Get the facts regarding view, download and transmit 2014 requirements

As the Medical Officer for Innovation at the ONC and a proud member of the Blue Button team, I am working hard to understand the challenges and opportunities that lie ahead in the implementation of patient engagement functionality in EHRs, including new requirements that a certain percentage of patients view, download and transmit their health data in 2014.

We’ve been hearing about confusion around what to expect for view, download, and transmit (VDT) as part of the Meaningful Use requirements in 2014. We would like to address that confusion and offer a few tips for a successful year.

All providers and hospitals attesting to Meaningful Use in 2014 will need to implement the VDT capabilities for their patients. Those in Stage 1 will attest for access, those in Stage 2 will attest for use (see below). The term “online access” used in the VDT measure definitions refers to all three capabilities – view, download and transmit.

Attesting for Access:
Fifty percent of patients must have the ability to view their data, download it in both human and machine readable formats, and electronically transmit their data. Note the AND – patients must have access to all three functions during the provider’s reporting period. It is not accurate to say that any of these functions is optional.

The types of data that must be viewed, how quickly after an encounter with a provider or institution, and in what format it must be available to be downloaded and transmitted are explicitly defined in ONC’s and CMS’ rules. For example, the required machine-readable format for download and transmit purposes is the Consolidated CDA.

Attesting for Use:
Five percent of all patients must view, download, or transmit their data within the given reporting period. This may involve any combination of VDT, but does not mean that providers or institutions can turn the other functions off.

We are also hearing confusion surrounding whether the Direct Protocol is required for the transmit portion of VDT. Direct for patient transmit is required as part of ONC certification, so every certified EHR comes with this functionality. However, CMS attestation allows for providers to use other forms of transmit to meet their 50% “access” and 5% “use” requirements. The Blue Button team is interested to hear what other Transmit methods providers and hospitals are considering to achieve these requirements.

The Direct Protocol is currently the easiest way to meet the transmit requirement because Direct is built into certified EHRs, is the same transmit method that providers are using for Transition of Care requirements, and is currently being implemented by many patient- facing tools and applications, including those in the Blue Button Consumer Bundle. Judging from the enthusiastic turnout at our Blue Button Developer Forums, Challenges, and Codeathons this year, many more developers are eager to join the ecosystem as soon as they see providers and institutions ready to make the data available.

Finally, patients using VDT will choose where to transmit their own health information. Direct or any other transmit method should be implemented in a way that allows a patient to designate what Direct address or consumer application or tool will receive their information.

2014 will be an important year for Meaningful Use, Blue Button and the community of patients, providers, caregivers, and entrepreneurs building an ecosystem to support patient access to data. We are looking forward to hearing from you about your successes and concerns with meeting the view, download and transmit  requirements.


  1. Ann Guilmette says:

    Direct means provider will send the information to the patient probably through a patient portal and the patient will be responsible to transmit their own information?

    Please clarify this statement for me.

    Finally, patients using VDT will choose where to transmit their own health information. Direct or any other transmit method should be implemented in a way that allows a patient to designate what Direct address or consumer application or tool will receive their information.

    I would like FAQ’s about transmitting TOC documents.

  2. State law in certain states do not allow labs to be published unless a provider has reviewed them or in some States unless providers have communicated with patients. This is a quandry as it calls for a preprequisite that likely cannot be accommodated in the EHR prior to publishing the labs to a portal, depending on how sophisticated the code is. Can you comment.

  3. Jeff Lowman says:

    Patients and customers are going to have to be schooled on all of this new software. For every piece of excitement I have for new IT Technology in healthcare I get a little apprehensive. Because the older you get, the less tech savvy you are and the more healthcare you need.

  4. Jeff Lowman says:

    But I do not want to sound pessimistic at all. We need to use all technology where it can help. That is for sure! Some good outweighs bad. Sorry for the follow up. I get fired up.

  5. This is a good write-up but there’s still lots to worry about if you read between the lines:

    1 – The institution is not forced to use Direct just because the EHR vendor is forced to make it available.

    2 – The rules for adding a Direct endpoint to the Blue Button Consumer Bundle are still very much in flux and may be the subject of a contract yet to be issued.

    3 – Patient directed exchange is subject to long delays (as much as 30 days) so the CCDA will be useless for a lot of apps and shopping opinions. Physicians need a way to bypass these delays if they want the patient to have the CCDA immediately. This may not be part of the EHR vendor’s spec and is the subject of the MA Medical Society resolution last December.

  6. Excellent post. Succinct and clear.

    Quick confirmation on one aspect. You wrote MU2 attestation for “Use” requires 5% to view, download OR transmit. The “OR” there – does that mean that just view, download will suffice for attestation?

    So the transmit part becomes optional in some sense, doesn’t it?

    I probably know the answer, but wanted to confirm my interpretation of the wording. Thanks.

    • Rebecca Mitchell Coelius, MD says:

      Measure #1 for attestation requires the data be made available to 50% of patients for all three functions, View, Download, and Transmit. Due to Measure #1, the patient ability to Transmit their data is absolutely required.
      Measure #2 , 5% must View, Download, or Transmit, doesn’t discriminate between each function when giving credit to the numerator. So one provider could have the entire 5% made up of Views, another all Transmit, or another a mix of View, Download, and Transmit. Thus Transmit is not any more or less required than View or Download for this Measure.

      • Sherry Reynolds says:

        I think we should have your answer printed up on cards!

        There are so many people who think they have to get 50% of their patients to download their records.

        If only 5% of your active patients log on and look at a lab result.. TADA!

        So here are 2 questions I often hear – (and now that I am not at ONC can’t answer officially)

        1) what about shared patients? IE ones in a large system – Does every doctor who saw the patient “get credit” if they log on to view the test results from any one of them?

        2) With the new push to encourage the patient to go directly to the lab site or to a pharmacy for their results or medication history how are they “counted?”

        • Brett Coughlin says:

          With the new push to encourage the patient to go directly to the lab site or to a pharmacy for their results or medication history how are they “counted?”

          refers to is this :

          … if patients are logging on to CVS to see RXs and can access lab data via Quest etc (when they otherwise may have gone to the providers portal to see that information and therefore the provider would have gotten “credit” for that access)…… what will that impact be to providers attempting to get patients to access their portal…..?

          We have heard that question raised before; some providers worried that the increased alternatives for patients to access their data via “Blue Button partners” will cause the providers to have increased difficulty in making the 5% goal of VDT. However, at this stage we cannot imagine that the number would be a big game changer. Nevertheless that is the fear that has been expressed.

          CMS also has a Frequently Asked Question that might help:

          Thanks for reading, Sherry and we all hope you are well!

  7. Clayton Curtis MD says:

    Thanks for the informative article. It would help to clarify three more aspects of this topic and requirements:

    * Alternatives ONC was thinking of if Direct is not available. E.g., when the patient wants to ‘Transmit’ the structured data to a desitnation — source of care or not — that does not yet (or may never) have Direct.

    * What the impact is on attestation for use if there aren’t enough candidate recipients that are adequately equipped to allow an institution to meet the 5%.

    * What responsibility ONC views a healthcare source as having when the patient requests ‘Transmit’ — especially if not using Direct to a known healthcare provider.

    Thanks again.

    • Rebecca Mitchell Coelius, MD says:

      Alternatives to Direct: Per the blog, we are very interested in hearing what other approaches institutions and providers are considering. CMS defines other acceptable forms of Transmit as the following.
      Transmission – Any means of electronic transmission according to any transport standard(s) (SMTP, FTP,
      REST, SOAP, etc.). However, the relocation of physical electronic media (for example, USB, CD) does not
      qualify as transmission although the movement of the information from online to the physical electronic
      media will be a download.

  8. Sasha TerMaat says:

    Rebecca, I think your blog post might have a typo. You say, “Five percent of all patients must view, download, or transmit their data within the given reporting period.”

    However, this is inconsistent with the ONC Test Procedure and Data for Automated Measure Calculation,which is clear that patients should be counted in the numerator if they have viewed, downloaded, or transmitted before, during OR after the reporting period.

    Take for example the ONC test patient Nicole Kosta (1.4). She is seen during the reporting period, views her chart outside the reporting period, and is counted in both the denominator and the numerator.

    Could you consider updating your blog post to avoid generating any confusion on how the measure is to be calculated?

    Sasha TerMaat

  9. Patrick Yount says:

    I’d love to receive these updates

  10. Pamela Foyster says:

    Trying to subscribe to updates.

  11. sherry reynolds @cascadia says:

    Nice clarification of the difference between the capability required to be

    EHR certified (view download AND transmit) and what is required in

    Stage 1 (50% have ability to access) and what is required to meet

    Stage 2 – Attestation (view, or download or transmit) – (5% actually use VDT).

    With the shorter 90 day reporting requirements it will be interesting to see what happens this summer for EH’s and this fall for EP’s

  12. Shu Arvilla says:

    I have never seen the medical data that is in my record. This is an important part of the meaningful use requirement.

  13. Well written, and a step in the right direction of better clarification. The CDA is important. My only fear is the ‘interpretation’ that will vary from one vendor to another leading to lack of ‘interoperability’.

    • Jeff Brandt says:

      I have many years of experience with tele/datacom protocol integrations and it has been my experience that all interfaces take manual work. I connected my Android PHR to Healthvault and it took a lot of hours to normalized the CCR data, and I had the specs. Take WIFI, as long as it has been around, and it can still be difficult to link.

      What might make sense for healthcare; modem type technology (for lack of better term) could handle the transport and api from the modem companies could provide the interface.

      Jeff Brandt

  14. It’s nice to have some clarification on this MU2 requirement, up until recently it’s been left open for interpretation.

  15. Baylie Newton says:

    Thank you for the information. I am having trouble, however, finding definitive documentation on this updated objective as being part of Stage 1.

    The Core objective summaries on this page: seem to suggest that the original objective (e-copy of health info) is still in place. Clicking on the objective takes you to a summary that discusses the “Changes as of August 2012″ which directly references the change to the VDT objective for 2014.

    However, further down on that same page is a link to the EHR Meaningful Use Specification Sheet for Eligible Professionals – Electronic Copy of Health Information which states “Last updated April 2013″ and makes no mention of the change.

    In summary, the most recent reference seems to make no mention of the change but “older” reference state that the change was due to take place for Stage 1 in 2014:

    Aside from your article, is there a definitive reference that I can access to show that this objective is indeed in place for Stage 1 in 2014? Any insight would be most appreciated. Thank you!

  16. Jeff Brandt says:

    Great information, Wondering if BlueButton is going to host any Dev conferences this year.

    I have been speaking to some developers and orgs about BB, BB+ and direct. lot of confusion and concern about “bridge to nowhere”.

    I still have issues with the CDA for mHealth, heavy protocol for mobile transmission. Most of the US does not have 4G.

    Jeff Brandt

  17. Mark says:

    Timing Question: If a portal technology is certified for a 90 day reporting period, does it have to be available to the patient starting on Day 1 for a Stage 1 2014 attestation?

    If an institution wanted to wait 10-15 days to get clinic workflow in order and then “turn on” the portal for access and only start the counting at that time (forfeit the first 10-15 days of numerator counting), would that be acceptable if the goal was to get the staff properly prepared to handle workflow to support patient engagement?

  18. Tony says:


    Could you clarify the attestation for access of 50 percent of the patient population?

    Based on previous documentation, I have interpreted it as having the information available, and not necessarily having created the username and password etc., for them to access.

    For example, providing 50 percent of the patient population the ability to enroll and access their information whether they choose to create their login, by giving them the link or website to do so if they choose.

    From CMS: “This could include providing patients with instructions on how to access their health information, the website address they must visit for online access, a unique and registered username or password, instructions on how to create a login, or any other instructions, tools, or materials that patients need in order to view, download, or transmit their information”


    • Brett Coughlin says:

      The Meaningful Use gurus at CMS tell us: “The description means that a provider must give the patient access to the information, or everything they need to get access to the information, without any further action by the provider. In other words, the only thing that can be standing between the patient and their information is patient action.”

  19. Tony says:

    How can a healthcare provider control what cannot be controlled? What if a hospital is in a rural area with mostly older patients; those who may not have access to or even want access to a computer? The hospital could have the best patient portal in the business but there is no way to meet that 5% requirement if patients aren’t willing to sign up for the patient portal.

  20. Teresa Niblett says:

    Does any one know where to find documentation stating that Patients 13 and younger must be included in the denominator for part 1 of the stage 2 measure but EXCLUDED from the numerator? Our vendor has built the scorecard using this information but has yet to provide evidence this is right. It does not make sense and is unlike any other measure which excludes completely or offers exemptions.

    If this is true, there is roughly 10% of our hospitals population we can’t get credit for! Thanks.

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