Measures Reporting for Eligible Hospitals

posted by Kevin Heubusch

Feb 11, 2010 12:02 am

AHIMA Meaningful Use White Paper Series
Paper no. 5b

The fourth paper in this series reviewed the EHR certification requirements related to the notice of proposed rulemaking on meaningful use, published by the Centers for Medicare and Medicaid Services on January 13, 2010. This paper offers an overview of the health IT functionality measures for eligible hospitals. A companion paper (5a) provides an overview of the requirements for providers.

Hospitals that intend to qualify early for the meaningful use EHR incentive program can first apply in the federal fiscal year 2011, which begins October 1, 2010, less than a year after the rules were first published. The qualification period in the first year is only 90 days.

While this is a short period, hospitals seeking to qualify should be determining their current capabilities to qualify and what related functionalities will be available from existing vendors in products to be offered or upgraded in the next year.

Criteria and Objectives

To qualify as a meaningful user an eligible hospital must demonstrate that it meets all of the objectives and their associated measures (p. 1854). Except as otherwise indicated, each objective must be satisfied by an individual hospital as determined by unique CMS certification numbers. Within the NPRM CMS asks for public comment on whether hospitals might have difficulty meeting the proposed objectives.

The objectives proposed were guided by the recommendations presented by the Health IT Policy Committee, the advisory body also established under HITECH. The objectives are grouped under care goals, which are in turn grouped under health outcomes policy priorities.

The criteria for meaningful use are based on these objectives and their associated measures. Pages 1854–58 cover the five objectives and CMS’s rationale for choosing each, including those instances where they differ from the recommendations of the Health IT Policy Committee.

Health IT Functionality Measures

CMS next discusses the functionality measures, stating: “In order for an…eligible hospital to demonstrate that it meets these proposed objectives, we believe a measure is necessary for each objective” (p. 1858). CMS then breaks the measures down into functionality and clinical quality measures (which will be the subject or the next paper).

CMS notes: “without a measure for each objective we believe that the definition of meaningful use becomes too ambiguous to fulfill its purpose. The use of measures also creates the flexibility to account for realities of current HIT products and infrastructure and the ability to account for future advances.”

The functionality measures describe either the eligible provider or eligible hospital requirement for each objective and the target compliance in order to meet the eligibility criteria. Many of these targets are percentages for which CMS provides a numerator, denominator, and the required percentage. In most instances the numerator is the number of activities or functions performed using an EHR, and the denominator being the full population.

It is this concept that is receiving considerable discussion, particularly a hospital’s ability to record these numbers, especially the denominator, during a specified period (i.e., the EHR reporting period). Hospitals will have to take a careful look at how such numbers might be captured in order to meet the recording requirements and possible audit of such numbers.

This review should serve to both suggest comments hospitals might wish to make on the NPRM as well as specify requirements for hospital staff and vendors to discuss so that hospitals can take advantage of the program.

The list of functionality measures provides further rationale and detail on exactly what needs to be recorded and reported (pp. 1858–67). Not all of the measures require a reporting of a percentage. For instance, the requirement for implementation of drug-drug, drug-allergy, and drug-formulary checks merely requires affirmation that the eligible hospital has enabled the functionality.

The reason is partly due to the inability of CMS and some states to receive electronic reports of hospital quality as early as 2011. This requirement could change in 2012, when CMS expects to have the electronic capability.

Clinical decision support rules are another example of a measure that will require attestation, while certain capabilities such as exchange of electronic information requires attestation that the systems has been tested and not necessarily that an ongoing exchange is under way. As hospitals look to qualify as eligible facilities, they will have to develop audit trails of these attestations, as it is expected that audits will occur.

Privacy and Security Requirements

The final requirement is to “protect electronic health information maintained using certified EHR technology through the implementation of appropriate technical capabilities.” The measure requires that the hospital complete a security risk analysis as prescribed under the HIPAA security rules. HIPAA requires that such risk assessments be made periodically.

In this case, such an assessment would not only include security as it relates to the EHR, EHR modules, and other technology, but also the full hospital system that is affected by the increase or introduction of EHR technology as required for meaningful use.

Hospitals should also be aware that there will be additional HIPAA requirements added or modified by HITECH. The proposal for these requirements should be published before February 18, 2010, and most of these requirements will likely be in effect before October 1, 2010.

The table available in the PDF version of this white paper is developed from table 2 in the NPRM (pp. 1867–70). It collects the eligible hospital objectives, Stage 1 measures, numerators and denominators, as well as the related technology requirements for the EHR technology required (the table appears in the full PDF version of this paper).

While the technology requirements are not part of the measures, and are described in a separate rule from the Office of the National Coordinator,  this table provides a look at what certification and standards are  necessary to meet a requirement.

Finally, under the functionality measurement section, CMS highlights its needs for public comment both on the measures presented for Stage 1 and future stages (p. 1870). CMS notes that it intends to build up health IT functionality measures, including:

  • CPOE use to include not only the percentage or orders entered directly by provides but also the electronic transmission of those orders
  • Extend incorporated clinical lab test results into EHR structured data to include “the full array of diagnostic test data used for the treatment and diagnosis of disease, where feasible”
  • Capture measures in situations that currently allow provision and exchange of unstructured data where now there will be the requirement for the provision and exchange of electronic and structured data that currently require the performance of a capability tests and will require the actual submission of data.

The next papers in this series will cover the reporting of clinical quality measures using EHRs.

AHIMA. "Measures Reporting for Eligible Hospitals." (AHIMA report, February 11, 2010).