The Menu Objectives: Last Stop on the Stage 2 Tour

November has arrived and the days are growing shorter. By the time you read this post the World Series will be history and that most exciting of sports seasons will be gearing up. That’s right…it’s almost time to begin the annual March to Madness! But I digress. Before we start talking turkey we have one stop left on our Stage 2 tour. We need to discuss the meaningful use Stage 2 menu objectives.

 

The menu in Stage 2 consists of six objectives, and the successful provider will report three of these six along with the 17 core objectives and the clinical quality measures. Of note, unlike our recent experience reporting Stage 1 menu objectives, in Stage 2 an “exclusion” will not count as one of your menu objectives. For example, in Stage 1, if I elected to report syndromic surveillance but my local public health authority was not prepared to receive the EHR’s export, I could report an exclusion when attesting and this would count as one of my five Stage 1 menu objectives. In Stage 2, if you qualify for an objective’s exclusion, you must select another menu objective to report.

 

Objectives with a target

 

The six objectives on the Stage 2 menu are equally split into three objectives with a target threshold and three without a threshold. Those with a target include:

1. Electronic Progress Notes: Simple and straightforward, this objective is asking if at least 30% of your unique patient encounters during the reporting period have at least one electronic progress note “created, edited and signed” by the provider during the reporting period. Most providers using a certified EHR are using electronic “templates” to document encounters already. This objective simply requires counting those template encounters. Of note, the fact that this one is on the menu further debunks the myth that you must use a template to qualify for meaningful use. Notice that even in Stage 2 you could forgo this menu objective and continue to dictate all of your progress notes (as long as your EHR is not relying on templates to count MU objectives).
2. Family History: Also straightforward in my view, this Stage 2 menu objective is asking if at least 20% of the unique patients you encounter during the reporting period have a structured data entry for one or more first-degree relatives. In using the phrase “structured data,” ONC expects a SNOMED code to be attached to this information. Most EHRs will handle this under the covers, storing those codes in a database, hidden from the provider’s view. Again, as with e-Progress notes, this one is low-hanging fruit in my view.
3. Imaging Results: This menu objective gets a bit exciting. The imaging objective is asking if at least 20% of all “scans and tests whose result is an image” ordered by the provider during the reporting period are incorporated into or available through the certified EHR. A bit of a mouthful, but in effect this one is trying to determine if the results of 20% of the X-rays you order during the reporting period are “accessible” from within your EHR. Note they mean both the image itself and the report. Quoting from the Stage 2 final rule, “We defined accessible as either incorporation of the image and accompanying information into CEHRT or an indication in CEHRT that the image and accompanying information are available for a given patient in another technology and a link to that image and accompanying information. Incorporation of the image means that the image and accompanying information is stored by the CEHRT.” There are several exclusions here applicable to the nephrologist, but unlike in Stage 1, the exclusions do not bring us closer to successfully reporting. I doubt we will see nephrologists flocking to this objective.

 

Objectives without a target

 

Finally there are three Stage 2 objectives that require the provider to attest that he or she did something during the reporting period. They include:

1. Syndromic Surveillance: A left over, if you will, from the Stage 1 menu, syndromic surveillance is the only objective common to the menu in both of the current stages of meaningful use. There are some differences in Stage 2 however. In Stage 1, a single provider could send test data to a public health agency and, if successful, all providers in the practice received credit for this menu objective. Stage 2 requires the successful and ongoing electronic transmission of syndromic surveillance data to a public health agency by each provider. Further complicating matters for nephrologists, the CDC is expected to issue guidance regarding ambulatory syndromic surveillance. ONC may use this guidance to determine which categories of eligible professionals will not collect this data. Reading between the lines, I am not certain nephrologists will be eligible to report this measure. Stay tuned.
2. Cancer Registry: This menu objective creates a mechanism to report new cases of cancer to State Cancer registries. This replaces a process that today occurs via paper. Meeting the objective requires “successful ongoing submission of cancer case information from CEHRT to a public health central cancer registry for the entire EHR reporting period.” Of course very few nephrologists I have met render a new diagnosis of cancer in the course of routine practice, which brings us to our final Stage 2 menu objective.
3. Specialized Registry: In lieu of reporting new cases of cancer to a state cancer registry, ONC has created an opportunity for a provider to regularly report specific case information to specialized registries for the entire reporting period. Perhaps the best examples of specialized registries are the Stroke, Heart Failure, and A fib registries sponsored by the American Heart Association. In a similar vein, the Fresenius Medical Care CKD Data Registry, among the largest in the world, will offer an opportunity for nephrologists to report CKD-related information to a specialized registry.

 

This concludes our review of the Stage 2 objectives. Although they share the same number of objectives (20), Stage 2 will clearly be tougher than Stage 1. Reporting CQMs has become a given; several of the Stage 1 objectives have been combined in Stage 2; and the Stage 2 menu is a bit restrictive from the nephrologist’s perspective. Nevertheless, for those of you ineligible for the 50% rule related hardship exception, Stage 2 is doable. But you need to put some thought into changes necessary in your workflow. Thankfully, you have the luxury of selecting one of the four calendar quarters to report in 2014. While few will select Q1, do not procrastinate, as you could find yourself in a corner when Q4 rolls around in concert with the ICD-10 transition, a topic that will see attention in future posts.