Rhapsody Health Solutions Team

Meaningful Use Stage 2: How the Final Rule Impacts Integration

Following up on my blog post in March on the proposed rules for Meaningful Use Stage 2, the final rules can now be analyzed for their impact on integration and interfacing. This blog will discuss changes from Meaningful Use Stage 1 to Stage 2, as well as changes from the proposed rules released earlier this year.

The final rule for Meaningful Use Stage 2 certification criteria define the standards used for data exchange and the required utilization of interoperability by providers. Areas most impacted by the final rule certification criteria include:

  • Patient Summary
  • Clinical Messages
  • Electronic Prescribing
  • Transport Specifications

Patient Summary

  • Meaningful Use Stage 1: HL7 CCD (C32), or CCR
  • Meaningful Use Stage 2: HL7 Consolidated CDA (for create, transmit and display), HL7 CCD (C32) or CCR (for display only)

In somewhat of a surprise, the final rule included both standards from Meaningful Use Stage 1, as well as the new Consolidated CDA standard mentioned in the proposed rules. It was stated in the final rule a desire to maintain backwards compatibility based on public comment for display purposes only. This makes the transition from Stage 1 to Stage 2 easier and more interoperable, as Stage 2 requires EHRs to display Stage 1 documents.

Consolidated CDA makes it much easier for implementers and providers alike to analyze and understand the standard. For more information on Consolidated CDA, please see 6 things to know about Consolidated CDA in Healthcare IT News.

The hurdle for providers to demonstrate the electronic transfer of patient summaries has also increased. Stage 2 requires that a provider electronically transmit a summary of care for more than 10% of transitions of care and referrals. Further, at least one summary of care document must be sent to a recipient with a different EHR vendor or to a CMS test EHR.

Clinical Messages

  • Meaningful Use Stage 1: HL7 2.3.1 and 2.5.1 
  • Meaningful Use Stage 2: HL7 2.5.1 only

Many criteria which allowed for either HL7 v2.3.1 or HL7 v2.5.1 messaging in Stage 1 will now only allow HL7 v2.5.1 messaging. The criteria impacted include:

  • Clinical quality measure data import, export, and electronic submission
  • Transmission to public health agencies (surveillance)
  • Transmission to immunization registries
  • Transmission of reportable laboratory tests and values/results

In addition, a new standard will be utilized for Stage 2.

  • CDA, Implementation Guide for Ambulatory Healthcare Provider Reporting to Central Cancer: Utilized for the transmission of cancer information.

One standard included in the proposed rules, but not included in the final rules: 

  • DICOM PS3 – 2011: A standard for image transfer that was called out in the proposed Meaningful Use Stage 2 criteria. The ONC stated that “the adoption of this or other standards was not necessary to enable users to electronically access images and their narrative interpretations.”

Electronic Prescribing

  • Meaningful Use Stage 1: NCPDP 8.1 and 10.6
  • Meaningful Use Stage 2: NCPDP 10.6 only

For electronic prescribing, only NCPDP 10.6 will be allowed for Meaningful Use Stage 2.

Transport Specifications

  • Applicability Statement for Secure Health Transport (primary Direct Project spec)
  • XDR and XDM for Direct Messaging
  • SOAP-Based Secure Transport Requirements Traceability Matrix (RTM)

As expected, the Direct Project will be the required transport for summary of care documents. Specifically, the Applicability Statement for Secure Health Transport, which is referred to as the primary Direct Project specification will be the required transport. For more information on this specification, please visit the Direct Project website.

There are optional transport standards as well. There are two choices for the use of optional standards:

  • Option 1: Certification can be performed for both the Applicability Statement for Secure Health Transport specification and the specification utilizing the XDR and XDM profiles for Direct Messaging.
  • Option 2: Certify for both Simple Object Access Protocol (SOAP)-Based Secure Transport Requirements Traceability Matrix (RTM) version 1.0 standard and the XDR and XDM for Direct Messaging.

For the optional standards, the SOAP-Based Secure Transport Requirements Traceability Matrix (RTM) specification was selected instead of specific IHE profiles. This was purposefully done by the ONC because “it serves as the baseline SOAP specification on top of which other Nationwide Health Information Network Exchange specifications (using IHE profiles) can be implemented.”

As previously discussed, the Direct Project specifications provide entry-level transport in a point-to-point fashion, while the SOAP-based IHE profiles provide for more advanced communications where healthcare facilities can query one another for patient information.

While there were a few surprises in the final rules Meaningful Use Stage 2, many health organizations still have plenty of work to do to before beginning compliance testing by July 1, 2014. Then, on to Stage 3 criteria, which will be implemented in 2016 at the earliest. 


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