CMS has released the final rule (pdf) for the second stage of the Medicare and Medicaid Electronic Health Record Incentive Program.
The stage 2 rule includes the criteria eligible professionals, eligible hospitals and critical access hospitals must meet in order to qualify for incentive payments. With the stage 2 rule, CMS seeks to expand the meaningful use of certified EHR technology. According to the news release, certified EHR technology used in a meaningful way is one piece of a broader health information technology infrastructure needed to reform the healthcare system as well as improve healthcare quality, efficiency and patient safety.
Much of what CMS proposed in March was incorporated into the final rule; however, CMS did incorporate revisions based on information it received from thousands of providers concerning the proposed rule. In addition, the final rule derives from data elements from providers who already registered and attested to stage 1, including demographic information and performance statistics on the meaningful use objectives and measures, according to the report. Here are six highlights of the final stage 2 provisions.
1. Timing. In Stage 1 meaningful use regulations, CMS established a timeline that would have required Medicare providers who first demonstrated meaningful use in 2011 to meet the stage 2 criteria in 2013. The stage 2 final rule has adjusted the timeline so that a provider who attested to stage 1 of meaningful use in 2011 will not need to attest to stage 2 until 2014.
2. Meaningful use objectives changes. The core-menu structure of stage 2 is similar to that of stage 1. Eligible hospitals and CAHs must meet the measure or qualify for exclusion for 16 core objectives and 3 of 6 menu objectives. Eligible professionals must meet the measure or qualify for an exclusion for 17 core objectives and 3 of 6 menu objectives. While the structure is similar, some core and menu objectives have changed:
• 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. It has been replaced by a "view online, download and transmit" core objective. This is slightly different than the suggested "electronic/online access" core objective in the Stage 2 proposed rule.
• The final rule adds "outpatient lab reporting" to the menu for hospitals and "recording clinical notes" was added as a menu objective for both EPs and hospitals.
• CMS finalized the ability to use a batch reporting process for meaningful use, which will allow groups to submit attestation information for all individual EPs in one file.
In addition to the changes above, CMS added two new core objectives:
• EP stage 2 core objective — Use electronic messaging to communicate with patients on relevant health information.
• Eligible hospital and CAH stage 2 core objective — Automatically track medications from order to administration using assistive technologies in conjunction with an electronic medication administration record.
3. Patient engagement. In the proposed stage 2 rule, CMS listed two new core objectives to encourage patient engagement — providing patients online access to health information and secure messaging between patient and provider. The measures required patients to take specific actions in order for a provider to achieve meaningful use and receive an EHR incentive payment. The threshold was set to 10 percent for both objectives. According to CMS, many providers were concerned about the proposed objectives. For this reason, CMS finalized the proposed measures but with reduced thresholds of 5 percent for both objectives.
4. Electronic exchange of summary care documents. CMS also proposed two measures to spur commitment to electronic exchange for stage 2 meaningful use. The first measure required that a provider send a summary of care record for more than 65 percent of transitions of care and referrals. CMS has reduced the threshold to 50 percent for the final rule. The second measure required that a provider electronically transmit a summary of care for more than 10 percent of transitions of care and referrals, and that the summary of care be electronically sent to a provider with no organizational or vendor affiliation. According to the release, the intent of this measure was to foster electronic exchange outside established vendor and organization networks. However, CMS is eliminating the organizational and vendor limitations. Instead, CMS is requiring at least one instance of exchange with a provider using EHR technology designed by a different EHR vendor. The 10 percent threshold for electronic transmittal is included in the final rule.
5. Clinical quality measures. In the stage 2 proposed rule, CMS suggested that EPs, eligible hospitals, and CAHs be required to report on specified clinical quality measures in order to qualify for incentive payments. For EPs, CMS proposed 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. The Stage 2 proposed rule also outlined 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.
In this final rule, CMS finalized that eligible hospitals and CAHs must report on 16 out of 29 CQMs, and EPs must report on 9 out of the 64 total CQMs. In addition, all providers must select CQMs from at least 3 of the 6 key healthcare policy domains from the HHS' National Quality Strategy:
• Patient and family engagement
• Patient safety
• Care coordination
• Population and public health
• Efficient use of healthcare resources
• Clinical processes/effectiveness
6. Payment adjustments. Medicare payment adjustments are required by statute to take effect in 2015. In the final rule, CMS maintained its proposal that any Medicare EP or hospital that demonstrates meaningful use in 2013 will avoid payment adjustment in 2015. Also, any Medicare provider that first demonstrates meaningful use in 2014 will now avoid the penalty if they meet the attestation requirement by July 3, 2014 for eligible hospitals or Oct. 3, 2014 for EPs.
Although CMS originally proposed three exceptions to these payment adjustments, it finalized four. The three exceptions, which were originally proposed, include exceptions based on infrastructure, newly practicing EPs who would not otherwise be able to avoid payment adjustments and unforeseen circumstances. The new exception is by specialty/provider type concentrated among three specialties: anesthesiology, radiology and pathology. Infrastructure, unforeseen circumstances, and new CAHs/eligible hospitals are also exception categories for eligible hospitals and CAHs.
The final rule may be viewed here.
39 Things to Know About CMS' Stage 2 Requirements for Meaningful Use
CMS Delays Stage 2 Meaningful Use; Proposed Rule Released
The stage 2 rule includes the criteria eligible professionals, eligible hospitals and critical access hospitals must meet in order to qualify for incentive payments. With the stage 2 rule, CMS seeks to expand the meaningful use of certified EHR technology. According to the news release, certified EHR technology used in a meaningful way is one piece of a broader health information technology infrastructure needed to reform the healthcare system as well as improve healthcare quality, efficiency and patient safety.
Much of what CMS proposed in March was incorporated into the final rule; however, CMS did incorporate revisions based on information it received from thousands of providers concerning the proposed rule. In addition, the final rule derives from data elements from providers who already registered and attested to stage 1, including demographic information and performance statistics on the meaningful use objectives and measures, according to the report. Here are six highlights of the final stage 2 provisions.
1. Timing. In Stage 1 meaningful use regulations, CMS established a timeline that would have required Medicare providers who first demonstrated meaningful use in 2011 to meet the stage 2 criteria in 2013. The stage 2 final rule has adjusted the timeline so that a provider who attested to stage 1 of meaningful use in 2011 will not need to attest to stage 2 until 2014.
2. Meaningful use objectives changes. The core-menu structure of stage 2 is similar to that of stage 1. Eligible hospitals and CAHs must meet the measure or qualify for exclusion for 16 core objectives and 3 of 6 menu objectives. Eligible professionals must meet the measure or qualify for an exclusion for 17 core objectives and 3 of 6 menu objectives. While the structure is similar, some core and menu objectives have changed:
• 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. It has been replaced by a "view online, download and transmit" core objective. This is slightly different than the suggested "electronic/online access" core objective in the Stage 2 proposed rule.
• The final rule adds "outpatient lab reporting" to the menu for hospitals and "recording clinical notes" was added as a menu objective for both EPs and hospitals.
• CMS finalized the ability to use a batch reporting process for meaningful use, which will allow groups to submit attestation information for all individual EPs in one file.
In addition to the changes above, CMS added two new core objectives:
• EP stage 2 core objective — Use electronic messaging to communicate with patients on relevant health information.
• Eligible hospital and CAH stage 2 core objective — Automatically track medications from order to administration using assistive technologies in conjunction with an electronic medication administration record.
3. Patient engagement. In the proposed stage 2 rule, CMS listed two new core objectives to encourage patient engagement — providing patients online access to health information and secure messaging between patient and provider. The measures required patients to take specific actions in order for a provider to achieve meaningful use and receive an EHR incentive payment. The threshold was set to 10 percent for both objectives. According to CMS, many providers were concerned about the proposed objectives. For this reason, CMS finalized the proposed measures but with reduced thresholds of 5 percent for both objectives.
4. Electronic exchange of summary care documents. CMS also proposed two measures to spur commitment to electronic exchange for stage 2 meaningful use. The first measure required that a provider send a summary of care record for more than 65 percent of transitions of care and referrals. CMS has reduced the threshold to 50 percent for the final rule. The second measure required that a provider electronically transmit a summary of care for more than 10 percent of transitions of care and referrals, and that the summary of care be electronically sent to a provider with no organizational or vendor affiliation. According to the release, the intent of this measure was to foster electronic exchange outside established vendor and organization networks. However, CMS is eliminating the organizational and vendor limitations. Instead, CMS is requiring at least one instance of exchange with a provider using EHR technology designed by a different EHR vendor. The 10 percent threshold for electronic transmittal is included in the final rule.
5. Clinical quality measures. In the stage 2 proposed rule, CMS suggested that EPs, eligible hospitals, and CAHs be required to report on specified clinical quality measures in order to qualify for incentive payments. For EPs, CMS proposed 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. The Stage 2 proposed rule also outlined 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.
In this final rule, CMS finalized that eligible hospitals and CAHs must report on 16 out of 29 CQMs, and EPs must report on 9 out of the 64 total CQMs. In addition, all providers must select CQMs from at least 3 of the 6 key healthcare policy domains from the HHS' National Quality Strategy:
• Patient and family engagement
• Patient safety
• Care coordination
• Population and public health
• Efficient use of healthcare resources
• Clinical processes/effectiveness
6. Payment adjustments. Medicare payment adjustments are required by statute to take effect in 2015. In the final rule, CMS maintained its proposal that any Medicare EP or hospital that demonstrates meaningful use in 2013 will avoid payment adjustment in 2015. Also, any Medicare provider that first demonstrates meaningful use in 2014 will now avoid the penalty if they meet the attestation requirement by July 3, 2014 for eligible hospitals or Oct. 3, 2014 for EPs.
Although CMS originally proposed three exceptions to these payment adjustments, it finalized four. The three exceptions, which were originally proposed, include exceptions based on infrastructure, newly practicing EPs who would not otherwise be able to avoid payment adjustments and unforeseen circumstances. The new exception is by specialty/provider type concentrated among three specialties: anesthesiology, radiology and pathology. Infrastructure, unforeseen circumstances, and new CAHs/eligible hospitals are also exception categories for eligible hospitals and CAHs.
The final rule may be viewed here.
More Articles on Meaningful Use EHR Incentive Program:
AMA, Medical Societies Comment on Proposed "Meaningful Use" Rule for EHR Programs39 Things to Know About CMS' Stage 2 Requirements for Meaningful Use
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