As the industry awaits the final rule for Stage 2 of electronic health records meaningful use, the ultimate success of Stage 2 may hinge on a requirement that was not even included in the proposed rule from the Centers for Medicare and Medicaid Services.
Electronic physician notes as a meaningful use criterion have had a strange ride during the regulatory process. Originally proposed by the HIT Policy Committee as a criterion in Stage 1 to promote quality, safety and efficiency, CMS decided such a requirement would be overly prescriptive. Their rationale at the time was that physicians were already documenting their notes electronically. Dr. Paul Tang and the HIT Policy Committee’s meaningful use work group disagreed with this assessment and proposed an electronic notes requirement in Stage 2 in their recommendations submitted last June. The Office of the National Coordinator appears to agree with Tang and company, and included a certification criterion for electronic notes in their proposed rule for the Stage 2 certification criteria and standards. Unfortunately, CMS has held firm in its belief that patient encounters are already sufficiently documented and did not include an electronic notes requirement for Stage 2.
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