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.  

The contention that electronic documentation of clinical encounters is occurring de facto, obviating the need for an electronic notes criterion, does not accurately reflect current market conditions and actual HIT utilization.  A report released earlier this year by CSC on hospital and eligible professional readiness for Stage 2 revealed that one of the biggest challenges facing hospitals was electronically capturing needed data from physician documentation, which was rated ‘hard’ by 38 percent of respondents and moderately difficult by 47 percent.  Data analysis for quality reporting was rated as moderately challenging by 55 percent of respondents and hard by an additional 24 percent.  Perhaps most revealing, the report found that almost 3 out of 4 providers surveyed said they would need moderate to major process and product changes to fulfill a new electronic documentation criterion for meaningful use.  More recently, a survey of health care organizations conducted by Anoto found that paper is still a primary source for tracking information within their organizations.  Nearly 80% responded that they still rely on paper records, despite either having or currently implementing an EHR system.  

Electronically documenting patient encounters across care settings is vital to achieving the goals of the HITECH Act and the EHR incentive program.  CMS and ONC have identified interoperability and the exchange of health information as a major theme for Stage 2, but such exchange can only succeed if patient encounter data is reduced to digital formats that providers can readily share, understand and act upon.  Stage 2 goals for care coordination similarly hinge on the broad use of electronic documentation.  One of the more difficult areas of compliance in Stage 1 centered on the quality reporting criteria for meaningful use.  An argument can be made that these challenges can be traced to the absence of an electronic notes criterion.     

The link between electronic notes and quality reporting is starting to be appreciated by the provider community. In their recent comments on the proposed rule for Stage 2 of meaningful use, the American Hospital Association urged the inclusion of an electronic notes criterion, calling it a “key element of ensuring that we can move forward with automated quality measurement.”  The AHA went on to add that “many quality measures require pieces of information that are most often found in clinical notes, particularly when looking for exclusions.” 
CMS’ intention not to be overly prescriptive with many aspects of meaningful use should be applauded.  But in the case of electronic notes, a little prescription seems to be in order.  Without it, doctors and hospitals will continue to face challenges in meeting the exchange, care coordination and quality reporting requirements of Meaningful Use.

Sean Benson is Vice President of Innovation at Wolters Kluwer Health Clinical Solutions and the Co-Founder of its ProVation Medical subsidiary, which provides procedure documentation and clinical decision support solutions for hospitals and Ambulatory Surgery Centers

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