SEPTEMBER 11, 2012 CMS and ONC release final rules for Stage 2 meaningful use requirements By Linn Foster Freedman and Kathryn Sylvia On August 23, 2012, the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) released the final requirements with which hospitals and health care providers must comply to qualify for Stage 2 meaningful use incentives. The Department of Health and Human Services (HHS) Secretary, Kathleen Sebelius announced that the changes 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 meaningful use incentive program By signing the American Recovery and Reinvestment Act of 2009 (ARRA), President Obama sought to achieve the use of electronic health records (EHRs) for all Americans by 2014. Under the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH), health care providers and facilities can qualify for Medicare and Medicaid incentive payments if they adopt and meaningfully use certified EHR technology. The meaningful use incentive program will pay out $27 billion over a ten-year period. Medicare eligible providers (EPs) who are meaningful users of EHRs, may receive up to $44,000 while Medicaid providers are eligible to receive $63,750 in total. Hospitals can also receive incentives for achieving meaningful use. The standard for meaningful use advances as each stage of the incentive program is implemented. In Stage 1, which began in 2011, meaningful use consisted of the basic use of EHRs and the ability to share and transmit health information to improve access and quality. Stage 1 allowed flexibility and choice for EPs. Under Stage 1, hospitals must obtain 14 objectives while EPs must obtain 15 objectives, with an additional 10 objectives in the a la carte menu. Hospitals and EPs must choose 5 objectives from that a la carte menu, while the other 5 objectives could be deferred to the completion in Stage 2. Stage 1 meaningful use remains the starting base for all health care providers and hospitals. According to CMS, $3.2 billion has been paid to date in meaningful use incentive payments to EPs and hospitals as of July 2012.
Read about the full list of objectives in Stage 1 by clicking here. As discussed below, Stage 2, scheduled to be implemented in 2014, increases the requirements for meaningful use in order to receive additional incentive payments. These requirements include online access for patients to their health information and the use of an electronic health information exchange (HIE) between providers. Stage 2 holds providers more accountable for their patients use of EHRs, but only requires that 5% of each EP s patients use the HIE in order to comply with meaningful use requirements. Stage 2 allows providers and hospitals to start the meaningful use process if they have not yet done so, but does not allow providers to passively engage an EHR. In 2016, Stage 3 will include demonstrating that through the use of EHR technology, the quality of health care and the services provided has been improved. The CMS final rule for Stage 2 The final rule for Stage 2 requires that all physician practices achieve meaningful use in 2014, but no providers will be required to follow the Stage 2 requirements any time before 2014. Originally, Stage 1 set a timeline that required those who met the meaningful use requirements in 2011 to meet the Stage 2 criteria by 2013. Further, any physicians who received EHR bonuses in 2011 and 2012 are required to meet Stage 2 requirements in 2014, and any physicians who start achieving meaningful use in 2013 or later must meet Stage 1 requirements for up to two years before moving onto Stage 2, regardless of incurring noncompliance penalties for late adoption of EHRs. The final rule requires that physicians meet a greater number of core objectives, and imposes stricter guidelines for some of those objectives already in place under Stage 1. Physicians who do not adopt meaningful use of EHRs by October 1, 2014 will be assessed a 1% penalty from Medicare. In 2016, the penalty increases to 2% and in 2017 to 3%. Both Stage 1 and Stage 2 require 20 objectives, but Stage 2 mandates some of the EHR measures that are optional in Stage 1. Other measures stay the same, but impose a higher threshold. For example, in Stage 2, physicians are required to send more than 50% of qualifying prescriptions electronically, compared to the original standard of 40%. Also, the required number of core objectives in Stage 1 of 15 increases to 17 in Stage 2, and there are three out of six added menu set measures. The following are the core set and menu set of objectives in Stage 2, and EPs must meet at least 20 of these measures: Core set Use computerized physician order entry (more than 60% medication, 30% lab, and 30% radiology orders) Prescribe permissible drugs electronically (more than 50%) Record patient demographics (more than 80%) Record and chart changes in vital signs (more than 80%) Record smoking status (more than 80%) 2
Use clinical decision support (at least five interventions) Incorporate clinical lab results into EHR (more than 55%) Generate lists of patients by specific conditions (at least one list) Identify patients who need reminders for preventive or follow-up care (more than 10%) Provide at least half of patients with access to health information (more than 5% use access) Provide clinical summaries for patients within one business day (more than 50%) Identify patient-specific education resources (more than 10%) Communicate with patients on relevant health information (more than 5%) Perform medication reconciliation during care transitions (more than 50%) Send summaries of care during referrals (more than 50%) Submit electronic data to immunization registries (ongoing submissions during reporting period) Protect EHR information Menu set Access imaging results through EHR (more than 10%) Record patient family health histories (more than 20%) Record electronic notes (more than 30%) Submit electronic syndromic surveillance data to public health registries (ongoing submissions) Identify and report cancer cases to a public health registry (ongoing submissions) Identify and report noncancer cases to a specialized registry (ongoing submissions) The CMS final rule eliminates the exchange of key clinical information core objective and replaces it with transitions of care core objective in Stage 2. Also, the provide patients with an electronic copy of their health information objective has been eliminated in Stage 2 and replaced with the electronic/online access core objective. There has been an addition of outpatient lab reporting to the menu for hospitals, and recording clinical notes to the menu objective for eligible professionals and hospitals. Moreover, another core objective for eligible professionals has been added the use [of] secure electronic messaging to communicate with patients on relevant health information to increase patient engagement. A core objective for hospitals to automatically track medications from order to administration using assistive technologies in conjunction with an electronic medication administration record (emar) has also been included. While the guidelines are stricter and a bit more difficult to achieve, the CMS final rule does reduce a few of the thresholds for achieving certain objectives. For example, the threshold for the requirement that all patients have online availability of their records has been lessened to 3
accommodate hospitals and health care professionals in rural or underserved areas where the Internet is not as readily accessible as in urban areas. Further, the rule permits the use of batch reporting process where groups will be able to submit attestation information for all of their individual eligible professionals in one file upload rather than having to enter each eligible professional individually. The CMS final rule further outlines the criteria for the certification of EHR technology in order to assure eligible professionals and hospitals that the systems being used work efficiently and effectively. It modifies the certification program to eliminate the red tape and allow the certification process to run more efficiently. It allows health care providers and facilities a flexible reporting period for 2014 so that there will be sufficient time to adopt or upgrade to the EHR technology that is required in 2014. Moreover, the final rule allows eligible professionals to apply for hardship exceptions under the categories of infrastructure, new practicing eligible professionals, unforeseen circumstances such as natural disasters or bankruptcy of EHR vendors, those who lack faceto-face or telemedicine interaction with patients or lack of follow-up need with patients, and eligible professionals who practice in multiple locations if there is a lack of control over availability of Certified EHR Technology (CEHRT) for more than fifty percent (50%) of patient encounters. Lastly, the final rule changes the Stage 1 definition of Medicaid encounters from services rendered on any one day where Medicaid paid for all or part of the service to service rendered any one day to a Medicaid-enrolled individual regardless of payment liability. CMS has also announced that it will begin to audit Medicare providers who have received federal EHR incentive payments. A Garden City, New York accounting firm, Figliozzi & Company, will conduct the audits. Any providers who have already attested to achieving Stage 1 meaningful use may be audited. Providers will receive notification of an audit from Figliozzi & Company. If a provider is found to be ineligible after the audit, the provider will have to return any financial incentives paid. Any providers who have attested to achieving meaningful use should be sure to retain all documentation used in the completion of the Attestation Module responses, documents containing proof of certification, and documents showing that the core objectives were met. All providers should be cautious when providing information to the auditing firm to ensure that no protected health information or sensitive information is disclosed. CMS will establish an appeals process for any provider found ineligible who wishes to dispute such findings. More information will be released shortly regarding those procedures on the CMS website. The ONC final rule for Stage 2 The ONC final rule completes its standards, implementation specifications, and certification criteria for EHR technology. The ONC final rule defines CEHRT in a way that allows providers to choose the EHR technology that is best for them and their patients. Under the new definition, eligible providers can meet the CEHRT definition in any of the following ways: 4
1. Adopt EHR technology certified to the 2011 Edition EHR Certification criteria that meets all applicable certification criteria, 2. Upgrade parts of their 2011 Edition EHR technology to the equivalent 2014 Edition EHR technology, or 3. Adopt EHR technology that meets the CEHRT definition for fiscal year 2014. The ONC final rule also improves security by focusing on encryption, requiring the use of technology that supports corrections and amendments to a patient s record; that enables secure messaging between provider and patient; and that allows a patient to securely view, download, and electronically transmit health information. The final rule addresses interoperability by creating a standards-based exchange with single vocabulary and providing a common interface for laboratory and ambulatory providers to share information. It also sets a goal of creating a system in which automatic reports will be sent to public health agencies and data collection or research banks upon entering the information into the HIE. The ONC final rule helps to increase data portability; enhances safety, usability, and clinical quality measures; reduces the regulatory burden; and increases flexibility. Further, the ONC final rule promotes transparency regarding EHR technology price and limits purchasing confusion. All test results from authorized certification bodies must be submitted via hyperlink that connects to the tests and methods used to certify an EHR, in addition to the publication of a public report on the ONC s website. For further information, the CMS and ONC final rules can be found at the following links: CMS: http://www.ofr.gov/ofrupload/ofrdata/2012-21050_pi.pdf ONC: http://www.ofr.gov/ofrupload/ofrdata/2012-20982_pi.pdf For more information about meaningful use or for assistance with any questions regarding attestation for incentive payments, please contact: Linn Foster Freedman, Privacy & Data Protection Group Leader; Chair, Health Information Technology (HIT) Team, at lfreedman@nixonpeabody.com or (401) 454-1108 5