Use of CPOE for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local, and professional guidelines. This guideline covers ePrescribing as well as the recording of medications that are dispensed and administered within the facility.

More than 30% of unique patients seen by the eligible provider (eligible hospital’s or critical access hospital’s [CAH] inpatient or emergency department), who have at least one medication in their medication list, have at least one medication order entered using CPOE.

Implement drug-drug and drug-allergy interaction checks. Typically this guideline involves both drug-to-allergy and drug-to-drug contraindications, although there is flexibility in the guidelines text in this regard.

The eligible hospital’s or CAH’s inpatient or emergency department has enabled this functionality for the entire EHR reporting period.

Generate and transmit permissible prescriptions electronically (eRx). As a practical matter, at the time of this writing, only Surescripts is recognized as a valid bureau for the transmission of electronic prescriptions to pharmacies for outpatient facilities, although the guideline itself does not mention Surescripts by name.

More than 40% of all permissible prescriptions written by the eligible provider (eligible hospital’s or CAH’s inpatient or emergency department) are transmitted electronically using certified EHR technology.

These include preferred language, gender, race, ethnicity, and date of birth. Some of that data is already tracked by most facilities, but preferred language, race, and ethnicity are new demographics to many lines of care.

More than 50% of all unique patients seen by the eligible provider (eligible hospital’s or CAH’s inpatient or emergency department) have demographics recorded as structured data.

Maintain an up-to-date problem list of current and active diagnoses.

More than 80% of all unique patients seen by the eligible provider (eligible hospital’s or CAH’s inpatient or emergency department) have at least one entry or an indication, recorded as structured data, that no problems are known for the patient. Structured data here refers to the ability to report distinctly on individual problems by code. A clinical note recorded during a patient-provider interaction is insufficient to comply with this guideline.

Maintain an active medication list detailing medications the patient is actively taking that are prescribed by the provider’s facility or reported by the patient. Again, this guidelines requires data on each individual medication and cannot be complied with using only text clinical notes.

More than 80% of all unique patients seen by the eligible provider (eligible hospital’s or CAH’s inpatient or emergency department) have at least one entry (or an indication that the patient is not currently prescribed any medication), recorded as structured data.

Maintain an active medication allergy list that tracks medication allergies, at a minimum. All meaningful use certified systems to date also permit tracking of environmental, food, and other miscellaneous allergies as well as medications.

More than 80% of all unique patients seen by the eligible provider (eligible hospital’s or CAH’s inpatient or emergency department) have at least one entry (or an indication that the patient has no known medication allergies) recorded as structured data.

Record patient vitals as part of typical workflow. Vital signs include taking height, weight, and blood pressure, calculating and displaying body mass index (BMI), and plotting and displaying growth charts for children 2 to 20 years old including BMI. This measure will be a significant workflow change for many types of facilities not accustomed to tracking vital statistics with this level of detail on each visit. A few select exemptions apply; please check CMS advisories for more information. The reasoning for this measure, even in lines of care where the necessity for vitals might not be immediately apparent, is that vital statistics provide a solid evidentiary base for earlier prevention of the most problematic chronic diseases, and each interaction with a provider of any specialty is a good opportunity for this basic prevention step.

For more than 50% of all unique patients age 2 and over seen by the eligible provider (eligible hospital’s or CAH’s inpatient or emergency department), record height, weight, and blood pressure as structured data.

Record smoking status for patients 13 years old or older. Again, this guideline applies to all specialties, even those that have not historically tracked this information and even if it is not immediately obvious how it might be connected to their practices. Smoking-related illness remains a significant cause of adverse health, and any interaction with a medical provider of any kind is a good opportunity to help patients stop smoking or to create correlating data about all types of illness and smoking.

More than 50% of all unique patients 13 years old or older seen by the eligible provider (eligible hospital’s or CAH’s inpatient or emergency department) have smoking status recorded.

Implement one clinical decision support rule relevant to specialty or high clinical priority, along with the ability to track compliance for this rule. Clinical decision support remains the holy grail of EHRs in many circles. It is an advanced concept where the system can apply logical conditions to known data points and make recommendations or present evidentiary advisements about possible diagnosis, treatment, and outcomes for the patient. CDS is a radical jump toward consistent and systematized care, which is still rare in the United States today. CDS is expected to play a larger and larger role as guidelines continue to expand in future years. This guideline provides enormous flexibility in compliance and sets a low bar, requiring the provider to implement only a single CDS rule, no matter how simplistic. To a large extent, this guideline is an indicator and placeholder to introduce facilities to the concept.

Implement one clinical decision support rule.

Report ambulatory clinical quality measures to CMS or the states. This guideline takes the big step of actually demonstrating meaningful use compliance by submitting the summarized numbers, proving compliance with each guideline.

For 2011, provide aggregate numerator, denominator, and exclusions through attestation to the state or federal government through the web-based reporting system. The specific measures for outpatient facilities are itemized in the list that follows. Not all items have to be reported to be compliant. If you try to identify the heart of meaningful use, you could locate it in the ability to answer all of the questions in the list. These questions have been identified as critical by the leading agencies involved in funding and researching health and healthcare. Having a large, concise, and accurate pool of data regarding these issues is the best chance we have to improve patient outcomes in the system. Although the list is dense and filled with confusing terminology, it is important to spend a little time reviewing these questions and determining how your organization will need to change in order to be able to answer them.

Probably more so than any other guideline, this item is a large enhancement or change to existing workflows. This guideline requires that a facility provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies), on request. Ultimately this sets the course for the elimination of traditional paper-based records. Some systems implement this access as a web-based portal that can be used to access the information, others produce PDF files or other exportable documents that can be provided to a patient on a CD-ROM or other electronic sharing medium.

More than 50% of all patients of the eligible provider (eligible hospital’s or CAH’s inpatient or emergency department) who request an electronic copy of their health information are provided it within three business days.

Provide clinical summaries for patients for each office visit.

Clinical summaries provided to patients for more than 50% of all office visits within three business days. The clinical summary needs to include a textual summary of the visit, coding and charge information, and as appropriate medications, labs, and other data.

The capability to exchange key clinical information (e.g., problem list, medication list, medication allergies, diagnostic test results) among providers of care and patient-authorized entities electronically. Many people in the healthcare industry, although David is not among them, see electronic clinical information exchange as a panacea of sorts, on one level to resolve problems of duplication in services and data, on another to provide a basis for analysis of data, and finally as a mechanism to improve patient care. Meaningful use strongly sets a foundation for future expansion of clinical information exchange by requiring support of structured data tracking and by requiring support for the CCD exchange format. In the current guidelines this one sets a very low bar for exchange, simply requiring support for the exchange format and that a single test be conducted. At the time of this writing it appears very likely that substantially more in-depth exchange will be necessary to be compliant in the coming years.

Performed at least one test of information exchange using the CCD (or related) format with another provider organization. For larger facilities this may involve use of a Health Interoperability Exchange (HIE) discussed elsewhere in this text. For most small and medium facilities completing the exchange can be done simply by utilizing some of the support required in other guidelines, specifically file encryption and CCD support. The facility can produce a CCD for a patient, encrypt it, and transfer it to another facility that also has a meaningful use compliant EHR system.

Protect electronic health information created or maintained by the certified EHR technology. This is probably one of the least understood guidelines and in practice is not that large an undertaking for most organizations but on first appearance can seem daunting. The actual heart of this guideline is that as a facility you create a written policy regarding your passwords, access controls, and other electronic and physical measures you take to protect health information and then follow and conduct periodic audits of compliance to the written policy. The specific federal rules that must be reviewed go to pretty long lengths not to codify specific details of the policy that must be in place, only that there be a written policy and it is followed and audited.

Conduct or review a security risk analysis per 45 CFR 164.308 (a)(1) and implement security updates as necessary and correct identified security deficiencies as part of the risk management process. Implement standardized access, password, and logging policies. Conduct periodic audits against those policies to find noncompliance. The federal regulation is a bit difficult to digest but again the heart of it is just to take steps to create written versions of policies that protect health information and to follow those policies. It prescribes very little by way of what the policies your organization has must contain.

Implement drug-formulary checks for at least one internal and one external formulary. There is often confusion about what exactly a formulary is. It is a preferential list of drugs, doses, and forms that can be put together by a facility to make prescribing more consistent. It is also published by payers to indicate drugs that are covered by their programs.

The eligible hospital’s or CAH’s inpatient or emergency department has enabled this functionality and has access to at least one internal or external drug formulary for the entire EHR reporting period.

Incorporate electronic clinical lab test results into certified EHR technology as structured data. All major labs have various kinds of support for electronic importation of results. There can be problems if your facility works primarily with specialty labs or those that are regional or internal. To be compliant the results must be importable into the EHR’s structured electronic data.

More than 40% of all clinical lab test results ordered by the eligible provider (eligible hospital’s or CAH’s inpatient or emergency department) during the EHR reporting period whose results are either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data. Note that the relatively low threshold of 40% provides ample room for special cases involving regional or onsite labs that are not electronically importable.

Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach. Of all of the pieces of meaningful use this capability and its potential strike us as the most underrated and most likely to have real-world benefits for patient outcomes. It is shocking just how little data analysis is done by facilities themselves and the capability offers a straightforward and powerful means to get facilities involved in looking at their own patient populations and important statistics about them. That introspection offers what might be the most promising avenue for significant improvements in patient outcomes with a minimum of effort.

Generate at least one report listing patients of the eligible hospital’s or CAH’s inpatient or emergency department, eligible hospital, or CAH with a specific condition.

Send reminders to patients respecting patient preference for preventive/follow-up care. Many facilities currently employ some process for reminding patients about upcoming interactions. This guideline brings into the electronic age the existing processes and is very synergistic with the patient lists of guideline requirements. This capability has the dramatic potential to improve patient outcomes with minimum effort.

More than 20% of all unique patients 65 years or older or 5 years old or younger were sent an appropriate reminder during the EHR reporting period.

Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, medication allergies) within four business days of the information being available to the eligible hospital’s or CAH’s inpatient or emergency department. A supplement to the guideline regarding access to electronic visit information, this guideline expands that to the ability to provide a comprehensive record rather than just that of a current visit.

More than 10% of all unique patients seen by the eligible provider (eligible hospital’s or CAH’s inpatient or emergency department) are provided timely (available to the patient within four business days of being updated in the certified EHR technology) electronic access to their health information subject to the eligible hospital’s or CAH’s inpatient or emergency department’s discretion to withhold certain information. For various reasons providers might choose to exclude certain classes or specific parts of records from this general sharing. Some states do have additional laws regarding access to legally complete records that might apply to this set of capabilities.

Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate. Facilities often have various mediums of patient education resources from videos to handouts and even websites. This guideline builds on the process by requiring documented and structured information about what education has been provided and what level of understanding the patient has regarding the resource.

More than 10% of all unique patients seen by the eligible provider (eligible hospital’s or CAH’s inpatient or emergency department) are provided patient-specific education resources.

The eligible hospital’s or CAH’s inpatient or emergency department that receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation between the medication details provided by the other facility and any medication records at the currently treating facility. This process in most systems is done by recording the second set of medications as “outside reported” rather than prescribed or ordered and performing duplication, allergy, and contraindication checking among all those entries.

The eligible hospital’s or CAH’s inpatient or emergency department performs medication reconciliation for more than 50% of transitions of care in which the patient is transitioned into the care of the eligible provider (eligible hospital’s or CAH’s inpatient or emergency department).

The eligible hospital’s or CAH’s inpatient or emergency department who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide a summary of care record for each transition of care or referral. Similar to the other patient and electronic interchange guidelines, this item just ensures that information sharing is done in a compliant format when transferring patients to other care facilities or settings.

The eligible hospital’s or CAH’s inpatient or emergency department refers their patient to another setting of care or provider of care or referral care and provides a summary of care record for more than 50% of transitions of care and referrals.

Capability to submit electronic data to immunization registries or immunization information systems and actual submission in accordance with applicable law and practice. This guideline seems to have had the largest amount of errata and additional comment applied by CMS and other authoritative agencies. Although a valiant attempt to improve sharing of data with public health systems, implementation is severely hampered by the limited number and unique requirements of immunization registry systems present at most public health agencies. As a result the guidelines have been watered down to a point of reference only with the submission of very simplistic electronic data by existing means for a single test.

Perform at least one test of certified EHR technology’s capacity to submit electronic data to immunization registries and follow-up submission if the test is successful (unless none of the immunization registries to which the eligible hospital’s or CAH’s inpatient or emergency department have the capacity to receive the information electronically).

Capability to submit electronic syndromic surveillance data to public health agencies and actual submission in accordance with applicable law and practice. This guideline has suffered much the same fate as that regarding immunization registry submission with a number of comments and errata that erodes much of the potential benefit of this. A simple test can be conducted using a variety of formats that might or might not be of practical use. Only a single test must be conducted to comply.

Perform at least one test of certified EHR technology’s capacity to provide electronic syndromic surveillance data to public health agencies and follow-up submission if the test is successful (unless none of the public health agencies to which an eligible hospital’s or CAH’s inpatient or emergency department submits such information have the capacity to receive the information electronically).

Use of CPOE for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local, and professional guidelines. This guideline covers ePrescribing as well as recording of medications that are dispensed and administered within the facility.

More than 30% of unique patients with at least one medication in their medication list seen by the eligible provider (eligible hospital’s or CAH’s inpatient or emergency department) have at least one medication order entered using CPOE.

Implement drug-drug and drug-allergy interaction checks. Typically this guideline involves both drug to drug allergy and drug to drug contraindications, although there is flexibility in the guidelines text in this regard.

The eligible hospital’s or CAH’s inpatient or emergency department has enabled this functionality for the entire EHR reporting period.

These include preferred language, gender, race, ethnicity, and date of birth. Some of those data points are tracked by most facilities but preferred language, race, and ethnicity are new demographics to many lines of care.

More than 50% of all unique patients seen by the eligible provider (eligible hospital’s or CAH’s inpatient or emergency department) have demographics recorded as structured data.

Maintain an up-to-date problem list of current and active diagnoses.

More than 80% of all unique patients seen by the eligible provider (eligible hospital’s or CAH’s inpatient or emergency department) have at least one entry or an indication that no problems are known for the patient recorded as structured data. Structured data here refers to the ability to report distinctly on individual problems by code. Clinical notes that might be recorded during a patient provider interaction are insufficient to comply with this guideline.

Maintain an active medication list detailing medications the patient is actively taking that are prescribed by the provider’s facility or reported by the patient. Again this guideline requires data that can be reported on for each individual medication and cannot be complied with using only text clinical notes.

More than 80% of all unique patients seen by the eligible provider (eligible hospital’s or CAH’s inpatient or emergency department) have at least one entry (or an indication that the patient is not currently prescribed any medication) recorded as structured data.

Maintain an active medication allergy list that tracks medication allergies at a minimum. All meaningful use certified systems to date also permit tracking of environmental, food, and other miscellaneous allergies as well as medications.

More than 80% of all unique patients seen by the eligible provider (eligible hospital’s or CAH’s inpatient or emergency department) have at least one entry (or an indication that the patient has no known medication allergies) recorded as structured data.

Record patient vitals as part of typical workflow including height, weight, and blood pressure; and calculate and display BMI and plot and display growth charts for children 2 to 20 years old, including BMI. This measure will be a significant workflow change for many types of facilities not accustomed to tracking vital statistics with this level of detail on each visit. A few select exemptions apply, so please check CMS advisories for more information. The reasoning for this measure even in lines of care where the necessity for vitals might not be immediately apparent is that vital statistics provide a solid evidentiary base for earlier prevention of the most problematic chronic diseases, and each interaction with a provider of any specialty is a good opportunity for this basic prevention step.

For more than 50% of all unique patients age 2 and over seen by the eligible provider (eligible hospital’s or CAH’s inpatient or emergency department) have height, weight and blood pressure recorded as structured data.

Record smoking status for patients 13 years old or older. Again this guideline applies to all specialties even if it has not historically been the case for this information to be tracked and even if it is not immediately obvious how it might be connected. Smoking-related illness remains a significant cause of adverse health and any interaction with a medical provider of any kind is a good opportunity to attempt to stop patients from smoking or to create correlating data about all types of illness and smoking.

More than 50% of all unique patients 13 years old or older seen by the eligible provider (eligible hospital’s or CAH’s inpatient or emergency department) have smoking status recorded.

Implement one clinical decision support rule relevant to specialty or high clinical priority along with the ability to track compliance with that rule. Clinical decision support remains the holy grail of EHR in many circles and is an advanced concept where the system can apply logical conditions to known data points and make recommendations or present evidentiary advisements about possible diagnosis, treatment, and outcomes for the patient. It is expected that CDS will play a larger and larger role as guidelines continue to expand in future years. This guideline provides enormous flexibility in how it can be complied with and sets a low bar with only the need to implement a single CDS rule, no matter how simplistic. To a large extent this guidelines is an indicator and placeholder to introduce facilities to the concept. CDS is a radical departure toward consistent and systematized care that is not that common today.

Implement one clinical decision support rule.

Report ambulatory clinical quality measures to CMS or the states. This guideline is the actual step of demonstrating meaningful use compliance by submitting the summarized numbers to provide compliance with each guideline.

For 2011, provide aggregate numerator, denominator, and exclusions through attestation to the state or federal government through the web-based reporting system. For inpatient facilities the measures are fairly complex and itemized here.

Probably more so than any other guideline, this item is a large enhancement or change to existing workflows. This guideline requires that a facility provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, and medication allergies), on request. Ultimately this sets the course for the elimination of traditional paper-based records. Some systems implement this access as a web-based portal that can be used to access the information, and others produce PDF files or other exportable documents that can be provided to a patient on a CD-ROM or other electronic sharing medium.

More than 50% of all patients of the eligible provider (eligible hospital’s or CAH’s inpatient or emergency department) who request an electronic copy of their health information are provided it within 3 business days.

Provide clinical summaries for patients for each office visit.

Clinical summaries provided to patients for more than 50% of all office visits within 3 business days. The clinical summary needs to include a textual summary of the visit, coding and charge information, and, as appropriate, medications, labs, and other data.

The capability to exchange key clinical information (e.g., problem list, medication list, medication allergies, diagnostic test results) among providers of care and patient-authorized entities electronically. Many people in the healthcare industry, although David is not among them, see electronic clinical information exchange as a panacea of sorts, on one level to resolve problems of duplication in services and data, and on another to provide a basis for analysis of data and finally as a mechanism to improve patient care. Meaningful use sets a strong foundation for future expansion of clinical information exchange by requiring support of structured data tracking and by requiring support for the CCD exchange format. In the current guidelines this one sets a very low bar for exchange, simply requiring support for the exchange format and that a single test be conducted. At the time of this writing it appears very likely that substantially more in-depth exchange will be necessary to be compliant in the coming years.

Perform at least one test of information exchange using the CCD (or related) format with another provider organization. For larger facilities this may involve use of an HIE, discussed elsewhere in this text. For most small and medium facilities completing the exchange can be done simply by utilizing some of the support required in other guidelines, specifically file encryption and CCD support. The facility can produce a CCD for a patient, encrypt it, and transfer it to another facility that also has a meaningful use compliant EHR system.

Protect electronic health information created or maintained by the certified EHR technology. This is probably one of the least understood guidelines and in practice is not that large an undertaking for most organizations, but on first appearance it can seem daunting. The actual heart of this guideline is that as a facility you create a written policy regarding your passwords, access controls, and other electronic and physical measures you take to protect health information and then follow and conduct periodic audits of compliance with the written policy. The specific federal rules that must be reviewed go to pretty long lengths not to codify specific details of the policy that must be in place, only that there be a written policy and it is followed and audited.

Conduct or review a security risk analysis per 45 CFR 164.308 (a)(1) and implement security updates as necessary and correct identified security deficiencies as part of its risk management process. Implement standardized access, password, and logging policies. Conduct periodic audits against those policies to find noncompliance. The federal regulation is a bit difficult to digest but again the heart of it is just to take steps to create written versions of policies that protect health information and to follow those policies. It prescribes very little by way of what the policies your organization has must contain.

Implement drug-formulary checks for at least one internal and one external formulary. There is often confusion about what exactly a formulary is. It is a preferential list of drugs, doses, and forms that can be put together by a facility to make prescribing more consistent. It is also published by payers to indicate drug costs covered by their programs.

The eligible hospital’s or CAH’s inpatient or emergency department has enabled this functionality and has access to at least one internal or external drug formulary for the entire EHR reporting period.

Incorporate electronic clinical lab test results into certified EHR technology as structured data. All major labs have various kinds of support for electronic importation of results. There can be problems if your facility works primarily with specialty labs or those that are regional or internal. To be compliant the results must be importable into the EHR’s structured electronic data.

More than 40% of all clinical lab tests results ordered by the eligible provider (eligible hospital’s or CAH’s inpatient or emergency department) during the EHR reporting period whose results are either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data. Note that the relatively low threshold of 40% provides ample room for special cases involving regional or onsite labs that are not electronically importable.

Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach. Of all of the pieces of meaningful use this capability and its potential strike us as the most underrated and most likely to have real-world benefits for patient outcomes. It is shocking just how little data analysis is done by facilities themselves and the capability offers a straightforward and powerful means to get facilities involved in looking at their own patient populations and important statistics about them. That introspection offers what might be the most promising avenue for significant improvements in patient outcomes with a minimum of effort.

Generate at least one report listing patients of the eligible hospital’s or CAH’s inpatient or emergency department, eligible hospital or CAH with a specific condition

Send reminders to patients respecting patient preference for preventive/follow-up care. Many facilities currently employ some process for reminding patients about upcoming interactions. This guideline brings into the electronic age the existing processes and when combined with the patient lists guideline requirements is very synergistic. This capability has the dramatic potential to improve patient outcomes with minimum effort.

More than 20% of all unique patients 65 years or older or 5 years old or younger were sent an appropriate reminder during the EHR reporting period.

Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, and medication allergies) within four business days of the information being available to the eligible hospital’s or CAH’s inpatient or emergency department. A supplement to the guideline regarding access to electronic visit information, this guideline expands that to the ability to provide a comprehensive record rather than just that of a current visit.

More than 10% of all unique patients seen by the eligible provider (eligible hospital’s or CAH’s inpatient or emergency department) are provided timely (available to the patient within four business days of being updated in the certified EHR technology) electronic access to their health information subject to the eligible hospital’s or CAH’s inpatient or emergency department’s discretion to withhold certain information. For various reasons providers might choose to exclude certain classes or specific parts of records from this general sharing. Some states do have additional laws regarding access to legally complete records that might apply to this set of capabilities.

Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate. Facilities often have various mediums of patient education resources from videos to handouts and even websites. This guideline builds on the process by requiring documented and structured information about what education has been provided and what level of understanding the patient has regarding the resource.

More than 10% of all unique patients seen by the eligible provider (eligible hospital’s or CAH’s inpatient or emergency department) are provided patient-specific education resources.

The eligible hospital’s or CAH’s inpatient or emergency department who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation between the medication details provided by the other facility and any medication records at the currently treating facility. This process in most systems is done by recording the second set of medications as “outside reported” rather than prescribed or ordered and performing duplication, allergy, and contraindication checking among all those entries.

The eligible hospital’s or CAH’s inpatient or emergency department performs medication reconciliation for more than 50% of transitions of care in which the patient is transitioned into the care of the eligible provider (eligible hospital’s or CAH’s inpatient or emergency department).

The eligible hospital’s or CAH’s inpatient or emergency department that transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide a summary of care record for each transition of care or referral. Similar to the other patient and electronic interchange guidelines, this item just ensures that information sharing is done in a compliant format when transferring patients to other care facilities or settings.

The eligible hospital’s or CAH’s inpatient or emergency department refers their patient to another setting of care or provider of care or referral provides a summary of care record for more than 50% of transitions of care and referrals.

Capability to submit electronic data to immunization registries or immunization information systems and actual submission in accordance with applicable law and practice. This guideline seems to have had the largest amount of errata and additional comment applied by CMS and other authoritative agencies. Although a valiant attempt to improve sharing of data with public health systems, implementation is severely hampered by the limited number and unique requirements of immunization registry systems present at most public health agencies. As a result the guidelines have been watered down to a point of reference only with the submission of very simplistic electronic data by existing means for a single test.

Perform at least one test of certified EHR technology’s capacity to submit electronic data to immunization registries and follow-up submission if the test is successful (unless none of the immunization registries to which the eligible hospital’s or CAH’s inpatient or emergency department have the capacity to receive the information electronically).

Capability to submit electronic syndromic surveillance data to public health agencies and actual submission in accordance with applicable law and practice. This guideline has suffered much the same fate as that regarding immunization registry submission, with a number of comments and errata that erode much of the potential benefit of this. A simple test can be conducted using a variety of formats that might or might not be of practical use. Only a single test must be conducted to comply.

Perform at least one test of certified EHR technology’s capacity to provide electronic syndromic surveillance data to public health agencies and follow-up submission if the test is successful (unless none of the public health agencies to which an eligible hospital’s or CAH’s inpatient or emergency department submits such information have the capacity to receive the information electronically).

Enable a user to electronically record whether a patient has an advance directive. An advance directive is a legal document often called an advance healthcare directive that is created by a patient or his or her legal guardian and instructs providers what actions they can and cannot take in the event the patient is no longer able to make decisions due to illness or incapacity, and appoints a person to make such decisions on his or her behalf.

Implement the capability to record whether a patient has an advance directive.