Stage 2 of Meaningful Use Summary of Proposed Rule

Stage 2 of Meaningful Use Summary of Proposed Rule Background In order to receive incentives for the adoption of electronic health records (EHRs) under either the Medicare or Medicaid (Medi-Cal) incentive programs, physicians must demonstrate meaningful use. In general, meaningful use is a set of measures for which physicians must collect data and then report to either the federal government or the State of California. In order to help physicians make the transition to EHR, the federal Centers for Medicare and Medicaid Services (CMS) proposed a staged approach, where each successive stage would require more stringent measures. From now until 2014, physicians are reporting on Stage 1 of meaningful use. Last week, CMS released a draft notice of proposed rulemaking (NPRM) defining Stage 2 of Meaningful Use. Like Stage 1, this new definition of meaningful use contains a set of mandatory measures that physicians must report, as well as a series of clinical quality measures from which physicians must select. The NPRM released last week also proposes some changes to the existing Stage 1 of Meaningful Use. The proposed changes, which are detailed below, would take place in 2013 and 2014 for physicians demonstrating Stage 1 Meaningful Use during those calendar years. On January 1, 2015, the federal government will begin reducing Medicare payments for physicians who don t meet meaningful use. The rule provides clarification on the basics of the incentive program, including how physicians can comply with meaningful use in time to avoid payment reductions in Medicare. This summary of the NPRM is intended to help physicians understand what is currently being proposed. This rule is not final; it will be subject to a 60-day comment period once it if officially published in the Federal Register. CMA will be filing formal comments once the comment period opens. Changes to Stage 1 Consistent with earlier public announcements, this proposed rule delays the implementation of Stage 2 of Meaningful Use until 2014, regardless of when they begin demonstrating meaningful use (previously, physicians who began in 2011 would have had to demonstrate Stage 2 in 2013). However, CMS chose to make some changes to Stage 1, in order to react to physician concerns. The chart below highlights several current and proposed Stage 1 objectives and measures.

Table 1: Changes to Stage 1 Current Objective: Record vital signs and chart changes (height, weight, blood pressure, body-mass index, growth charts for children). Measure: More than 50% of patients 2 years of age or older have height, weight, and blood pressure recorded as structured data. Objective: Computer provider order entry (CPOE) for medication orders. Measure: More than 30% of patients with at least one medication in their medication list have at least one medication ordered through CPOE. Objective: Implement capability to electronically exchange key clinical information (for example, problem list, medication list, medication allergies, and diagnostic test results) among providers and patient-authorized entities. Measure: Perform at least one test of EHR's capacity to electronically exchange information. Objective #1: On request, provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, and medication allergies). Measure #1: More than 50% of requesting patients receive electronic copy within 3 business days. Objective #2: Provide patients with timely electronic access to their health information (including laboratory results, problem list, medication lists, and medication allergies). Measure #2: More than 10% of patients are provided electronic access to information within 4 days or its being updated in the EHR. Proposed (This change is optional in 2013, mandatory in 2014) Measure: More than 50% of all patients seen have blood pressure (patients 3 and over only), and height and weight (all patients) recorded in the EHR. (This change is optional in 2013, mandatory in 2014) Measure: More than 30% of medication orders created by the physician (or other authorized provider) are recorded using CPOE. Beginning in 2013, this objective is no longer required. It will be replaced with alternative measures in Stage 2. Effective in 2014, these two objectives are combined into one new objective and measure, as follows: Objective: Provide patients the ability to view online, download, and transmit their health information within 4 business days of the information being available. Measure: More than 50% of all unique patients seen are provided timely (within 4 business days) access to their health information subject to the physician s discretion to withhold certain information. Stage 2 Objectives and Measures As stated above, when a physician moves on to Stage 2 of Meaningful Use depends on when they first report. The chart below lays out which stage of Meaningful Use a physician would have to achieve, based on the first payment year:

First Payment Year 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2011 1 1 1 2 2 3 3 TBD TBD TBD TBD 2012 (AIU) 1 1 2 2 3 3 TBD TBD TBD TBD 2013 (AIU) 1 1 2 2 3 3 TBD TBD TBD 2014 (AIU) 1 1 2 2 3 3 TBD TBD 2015 (AIU) 1 1 2 2 3 3 TBD 2016 (AIU) 1 1 2 2 3 3 2017 (AIU) 1 1 2 2 3 For physicians who are accessing the Medi-Cal EHR incentive program, they can access their first incentive payment for demonstrating adoption, implementation, or upgrade (AIU). For those physicians, they would move through the stages depending on when they first achieved Meaningful Use. For example, a physician who achieves AIU in 2012 would demonstrate Stage 1 in 2013 and 2014, and then Stage 2 in 2015 and 2016. Proposed Objectives and Measures Like Stage 1, the main portion of Meaningful Use is a series of objectives and measures on which physicians must report. The objectives are broad policy goals (such as use electronic prescribing ), while the measures are the actual criteria on which physicians must report. Also like Stage 1, the measures would be divided between a core set, on which all physicians would report, and a menu set from which physicians could select. As described in the proposed rule, Stage 2 of Meaningful Use would require physicians to report on 17 core measures, and 3 of 5 from a menu set. The core and menu set are listed in the table below. Note that, in some cases, there is more than one measure for an objective. In those cases, a physician would have to meet both measures in order to qualify. OBJECTIVES: CORE SET Objective Record patient demographics (sex, race, ethnicity, date of birth, and preferred language). Record vital signs and chart changes (height, weight, blood pressure, body-mass index, growth charts for children). Record smoking status for patients 13 years of age or older. Provide patients with clinical summaries for each office visit. Measure More than 80% of patients' demographic data recorded as structured data. More than 80% of patients 2 years of age or older have height, weight, and blood pressure recorded as structured data. More than 80% of patients 13 years of age or older have smoking status recorded as structured data. Clinical summaries provided to patients for more than 50% of all office visits 24 hours.

Provide patients the ability to view online, download, and transmit their health information within 4 business days of the information being available to the physician Generate and transmit permissible prescriptions electronically Use computer provider order entry (CPOE) for medication orders, laboratory, and radiology orders. Use clinical decision support to improve performance on high-priority health conditions Protect electronic health information created or maintained by the EHR through the implementation of appropriate technical capabilities. Incorporate Clinical lab-test results into Certified EHRs Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach. Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care. Use EHR technology to identify patient-specific education resources and provide those to the patient as appropriate. Use secure electronic messaging to communicate with patients on relevant health information A physician who receives a patient from another setting of care should perform medication reconciliation. 1. More than 50% of all unique patients are provided timely (within 4 days) online access to their health information. 2. More than 10% of all unique patients view, download, or transmit to a third party their health information. More than 65% of permissible prescriptions are transmitted electronically using certified EHR technology. More than 60% of medication, laboratory, and radiology orders created by the physician are recorded using CPOE. 1. Implement 5 clinical decision support interventions related to 5 or more clinical quality measures. 2. Enable and implement the functionality for drug-drug and drug-allergy interaction checks. Conduct or review a security risk analysis, implement security updates as necessary, and correct identified security deficiencies, including addressing the encryption/security of data at rest. More than 55% of all clinical lab test results whose results are either in a positive/negative or numerical format are incorporated as structured data. Generate at least one listing of patients with a specific condition. More than 10% of unique patients who have had an office visit in the previous 24 months were sent a reminder. More than 10% of patients are provided patientspecific education resources. A secure message was sent using the electronic messaging function of the EHR by more than 10% of unique patients. Medication reconciliation is performed for more than 65% of transitions of care.

The physician 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 by law, and actual submission in accordance with applicable law and practice. 1. Summary of care record is provided for more than 65% of patient transitions or referrals. 2. The summary of care record is transmitted electronically for 10% of transitions of care and patient referrals. Successful ongoing submission of electronic immunization data from EHR to an immunization registry or immunization information system. OBJECTIVES: MENU SET Objective Imaging results and information available through EHR. Record patient family health history. Submit electronic syndromic surveillance data to public health agencies. 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 Measure More than 40% of all scans and tests whose result is an image ordered by the physicians are accessible through the EHR. More than 20% of all unique patients have a family history recorded for one or more firstdegree relatives. Successful ongoing submission of electronic syndromic surveillance data. Successful ongoing submission of cancer case information to a cancer registry. Successful ongoing submission of specific case information to a cancer registry. Clinical Quality Measures Under the rules for Stage 1, physicians had to report on 3 core quality measures and 3 menu set measures from a list of 38. For Stage 2, CMS is considering several options for clinical quality measure reporting, as described below. CMS has developed a list of 125 clinical quality measures, divided into six domains : patient and family engagement, patient safety, care coordination, population and public health, efficient use of health care resources, and clinical process/effectiveness. While not all 125 measures are expected to be included in the final rule, CMS is attempting to ensure that all physicians can find measures that are applicable to their practice. The reporting options are:

Option 1a: A physician would report on 12 clinical quality measures (from a proposed list of 125), including at least one from each of each of the six domains. Option 1b: Submit 11 core clinical quality measures and 1 menu set measure. Option 2: Physicians who report to the Physician Quality Reporting System (PQRS) in Medicare could be deemed to have met this requirement. Medicare Payment Reductions In the Medicare program, physicians who do not achieve Meaningful Use before January 1, 2015 will face payment reductions. This proposed rule describes a timeline for when physicians will be deemed to be subject to these reductions. What a physician must do in order to avoid reductions depends on when they enter the EHR incentive program. In the first year that a physician demonstrates Meaningful Use, they must demonstrate for 90 consecutive days fully within the calendar year. For every year after that, the physician must achieve Meaningful Use for the complete calendar year. A physician who achieves Meaningful Use in one year but not the next would still be subject to reductions. For physicians who first demonstrate Meaningful Use in 2011 or 2012, they must demonstrate a full year of Meaningful Use in 2013 in order to avoid reductions in 2015. For physicians who begin in 2014, they would have to achieve Meaningful Use for 90 days before October 1, 2014. That is, they would have to start their 90 day reporting period on or before July 3, 2014. The Chart below lays out when a physician must demonstrate Meaningful Use in order to avoid reductions: Group Reporting To Avoid a Reduction in the Year Below Meaningful Use for a Full Calendar Year OR For First Year, Demonstrate for 90 Days Beginning 2015 2013 July 3, 2014 2016 2014 July 3, 2015 2017 2015 July 3, 2016 2018 2016 July 3, 2017 2019 2017 July 3, 2018 Under Stage 1, physicians in group settings were required to attest to Meaningful Use individually. The NPRM proposes to begin moving away from this requirement to allow group reporting. Beginning in 2014, CMS is considering allowing groups to attest through batch reporting of all data for their affiliated providers. Timelines and Next Steps Once the rule is formally published in the Federal Register, it will be subject to a 60-day comment period. As stated above, CMA will be commenting during that time. CMS expects to publish a final rule sometime in Summer 2012.