1. Care Coordination and Interoperable Health IT Systems
Unit 7: Policy and Interoperable Health IT
Lecture c – Meaningful Use, ONC Certification, and Interoperability (Part 2)
Welcome to Care Coordination and Interoperable Health IT Systems, Policy and Interoperable Health IT, Lecture c.
This material (Comp 22 Unit 7) was developed by Columbia University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0004.
This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit

2. Policy and Interoperable Health IT Learning Objectives
Objective 1: List and discuss the impact of key health interoperability related topics in health care legislation (Lecture a)
Objective 2: Identify and discuss how the Meaningful Use program and the ONC certification programs have impacted interoperable health IT (Lectures b and c)
Objective 3: Assess and leverage Meaningful Use, ONC certification, and other health IT policy activities to facilitate interoperability (Lecture d)
This unit will cover the following learning objectives: 1) List and discuss the impact of key health interoperability related topics in health care legislation; 2) Identify and discuss how the Meaningful Use program and the ONC certification programs have impacted interoperable health IT; and 3) Assess and leverage Meaningful Use, ONC certification, and other health IT policy activities to facilitate interoperability. This lecture will focus on the Meaningful Use regulations from the end of 2015 onward and how they have impacted interoperability.

3. Stage 3 regulations were released October 7, 2015
Meaningful Use (MU):
Medicare and Medicaid Programs; Electronic Health Record Incentive Program—Stage 3 and Modifications to Meaningful Use in 2015 through 2017
Standards and Certification:
2015 Edition Health Information Technology (Health IT) Certification Criteria, 2015 Edition Base Electronic Health Record (EHR) Definition, and ONC Health IT Certification Program Modifications
On October 7, 2015, the Stage 3 regulations were released. This consisted of two important regulations. The first one is Medicare and Medicaid Programs; Electronic Health Record Incentive Program—Stage 3 and Modifications to Meaningful Use in 2015 through This rule is commonly referred to as the MU Stage 3 and Modified Stage 2 rule because it defined Meaningful Use Stage 3 of the EHR Incentive Program and modifications to Meaningful Use Stage 2 in 2015 to So there are two things going on: one is there are new requirements with Stage 3, but there are also modifications to the previous requirements. We will go into these changes in a little bit. The second regulation is the 2015 Edition Health Information Technology (Health IT) Certification Criteria, 2015 Edition Base Electronic Health Record (EHR) Definition, and ONC Health IT Certification Program Modifications. Note that systems certified based on the requirements in this rule are referred to as ONC 2015 certified. The ONC 2015 certification regulation included the certification of standards-based functionality needed for Stage 3, as well as additional functionality to support other policy activities beyond MU, such as to support long-term care. The plan was that other programs outside of Meaningful Use will now require certified health information technology.
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4. Stage 3 regulations included new timeline and “Modified Stage 2”
The Stage 3 and Modified Stage 2 regulation included a new timeline and a new stage called “Modified Stage 2”. On the slide is the new timeline that delays the requirement for Stage 3 until 2018 with the ability to optionally start Stage 3 in 2017 for just one quarter. Modified Stage 2 was created to for two purposes. The first purpose was to replace both Stage 1 and Stage 2. Now everyone is attesting to the same stage and meets the same requirements, instead of having some providers in Stage 1 and some in Stage 2. So even if you are just starting out, you would have to attest to Modified Stage 2. This was helpful for people who were managing providers or hospitals at multiple stages because now everyone is at the same stage. Everyone is on Modified Stage 2 and then for 2018, everyone needs to be on Stage 3. The second purpose for creating a Modified Stage 2 was to streamline the objectives from Stage 2 to reduce burden on program participants as well as set a clear focus and direction towards Stage 3. Quite a few objectives were removed and several thresholds were reduced from the original Stage 2 requirements as a result. A few of the priority objectives actually became more stringent. Menu objectives became required or thresholds increased or definitions changed slightly. Although much of Stage 2 was simplified, the majority of the objectives that were retained focused on interoperability! For the Modified Stage 2 objectives with more stringent requirements, these were introduced gradually. The requirements or thresholds potentially change slightly with each year as you progress towards 2018; thus, preparing providers and hospitals for much higher thresholds and requirements that would be needed with Stage 3.
7.5 Table (U.S. Department of Health and Human Services, 2015)
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5. Modified Stage 2: eligible providers
Objective
Description
2016
2017
ePrescribe
EP Measure: All permissible Rx (or all Rx’s) written are ePrescribed.
>50%
Patient Electronic Access
Measure 1: Patient Electronic Access within 4 business days
Measure 2: Patient seen by EP views, downloads, or transmits
At least 1 patient
>5%
Medication Reconciliation
Measure: Medication reconciliation performed for transitions of care into the care of the Eligible Professional
Let’s look at that gradual preparation. In 2015, which is not shown here, hospitals were able to opt out of any objective that had previous been a menu objective and were not required to support any increased threshold. Starting in 2016, some objectives that were previously menu become required and thresholds begin to be increased again. For example, e-prescribing has been around a relatively long time, the threshold has increased to 50%, starting in 2016 and continuing to A second objective is patient electronic access. Providers must give at least 50% of patients the ability to access their data. This objective existed previously and is continuing. In Stage 2, the problem was getting patients to log into their portal and access their data. So for 2015 and 2016, only one patient has to look at their data. But by 2017, we are back to requiring at least 5% of patients, which was originally required in Stage 2. This prepares for Stage 3 which will require a higher threshold. The medication reconciliation objective stayed, but with higher thresholds.
7.6 Table (Lorenzi, V., 2016). Adapted from U.S. Department of Health and Human Services, 2015.
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6. Modified Stage 2: eligible providers (Cont’d – 1)
Objective
Description
2016
2017
Health Information Exchange
Measure: The EP that transitions/refers their patient to another setting of care or provider of care uses CEHRT to 1) create a summary of care record; and 2) electronically transmits the summary to a receiving provider.
>10%
Secure Messaging
Measure: a secure message was sent using CEHRT to the patient (or the patient-authorized representative)
At least 1 patient
>5%
Patient-Specific education
Measure:Patient-specific education resources identified by CEHRT are provided to patients for
with office visits seen by the EP
Continuing on, the health information exchange objective stayed, even though it is a really hard objective, with a threshold of 10%. Another difficult objective was secure messaging. In Stage 2, we did not have meet this requirement, but in 2016, at least one patient must be sent a message from the eligible provider and then greater than 5% in Also, originally, the patient had to send the provider a message, but instead it is the provider that has to send a message, making the requirement easier to obtain.
7.7 Table (Lorenzi, V., 2016). Adapted from U.S. Department of Health and Human Services, 2015.
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7. Modified Stage 2: eligible hospitals
Objective
Description
2016
2017
Patient Electronic Access
Measure 1: Patient Electronic Access within 36 hours of inpatient or ED discharge
Measure 2: Patient who is discharged from inpatient or ED
of an Eligible Hospital views, downloads, or transmits (VDT)
>50%
At least 1 patient
>5%
Patient Education
Measure: Patient-specific education resources identified by CEHRT are provided to patients
>10%
Medication Reconciliation
Measure: Medication reconciliation performed for transitions of care into the care of the Eligible Hospital
This chart shows Modified Stage 2 for eligible hospitals. It is similar to the eligible provider chart on previous slides.
7.8 Table (Lorenzi, V., 2016). Adapted from U.S. Department of Health and Human Services, 2015.
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8. Modified Stage 2: eligible hospitals (Cont’d – 1)
Objective
Description
2016
2017
Health Information Exchange
Measure: The Eligible Hospital that transitions/refers their patient to another setting of care or provider of care uses CEHRT to 1) create a summary of care record; and 2) electronically transmits the summary to a receiving provider.
>10%
ePrescribe
Measure: Hospital discharge medication orders for permissible Rx’s written are queried for a drug formulary & transmitted electronically w/ CEHRT
Medication Reconciliation
Measure: Medication reconciliation performed for transitions of care into the care of the Eligible Hospital
>50%
Health information exchange, ePrescribe, and medication reconciliation also remained for eligible hospitals and their thresholds are now 10% or higher. Starting with 2016 and 2017, e-prescribing has now become a core objective, or mandatory requirement, for eligible hospitals. So as you can expect to see in Stage 3, there will be higher thresholds.
7.9 Table (Lorenzi, V., 2016). Adapted from U.S. Department of Health and Human Services, 2015.
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9. Stage 3’s primary focus is interoperability
Stage 3 objectives, with interoperability-specific ones in bold:
Protection of Electronic Health Information
Electronic Prescribing (EP 60%, EH 25%)
Clinical Decision Support
Computerized Provider Order Entry (CPOE)
Patient Electronic Access to Health Information
Coordination of Care through Patient Engagement
Health Information Exchange (HIE)
Public Health and Clinical Data Registry Reporting
MU Stage 3 also requires electronic submission of quality measure data.
IPPS and MIPS also require use of the eCQM eSubmission
Here is a list of Stage 3 objectives, with those specific to interoperability in bold. The Stage 3 objectives look exactly the same as Modified Stage 2. The differences are the changes in thresholds and the increase in functionality requirements for some of the objectives. The objectives specific to interoperability are: electronic prescribing, patient electronic access, coordination of care through patient engagement, health information exchange, and public health and clinical data registry reporting. Note that the threshold for ePrescribing has increased from Modified Stage 2. Patient electronic access or giving patients access to their data encourages care coordination and patient engagement. The HIE or Health information exchange objective is related to interoperability and care coordination. Public health and clinical data registry reporting is also required in Stage 3 and helps to lay the foundation for a learning health system. The other objectives are: protection of electronic health information, which is important for interoperability because then it would not be trusted without privacy and security of data. Another objective is clinical decision support, which uses the interoperability-related feature of an Infobutton. And lastly, computerized provider order entry, or CPOE, still remains. Stage 3 also requires electronic submission of clinical quality measure data that was captured in the EHR. As you may recall, these are referred to as eCQMs or electronic clinical quality measures to differentiate them from the paper abstraction process of healthcare quality departments in the past. This is important because until Stage 3, manual submission was still allowed and was prevalent. Now, patient level clinical quality measure findings are not only collected and recorded electronically in EHRs, they also must be electronically submitted to CMS using the HL7 QRDA standard. It is also being used for other programs. Starting with Inpatient Prospective Payment System or IPPS in 2016 and the Merit-Based Incentive Payment System or MIPS 2017 electronic submission of quality measures using certified technology is now strongly encouraged with penalties or incentives from those programs. Hospitals do not have to submit the data twice. If a Meaningful Use hospital electronically submitted 4 quality measures to CMS for the IPPS program, it can check a box in attestation confirming this was done and satisfy the Meaningful Use quality measure requirement at exactly the same time.
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10. Stage 3 Objective 5: Patient Electronic Access, Measure 1
For more than 80% of all unique patients seen by the eligible provider or discharged from eligible hospital:
The patient (or the patient authorized representative) is provided timely access to view online, download, and transmit his or her health information; and
The eligible provider ensures the patient’s health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the API in the provider’s certified EHR technology
Patient electronic access is objective five in Stage 3. To meet this objective the eligible hospital or eligible provider must support two measures. The first is to provide timely access to view online, download, and transmit his or her health information. The second measure is to provide to access his or her health information using any application of their choice that is configured to meet the technical specifications of the EHR’s API They can either access the data through the portal or an application programming interface, or API. With access via an API, that means you could create mobile apps to access data. Using any combination of these two measures they must provide access for more than 80% of patients. This is a much higher threshold than for Modified Stage 2.
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11. Stage 3 Objective 5: Patient Electronic Access, Measure 2
The eligible provider must use clinically relevant information from certified EHR technology to identify patient-specific educational resources and provide electronic access to those materials to more than 35% of unique patients seen by the eligible provider or discharged from eligible hospital
For measure two, the eligible provider must use clinically relevant information to provide patients with educational materials, with more than 35% of those patients receiving it electronically. Note that the requirement for it to be provided electronically is new. Modified Stage 2 did not require that.
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12. Stage 3 Objective 6: Coordination of Care through Patient Engagement, Measure 1
More than 10% of all unique patients (or patient-authorized representative) seen by the eligible provider or discharged by the eligible hospital actively engage with the EHR made accessible by the provider. An eligible provider may meet the measure by either:
(1) view, download, or transmit to a third party their health information; or
(2) access their health information through the use of an API that can be used by applications chosen by the patient and configured to the API in the provider's certified EHR technology; or
(3) a combination of (1) and (2)
Objective 6 is also about patient engagement. It is called coordination of care through patient engagement. It consists of three measures. For the first one, the patient must either view, download, or transmit their information, or access their health information via an API. More than 10% of unique patients must actually use these functions.
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13. Stage 3 Objective 6: Coordination of Care through Patient Engagement, Measures 2 and 3
Measure 2: For more than 25% of all unique patients seen by the eligible provider or discharged by the eligible hospital during the EHR reporting period, a secure message was sent using the electronic messaging function of certified EHR technology to the patient (or the patient-authorized representative), or in response to a secure message sent by the patient (or the patient-authorized representative.)
Measure 3: Patient-generated health data or data from a non-clinical setting is incorporated into the certified EHR technology for more than 5% of all unique patients seen by the eligible provider or discharged from the eligible hospital during the EHR reporting period
The second measure of objective six requires that greater than 25% of patients must receive secure messages from their provider. The third measure requires that greater than 5% of patients be able to generate data and upload it into an EHR. The eligible provider or eligible hospital has to meet all three of the measures in Objective 6. However, they only need to meet the thresholds on 2 out of 3. These measures truly support an increase in interoperability with patients.
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14. Stage 3 Objective 7: Health Information Exchange, Measure 1
For more than 50% of transitions of care and referrals, the eligible provider or eligible hospital that transitions or refers their patient to another setting of care or provider of care:
(1) creates a summary of care record using certified EHR technology; and
(2) electronically exchanges the summary of care record
Objective 7 is about the exchange of information to support care transitions and referrals. It consists of three measures. Measure one is the same as the measure for Modified stage 2. An electronic summary of care record must be sent when a patient is transferred or referred. The difference is the threshold is now greater than 50%.
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15. Stage 3 Objective 7: Health Information Exchange, Measures 2 and 3
Measure 2: For more than 40% of transitions or referrals received and patient encounters in which the eligible provider has never before encountered the patient, the eligible provider or eligible hospital receives or retrieves and incorporates into the patient's record an electronic summary of care document
Measure 3: For more than 80% of transitions or referrals received and patient encounters in which the eligible provider or eligible hospital has never before encountered the patient, the eligible provider performs clinical information reconciliation
Measure 2 is brand new. Now summaries of care must not only be sent. They must also be received. This supports the recipient side of the transition of care or referral. Greater than 40% of the summaries of care must be received electronically and incorporated into the patient’s record. Measure 3 builds on the Modified Stage 2 concept of Medication Reconciliation but now also requires reconciliation for allergies and problems as well. Is reconciliation is called clinical reconciliation. In Stage 3, greater than 80% of new transitions or referrals must be reconciled. For Objective 7, the meaningful user must attest to doing all three of these objectives but only needs to meet the thresholds on 2 out of 3.
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16. Stage 3 Enhanced Common Clinical Data Set (CCDS) for Patient Engagement and HIE
Patient Name
Sex
Date of Birth
Race
Ethnicity
Preferred Language
Smoking Status
Medications
Medication Allergies
Laboratory Tests
Laboratory Value / Results
Vital Signs
Procedures
Care Team Members
Immunizations
Unique Device Identifiers
Assessment and Plan of Treatment
Goals
Health Concerns
Objectives 5, 6, and 7 use the HL7 CCDA document as the exchange format to communicate with the patient and the next provider of care, just like in Modified Stage 2. The Meaningful Use Stage 3 rule also defined the set of data to be exchanged using this format for all three objectives and them additional objective specific data types. The dataset common to 5, 6, and 7 or rather the patient engagement and HIE objectives is defined in the regulation and called the Common Clinical Data Set (CCDS). It consists of the fields listed above. Many were required in Modified Stage 2 but some are new like Health Concerns and Unique Device Identifiers. Don’t confuse CCDS with CCDA! They sound similar but remember that CCDA is the HL7 standard document type for the information to be communicated, and CCDS is the set of fields that must be in the CCDA document as per the MU Stage 3 regulation.
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17. Stage 3 Patient Engagement: CCDS and these fields
Laboratory test reports
Diagnostic image reports
Activity history log
Ambulatory setting
Provider name
Office contact information
Inpatient setting
Admission and discharge dates and locations
Discharge instructions
Reason(s) for hospitalization
The Patient Engagement objectives, objectives 5 and 6, require that the CCDS, as well as lab tests, diagnostic image reports, activity history log, provider name, office contact information, discharge dates, discharge instructions, and reason for hospitalization be made available to patients either to view, download, or transmit via API access.
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18. Stage 3 Health Information Exchange: CCDS and these fields
Encounter diagnosis
Cognitive status
Functional status
Ambulatory setting
Reason for referral
Referring provider’s name and office contact information
Inpatient setting
Discharge instructions
Patient matching
First name, last name, previous name, middle name, suffix, date of birth, address, phone number, and sex
The health information exchange objective, objective 7, requires that on transition of care or referral a summary of care be exchanged consisting of the CCDS as well as encounter diagnosis, cognitive status, functional status, reason for referral, referring provider’s name and office contact information, and discharge instructions. In addition, fields to support patient matching must be exchanged – these are first name, last name, previous name, middle name, suffix, date of birth, address, phone number, and sex. Recall that patient matching is an important requirement for inter-organizational interoperability.
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19. Stage 3 Objective 8: Public Health
Eligible providers choose two, eligible hospitals choose four
Measure 1: Immunization Registry Reporting
Measure 2: Syndromic Surveillance Reporting
Measure 3: Electronic Case Reporting
Measure 4: Public Health Registry Reporting
Measure 5:Clinical Data Registry Reporting
Measure 6: Reportable Lab Results Reporting (EH only)
The last Stage 3 objective that we will focus on for interoperability is objective 8, the public health objective. There are a total of six measures, but eligible providers only need to choose two and eligible hospitals need to choose four. This is an increase from Modified Stage 2 signaling the importance of increasing interoperability to support public and population health. These measures require that the eligible hospital or eligible provider actively engage with either public health authorities or clinical data registries to implement exchange of information to the public health authorities and to the registries. The immunization measure is actually bi-directional. Not only is the hospital or doctor required to send immunizations, they are also required to query for immunization history.
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20. ONC 2015 features to support interoperability
Adopts new and updated vocabulary and content standards for enhanced interoperability
Includes enhanced data export and transitions of care functionality
Provides an application programming interface (API) to access EHR data
Includes health IT to support a variety of care and practice settings, such as long-term care and behavioral health
(ONC 2015 Fact Sheet)
In another lecture, we discussed ONC 2011 and ONC 2014 requirements for certified EHR technology. For Meaningful Use Stage 3, you have to adopt ONC 2015 certified technology. For 2015, there are requirements to support the challenging requirements of Meaningful Use stage 3, such as new and updated vocabulary and content standards for enhanced interoperability; enhanced data export and transitions of care functionality; and API support to access EHR data. In addition, ONC 2015 certified technology includes capabilities to support requirements not needed by Meaningful Use, but instead useful to support a wider variety of care and practice settings, such as long-term care and behavioral health.
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21. Meaningful Use interoperability: patient-centered care
Measure
Stage 1
Stage 2 / Modified Stage 2
Stage 3
Patient access to data
Rudimentary sharing with patients
More advanced sharing with patients (view / download / transmit, or VDT), more data types
Higher thresholds, VDT, API “app” access, patient education, more data types
Patient-generated data
N/A
Electronically shared with providers
Patient / provider communication
Secure messaging
Secure messaging at higher threshold
In summary, let us take a look at how Meaningful Use’s stages have improved interoperability to advance patient-centered care, care coordination, and the learning health system. Let’s start with patient-centered care and Stage 1. We had rudimentary sharing of data with patients. Some sharing was electronic and some was through paper, but we started to change the workflow and culture to support the concept of data-sharing with patients. There was advanced sharing in Stage 2 and Modified Stage 2, with patients doing view, download, or transmit but with low thresholds of patients actually required to participate. By 2017, providers are required to get greater than 5% of their patients to access their healthcare information electronically. In Stage 3, the threshold is much higher. In addition the patient can also access his or her data through an API – most likely this means patients using mobile health devices to access their data in EHRs. Brand new in Stage 3 is that patients and outside sources can generate data that could be electronically shared with providers. For patient-provider communication, in Stage 1, there was a basic concept of patient reminders in the form of paper, phone call, , etc. In Stage 2, secure messaging came about with patient reminders still in existence for Meaningful Use. In Stage 3, the threshold for secure messaging was raised to 25%. So you can see that patient-centered care is enhanced through Meaningful Use’s support to increase interoperability through providing and encouraging patient access to data, accepting in patient-generated data and other non-traditional sources, and patient-provider communication.
7.10 Table (Lorenzi, V., 2016).
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22. Meaningful Use interoperability: care coordination
Measure
Stage 1
Stage 2 / Modified Stage 2
Stage 3
Medication reconciliation
Optional
Medication reconciliation required
Clinical data reconciliation using structured data received upon care transition
e-Prescribing
Eligible providers
Eligible providers, optional for eligible hospitals
EP and EH e-prescribing of all substances at higher threshold
Summaries of care
Optional sharing with next provider of care
Sending summaries to next provider of care, could go through HIE, more data types
Sending summaries to next provider of care, higher threshold, could go through HIE, more data types
Let’s look at how Meaningful Use has improved interoperability to support care coordination. Clinical data reconciliation is an important function to coordinate care. In Stage 1 Medication reconciliation was a menu requirement that some hospitals and providers chose. It consisted of checking off a box and manually looking at data. In Stage 2, medication reconciliation was required, but again, it was just comparing data on a screen with data that you entered. Stage 3 required that medications, allergies, and problems be reconciled and raised the threshold significantly. In Stage 3, there is more of a chance that the information is coming in electronically in a structured format and sometimes even automatic comparison might be possible. E-prescribing also helps with care coordination between the pharmacists and the clinicians. Right from Stage 1, e-prescribing was being done and then the thresholds increased in Stage 2 and Modified Stage 2, which is when hospitals were required to do e-prescribing as well. We continue e-prescribing in Stage 3, but the thresholds were higher. Additionally, we start to see new functionalities like refills and queries. So e-prescribing becomes more sophisticated in Stage 3 which helps patient care management across the continuum. And what about actually sharing data with the next provider of care? In Stage 1, you just had to test that you could do it. In Stage 2, you were now required to start sending summaries of care to the next provider of care, but it was a low threshold at 10%. Stage 3 raises this threshold significantly. Also, Stage 3 required that you can also receive summaries of care, and actually use them within your system. So as you can see how Meaningful Use’s Stages have improved interoperability to support care coordination.
7.11 Table (Lorenzi, V., 2016).
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23. Meaningful Use interoperability: learning health system
Measure
Stage 1
Stage 2 / Modified Stage 2
Stage 3
Clinical Decision Support
1 CDS
5 CDS – use of infobutton
Electronic sharing of quality metrics
Optional
Required
Sharing for public health
Sharing with public health authorities
Sharing with public health authorities and registries
Sharing with public health authorities and registries, bi-directional, more data types
Finally, let’s look at Meaningful Use, interoperability, and the learning health system. One objective we have not discussed that much is clinical decision support In Meaningful Use Stage 1, doctors and hospitals implemented a single clinical decision support function. In Stage 2, Modified Stage 2, and Stage 3 this requirement was increased to 5. Also, the hospital or provider was able to take advantage of Infobutton functionality which meant that the clinical decision support function had the ability to perform a knowledge source query based in the context of care. . This capability is aligned with the concept of a learning health system since the clinician is able to use data collected from the system to help drive decisions for care. Another measure related to the learning health system is the electronic sharing of quality metrics. In Stage 1, we started out collecting and recording quality measure information electronically in EHRs. This was a big departure from standard practice which was for quality personnel to manually review and abstract charts. Stage 1 allowed optional submission to CMS of summary-level data. Stage 2 added requirements for additional, we started having the ability to do sharing of detailed level data and again, this was optional. and even some electronic sharing. So in Stage 1, we started capturing the data, but in Stage 2 and Modified Stage 2, we had more quality measures. Now in Stage 3, electronic sharing is required and at a detailed, patient-specific level, which is very useful for building a learning health system because we can get data about quality, push for informed quality rules, decide what we need to do as a country to inform people about quality, figure out how to improve quality, and make strategic decisions. The last learning health system-related measures is sharing data with public health organizations and registries. We started out by just testing the submission of some tests with public health authorities in Stage 1 and then started sharing data with public health authorities and registries in Stage 2 and Modified Stage 2. Stage 3 required implementation of more public health or clinical registry interoperability. Also with the Stage 3 Immunization measure you can query a public health immunization registry and get back immunizations for a patient no matter where they were immunized. This communication of information to public health authorities and to registries and in the case of immunizations, this bi-directional communication helps to build a learning health system by collecting data that can be used to improve public and population health. So you can see that the Meaningful Use stages have help to set an interoperability platform for the building of a Learning Health System.
7.12 Table (Lorenzi, V., 2016).
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24. Merit-based Incentive Payment System (MIPS)
Is an incentive program that replaces Meaningful Use for Medicare eligible professionals
Requires most of the Meaningful Use objectives that are in the Modified Stage 2 and Meaningful Use Stage 3 rule
However, not all thresholds are required
Meaningful Use is only a percentage of the requirements needed to obtain incentives
Note: Does not apply to hospitals
Note that in the discussions on Meaningful Use, clinicians struggled in implementing Stage 2. An important improvement to the concept of Meaningful Use was proposed in Spring 2016 with the MIPS proposed rule, which effects Medicare-eligible clinicians. MIPS stands for Merit-based Incentive Payment System and it eventually superceded the EHR Incentive Program by providing new incentives for doctors that meet Meaningful Use Modified Stage 2 and Stage 3 requirements, as well as other requirements, such as quality reporting. Note that it does not apply to hospitals. The MIPS regulation reduces the Meaningful Use requirements for clinicians by not requiring that they meet every objective and threshold. Actually, increasing incentives are based on how well they do in meeting the objectives and thresholds. MIPS was designed to continue to encourage the adoption of EHR functionality and interoperability without the burden of needing to meet every objective and every threshold requirement.
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25. Unit 7: Policy and Interoperable Health IT, Summary – Lecture c, Meaningful Use, ONC Certification, and Interoperability (Part 2)
Stage 3 and Modified Stage 2 Meaningful Use was released in October 2015
Stage 3 included more data types and 2015 ONC certification requirements to support interoperability
Stage 3’s primary focus was interoperability, with specific objectives that also encouraged patient-centered care, care coordination, and the learning health system
This concludes Lecture c of Policy and Interoperable Health IT. In this lecture, we focused on the policies from the end of 2015 and onward that are related to interoperability. To summarize, the Modified Stage 2 and Stage 3 Meaningful Use regulation and the ONC 2015 regulation were released in October The Merit Based Incentive Payment System or MIPS was released in Spring 2016 which also requires a variant of Modified Stage 2 and Stage 3. Stage 3 is the most difficult of all the stages and its primary focus is on interoperable Health IT. The objectives and ONC certification requirements require implementation and use of interoperability functionality to advance patient-centered care, care coordination, and ONC’s vision of a learning health system.

26. Policy and Interoperable Health IT References – Lecture c (Cont’d)
Office of the National Coordinator for Health Information Technology (2015). ONC Fact Sheet: 2015 Edition Health IT Certification Criteria, Base EHR Definition, and ONC Health IT Certification Program Modifications Final Rule.
U.S. Government (2016). Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models. (2016).
No audio.
Charts, Tables, Figures
7.5 Table: U.S. Department of Health and Human Services. (2015).
7.6 Table: Lorenzi, V. (2016). Modified Stage 2: eligible providers. Adapted from U.S. Department of Health and Human Services, 2015.

27. Policy and Interoperable Health IT References – Lecture c
Charts, Tables, Figures
7.7 Table: Lorenzi, V. (2016). Modified Stage 2: eligible providers (Cont’d – 1). Adapted from U.S. Department of Health and Human Services, 2015.
7.8 Table: Lorenzi, V. (2016). Modified Stage 2: eligible hospitals. Adapted from U.S. Department of Health and Human Services, 2015.
7.9 Table: Lorenzi, V. (2016). Modified Stage 2: eligible hospitals. (Cont’d – 1). Adapted from U.S. Department of Health and Human Services, 2015.
7.10 Table: Lorenzi, V. (2016). Meaningful Use interoperability: patient-centered care.
7.11 Table: Lorenzi, V. (2016). Meaningful Use interoperability: care coordination.
7.12 Table: Lorenzi, V. (2016). Meaningful Use interoperability: learning health system.
No audio.

28. Unit 7: Policy and Interoperable Health IT, Lecture c – Meaningful Use, ONC Certification, and Interoperability (Part 2)
This material was developed by Columbia University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0004.
No audio.