The Centers for Medicare & Medicaid Services (CMS) recently published the final rule outlining the requirements for Stage 2 of the Meaningful Use incentive program, adopting many, but not all of the provisions they proposed in March.
Under the Health Information Technology for Economic and Clinical Health (HITECH) Act, part of the American Recovery and Reinvestment Act of 2009 (ARRA), eligible health care professionals and hospitals can qualify for Medicare and Medicaid incentive payments when they adopt and meaningfully use certified electronic health record (HER) technology.
More than 120,000 eligible health care professionals and more than 3,300 hospitals have qualified to participate in the program and receive an incentive payment since it began in January 2011. That exceeds a 100,000 goal set earlier this year.
That includes more than half of all eligible hospitals and critical access hospitals and 1 out of every 5 eligible health care professionals. The program is divided into three stages:
- Stage 1 sets the basic functionalities electronic health records must include such as capturing data electronically and providing patients with electronic copies of health information.
- Stage 2 (which will begin as early as 2014) increases health information exchange between providers and promotes patient engagement by giving patients secure online access to their health information.
- Stage 3 will continue to expand meaningful use objectives to improve health care outcomes.
ONC already is working on Stage 3 of the program, which won't be implemented until 2016 at the earliest.
CMS’s 672-page rule delays the Stage 2 requirements to 2014, giving providers more time to meet the Stage 2 criteria. No provider will have to follow the Stage 2 requirements before then. Stage 2 originally was slated to begin in 2013. Other changes to the rule include:
- There will be 20 measures for eligible professionals and 19 for eligible hospitals and critical access hospitals;
- There are two new core objectives: one on the use of secure electronic messaging to communicate with patients, and another requiring hospitals to automatically track medications from order to administration using assistive technology with electronic medication administration records (eMAR);
- Several proposed measurement thresholds–such as for patient engagement and electronic exchange summary of care documents–have been reduced from those suggested in the proposed rule. Specifically for the former, both eligible providers and hospitals now will need "more than 5 percent" of unique patients to view, online, download or transmit their information to a third party (the proposed threshold was 10 percent);
- Batch reporting for medical groups and the process for implementing penalties for not meeting Meaningful Use have both have been finalized;
- An outpatient lab reporting requirement has been added;
- Eligibility of the Medicaid incentive program has been expanded to 12 children's hospitals that originally didn't meet the eligibility requirements.
As noted by InformationWeek Healthcare, “the final rule does dial back some proposed thresholds. Notably, providers now only have to offer online access to health information and secure messaging for 5% of patients, not 10%, as had been proposed.
The final certification rule adds a requirement that all personally identifiable health data be encrypted while “at rest,” in response to a recommendation from the Health IT Policy Committee, a federal advisory board, and public comments.
All told, physicians, chiropractors, dentists, physical therapists, and other individual providers have to meet 17 core measures for EHR usage, and also choose three from a menu of six additional measures. Hospitals must achieve 16 core measures plus three of six menu items.
In a Thursday conference call with journalists, national health IT coordinator Dr. Farzad Mostashari called the menu items “potentially more relevant to specialists” than those in Stage 1. Many people have criticized the current stage as being skewed toward primary care. “The big message here is the push on standards-based interoperability of information,” Mostashari said. “We are staying on course with the roadmap that we set in Stage 1.”
Eligible providers also must report on nine of a total of 64 specific clinical quality measures, while hospitals need to choose 16 of 29. Starting with the 2014 reporting period, providers will have to submit their Meaningful Use-related clinical quality measures electronically, Elizabeth Holland, director of health information technology initiatives for CMS, said during the teleconference. To date, CMS has paid out $6.6 billion in incentive money to about 3,600 hospitals and more than 128,000 individuals, Holland said.
CMS received 6,100 comments on the proposed rule. Health and Human Services (HHS) Secretary Kathleen Sebelius the final rule “will lead to more coordination of patient care, reduced medical errors, elimination of duplicate screenings and tests and greater patient engagement in their own care.”
The Office of the National Coordinator for Health IT's (ONCHIT) Standards and Certification criteria, which weighs in at 474 pages, adopts the certification criteria to support the changes in the program. It also updates the certification program to make it easier and more efficient, and changed the name of the permanent certification program to “ONC HIT Certification Program.”
“Certified EHR technology used in a meaningful way is one piece of a broader health information technology infrastructure needed to reform the health care system and improve health care quality, efficiency, and patient safety,” CMS said in a fact sheet explaining the rules.
CMS also provided additional guidance to stakeholders by issuing answers to three frequently asked questions about changes to the Medicaid electronic health records meaningful use incentive program under Stage 2. The changes cover determination of patient volume calculations that are intended to ease eligibility requirements, the types of CHIP patients eligible to be considered in Medicaid patient volume, and changes to the base year for hospital incentive payment calculation.
Among the answers, CMS officials confirmed that there are, in fact, changes to the base year for the Medicaid hospital incentive payment calculation under the Stage 2 rules. "In an effort to encourage timely participation … the rule was amended to allow hospitals to use the most recent continuous 12 month period for which data are available prior to the payment year," CMS officials said.
CMS also issued a series of tip sheets to help eligible professionals and hospitals transition to Stage 2 of the Meaningful Use requirements on its Website. The tip sheets include an overview of the new rules, comparison tables between Stage 1 and Stage 2, tips on the clinical quality measures, and explanations of the mechanisms of the hardship exceptions and upcoming payment adjustments. Electronic health record vendor Greenway, meanwhile, created a nifty sheet detailing the Stage 2 measures and threshold requirements. The sheet also outlines changes from Stage 1.
Reaction to Final Rule on Meaningful Use Stage 2
According to FierceHealthIT, initial responses to the final rule thus far, have been mostly positive. Drex DeFord, CIO of Boston-based Steward Health Care, was pleased with the delay in making the transition to Stage 2.
John Halamka, CIO of Beth Israel Deaconess Medical Center, also in Boston, wrote in a blog post that with regard to the standards and certification criteria published by ONCHIT, “the vocabulary, transport, and content standards" lined up perfectly with recommendations made by the Health IT Standards Committee.”
Halamka seemed particularly interested in the fact that Simple Mail Transfer Protocol–which now is part of the base EHR definition–will be the required transport standard for all certified electronic health records. “[A]ll EHR technology used by [eligible providers, eligible hospitals and critical access hospitals] that meets the [Certified Electronic Health Record Technology] definition will, at a minimum, be capable of SMTP-based exchange,” he said.
The College of Healthcare Information Executives (CHIME), of which DeFord serves as chairperson for the board of trustees, was happy that CMS added more measures to the menu set, and that they implemented a 90-day EHR reporting period for 2014 for providers to demonstrate Meaningful Use.
The American Health Information Management Association (AHIMA), meanwhile, praised the decision to maintain patient engagement requirements, even though the threshold for those requirements was lowered. “We believe patients must be partners and work side-by-side with their providers to achieve the best possible healthcare outcomes,” AHIMA CEO Lynne Thomas Gordon said in a statement.
However, Indranil Ganguly, CIO at Freehold, N.J.-based CentraState Healthcare System, told FierceHealthIT in an email that he was disappointed by the patient engagement measures. “I understand the desire to drive patient’s online and change behavior, but feel that it is unreasonable to put that burden on the healthcare provider,” he said.
Additionally, the American Hospital Association (AHA) said the final rule makes the path toward IT adoption for hospitals “more challenging.” It is disappointed “that this rule sets an unrealistic date by which hospitals must achieve the initial Meaningful Use requirements to avoid penalties,” Linda Fishman, senior vice president of public policy, analysis and development for AHA, said in a statement. “In addition, CMS complicated the reporting of clinical quality measures and added to the Meaningful Use objectives, creating significant new burdens.”