April 15, 2015

Meaningful Use in 2015: Meaningful Use Stage 3 Proposed Rule

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Note: This is the second of a three part series on the current state of Meaningful Use. Read part one on the history of Meaningful Use here, and check back next week  for the final article.


The recent announcement of the Meaningful Use Stage 3 proposed rule has placed reporting on the near horizon — 2017. In this article, we’re looking at changes to objectives and reporting measures.

In the remaining two sections of our three-part series on the program’s status and Stage 3 meaningful use concerns, we’ll outline each of the proposed changes to objectives, clinical quality measures, and  interoperability requirements. We’ll also show how they could affect your practice, and investigate the ways EHR vendors are preparing.

Meaningful Use Stage 3 Objectives

Protect Patient Health Information

Continuing the theme set by HIPAA and the first two stages of the Meaningful Use Incentive Program, the first Stage 3 objective focuses on electronic protected health information (ePHI). According to the proposed rule, “some confusion remains among providers between the requirements of this meaningful use objective and … the HIPAA security rule.” As a result of this confusion, CMS has proposed “to maintain the previously finalized Stage 2 objective,” with measures requiring encrypted data storage, audit logs, timely installation of software security updates, and regular security risk analyses (SRAs).

Electronic Prescribing

Electronic prescriptions are nothing new for most providers, especially those who have attested to previous Meaningful Use Stages. As with the previous objective, little has changed since Stage 2. The new proposed objective requires EPs to generate and transmit permissible prescriptions electronically, but increases the minimum requirements from 50 to 80 percent of patient prescriptions to be “queried for a drug formulary and transmitted electronically using CEHRT.”

Clinical Decision Support (CDS)

One of the more important requirements from previous stages, Clinical Decision Support would remain an important objective, with some slight modifications. The CMS has proposed that certain types of CDS are appropriate for certain types of providers or care delivery settings. Measures for EPs include a requirement that at least five clinical decision support interventions related to four or more clinical quality measures (CQMs) must take place at a relevant point in patient care during the course of the reporting period. The CMS has also reiterated the requirement that providers automate drug-drug and drug-allergy interaction checks, and include them throughout the entire reporting period.

Computerized Provider Order Entry (CPOE)

Once again, the CMS has maintained the importance of CPOE for medication and laboratory orders. More than 80 percent of medication orders and more than 60 percent of laboratory orders must be recorded using CPOE. New for Stage 3, more than 60 percent of diagnostic imaging orders must also be recorded using CPOE. An expansion of previous requirements for radiology orders, diagnostic imaging is a broader category and includes tests such as ultrasound, magnetic resonance, and computed tomography. According to CMS, “this change addresses the needs of specialists and allows for a wider variety of clinical orders relevant to particular specialist to be included for purposes of measurement.

Patient Electronic Access to Health Information

The first truly ‘new’ objective from Stage 3 focuses on using CEHRT to support better patient access to their important health information. An improvement to Stage 2 ‘View, Download, Transmit’ requirements, the Stage 3 objective no longer requires a specific percentage of patients to actually take action (view, download, or transmit protected health information). Instead it requires only that patients be able to access this information electronically, preferably through use of an application-program interface (API).

This is a vast improvement from the Stage 2 requirements, as providers will no longer have to make extraordinary efforts to assist patients in order to meet a minimum threshold. As long as more than 80 percent of patients are able to access their information within 24 hours of its availability to the provider, and 35 percent of unique patients seen are given ONC-certified access to electronic patient education resources (through a patient portal, API, or personal health record) EPs will be able to meet this requirement.

The CMS is seeking comment as to whether the API option should instead be made a requirement — it is the opinion of this writer that an API should be required of all CEHRT if true semantic interoperability is desired.

Coordination of Care Through Patient Engagement

This objective proposes that EPs should “use communications functions of CEHRT to engage with patients or their authorized representatives about the patient’s care.” As a continuation of the previous objective on patient access to their protected health information, this objective encourages electronic communication and engagement between and among patients and their diverse care teams, including nutritionists, social workers, physical therapists, etc.

While the CMS has proposed removing previously required patient action for View-Download-Transmit, this new proposed objective details that more than 25 percent of unique patients (or their authorized representatives) actively engage with the electronic health record made accessible by the provider. This could mean View-Download-Transmit, or use of an API.

Additionally, for more than 35 percent of unique patients, a message must be sent from provider to patient. Furthermore, CMS has proposed that more than 15 percent of unique patient records should include patient-generated health data from a non-clinical setting, which could include health and care-related data from nutritionists, physical or occupational therapists, psychologists, home health providers, or data from the patients themselves, such as self-monitoring data from wearable trackers, manual recording of vital signs, etc.

This patient-generated data requirement will likely spawn considerable discussion. The CMS has already included several questions on which they’d like to see provider comments:

  1. Should patient-generated data require verification by an authorized provider?
  2. Should the incorporation of the data [into the EHR] be automated?
  3. Should there be structured data elements available for this data as fields in an EHR?
  4. Should the data be incorporated in the CEHRT with or without provider verification?
  5. Should the provenance of data be recorded in all cases and for all types of data?

Health Information Exchange (HIE)

Stage 3 tackles more specific requirements for health information exchange than previous stages. The new HIE objective requires EPs to provide a summary of care record when transitioning or referring their patient to another setting of care (more than 50 percent of patients), retrieve a summary of care record upon the first patient encounter with a new patient (more than 40 percent of patients), and incorporate summary of care information into their EHR. All summary of care documents must adhere to the Common Clinical Data Set (CCDS), a newly established standard for clinical data, and providers must perform a clinical information reconciliation for more than 80 percent of transitions or referrals of new patients received.

Public Health and Clinical Data Registry Reporting

This objective, a consolidation of similar objectives from stages 1 and 2, requires providers to “actively engage” with a public health agency (PHA) or clinical data registry (CDR) in order to submit data using CEHRT. In order to demonstrate active engagement, EPs have several options, including showing a completed registration within 60 days of the start of the reporting period, responding within 30 days to testing and validation requests from the CDR or PHA, or completion of both registration and testing/validation followed by actual submission of production data, or data generated by the EPs EHR. It is this objective, along with API requirements, that will likely cause the most difficulty for EPs in addition to vendors.


Thus far, the proposed rule is simultaneously lauded and derided. It’s either the engine delivering the promise of healthcare 3.0 — semantic interoperability — or it’s the third horseman of the forthcoming government-caused healthcare apocalypse, depending on whom you ask. We’d also like to remind readers that this is the Meaningful Use Stage 3 proposed rule here, not the final Meaningful Use Stage 3 rule. Check back next week for the final part of our series, where we’ll discuss provider and vendor concerns and address any of your comments on the first two parts of our series.

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