Electronic Documentation is a Curious Omission from Stage 2 Proposed Rules

April 2, 2012  |  Category: Clinical ApplicationsRegulatory Updates

The proposed rule for Stage 2 Meaningful Use is a veritable symphony of healthcare IT guidelines and requirements. But in at least one sense, the unveiling last month felt like a long drum-roll without a climactic cymbal crash.

That’s because Stage 2 omits electronic physician documentation as a core objective – which is a shame, because documentation remains a key part of physicians’ workflow that cries out for an efficient, integrated solution.

While documentation is (at least temporarily) gone, it clearly is not forgotten. Although CMS has not proposed this objective (despite the HIT Policy Committee’s recommendations), CMS and ONC have:

1) requested public comment about including it;

2) proposed standards for certification; and

3) required structured electronic documentation of family medical history.

Furthermore, electronic structured notes provide a major source of data that is required for electronic reporting of quality measurements, exchange and care coordination.

So it’s possible that documentation may reappear in the final Stage 2 rule later this year. Now wouldn’t that beat the band!

This post was written by PatientKeeper's TransforMED blogging team.