Meaningful Use Stage 2: A Giant Leap in Data Exchange

The CMS and ONC Meaningful Use Stage 2 rules we just issued represent a massive step forward in advancing the secure exchange of information between providers and patients to support better care across the nation. Getting the right information to the right person at the right time can be a matter of life and death.  Unfortunately, anyone who has been a patient or cared for a patient understands that it’s simply not happening today.

Back in 2009 when we were drafting the initial set of meaningful use criteria and required standards, our hopes and expectations were subdued by the reality we faced. Different vendor products used different proprietary or local codes, there were strong disagreements about how laboratory results or patient summaries should be packaged, and there was simply no consensus on how the Internet could be used to securely send patient information. Over the past two years, thanks to the initial steps we took in Stage 1 and the relentless work of almost 1,000 volunteers in ONC’s standards and implementation activities, we can now leap towards interoperability and exchange in Stage 2.

Meaningful Use Stage 2 and Health Information Exchange Highlights

  • Common Standards and Implementation Specifications for Electronic Exchange of Information: The Meaningful Use Stage 2 final rules define a common dataset for all summary of care records, including an impressive array of structured and coded data to be formatted uniformly and sent securely during transitions of care, upon discharge, and to be shared with the patient themselves. These include:
    • Patient name and demographic information including preferred language (ISO 639-2 alpha-3), sex, race/ethnicity (OMB Ethnicity) and date of birth
    • Vital signs including height, weight, blood pressure, and smoking status (SNOMED CT)
    • Encounter diagnosis (SNOMED CT or ICD-10-CM)
    • Procedures (SNOMED CT)
    • Medications (RxNorm) and medication allergies (RxNorm)
    • Laboratory test results (LOINC)
    • Immunizations (CVX)
    • Functional status including activities of daily living, cognitive and disability status
    • Care plan field including goals and instructions
    • Care team including primary care provider of record
    • Reason for referral and referring provider’s name and office contact information (for providers)
    • Discharge instructions (for hospitals)

In addition, there are a host of detailed standards and implementation specifications for a number of other transactions including quality reporting, laboratory results, electronic prescribing, immunizations, cancer registries, and syndromic surveillance (see below for a detailed list).

What does this mean? It means that we are able to break down barriers to the electronic exchange of information and decrease the cost and complexity of building interfaces between different systems while ensuring providers with certified electronic health record (EHR) technology have the tools in place to share, understand, and incorporate critical patient information. It also means that providers can improve workflow and dig deeper into the data. Certified EHR technology must be able to support identity reconciliation—matching the right record to the right person—and will give doctors the tools to reconcile a new document with the information already on file, for instance by incorporating medications and problems identified by another provider into a patient’s record,  thus creating a single source of truth. The Stage 2 regulations also require developers to build systems that allow each segment of the patient summary, whether it is  procedures or lab results, to be retrievable by the end user, getting us closer to the goal of being able to efficiently search and assemble individual data elements through metadata tags.

  • Rigorous Testing of Exchange for Stage 2: To ensure certified EHR technology supports providers in exchanging health information with greater frequency and across vendor boundaries, ONC will work with NIST to develop an interoperability testing platform for Stage 2 that will rigorously test that EHR technology can send, receive, and incorporate standardized data using the specified standards and protocols. Any EHR technology that meets the demanding testing requirements should be able to send and receive standardized information with other certified EHRs. We will need your help over the coming months to develop and vet the Stage 2 certification test scripts. Check back to www.healthit.gov soon for additional information on this initiative.
  • Actual Electronic Exchange of Clinical Information: By 2014, providers will have to demonstrate, and vendors will have to support, the actual exchange of structured care summaries with other providers—including across vendor boundaries—and with patients. Whether through “push” or “query” methods, the requirements in the rule assure exchange is occurring while avoiding undue burden on providers and vendors to track and measure this exchange. As we stated unequivocally in the final rule (a dramatic reading of which is available Exit Disclaimer), we will pay close attention to whether the requirements in the rule are sufficient to make vendor-to-vendor exchange attainable for providers. If there is not sufficient progress or we continue to see barriers that create data silos or “walled gardens Exit Disclaimer,” we will revisit our meaningful use approach and consider other options to achieve our policy intent.

While any rule-making includes some compromises between the aspirational goals we want to achieve and the reality of where the market is, we continue to make progress toward the ultimate goal of nationwide health information exchanges. By setting ambitious, but achievable targets for providers and vendors alike, I’m confident that we’ll see the same hockey stick progress we’ve seen for adoption of EHRs for information exchange. The push on standards-based information exchange and other Meaningful Use Stage 2 requirements will allow the country to make meaningful use of the meaningful use roadmap for more coordinated, safer, and better care.

For More Information

MU Stage 2 Chart
Meaningful Use Chart Stage 2
Meaningful Use Stage 2 Chart

8 Comments

  1. Bobby Gladd says:

    All great stuff. I hope RECs will be still around to continue helping EPs and EHs.

  2. TANF says:

    Interesting read. The EHR is undergoing a standardization through either an RFID card or simple card. That way a patient would only have to hand over this card in order for the medical staff to swipe it through a reader and instantly be able to get access to all the things mentioned in your post. It is clearly going to greatly advance the processing time of health care once the bugs are worked out.

  3. Joel Ryba says:

    ONC is going to get more standards around the data so that they can do it more easily. Great! I only have one question “What happens when you version the standards?”

    The value of “HIE the noun”, for example an Enterprise Service Bus based regional patient-centric exchange, is that it abstracts between data providers and data consumers. Thus, if a new standard comes along, some can implement it and some can hold off. The HIE provides the abstraction between the two. There is no tight-coupling between trading partners. In the “we will all do the same thing peer to peer” model, doesn’t it break when something new comes along? Otherwise, every P2P end-point needs to support every standard that emerges as they emerge and until everyone has it implemented, the world is frozen.

    This sounds like where HIT is with ICD10 right now. Most systems seem to have tightly coupled to the ICD9 codes rather than having an abstraction in their system between internal coding and the outward facing standard codes, now they have trouble upgrading, and nobody can move until everybody moves or the trading partners need to build the abstraction that they missed so that they can do both without losing granularity in the coding. Why repeat this mess, build on abstraction.

  4. Crystal DeVelis says:

    The insurance companies already have in place in incredible mass of data on each of us. They seem to share that information seamlessly, as anyone who has ever applied for coverage or authorization quickly finds out. Why are we not leveraging on that system already in place?

    • Joel Ryba says:

      I don’t think anyone from ONC responds to comments in the blog, or at least I am still waiting on one to mine. So, I’ll give you my two cents. Claims systems are built on simple EDI transactions. E.g. submit a claim, system runs adjudication rules, you get an approval. This is usually a series of asynchronous, basically financial, transactions. The claim doesn’t actually have much clinical data. The database has a record that a procedure was done and perhaps paid for, but you don’t know what the results were from doing the procedure. HIE on the other hand is clinical data exchange for providers, care managers (ACOs like PCMHs, Health Homes, and payer based care management programs), and patients. Also, even for claims data, claims systems lack a complete patient record because the average person changes health coverage every couple of years.

      “HIE the Noun” provides a complete patient record for providers and care managers regardless of where the care occurred or who paid for it with access granted based on patient consent. “HIE the Verb” provide one to one exchange like email. It has its use cases, like provider to patient exchange. However it doesn’t work well to inform care managers so it doesn’t fit well with the ACO movement in this country.

      Joel Ryba, http://www.directhisp.com/

  5. Timothy H. says:

    Information is key, but without proper exchange it can become a pretty worthless one. Having been in treatment for some time over the last years, I witnessed the lack of this exchange first hand. Every step towards a better exchange system is great in my book, so keep up the good work. People all over the nation will be grateful.

  6. Richard says:

    We find significant problems with names and I must be missing it but I do not see name standardization in these requirements. We receive Sue Jones from one physician office in an inbound transaction, Susan Jones from another, Susie Jo Jones, Susan Jones-Smith, etc. all for the same person. Name reconciliation logic in our system then creates a new medical record number for all of these “patients”. Could physician offices using certified EHR technology be required to use a name exactly as it appears on a legal document, such as a drivers license, birth certificate, passport, etc. so that we could reduce the number of dissimilar names for the same person?

  7. Bill says:

    Adding on to what Richard said, there is no standard for documenting the Care Team as well the referring provider. I’ve gone through the documentation and don’t even see an NPI requirement.

    Their example for testing is:
    B) Care Team
     Dr. Samir Khan, Tel, 555-555-1004, Get Well Clinic, 1004 Healthcare Dr. Portland, OR 97005
     Nancy Nightingale, RN, 555-555-1014, Get Well Clinic, 1004 Healthcare Dr. Portland, OR 97005

    Wouldn’t it make more sense for standardization to include the NPI for a provider?

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