CMS has released the proposed rule for Stage 2 requirements for the Medicare and Medicaid Electronic Health Record Incentive Programs. The Stage 2 rule includes criteria eligible professionals, eligible hospitals and critical access hospitals must meet in order to qualify for an incentive payment. The rule also introduces changes to the program timeline and details payment adjustments.
The proposed Stage 2 criteria for meaningful use are based on a series of specific objectives, each of which is tied to a proposed measure that all EPs and hospitals must meet in order to demonstrate that they are meaningful users of certified EHR technology. This approach is similar to the objective and measure approach used in Stage 1 (i.e., each objective has its own measure and percentage requirement for EPs, eligible hospitals and CAHs). Objectives are outlined below; to see the full list of the related measures, click here the view the complete Stage 2 rule document.
Stage 2 criteria
CMS proposes retaining nearly all of the Stage 1 core and menu structure for Stage 2. EPs must meet or qualify for exclusions to 17 core objectives and 3 of 5 menu objectives. Hospitals must meet or qualify for exclusions to 16 core objectives and 2 of 4 menu objectives.
Core objectives for EPs, eligible hospitals and CAHs:
• Use computerized provider order entry for medication, laboratory and radiology orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines to create the first record of the order;
• Record the following demographics: preferred language, gender, race, ethnicity, date of birth. Eligible hospitals and CAHs would have to record date and preliminary cause of death as well;
• Record and chart changes in vital signs: height, weight, blood pressure and BMI;
• Record smoking status for patients 13 years old or older;
• Use clinical decision support to improve performance on high-priority health conditions;
• Incorporate clinical lab-test results into certified EHR technology as structured data;
• Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach;
• Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient;
• The EP who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation;
• The EP who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary care record for each transition of care or referral;
• Capability to submit electronic data to immunization registries or immunization information systems except where prohibited, and in accordance with applicable law and practice;
• Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities.
Core objectives specific to eligible hospitals and CAHs:
• Automatically track medications from order to administration using assistive technologies in conjunction with an electronic medication administration record;
• Provide patients the ability to view online, download, and transmit information about a hospital admission;
• Capability to submit electronic reportable laboratory results to public health agencies, except where prohibited, and in accordance with applicable law and practice;
• Capability to submit electronic reportable laboratory results to public health agencies, except where prohibited, and in accordance with applicable law and practice.
Core objectives specific to EPs:
• Generate and transmit permissible prescriptions electronically;
• Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care;
• Provide patients the ability to view online, download, and transmit their health information within 4 business days of the information being available to the EP;
• Provide clinical summaries for patients for each office visit;
• Use secure electronic messaging to communicate with patients on relevant health information.
Menu objectives for EPs, eligible hospitals and CAHs:
• Imaging results and information are accessible through certified EHR technology;
• Record patient family health history as structured data.
Menu objectives specific to eligible hospitals and CAHs:
• Record whether a patient 65 years old or older has an advance directive;
• Generate and transmit permissible discharge prescriptions electronically.
Menu objectives specific to EPs:
• Capability to submit electronic syndromic surveillance data to public health agencies, except where prohibited, and in accordance with applicable law and practice;
• Capability to identify and report cancer cases to a state cancer registry, except where prohibited, and in accordance with applicable law and practice;
• Capability to identify and report specific cases to a specialized registry (other than a cancer registry), except where prohibited, and in accordance with applicable law and practice.
Changes from Stage 1
Although many core and menu objectives are retained for Stage 2, CMS does propose several changes to existing Stage 1 criteria for meaningful use. Some of these changes would be optional for use by providers in Stage 1 but would be required for use in Stage 2. Other changes would not take effect until providers have to meet the Stage 2 criteria.
Proposed changes include:
• The "exchange of key clinical information" core objective from Stage 1 was eliminated in favor of a more robust "transitions of care" core objective in Stage 2;
• The "provide patients with an electronic copy of their health information" objective was eliminated because it has been replaced by an "electronic/online access" core objective;
• Changes to the denominator of computerized provider order entry;
• Changes to the age limitations for vital signs.
There are also multiple Stage 1 objectives that have been combined into more unified Stage 2 objectives. According to the CMS fact sheet, this eliminates unnecessary accounting and reporting burden for providers by recognizing that recording data in a structured form has become a normal part of care delivery.
As well, new objectives were proposed that have greater applicability to many specialty providers:
• Imaging results and information accessible through certified EHR technology;
• Capability to identify and report cancer cases to a State cancer registry, except where prohibited, and in accordance with applicable law and practice;
• Capability to identify and report specific cases to a specialized registry (other than a cancer registry), except where prohibited, and in accordance with applicable law and practice.
Clinical quality measures
Just as in Stage 1, CMS proposes that EPs, eligible hospitals, and CAHs be required to report on specified clinical quality measures in order to qualify for incentive payments under the Medicare and Medicaid EHR Incentive Programs.
For EPs, Stage 2 proposes a set of clinical quality measures beginning in 2014 that align with the existing quality programs such as measures for Physician Quality Report System and CMS Shared Savings Program. This proposed rule also outlines a process by which EPs, eligible hospitals and CAHs would submit CQM data electronically, reducing the associated burden of reporting on quality measures for providers.
Payment adjustments
Medicare payment adjustments are required by statute to take effect in 2015. CMS proposes that any Medicare EP or hospital that demonstrates meaningful use in 2013 would avoid payment adjustment in 2015. Also, any Medicare provider that first demonstrates meaningful use in 2014 would avoid the penalty if they meet the attestation requirement by July 3, 2014 for eligible hospitals or Oct. 3, 2014 for EPs.
CMS is proposing exceptions to these payment adjustments. This proposed rule outlines three categories of exceptions based on:
• Availability of internet access or barriers to obtaining IT infrastructure;
• A time-limited exception for newly practicing EPs who would not otherwise be able to avoid payment adjustments;
• Unforeseen circumstances such as natural disasters that would be handled on a case-by-case basis.
Extension of Stage 1
CMS also is proposing an extension of Stage 1, so that providers have an additional year for implementation of Stage 2 criteria. CMS originally established that any provider who first attested to Stage 1 criteria in 2011 would have to begin using Stage 2 criteria in 2013. The proposed Stage 2 rule delays the onset of Stage 2 criteria for those providers until 2014, which CMS believes would allow the needed time for vendors to develop certified EHR technology that can me
The proposed Stage 2 criteria for meaningful use are based on a series of specific objectives, each of which is tied to a proposed measure that all EPs and hospitals must meet in order to demonstrate that they are meaningful users of certified EHR technology. This approach is similar to the objective and measure approach used in Stage 1 (i.e., each objective has its own measure and percentage requirement for EPs, eligible hospitals and CAHs). Objectives are outlined below; to see the full list of the related measures, click here the view the complete Stage 2 rule document.
Stage 2 criteria
CMS proposes retaining nearly all of the Stage 1 core and menu structure for Stage 2. EPs must meet or qualify for exclusions to 17 core objectives and 3 of 5 menu objectives. Hospitals must meet or qualify for exclusions to 16 core objectives and 2 of 4 menu objectives.
Core objectives for EPs, eligible hospitals and CAHs:
• Use computerized provider order entry for medication, laboratory and radiology orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines to create the first record of the order;
• Record the following demographics: preferred language, gender, race, ethnicity, date of birth. Eligible hospitals and CAHs would have to record date and preliminary cause of death as well;
• Record and chart changes in vital signs: height, weight, blood pressure and BMI;
• Record smoking status for patients 13 years old or older;
• Use clinical decision support to improve performance on high-priority health conditions;
• Incorporate clinical lab-test results into certified EHR technology as structured data;
• Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach;
• Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient;
• The EP who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation;
• The EP who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary care record for each transition of care or referral;
• Capability to submit electronic data to immunization registries or immunization information systems except where prohibited, and in accordance with applicable law and practice;
• Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities.
Core objectives specific to eligible hospitals and CAHs:
• Automatically track medications from order to administration using assistive technologies in conjunction with an electronic medication administration record;
• Provide patients the ability to view online, download, and transmit information about a hospital admission;
• Capability to submit electronic reportable laboratory results to public health agencies, except where prohibited, and in accordance with applicable law and practice;
• Capability to submit electronic reportable laboratory results to public health agencies, except where prohibited, and in accordance with applicable law and practice.
Core objectives specific to EPs:
• Generate and transmit permissible prescriptions electronically;
• Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care;
• Provide patients the ability to view online, download, and transmit their health information within 4 business days of the information being available to the EP;
• Provide clinical summaries for patients for each office visit;
• Use secure electronic messaging to communicate with patients on relevant health information.
Menu objectives for EPs, eligible hospitals and CAHs:
• Imaging results and information are accessible through certified EHR technology;
• Record patient family health history as structured data.
Menu objectives specific to eligible hospitals and CAHs:
• Record whether a patient 65 years old or older has an advance directive;
• Generate and transmit permissible discharge prescriptions electronically.
Menu objectives specific to EPs:
• Capability to submit electronic syndromic surveillance data to public health agencies, except where prohibited, and in accordance with applicable law and practice;
• Capability to identify and report cancer cases to a state cancer registry, except where prohibited, and in accordance with applicable law and practice;
• Capability to identify and report specific cases to a specialized registry (other than a cancer registry), except where prohibited, and in accordance with applicable law and practice.
Changes from Stage 1
Although many core and menu objectives are retained for Stage 2, CMS does propose several changes to existing Stage 1 criteria for meaningful use. Some of these changes would be optional for use by providers in Stage 1 but would be required for use in Stage 2. Other changes would not take effect until providers have to meet the Stage 2 criteria.
Proposed changes include:
• The "exchange of key clinical information" core objective from Stage 1 was eliminated in favor of a more robust "transitions of care" core objective in Stage 2;
• The "provide patients with an electronic copy of their health information" objective was eliminated because it has been replaced by an "electronic/online access" core objective;
• Changes to the denominator of computerized provider order entry;
• Changes to the age limitations for vital signs.
There are also multiple Stage 1 objectives that have been combined into more unified Stage 2 objectives. According to the CMS fact sheet, this eliminates unnecessary accounting and reporting burden for providers by recognizing that recording data in a structured form has become a normal part of care delivery.
As well, new objectives were proposed that have greater applicability to many specialty providers:
• Imaging results and information accessible through certified EHR technology;
• Capability to identify and report cancer cases to a State cancer registry, except where prohibited, and in accordance with applicable law and practice;
• Capability to identify and report specific cases to a specialized registry (other than a cancer registry), except where prohibited, and in accordance with applicable law and practice.
Clinical quality measures
Just as in Stage 1, CMS proposes that EPs, eligible hospitals, and CAHs be required to report on specified clinical quality measures in order to qualify for incentive payments under the Medicare and Medicaid EHR Incentive Programs.
For EPs, Stage 2 proposes a set of clinical quality measures beginning in 2014 that align with the existing quality programs such as measures for Physician Quality Report System and CMS Shared Savings Program. This proposed rule also outlines a process by which EPs, eligible hospitals and CAHs would submit CQM data electronically, reducing the associated burden of reporting on quality measures for providers.
Payment adjustments
Medicare payment adjustments are required by statute to take effect in 2015. CMS proposes that any Medicare EP or hospital that demonstrates meaningful use in 2013 would avoid payment adjustment in 2015. Also, any Medicare provider that first demonstrates meaningful use in 2014 would avoid the penalty if they meet the attestation requirement by July 3, 2014 for eligible hospitals or Oct. 3, 2014 for EPs.
CMS is proposing exceptions to these payment adjustments. This proposed rule outlines three categories of exceptions based on:
• Availability of internet access or barriers to obtaining IT infrastructure;
• A time-limited exception for newly practicing EPs who would not otherwise be able to avoid payment adjustments;
• Unforeseen circumstances such as natural disasters that would be handled on a case-by-case basis.
Extension of Stage 1
CMS also is proposing an extension of Stage 1, so that providers have an additional year for implementation of Stage 2 criteria. CMS originally established that any provider who first attested to Stage 1 criteria in 2011 would have to begin using Stage 2 criteria in 2013. The proposed Stage 2 rule delays the onset of Stage 2 criteria for those providers until 2014, which CMS believes would allow the needed time for vendors to develop certified EHR technology that can me