One of Meaningful Use's most misunderstood requirements is the extent to which data needs to be captured in a structured format. As one transcription company owner recently wrote, "Right now, I feel (that) most transcription companies don't have the expertise to talk meaningfully about 'meaningful use'. I think we need to get to the 'meat'".

The "meat" transcription industry professionals are grappling to understand is: can a physician use dictation and transcription and still meet Meaningful Use's requirements for structured data?

The answer is yes, according to The Center for Medicaid and Medicare Services (CMS) - providing the physician is capturing a select number of data points the CMS requires in a structured format within an ONC-certified EHR.

What patient data does Meaningful Use require to be captured in a structured format? Of the twenty-three Objectives of Meaningful Use, only eight pertain to MU's requirement for structured data entry into the EHR. Those are:

1. Patient demographics
2. Problem list
3. Medication list
4. Medication allergy list
5. Patient Vitals
6. Smoking status
7. Family health history
8. Lab Results (LOINC format)

(One additional Meaningful Use Objective - "Record electronic notes in patient records", specifically states that the patient note can be dictated and transcribed, providing the document is in a searchable format. See #19 on attached Summary Table on page 3.

For the above eight Objectives, those data must be captured within the structured format of the EHR in order to meet Meaningful Use requirements. But all other patient information routinely documented as part of the patient encounter - such as the History of Present Illness, Subjective, Objective, Review of Systems, Social History, Assessment, and Plan, to name a few - can be dictated and transcribed without in any way preventing the physician and clinic from meeting Meaningful Use.

Structured vs. Unstructured Data

What is the difference between structured and unstructured data? Simply put, structured data is information captured within a field or format that can be automatically identified by the EHR. The CMS requires certain data to be structured for two key reasons: first, to make it portable to other EHRs or electronic applications; and secondly, to enable it to be associated with standardized code sets and clinical terminologies like SNOMED CT. Structured data is recorded within EHRs via documentation tools, including but not limited to, drop-downs, check boxes, radial buttons, and in limited cases via text entry (such as the entry of like blood pressure measures or patient weight, height, age, etc.).

The other type of data found within EHRs is "unstructured data", so named because it is not entered in a field or format automatically recognized or identified by the EHR. Examples of unstructured data are the free text notes typed into a text box by a healthcare professional, and transcribed patient notes which are interfaced into the patient record. Unstructured data is often, but not limited to, qualitative information about the patient's health history or health context that provides additional decision-making support.

The Structured Data Monster

Since Meaningful Use requires only a limited subset of patient data to be structured, could it be that EHRs are placing an over-emphasis on structured data at the expense of physician efficiency and patient care? Have we created a monster out of the EHR-based clinical documentation workflow, placing unnecessary demands on physicians to structure data that in many ways is better captured in an unstructured, or narrative, format?

A large population of physicians - as many as 30% or more - express on-going frustration with their EHR-based clinical documentation workflow. For many of those physicians, a greater use of dictation and transcription - provided it is in a searchable text format - could represent a faster, easier and less frustrating means of documenting their patient encounters.

In sum, there is nothing in Meaningful Use that restricts healthcare providers from using dictation and transcription to document those sections of the patient encounter not specifically cited as needing to be structured. For those physicians experiencing high levels of frustration with their EHR-based clinical documentation tools, transcription could provide an effective alternative for documenting those parts of the patient encounter that are not mandated for capture via the EHR's structured data capture tools.

Summary Table: Meaningful Use Stage 2 Objectives

as of July, 2014

	Stage 2 Measure	Description	Impacts Transcription?
1	Use computerized physician order entry (CPOE)	Physician order labs, medication, xray, radiology orders via the EHR	Little to none
2	Generate prescriptions electronically	Use EHR to send prescriptions to pharmacies	None
3	Record demographics as structured data	Language, gender, race, ethnicity, date of birth	Yes
4	Maintain an up to date problem list as structured data	Maintain an up to date problem list as structured data	Yes
5	Maintain active medication list as structured data	Maintain active medication list as structured data	Yes
6	Maintain active medication allergy list as structured data	Maintain active medication allergy list as structured data	Yes
7	Record and chart changes in vital signs as structured data	Height, weight, BP, BMI, children growth chart	Yes
8	Record smoking status as structured data	Record smoking status as structured data	Yes
9	Implementation of clinical decision support tools	Use EHR-based applications to improve patient care	No
10	Report Clinical Quality Measures (CQMs) to CMS	CQMs measure “degree to which a provider competently and safely delivers clinical services that are appropriate for the patient in an optimal timeframe.”	No
11	Provide patients with an electronic copy of their health information	Includes online access and ability to download	No
12	Provide clinical summaries for patients	Provide clinical summaries for patients	No
13	Protect electronic health information within the EHR	Protect electronic health information within the EHR	No
14	Incorporate clinical lab-test results into EHR	Incorporate clinical lab-test results into EHR. Lab results do require some structured data in LOINC for the purposes of the CCDA in transitions of care	Yes
15	Perform medication reconciliation on new patients	Insures that receiving physician has complete knowledge of patient’s medications	No
16	Provide summary of patient care for patients transitioning to other source of care	When transitioning a patient to a new source of care, patient documentation needs to be provided with transition. This objective incorporates the structured data into a C-CDA for transitions of care and that is fundamentally the biggest use of structured data.	Yes
17	Transmit electronic data to immunization registries	Functionality within EHR to transmit specific data	No
18 *NEW	Use electronic messaging to communicate with patients	Use electronic messaging to communicate with patients	No
19 *NEW	Record electronic notes in patient records	Notes can be dictated, text must be searchable	Yes
20 *NEW	Scans and test accessible via EHR	Scans and test accessible via EHR	No
21 *NEW	Record patient family health history as structured data	Indicate that first-degree family history has been reviewed or enter one structured data	Yes
22 *NEW	Report cancer cases to a registry	Report cancer cases to a registry	No
23 *NEW	Report cases other than cancer to specialized registries	Report cases other than cancer to specialized registries	No