Final Stage 1 Meaningful Use Objectives: Overview and Analysis of CPOE Objective

Final Stage 1 Meaningful Use Objectives: Overview and Analysis of CPOE Objective

Introduction

There are numerous aspects of the HIT Incentive Final Rule that providers will need to consider in order to be in a position to maximize incentives and achieve effective and safe EHR adoption.

• Providers will need to understand the meaningful use objectives and metrics, and to determine whether they’re on an EHR adoption path that will lead to Stage 1 meaningful use and beyond. Part of this assessment will involve asking the question of whether current vendors are likely to achieve certification, which is a strict requirement of the meaningful use incentive program.

• Providers will need to understand the quality metric requirements, and the additional data elements their certified EHR will ultimately need to capture in order to calculate quality measure results.

• Providers will need to understand which incentives (Medicare, Medicaid, or both) they qualify for, and how the timing of implementations may affect their incentive value. If they are CAHs, providers will need to understand which depreciable expenses qualify as “necessary for the administration of certified EHR.” And all providers will need to understand when they can expect to receive their incentive payments.

Each of these topics will play an important role in structuring any given provider’s meaningful use incentive achievement strategy. Over the next weeks and months, we at RWHC and WORH plan to develop rural-focused reports on these and other incentive program issues. Our goal is to provide rural hospitals with information that will help to maximize their chances of achieving effective meaningful use.

Stage 1 Meaningful Use Overview

The final rule requires (as did the proposed rule) that most providers meet a set of meaningful use objectives in order to qualify for incentives. I say most because providers that qualify for the Medicaid incentives do not need to meet the meaningful use objectives in their first year of participation. But all providers in the Medicare program, and all providers in the second year or later of the Medicaid program, will need to meet the meaningful use objectives in order to attain incentives.

That’s why it’s critical for providers to begin to familiarize themselves with the objectives and the metrics thresholds they will be required to meet.

The final rule is available at http://edocket.access.gpo.gov/2010/pdf/2010-17207.pdf The language describing the objectives and measures is on pages 19-57, and a grid that identifies each objective and measure is on pages 58-63. Additionally, language that further defines the objectives in the context of certification is contained in the final rule on standards, specifications, and certification: http://edocket.access.gpo.gov/2010/pdf/2010-17210.pdf

While the final rule does not (1) create a separate meaningful use objective glide path for small rural providers or (2) extend timelines out to 2017 (both of which rural providers advocated for), it does significantly improve on the proposed rule (NPRM) for the following reasons:

• Rather than requiring that hospitals meet all of 23 objectives and eligible professionals (EPs) meet all of 25 objectives, the final rule requires that hospitals meet a “core” set of 14 objectives, along with a selection of 5 objectives from a “menu” set of 10 objectives. EPs must meet a core set of 15 objectives, along with the 5 out of 10 menu objectives. While not revolutionary, this change will allow for additional flexibility that will help many providers.

• There is an ability to claim that an objective is inapplicable. If it is inapplicable in the core set, the objective is no longer required. If it is inapplicable in the menu set, the number of menu set objectives that need to be met is reduced to 4. This sounds good, but the definitions for what makes an objective inapplicable are relatively rigid, so only a limited number of providers will benefit from this.

• There has been a significant effort made to reduce the administrative burden of collecting numerators and denominators of the objective metrics. Unless the denominator is “all patients” (in which case the number should be known), the measures limit denominators to patients whose records are in the EHR. Additionally, the certification rule requires that vendors build their certified EHRs to be able to “electronically record the numerator and denominator and generate a report including the numerator, denominator, and resulting percentage associated with each applicable meaningful use measure.” This is something that RWHC argued for in our NPRM comments, and it will significantly ease the burden on providers.

• Many of the percentages required to meet the objectives have been reduced, and several definitions have been modified to make meaningful use more attainable.

Stage 1 Meaningful Use Objectives

Core Objectives

• Use CPOE
• Implement drug to drug and drug allergy interaction checks
• E-Prescribing (EP only)
• Record demographics
• Maintain an up-to-date problem list
• Maintain active medication list
• Maintain active medication allergy list
• Record and chart changes in vital signs
• Record smoking status
• Implement one clinical decision support rule
• Report quality measures as specified by the Secretary
• Electronically exchange key clinical information
• Provide patients with an electronic copy of their health information
• Provide patients with an electronic copy of their discharge instructions (Eligible Hospital/CAH Only)
• Provide clinical summaries for patients for each office visit (EP Only)
• Protect electronic health information created or maintained by certified EHR

Each of the core objectives must be met unless a provider qualifies for an exclusion.

Menu Objectives

• Implement drug formulary checks
• Record advanced directives
• Incorporate lab results as structured data
• Generate lists of patients by condition
• Send reminders to patients (EP only)
• Provide patients with timely electronic access (EPs only)
• Provide educational resources
• Perform medication reconciliation
• Summary care record for transfers
• Submit electronic data to immunization registries
• Submit reportable lab results to public health (hospitals only)
• Submit electronic surveillance data to public health

5 of the menu set objectives must be met, unless a provider qualifies for an exclusion, in which case 4 must be met. At least one of the 5 selected menu options must be a population health related objective (one of the last three on the menu list).

Analysis of Final Meaningful Use Objectives and Measures

Objective #1: CPOE (Core Set)

CPOE has been identified as a core objective. We and other rural provider groups have argued that this should be a deferrable objective, since (1) it is a late-stage EHR environment application, and (2) many small rural hospitals are starting at very early stages of EHR adoption, from which moving to CPOE will generally take at least 3-5 years. If CPOE had remained in its proposed form, keeping it as a core objective would have effectively excluded a large percentage of small rural hospitals from participating in the HIT Incentive program.

However, the definition of CPOE has been changed in a way that I believe largely mitigates the reason CPOE is generally so difficult to implement: namely, physician adoption challenges.

The proposed CPOE objective for hospitals was: “Use CPOE for orders (any type) directly entered by the authorizing provider.”

The final CPOE objective is: “Use CPOE for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local, and professional guidelines.”

The differences between the proposed and final CPOE objectives are: (1) “any” order has been changed to “medication” order (which reduces the scope of the requirement), and most important (2) the order no longer needs to be entered by the “authorizing provider.” It can be entered by any “licensed professional,” such as an RN or a pharmacist. RNs and pharmacists currently enter orders for physicians (i.e. authorizing providers) in many provider environments.

Link to CMS FAQ Updates on who can enter CPOE orders:

The change in language effectively expands the strategies providers may use to deploy the objective, and therefore will enable a much larger percentage of providers—whether small and rural or large and urban—to participate in the incentive program.

The objective must be achieved using certified EHR technology as defined in the final certification rule. The definition of CPOE in the final certification rule is: “CPOE—enable a user to electronically record, store, retrieve, and modify, at a minimum, the following order types: (1) Medications; (2) Laboratory; and (3) Radiology/imaging.” This definition is what vendors will need to certify to. Most hospital information system (HIS) vendors have distinctive pharmacy and provider ordering modules. To the extent that pharmacy modules do not allow for lab and radiology ordering, it is likely that the provider ordering module will need to be used to meet the CPOE objective.

For hospitals that are not in a position to implement “direct authorizing physician CPOE,” I believe we will see two primary strategies for satisfying the CPOE objective. One will be for nurses to enter physician handwritten orders through the provider ordering module. The other will be for pharmacists to enter the orders through the provider ordering module. In either case, pharmacists will then verify the orders in the pharmacy module.

In addition to the changes in the CPOE objective, there are several mostly favorable changes in the CPOE measure, including:

• Rather than “all orders,” the denominator is the number of unique patients with at least one medication in their medication list entered using CPOE. This is a significant change both because it is limited to medication orders, and because “unique patients with at least one medication on their lists” provides for enhanced flexibility in meeting the measure. “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 CPOE is performed during at least one of the patient encounters.

• The only patients that are included in the denominator are those whose records are maintained using certified EHR technology.

• The threshold percentage has risen from 10% to 30% for hospitals, and has been reduced from 80% to 30% for EPs. Additionally, in what is the only Stage 2 ruling in the final rule, the Stage 2 threshold has already been set at 60%.

• The ability to calculate the measure will be included in the certified EHR technology as a certification requirement.

The proposed CPOE measure for hospitals was: “CPOE is used for at least 10 percent of all orders.”

The final CPOE measure is: “More than 30% of all unique patients with at least one medication in their medication list seen by the EP or admitted to the eligible hospital’s or CAH’s inpatient or emergency department (point of service codes 21 or 23) during the EHR reporting period have at least one medication order entered using CPOE.”

The Denominator is: Number of unique patients with at least one medication in their medication list 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 only patients that are included in the denominator are those patients whose records are maintained using certified EHR technology).

The Numerator is: Number of patients in the denominator that have at least one medication order entered using CPOE.

The Threshold is: The resulting percentage must be more than 30 percent in order for an EP, eligible hospital or CAH to meet this measure.

Exclusion: If an EP writes fewer than one hundred prescriptions during the EHR reporting period they would be excluded from this requirement. There is no exclusion for hospitals.

Objective #2: Implement drug-drug and drug-allergy checks (Core Set)

To be addressed in future blog…