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Stage 2 Menu Objectives: Recording Electronic Notes


One of the new menu objectives for the Stage 2 rules of meaningful use stresses care coordination through recording electronic progress notes.

Time is running out for practices who haven't yet prepared for the Stage 2 rules of meaningful use.

"There is very little window of opportunity here to make sure that everything is running the way that it should for Stage 2 as opposed to the staggered on-boarding that you've had for Stage 1," said Naomi Levinthal, consultant and healthcare IT advisor at The Advisory Board.

According to CMS, the Stage 2 criteria will place an emphasis on health information exchange between providers to improve care coordination for patients. CMS believes eligible professionals (EPs) and hospitals are in the best position to encourage the use of health IT by patients to engage in their own care.

New Menu Objectives of Meaningful Use Stage 2

• Record electronic notes in patient records• Imaging results of the image itself and any accompanying information are accessible through CEHRT• Record patient family health history as structured data• Capability to identify and report cancer cases to a State cancer registry, except where prohibited, and in accordance with applicable law and practice• Capability to identify and report specific cases to a specialized registry (other than a cancer registry), except where prohibited, and in accordance with applicable law and practiceNote: The menu objective of capability to submit electronic syndromic surveillance data to public health agencies (and actual submission except where prohibited and in accordance with applicable law and practice) remains from the Stage 1 rules.

In addition to the 17 core objectives of Stage 2, eligible professionals must select three of six menu objectives to demonstrate meaningful use.

The first new menu objective for Stage 2 is to record electronic notes in patient records. The measuring criteria includes entering at least one electronic progress note created, edited, and signed by an EP for more than 30 percent of unique patients.

The objective is important because it is designed to ensure continuity of care for patients and it also promotes and supports care coordination, which is one of main tenets of meaningful use.

According to Levinthal, the objective of recording electronic notes in patient records should already be high on every provider's list.

"I think care coordination is probably top of mind," said Levinthal. "So if you have say a multi-specialty practice, [where] a patient goes from a specialist to a primary-care physician, electronic notes can really help the next provider of care see what's going on using text rather than just looking at numeric data and vitals, for example."

Mary Griskewicz, senior director of health information systems for Healthcare Information and Management Systems Society (HIMSS), said clinicians' notes often provide additional information as well as context to a patient's episode of care and medical history.

"The information is useful to the care team," she said.  "As patients request to see their medical information it allows for patients and families to become partners in their health."

Levinthal said that practices will have the option of dictating their written notes in order to meet the criteria of the measure, so physicians who use transcription services, take note.

Levinthal said perhaps the most important question for practices to answer is: Does our technology meet the requirements set forth by CMS?

Griskewicz thinks the transition from paper to electronic records should be a welcome one for clinicians.

"Ensuring clinicians sign-off on the notes is a work flow change that moves from paper to electronic," said Griskewicz. "It actually should be easier for the physician as system availability is easier than working on a paper chart."

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