October 10, 2014
6 min read

AAO prepares to meet stage 3 meaningful use criteria for EHRs

Experts have recommended alternative reporting requirements for ophthalmologists.

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Standardized data exchange is at the center of the American Academy of Ophthalmology’s efforts to meet meaningful use criteria for electronic health records, according to a group of experts.

An editorial published in Ophthalmology reviewed the AAO’s efforts to help members meet meaningful use criteria and improve care.

The Centers for Medicare and Medicaid Services created the meaningful use program in 2010. Participating physicians and practices must report performance measures to qualify for incentive payments of up to $44,000.

Meaningful use criteria are organized in three stages. Stage 1 established a baseline for electronic data capture. Stage 2 centers on information exchange. Stage 3 will focus on quality improvement measures that are not yet defined.

“Meaningful use is such a timely and significant topic right now, and it is incentivizing everyone to use electronic health records. We as a specialty are extremely engaged in this process, and the numbers show that,” lead author Michele C. Lim, MD, said.

Michael F. Chiang, MD

Michael F. Chiang


EHRs have the potential to improve quality of care, reduce costs and enhance clinical research, co-author Michael F. Chiang, MD, said.

“They also provide a potential to engage patients in the health care process like never before. Meaningful use is meant to be the mechanism for doing that and for transitioning providers from paper to EHRs,” Chiang said.

Stage 1 compliance

A total of 7,119 ophthalmologists received more than $167 million in EHR incentive payments between 2011 and 2013. Ophthalmologists were eighth among medical and surgical specialties in the total number of payments received; 36% of ophthalmologists received payments, which was comparable to primary care physicians (31%), the authors wrote.

“When you think about the fact that most EHRs are designed for primary care, it’s pretty remarkable that ophthalmology is attesting at similar rates,” Lim said. “That speaks to the fact that ophthalmologists are very technology-oriented people. Hopefully that plays a role in how open they are to engaging in meaningful use.”

Lim said that as of June, about 7,900 ophthalmologists, or 40%, had received a total of $186 million in incentive payments.

Core and menu objectives for stage 1 included reporting immunizations and vital signs. Ophthalmologists were exempt from those measures if their scope of practice did not include them.

“People were very confused about these measures that related to things like vital signs and measuring BMI in patients and children. Everyone was scratching their heads and asking, ‘What does this have to do with ophthalmology? Do we have to start doing this now?’” Lim said.

The AAO and other medical specialty societies successfully advocated for the addition of three items to stage 2 rules: continuation of the exemption from recording vital signs if not pertinent to the scope of practice; reporting to a specialty registry as an alternative to reporting immunizations or public health data; and an option to report on viewing images in a practice’s EHR.

“Ophthalmologists are often concerned … that the meaningful use guidelines have a bit of a one-size-fits-all approach where, to some extent, they want everybody to do the same thing,” Chiang said. “The concern is that what we do as ophthalmologists, and what other medical specialists do, is not the same as what primary care doctors do.”

Fine-tuning stages 2 and 3

Reporting on stage 2 begins this year, but CMS added a hardship exemption for providers who cannot participate because of EHR certification delays.

The AAO recommended that ophthalmologists should be able to report on electronic notes, imaging results and family health history; in addition, they should be able to report specific cases to a specialized registry.

Information exchange with patients and other providers is a focus of stage 2.

The AAO lobbied the Office of the National Coordinator for Health Information Technology and Congress to include registry reporting as a menu option that ophthalmologists can fulfill by joining the AAO’s Intelligent Research in Sight (IRIS) Registry.


“To me, it’s really exciting that we’re heading toward this era where we’ve got more data and better data. The challenge … is how we translate that to better outcomes. I think the IRIS Registry is going to be a huge step in terms of doing that,” Chiang said.

The goal of stage 3 meaningful use measures is to make a transition “from a setting-specific focus to a collaborative, patient- and family-centric approach,” the authors said.

In response to proposed stage 3 measures, the AAO recommended an alternate pathway to meaningful use by participating in an EHR-based national specialty registry, adopting Digital Imaging and Communication in Medicine (DICOM) standards and aligning clinical quality measures with other quality reporting programs such as the Physician Quality Reporting System.

Goals for compliance, improvement

The AAO proposed three initiatives to achieve meaningful use and improve care quality: continue development of the IRIS Registry; achieve standardization in patient information exchange by completing Clinical Document Architecture (CDA); and work with vendors to improve automated meaningful use reports, standardized integration of ophthalmic images with EHRs, electronic information sharing with patients and patient portals with secure messaging, the authors said.

“One of the ongoing challenges is that different EHR systems don’t talk well to each other,” Chiang said. “Also, as ophthalmologists, we use many machines in the office: visual field machines, fundus cameras, OCT devices. A lot of these machines don’t talk to EHRs without custom interfaces. In fact, they more often don’t than do talk to each other.”

Standard tools do exist for integrating ophthalmic images with EHRs, such as DICOM standards, Chiang said.

“In ophthalmology, we actually have those standards, but often the vendor devices don’t comply with them. This is a big problem, but we’re making progress,” he said.

A CDA specifies how data are stored and exchanged and facilitates the seamless exchange of data from one EHR to another. A CDA would enable the exchange of clinical data with registries such as the IRIS Registry, the authors said.

“We’re going to make a big push for that in the future to develop standards to help systems talk to each other,” Chiang said.

The IRIS Registry will also enable ophthalmologists to compare their outcomes with those of their colleagues around the country, Chiang said.

“I would be able to look at my outcomes and compare them to what everyone else is doing and figure out what I am doing well and, more importantly, what I’m not doing well and how I can improve,” he said. – by Matt Hasson


Lim MC, et al. Ophthalmology. 2014;doi:10.1016/j.ophtha.2014.06.048.

For more information:

Michael F. Chiang, MD, can be reached at Oregon Health & Science University Casey Eye Institute, 3375 SW Terwilliger Blvd., Portland, OR 97239; email: chiangm@ohsu.edu.
Michele C. Lim, MD, can be reached at UC Davis Health System Eye Center, 4860 Y St., Suite 2400, Sacramento, CA 95817; 916-734-6818; email: michele.lim@ucdmc.ucdavis.edu.

Disclosure: Chiang and Lim have no relevant financial disclosures.