On MeaningfulUse Stage3 Proposals

This document (docx) containing proposals for Meaningful Use Stage 3 has been circulating since the November HIT Policy Committee meeting.  I have at least half-dozen copies and links in my in-box already, and you probably have at least one link in yours.  The document is divided into several chunks:

1. A list of proposed Stage 3 objectives in table form, comparing Stage 2 final rule with the Stage 3 proposal, including several new proposals, and a suggestion to provide objectives focused on a single disease area (Cardiovascular disease)
2. A section containing questions about processes for development and implementation of Quality Measures.  These are NOT questions about which quality measures to include in Stage 3, but rather more fundamental questions about the use, creation and architecture for quality measures in stage 3.
3. A section on security, containing questions in three areas (7 questions total), three questions on user (provider) authentication, one on HIPAA and risks, and three questions on accounting for disclosures.
4. Finally, ONC added 13 questions addressing various areas.

The final RFC will likely be published in the Federal Register sometime in the next two weeks.  I have some initial thoughts on the draft proposed objectives that was discussed at the HIT Policy Committee meeting:

1. Consider that mandating use of an interface (e.g., for lab ordering) will be very hard for providers to implement if there is no mandate to implement the other side.  Most of Meaningful Use requirements must be met by providers by using the "certified capabilities" of the EHR (there is only one exception to this called out by CMS in Stage 2, and none in Stage 1).  Objectives like this should follow the "where available" pattern used for much of public health reporting, or other incentives should be provided to ensure that the other side is available first.
2. Questions about "what barriers would there be to..." would be best addressed by statistics on numbers of providers able to meet the MU Stage 2 objective before tightening it further.  In other words, it is too soon to tell.
3. Consider the pre-requisites for technology implementation and deployment before setting objectives using that technology. Some objectives rely heavily on decision support (e.g., maintain medication and problem lists), but necessary standards have yet to be adopted (c.f., ONC Health eDecisions Project). 
4. Consider cross-referencing.  The first objective discusses drug-drug-interactions (using DDI as an acronym without defining it), but later objectives note that standards work on contraindications is still necessary.  If standards are needed for contraindications, that is also true for DDI, and they should be similar in structure.
5. Define your acronyms (e.g.,  DDI,  DECAF, et cetera).
6. Capability to send... needs transport and standards defined.

I'll be reviewing these in much greater detail, and will also be reviewing the remaining sections in the coming weeks.  It's a shame that this is being released during a season where a) many are taking time off, and b) where most affected parties not taking time-off are heads down implementing the stage 2 rules.  At this early point in development of Stage 3, I see no reason why the proposals couldn't be given a 90-day comment period.