Meaningful Use Stage 2 Comments - Feb. 2011

General Comments

We thank HITPC for its continued leadership in establishing Meaningful Use criteria and appreciate the committee’s work toward expanding the definition of health data and freeing the data so that it can be shared in meaningful ways. The proposed Stage 2 Meaningful Use criteria build directly and in important ways on the Stage 1 Final Rule. Many of the requirements in Stage 2 will allow patients to take steps, much like health professionals have begun to take, toward meaningful use of health information technology.

Patients rely on many different types of health data, including protected health information (which is protected by HIPAA) and patient-generated, patient-defined data.
Rather than establishing all-new standards, encourage alignment with existing standards where possible.

Engaging Patients and Families in Their Care Section Comments

General

Patient-determined access controls should allow patients to share health data with trusted individuals, including family members, spouses, surrogate decision-makers and others.
Stage 2 should require that patients be able to track data that led to any specific clinical decision.

Stage 2 Requirements

EHR-enabled patient-specific educational resources (10%)

Patients are ready to use educational materials online and at their convenience. Use of these materials leads to better engagement in health care and better health outcomes. In Stage 2, requiring access for 10% of patients is too conservative; a higher requirement would allow more patients the freedom to access relevant educational materials. Data should be defined and/or tagged in ways that allow for third-party development of third-party educational resources.

80% of patients offered the ability to view and download via a web-based portal, within 36 hours of discharge, relevant information contained in the record about EH inpatient encounters. Data are available in human-readable and structured forms (HITSC to define).

All data made available to patients must be in both human-readable and machine-readable formats and must also be machine-interpretable. Successful secure approaches to this level of data liquidity already exist in the commercial banking space. Restricting patient data to pdf format or web-only data presentations is insufficient.

Patients have the ability to view and download (on demand) relevant information contained in the longitudinal record, which has been updated within four days of the information being available to the practice. Patient should be able to filter or organize information by date, encounter, etc. Data are available in human-readable and structured forms (HITSC to define).

We advocate replacing the concept of a single longitudinal record, stored in one physical repository, with the emerging distributed data models that are proving successful in other industries. The idea of a single, longitudinal record is flawed. Even if a patient’s clinical care occurs in only one location, longitudinal records are too institutionally focused. We cannot afford to keep health information confined in clinically focused enterprise systems. Clinical data stored securely, shared with the proper set of access-control measures and distributed in human- as well as machine-readable formats affords greater opportunities for leveraging clinical data through applications that make use of the data for personal health management, public health surveillance and clinical care.
Single-site “longitudinal records” require data redundancy, thus posing significant technical difficulties in maintaining current and correct information.

Patient preference for communication medium recorded for 20% of patients

Recording patient preference for communication medium without requiring health care providers to comply with these preferences is not sufficient.

New Stage 3 Requirements

EHRs have capability to exchange data with PHRs using standards-based health data exchange

We cannot afford to wait until Stage 3 for this requirement. The capacity to implement this requirement exists now. Going into Stage 2, we need to see high-level investment in governance and legal guidance that enables the free exchange of data between EHRs and PHRs.
Clinicians need to know what to do with patient-generated and/or patient-defined health data. Our Project HealthDesign project teams’ findings on how clinicians use patient-generated, patient-defined health data will be ongoing and shared later in 2011.

Offer capability to upload and incorporate patient-generated data (e.g., electronically collected patient survey data, biometric home monitoring data, patient suggestions of corrections to errors in the record) into EHRs and clinician workflow

In Stages 2 and 3, we hope to see these data types expanded to encompass patient-defined health data, or observations of daily living (ODLs). Project HealthDesign’s current project teams will be sharing findings related to incorporating patient-defined, patient-generated data into clinical workflows and EHRs later in 2011.

Improve Care Coordination Section Comments

General

PHRs are wonderful tools for care coordination; they could successfully coordinate patients, clinicians, caregivers and other trusted individuals.

Stage 2 Requirements

Connect to at least three external providers in primary referral network (but outside delivery system that uses the same EHR) or establish an ongoing bidirectional connection to at least one health information exchange

These exchanges must exchange all data. Data should include information about the point of origination, but institutions should not differentiate between their own data and data from external sources.

Medication reconciliation conducted at 80% of care transitions by receiving provider (transitions from another setting of care, or from another provider of care, or the provider believes it is relevant)

The ultimate purpose of medication reconciliation is to make sure patients understand which medications they should be taking. These reconciliations can be confusing to patients. We also recognize that medication reconciliations can create downstream work for clinicians as they answer questions that may arise from the process.

Provide summary of care record (50%)

This is an excellent requirement that must remain in the core for Stage 2.

List of care team members (including PCP) available for 10% of patients in EHR

Include care team members’ roles and designate the primary contact person.
Requiring a list of care team members for 10% of all patients is insufficient. Patients would benefit from access to this information.

Record a longitudinal care plan for 20% of patients with high-priority health conditions

A longitudinal care plan should include long-term goals with dates; assessment criterion; timely notification of alternatives if the care plan isn’t working; and a mechanism for the patient to participate in the assessment.

Additional Specific Questions for Public Comment

Question 4: What are providers’ and hospitals’ experiences with incorporating patient-reported data (e.g., data self-entered into PHRs, electronically collected patient survey data, home monitoring of biometric data, patient suggestions of corrections to errors in the record) into EHRs?

Our project teams have observed patients’ interest in both patient-reported and patient-defined data. It was the patients themselves who first told our project teams about the importance of observations of daily living (ODLs)—measures that track mood, pain levels and even environmental impacts on health. Our project teams will be sharing their findings, which relate to this question, later in 2011.

Question 7: In Stage 1, as an optional menu objective, the presence of an advance directive should be recorded for over 50% of patients 65 years of age or older. We propose making this objective required and to include the results of the advance-directive discussion, if available. We invite public comment on this proposal, or to offer suggestions for alternative criteria in this area.

We need systems that allow clinicians to access advanced directives. Although we recognize the importance of this information, we also acknowledge the challenges inherent in eliciting, keeping current and acting upon the directives in complex and/or emotionally charged situations that may include patients, clinicians, family members and significant others. We must remain mindful that establishing advanced directives is a process, not necessarily a one-time action.