
CMS supporting language: “We do not believe that all three must be updated by a provider at every patient encounter nor even once per patient seen during the EHR reporting period. For this objective we are primarily concerned that some information is available to the EP/eligible hospital/CAH, who can then make the determination based on the patient’s individual circumstances as to whether height, weight, and blood pressure needs to be updated.
The objective must be achieved using certified EHR technology as defined in the final certification rule. The definition of record vital sign functionality in the final certification rule is: “(1) Enable a user to electronically record, modify, and retrieve a patient’s vital signs including, at a minimum, height, weight, and blood pressure. (2) Automatically calculate and display body mass index (BMI) based on a patient’s height and weight. (3) Plot and electronically display, upon request, growth charts for patients 2-20 years old.”
Implications of the above: Community hospital information systems (HIS) generally have vital sign entry functions through the inpatient documentation, outpatient documentation (such as ER), and other modules. Providers should verify that existing vendors can (or at least are working to) meet the certification requirements as defined. The plot and display growth chart requirement may not have been a hospital system vendor priority prior to its inclusion in the proposed and final rules.
The proposed record vital sign measure for EPs and hospitals was: “For at least 80% of all unique patients age 2 and over seen by the EP or admitted to the eligible hospital, record blood pressure and BMI; additionally plot growth chart for children 2 to 20.”
The final record vital sign measure is: “For more than 50% of all unique patients age 2 and over seen by the EP or admitted to eligible hospital’s or CAH’s inpatient or emergency department (POS 21 or 23), height, weight and blood pressure are recorded as structured data.”
“Unique patient” means that if the patient is seen more than once during the reporting period, he or she only counts once in the denominator, which means that the objective has been met if the vital signs have been recorded during at least one of the patient encounters.
“Structured data is not fully dependent on an established standard. Established standards facilitate the exchange of the information across providers by ensuring data is structured in the same way. However, structured data within certified EHR technology merely requires the system be able to identify the data as providing specific information.”
The ability to calculate the measure will be included in the certified EHR technology as a certification requirement.
The Denominator is: “The number of unique patients age 2 and over seen by the EP or admitted to an eligible hospital’s or CAH’s inpatient or emergency departments (POS 21 or 23) during the EHR reporting period.” (The only patients that are included in the denominator are those patients whose records are maintained using certified EHR technology).
The Numerator is: “The number of patients in the denominator who have at least one entry of their height, weight, and blood pressure recorded as structured data.”
The Threshold is: “The resulting percentage must be more than 50% in order for an EP to meet this measure.”
Exclusion: “An EP who sees no patients 2 years old or younger would be excluded from this requirement … We would also allow an EP who believes that all three vital signs of height, weight, and blood pressure have no relevance to their scope of practice to so attest and be excluded … There is no exclusion for eligible hospitals and CAHs.”
Objective #10: Record Smoking Status (Core Set)
The proposed record smoking status objective (for EPs and hospitals) was: “Record smoking status for patients 13 years old or older.”
The final record smoking status objective is: No change: finalized as proposed.
CMS supporting language: “this is a check of the medical record for patients 13 years old or older. If this information is already in the medical record available through certified EHR technology, we do not intend that an inquiry be made every time a provider sees a patient 13 years old or older. The frequency of updating this information is left to the provider and guidance is provided already from several sources in the medical community. The information could be collected by any member of the medical staff.”
The objective must be achieved using certified EHR technology as defined in the final certification rule. The definition of record smoking status functionality in the final certification rule is: “Enable a user to electronically record, modify, and retrieve the smoking status of a patient. Smoking status types must include: current every day smoker; current some day smoker; former smoker; never smoker; smoker, current status unknown; and unknown if ever smoked.”
Implications of the above: Community hospital information systems (HIS) generally have smoking status entry functions through the inpatient documentation, outpatient documentation (such as ER), and other modules. Providers should verify that existing vendors can (or at least are working to) meet the certification requirements as defined.
The proposed record smoking status measure for EPs and hospitals was: “At least 80% of all unique patients 13 years old or older seen by the EP or admitted to the eligible hospital have “smoking status” recorded.”
The final record smoking status measure is: “More than 50% 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 departments (POS 21 or 23) have smoking status recorded as structured data.”
“Unique patient” means that if the patient is seen more than once during the reporting period, he or she only counts once in the denominator, which means that the objective has been met if the smoking status has been recorded during at least one of the patient encounters.
“Structured data is not fully dependent on an established standard. Established standards facilitate the exchange of the information across providers by ensuring data is structured in the same way. However, structured data within certified EHR technology merely requires the system be able to identify the data as providing specific information.”
The ability to calculate the measure will be included in the certified EHR technology as a certification requirement.
The Denominator is: “The number of unique patients age 13 or older seen by the EP or admitted to an eligible hospital’s or CAH’s inpatient or emergency departments (POS 21 or 23) during the EHR reporting period.” (The only patients that are included in the denominator are those patients whose records are maintained using certified EHR technology).
The Numerator is: “The number of patients in the denominator with smoking status recorded as structured data.”
The Threshold is: “The resulting percentage must be more than 50% in order for an EP, eligible hospital, or CAH to meet this measure.”
Exclusion: “EP’s, eligible hospitals or CAHs who see no patients 13 years or older would be excluded from this requirement.”
Objective #11: Record Advanced Directives (Menu Set)
There was no proposed record advanced directives objective.
The final record advanced directives objective (for hospitals only) is: “Record whether a patient 65 years old or older has an advanced directive as structured data.”
CMS supporting language: “advanced directives should be just an indication of the existence of an advanced directive…”
The objective must be achieved using certified EHR technology as defined in the final certification rule. The definition of record advanced directive functionality in the final certification rule is: “Enable a user to electronically record whether a patient has an advance directive.”
Implications of the above: Community hospital information systems (HIS) generally have the capability to record this type of data through the registration, inpatient documentation, outpatient documentation (such as ER), and other modules. Providers should verify that existing vendors can (or at least are working to) meet the certification requirements as defined.
The final record advanced directives measure is: “More than 50% of all unique patients 65 years old or older admitted to the eligible hospital’s or CAH’s inpatient department (POS 21) have an indication of an advanced directive status recorded as structured data.”
“Unique patient” means that if the patient is seen more than once during the reporting period, he or she only counts once in the denominator, which means that the objective has been met if the advanced directive has been recorded during at least one of the patient encounters.
“Structured data is not fully dependent on an established standard. Established standards facilitate the exchange of the information across providers by ensuring data is structured in the same way. However, structured data within certified EHR technology merely requires the system be able to identify the data as providing specific information.”
The ability to calculate the measure will be included in the certified EHR technology as a certification requirement.
The Denominator is: “The number of unique patients age 65 or older admitted to an eligible hospital’s or CAH’s inpatient department (POS 21) during the EHR reporting period.” (The only patients that are included in the denominator are those patients whose records are maintained using certified EHR technology).
The Numerator is: “The number of patients in the denominator with an indication of an advanced directive entered using structured data.”
The Threshold is: “The resulting percentage must be more than 50% in order for an eligible hospital or CAH to meet this measure.”
Exclusion: “An exclusion … would apply to an eligible hospital or CAH who admits no patients 65 years old or older during the EHR reporting period.”
