Overview and Key Takeaways from the Proposed Rule on Meaningful Use Stage 3

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1 Overview and Key Takeaways from the Proposed Rule on Meaningful Use Stage 3 April 2015 Impact Advisors LLC 400 E. Diehl Road Suite 190 Naperville IL Impact- Advisors.com

2 Background On March 20, 2015 CMS released the proposed rule for Stage 3 of meaningful use. Given the widespread problems with certification in 2014 and the difficulties providers faced meeting Stage 2 requirements related to patient engagement and health information exchange the proposed Stage 3 rule has been highly anticipated by many providers, hospitals, and health systems. Note that this is only a proposed rule. The deadline for public comments is May 29, CMS will review and respond to everything received about the proposed Stage 3 requirements, incorporate the feedback, and then issue a final rule later this year (probably sometime in the fall). Additionally, the scope of the Stage 3 proposed rule is only focused on 2017, 2018, and beyond. CMS is expected to publish a separate rule later this spring on changes to the 2015 reporting period. Key Changes Proposed for Stage 3: All hospitals and EPs would be required to be on Stage 3 by 2018 Stage 3 would be optional in Edition CEHRT would be required by 2018 Starting in 2017, the EHR reporting period for both hospitals and EPs would be a full 365 days, based on the calendar year No more core and menu sets; instead only 8 objectives for both hospitals and EPs Each objective would have one or more measures associated with it For 3 of the 8 objectives, providers actually could fail an associated measure and still achieve MU Starting in 2018, CQMs would need to be reported electronically where feasible Proposed Stage 3 Details Timing of Stage 3 CMS is proposing to make Stage 3 the final stage of MU. This doesn t mean that the MU program would end any time soon though; just that Stage 3 requirements would continue indefinitely. Stage 3 would be required for all hospitals and EPs in 2018, regardless of prior participation or where they currently are in the program. After 2018, Stage 1 and Stage 2 would no longer be options for any hospitals or EPs. The goal is to have everyone operating under one set of MU requirements starting in 2018 and to avoid complications associated with trying to manage various stages and different measures. Overview and Key Takeaways from the Proposed Rule on MU Stage 3 2

3 2017 will be an important transition year. Any hospital or EP will have the option of attesting to Stage 3 in 2017 which CMS strongly encourages in this proposed rule. Hospitals and EPs will also have the option of attesting to the same stage of MU that they attested to in For example, a hospital that attested to Stage 1 in 2015 and 2016 could also attest to Stage 1 (or even Stage 2) in However, a hospital that attested to Stage 2 in 2016 could only choose between Stage 2 and Stage 3 in In other words, providers would have some flexibility in 2017, but they would not be allowed to move backwards in terms of their stage progression. The important takeaway is that no matter which stage a provider attests to in 2017, Stage 3 would still be required for everyone in 2018 even hospitals and EPs who have never participated in the meaningful use program before. (See the chart below for details.) To coincide with the start of Stage 3, CMS is proposing that all EHRs will need to be certified to the 2015 Edition of EHR certification criteria by 2018, which ONC published in a separate proposed rule. EHR Reporting Periods Starting in 2017, the EHR reporting period for all hospitals and EPs will be a full 365 days. This will include hospitals and EPs in their first year of MU, as CMS would remove the existing 90-day reporting option for those providers. (Medicaid hospitals and EPs demonstrating MU for the first time are the only exception and would still be able to report using a 90-day period for their first year.) Overview and Key Takeaways from the Proposed Rule on MU Stage 3 3

4 Also starting in 2017, the reporting period for both hospitals and EPs would be based on a calendar year in an effort to better align the EHR Incentive Program with CMS quality reporting efforts like the Hospital IQR Program and PQRS. Stage 3 Objectives and Measures Stage 3 eliminates the core (i.e., required) and menu (i.e., optional) sets of measures used in Stages 1 and 2. CMS is now proposing a total of 8 objectives for all hospitals and EPs, each of which would have one or more associated measures. Overall, there are 20 measures proposed for EPs and 21 proposed for hospitals. Hospitals and EPs would be required to report on all of the measures associated with each objective. However, for 3 of the objectives, hospitals and EPs would only need to actually meet the thresholds for a subset of the associated measures. In other words, providers could fail one of the measures for certain objectives but still successfully achieve meaningful use. Many of the proposed measures have been carried over from Stage 1 or Stage 2, only with a higher threshold or broader scope in Stage 3. For example, CPOE would go from 60% of med orders, 30% of lab orders, and 30% of rad orders in Stage 2 to 80% of med orders, 60% of lab orders, and 60% of diagnostic imaging orders in Stage 3. Two increases in particular are likely to get the most attention though: The patient engagement measure which would require a staggering 25% of unique patients to actively engage with the information in their EHR in Stage 3, and The new transitions of care measure, which would require a summary of care record to be electronically transmitted for 50% of transitions of care up from just 10% in Stage 2. (The only potential positive here would be that CMS is considering allowing the transmission to occur via any electronic means rather than only via Direct, which was the requirement in Stage 2.) There are also a few completely new measures proposed for Stage 3. The most notable is a measure that would require patient-generated health data or data from a non-clinical setting to be incorporated into certified EHR technology for more than 15% of unique patients. Another measure worth mentioning is a proposed requirement for hospitals and EPs to incorporate electronic summary of care documents that are received into the EHR for more than 40% of transitions of care in which the provider has never before encountered the patient. Overview and Key Takeaways from the Proposed Rule on MU Stage 3 4

5 A complete list of all the proposed objectives and measures for Stage 3 is provided below: Proposed Objective Proposed Stage 3 Measure(s) Protect Patient Health Information Electronic Prescribing Clinical Decision Support CPOE The measure must be successfully met: Conduct or review a security risk analysis including addressing the security (including encryption) of data stored in CEHRT, implement security updates as necessary, and correct identified security deficiencies as part of the provider's risk management process. The measure must be successfully met: EPs: More than 80% of all permissible prescriptions written by the EP are queried for a drug formulary and transmitted electronically using CEHRT. Hospitals: More than 25% of hospital discharge medication orders for permissible prescriptions (for new and changed prescriptions) are queried for a drug formulary and transmitted electronically using CEHRT. Both measures must be successfully met: 1. Implement 5 clinical decision support interventions related to 4 or more CQMs at a relevant point in patient care for the entire EHR reporting period. Absent 4 CQMs related to an EP or eligible hospital s scope of practice or patient population, the clinical decision support interventions must be related to high-priority health conditions. 2. The EP or eligible hospital has enabled and implemented the functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period. All 3 measures must be successfully met: 1. More than 80% of medication orders created by the EP or authorized providers of the eligible hospital's inpatient or emergency department during the EHR reporting period are recorded using CPOE 2. More than 60% of laboratory orders created by the EP or authorized providers of the eligible hospital's inpatient or emergency department during the EHR reporting period are recorded using CPOE 3. More than 60% of diagnostic imaging orders created by the EP or authorized providers of the eligible hospital's inpatient or emergency department during the EHR reporting period are recorded using CPOE Overview and Key Takeaways from the Proposed Rule on MU Stage 3 5

6 Proposed Objective Proposed Stage 3 Measure(s) Patient Electronic Access to Health Information* Coordination of Care through Patient Engagement Both measures must be successfully met: 1. For more than 80% of all unique patients seen by the EP or discharged from the eligible hospital inpatient or emergency department: - The patient (or patient-authorized representative) is provided access to view online, download, and transmit their health information within 24 hours of its availability to the provider; or - The patient (or patient-authorized representative) is provided access to an ONC-certified API that can be used by third-party applications or devices to provide patients (or patient-authorized representatives) access to their health information, within 24 hours of its availability to the provider. 2. The EP or eligible hospital must use clinically relevant information from CEHRT to identify patient-specific educational resources and provide electronic access to those materials to more than 35% of unique patients seen by the EP or discharged from the eligible hospital or inpatient or emergency department during the EHR reporting period. Only 2 of 3 measures must be successfully met: 1. During the EHR reporting period, more than 25% of all unique patients seen by the EP or discharged from the eligible hospital inpatient or emergency department actively engage with the electronic health record made accessible by the provider. An EP or eligible hospital may meet the measure by either: - More than 25% of all unique patients (or patient-authorized representatives) seen by the EP or discharged from the eligible hospital inpatient or emergency department during the EHR reporting period view, download or transmit to a third party their health information; or - More than 25% of all unique patients (or patient-authorized representatives) seen by the EP or discharged from the eligible hospital inpatient or emergency department during the EHR reporting period access their health information through the use of an ONC-certified API that can be used by third-party applications or devices. 2. For more than 35% of all unique patients seen by the EP or discharged from the eligible hospital inpatient or emergency department during the EHR reporting period, a secure message was sent using the electronic messaging function of CEHRT to the patient (or the patient's authorized representatives), or in response to a secure message sent by the patient (or the patient's authorized representative). 3. Patient-generated health data or data from a non-clinical setting is incorporated into the certified EHR technology for more than 15% of all unique patients seen by the EP or discharged by the eligible hospital inpatient or emergency department during the EHR reporting period. Overview and Key Takeaways from the Proposed Rule on MU Stage 3 6

7 Proposed Objective Health Information Exchange Proposed Stage 3 Measure(s) Only 2 of 3 measures must be successfully met 1. For more than 50% of transitions of care and referrals, the EP or eligible hospital that transitions or refers their patient to another setting of care or provider of care: (1) creates a summary of care record using CEHRT; and (2) electronically exchanges the summary of care record. 2. For more than 40% of transitions or referrals received and patient encounters in which the provider has never before encountered the patient, the EP or eligible hospital incorporates into the patient's EHR an electronic summary of care document from a source other than the provider's EHR system. 3. For more than 80% of transitions or referrals received and patient encounters in which the provider has never before encountered the patient, the EP or eligible hospital performs a clinical information reconciliation. Public Health and Clinical Data Registry Reporting EPs: Only 3 of 5 measures must be successfully met Hospitals: Only 4 of 6 measures must be successfully met 1. Immunization Registry Reporting: The EP or eligible hospital is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system. 2. Syndromic Surveillance Reporting: The EP or eligible hospital is in active engagement with a public health agency to submit syndromic surveillance data from a non-urgent care ambulatory setting for EPs, or an emergency or urgent care department for eligible hospitals. 3. Case Reporting: The EP or eligible hospital is in active engagement with a public health agency to submit case reporting of reportable conditions. 4. Public Health Registry Reporting: The EP or eligible hospital is in active engagement with a public health agency to submit data to public health registries.** 5. Clinical Data Registry Reporting: The EP, eligible hospital is in active engagement to submit data to a clinical data registry.** 6. Electronic Reportable Laboratory Result Reporting: The eligible hospital is in active engagement with a public health agency to submit electronic reportable laboratory results. [Hospital only] *CMS is seeking public comment on alternative versions of these measures included in the proposed rule **Measures #4 and #5 for Public Health Registry Reporting and Clinical Data Registry Reporting may be counted more than once if more than one Public Health Registry or Clinical Data Registry is available CQMs Submission of Clinical Quality Measures (CQMs) would continue to be a requirement for meaningful use in Stage 3. In 2017, hospitals and EPs would have the option to report CQMs one of two ways: by electronic submission or by attestation. Starting in 2018, though, CMS is proposing that CQMs would need to be reported electronically where feasible and attestation to CQMs would only be an option in certain circumstances where electronic reporting is not possible. As with Stage 3 objectives and measures, the reporting period for CQMs would be a full 365-day calendar year starting in Overview and Key Takeaways from the Proposed Rule on MU Stage 3 7

8 Key Takeaways The Stage 3 requirements as proposed will likely be very challenging for many providers. The completely new measures proposed (particular the ones related to HIE and patient engagement) definitely have the potential to be confusing and awkward to track. Additionally, a number of the measures carried over from Stage 1 and 2 will have significantly higher thresholds in Stage 3; in fact, many will require performance over 80%. Such a high threshold leaves little room for error and makes it almost impossible to play catch up if performance is down in the first part of the year or if workflows are still being refined. Having everyone on the same stage of MU in 2018 will probably reduce a lot of confusion but the road will be very bumpy. Providers will have the option to attest to a full year of Stage 3 in 2017, but the practicality of this for most participants is doubtful given: 1) the certification and implementation challenges seen in 2014, and 2) the final Stage 3 rule isn t likely to be published until the fall of In fact, it is not hard to envision a similar scramble happening again in , especially without the benefit of the 3-month reporting period that was available in In some ways, there actually does appear to be more flexibility in the proposed Stage 3 measures compared to previous stages. The one that initially stands out is around electronic transmission of a summary of care document at transitions of care. The threshold has increased considerably over Stage 2 (from 10% to a potentially very challenging 50%), but it appears CMS is considering allowing the exchange to be through any electronic means and not requiring that a specific transport standard (like Direct) be used. The public health objective, which would permit hospitals and EPs to count certain measures more than once if multiple registries are available, also seems to be a positive change. In other ways the flexibility is somewhat overstated. There are fewer objectives in Stage 3, but the actual number of measures has not really changed and now there is no longer a menu set of optional measures. Yes, providers can fail one of the measures for some of the objectives and still achieve MU in Stage 3, but it is not as though any of the proposed requirements related to patient engagement or HIE are easy. In fact, the proposed patient engagement measure that would require 25% of unique patients to actively engage with information in the EHR is so high that we suspect only a few hospitals in the country could even meet it right now. This will definitely be something to watch when the final rule is published, because ultimately, the value of flexibility is only as high as the viability of the actual options. The bottom line is that we probably won t know what the biggest Stage 3 challenges are for a while. When the Stage 2 rule initially came out, the infamous transitions of care measure (requiring a summary of care record to be sent electronically for 10% of transitions of care) didn t look nearly as demanding as it turned out to be. In the Stage 3 proposed rule, many of the measures carried over from Stage 2 might have higher thresholds, but those measures are at least known quantities. The entirely new measures proposed for Stage 3 are essentially complete unknowns. The reality is we won t really know just how difficult those new requirements will be until vendors try to become certified and providers start implementing new capabilities and redesigning workflows and that uncertainty in and of itself will be a huge challenge. Overview and Key Takeaways from the Proposed Rule on MU Stage 3 8

9 About Impact Advisors Impact Advisors provides high-value strategy and implementation services to help healthcare clients drive clinical and operational performance excellence through the use of technology. We partner with industry-leading organizations to identify and implement improvements in quality, safety and value. Our Associates are experienced professionals with deep domain expertise and a commitment to delivering results. For more information visit: Follow us on Facebook and LinkedIn Copyright 2015 Impact Advisors, LLC. All rights reserved. These materials are provided to you by Impact Advisors as a professional courtesy for personal use only and may not be sold. Please appropriately credit/cite your source as Impact Advisors, LLC. All copying for commercial use requires written prior permission secured from impact-advisors.com. Overview and Key Takeaways from the Proposed Rule on MU Stage 3 9