Stage 3 MU policy draft wraps around decision support

Physicians and hospitals will need to integrate more clinical decision support (CDS) into their practices and coordinate care more extensively to meet meaningful use measures in 2016.

To make that happen, EHRs will have to be able to perform for Stage 3 of meaningful use more complex functions, such as including external medication lists for drug-drug interactions and being able to catch “never” combinations.

Providers will also perform existing measures more often or with a higher percentage of patients, according to preliminary draft recommendations for meaningful use Stage 3 that the advisory Health IT Policy Committee explored at its Aug. 1 meeting.

While stage 3 is three and one-half to four years into the future, and the Stage 2 rule is yet to be finalized, the public-private advisory group wanted to start early to signal to industry improvements it is aiming for in quality, safety, efficiency, patient engagement and population health. Some of the recommendations are still just concepts.

For example, physicians may not always pay attention to drug alerts because they believe the system generates many that are unnecessary or they turn off the feature, said Paul Tang, MD, committee vice chair and chair of the meaningful use panel that developed the Stage 3 draft recommendations.

“We’re looking for an externally maintained list of drug-drug interactions with a higher positive predictive value and that is meaningful about the patient so that the physician will pay attention to it,” Tang said.

“Wouldn’t it be nice if not every vendor or every provider reinvented their own clinical decision support rules and [produced] something that was open source,” said Tang, who is also chief innovation and technology officer at Palo Alto Medical Foundation. "That's what we're working toward."

A recommended measure to improve performance on priority health conditions would establish 15 CDS interventions related to five or more clinical quality measures at a relevant point in patient care.

For example, CDS could be used to determine the appropriateness of lab or radiology orders to avoid duplication. The provider would enable the EHR functionality for drug-drug and drug-allergy interaction checks. The EHR would also be able to track CDS triggers and how the provider responded to them.

The committee also proposed measures for which standards have not yet been decided but should be by 2016, such as being able to collect and record more extensive demographic structured data beyond language, ethnicity and date-of-birth to also include occupation, disability status and gender identity.

Some of the recommendations are solely certification criteria for EHRs, such as functionality to help maintain an up-to-date and accurate problem list. Diabetes may not be included in the problem list, for instance, but tests and prescribed medications are evidence that the patient is being treated for it. The system could prompt the physician about whether to include diabetes in the problem list.

Advance directives recorded for senior patients should be part of Stage 3 if the Stage 2 final rule does not include it. “It is important for patient and families to make this universally known. There are a lot of implications around this subject,” Tang said.

The committee will re-work some of its preliminary recommendations to ready them for a request for public comment expected in November.

By that time, the final rule for Stage 2 should be released and incorporated into the preliminary proposals, Tang said. Ultimately, the committee will send the final Stage 3 measures to the Office of the National Coordinator for Health IT in May 2013.

Many of the measures in Stage 3, such as sharing care summaries and care plans, rely on health information exchange, which is proposed in meaningful use Stage 2 requirements. However, a number of committee members said that exchanging information, especially beyond vendor boundaries, is very difficult.

"Interoperability remains a huge problem," said Mark Probst, CIO at Intermountain Healthcare and a committee member. "Yet we see so many benefits for it, whether it’s for transitions of care or around population health management.”

Exchanging data is expensive to take from one system and put it in another system, without addressing underlying problems in support, cost and safety issues and an inability to secure data when moving between different standards and processes. The core problem is standards -- for data, transport and patient identification.

“I strongly feel we aren’t addressing firmly enough some of these standards,” Probst said, such as for how states receive immunization records and use them to help a patient that moves from state to state or data standards to move computable data between information systems to help care for patients and share knowledge.

The committee suggested conducting a hearing in the fall focused on overcoming barriers to exchange and interoperability.