PROPOSED MEANINGFUL USE STAGE 2 REQUIREMENTS FOR ELIGIBLE PROVIDERS USING CERTIFIED EMR TECHNOLOGY On February 23, the Centers for Medicare & Medicaid Services (CMS) posted the much anticipated proposed rule for Stage 2 of meaningful use of EHRs. While CMS and ONC acknowledge the critical role that specialty providers have played in the meaningful use of health IT for quality improvement, there are few changes in the Stage 2 proposed rule that are beneficial. In keeping with, in cases in which there are situations that make it impossible for an EP to meet the measure, there is a scope of practice exclusion, such as vital signs. Proposed Changes: EPs must meet or qualify for an exclusion to 17 core objectives and 3 of 5 menu objectives EPs to report 12 CLINICAL QUALITY MEASURES (CQMs) ( required 6) Alignment with other Quality Measurement initiatives Two years reporting time in each stage Increased thresholds for many measures Integration of diagnostic imaging Increased patient engagement Eliminating the core objective that providers must demonstrate the capability to exchange key clinical information among providers of care; and Replacing the requirement that providers provide patients with an electronic copy of their health information with a core objective that would instead require providers to provide patients with the ability to view online, download and transmit their health information. TIMELINE FOR IMPLEMENTATION CMS is pushing back the start date for Stage 2 compliance to January 1, 2014. Those that attest to meaningful use first in 2011 must meet Stage 2 criteria in 2014 and Stage 3 in 2016. All others will be required to demonstrate 2 years at, 2 years at Stage 2, and then 2 years at Stage 3 (assuming the cut-off date for the program s payments have not passed). Providers attesting to Year 1, criteria, regardless of when they start, will continue to use a 90-day MEDICARE PAYMENT ADJUSTMENTS AND EXCEPTIONS In addition to the new requirements to be a meaningful user of EHRs, there is one important clarification to the requirements for avoiding penalties. To avoid penalties starting in 2015 for not being a meaningful user, eligible providers (EPs) need to either attest to meaningful use in 2013, or have achieved and attested to the first year of meaningful use by October 1, 2014. The penalty in 2015 would not apply to providers who achieve meaningful use for the first time in 2014, provided that they report this to CMS by October 3, 2014. 1
As authorized by the American Recovery and Reinvestment Act of 2009, physicians can qualify for up to $44,000 under Medicare over 5 years, provided they began to meet requirements in either 2011 or 2012. Physicians who fail to demonstrate meaningful use of EHRs will suffer a 1% reduction in Medicare pay in 2015. The penalty increases to 2% in 2016 and 3% in 2017 and beyond. Table 1: Recommended Changes to Timing FIRST PAYMENT YEAR 2011 (90 2012 2013 2014 REQUIREMENTS FOR EACH PAYMENT YEAR 2011 2012 2013 2014 2015 (90 (90 Stage 2 Stage 2 (90 Stage 2 (365 Stage 2 (365 Stage 2 (365 (90 PROPOSED STAGE 2 MEANINGFUL USE CRITERIA The charts below list the measures (and specialty exclusions) that eligible providers must demonstrate to become a Stage 2 meaningful user to qualify for Medicare or Medicaid incentives. EPs must report: 1.) All 17 of the Core Set Objectives and Measures Scope of Practice Exclusions has no relevance to the scope of the EPs practice. 2.) 3 out of 5 of the Set Objectives and Measures. 3.) A minimum of 12 Clinical Quality Measures (CQM) TBD - Quality measures are still not final, but in 2014 they will be submitted electronically to align with existing quality program measures, such as the Physician Quality Reporting System (PQRS) and the Medicare Shared Savings Program. The final list of quality measures will be published with the final rule. STAGE 2 MEANINGFUL USE 17 Core Measures + 3 Measures + 12 Clinical Quality Measures = Stage 2 Meaningful Use 2
The following are charts of Stage 2 meaningful use objectives that must be met, and applicable exclusions: CORE MEASURES IN STAGE 2 - SCOPE AND/OR THRESHOLD CHANGED (CHANGES FROM STAGE 1 UNDERLINED; **DENOTES NEW MEASURE) MEASURE STAGE 2 NPRM REQUIREMENT EXCLUSION 1 Use computerized physician order entry (CPOE) for medication orders 2 Generate and transmit permissible prescriptions electronically (e-rx) 3 Record patient demographics (preferred language, gender, race, ethnicity, date of birth) 4 Record and chart vital signs (height, weight, blood pressure) 5 Record smoking status for patients 13 years or older More than 60 percent of unique patients with a medication in their medication list have at least one medication order entered using CPOE [up from 30 percent] More than 65 percent of all permissible prescriptions written by the EP are compared to at least one drug formulary and transmitted electronically using Certified EHR. [up from 40 percent of medication orders] Technology. More than 80 percent of patients have demographics recorded and can use them to produce stratified quality reports [up from 50 percent and includes more granular categories] More than 80 percent of patients have vital signs recorded during the reporting year [up from 50 percent; BP age increased from 2 years to 3 years] More than 80 percent of unique patients over 13 years old have smoking status recorded as structured data [up from 50 percent] Any EP who writes fewer than 100 medication, laboratory, and radiology orders during the EHR reporting period. Any EP who writes fewer than 100 prescriptions during the EHR reporting period or does not have a pharmacy within their organization and there are no pharmacies that accept electronic prescriptions NA Any EP who-- (A) Sees no patients 3 years or older is excluded from recording blood pressure; (B) Believes that all three vital signs of height/length, weight, and blood pressure have no relevance to their scope of practice is excluded from recording them; (C) Believes that height/length and weight are relevant to their scope of practice, but blood pressure is not, is excluded from recording blood pressure; or (D) Believes that blood pressure is relevant to their scope of practice, but height/length and weight are not, is excluded from recording height/length and weight Any EP who sees no patients 13 years old or older. 3
6 Implement one clinical decision support rule Use clinical decision support to improve performance on highpriority health conditions [up from implement one rule] A. Implement five clinical decision support interventions related to five or more clinical quality measures, if applicable, at a relevant point in patient care for the entire EHR reporting period; B. The EP has enabled the functionality for drugdrug and drug-allergy interaction checks for the entire EHR reporting period. 7** Incorporate lab information as structured data 8 Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach. More than 55 percent of all clinical lab tests Any EP who orders no lab tests whose results ordered by the EP during the EHR results are either in a positive/negative reporting period whose results are either in or numeric format during the EHR a positive/negative or numerical format are incorporated in Certified EHR Technology as structured data. Generate at least one report listing patients of the EP with a specific condition. NA 9 Send reminders for preventive, follow-up care 10 percent of all unique patients who have had an office visit with the EP within the 24 months, per patient preference [threshold decreased from 20 percent to 10 percent, but scope expanded from patients 65 years or years or older or 5 years or younger to all active patients ] Any EP who has had no office visits in the 24 months before the beginning of the EHR 10 ** Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, allergies) upon request. 50 percent have access and 10 percent of patients have used the capability to access and download their information (available to the patient within 4 business days after the information is available to the EP). Any EP who neither orders nor creates any of the information listed for inclusion as part of this measure is excluded 11 Provide clinical summaries for patients for each office visit 50 percent of all visits within 24 hours (pending information, such as lab results, should be available to patients within 4 days of becoming available to EPs) [up from more than 50 percent of all visits within 3 business days ] Any EP who has no office visits during the EHR 4
12 Identify patient-specific education resources and provide those resources to the patient if appropriate More than 10 percent of patients are provided with EHR-enabled patient-specific educational resources [threshold unchanged but If appropriate removed] Any EP who has no office visits during the EHR 13 Perform medication reconciliation for a patient from another care setting or provider of care 14 Summary of care record transmitted between providers at transitions in care Medication reconciliation performed for more than 65 percent of transitions in care when the EP or hospital was the receiving provider [up from 50 percent] Required for 65% of care transitions [up from 50 percent]; must be electronic for 10% ( was one test) Any EP who was not the recipient of any transitions of care during the EHR Any EP who neither transfers a patient to another setting nor refers a patient to another provider during the EHR reporting period is excluded from both measures. 15 Submit electronic immunization Submit actual immunization data to at data to immunization registries or least one organization in accordance Immunization Information Systems with applicable law and practice [up from performing just a test; test or dummy data not permissible] 16 Conduct security analysis Conduct or review a security risk analysis, and implement security updates and correct identified security deficiencies. Attest that encryption/security functionalities for data at rest (which includes data located in data centers and also data in mobile devices) have been addressed. 17 ** Secure Messaging Patients are offered secure messaging online and at least 10 patients have been sent secure messages online. NA A. The EP does not administer any of the immunizations to any of the populations for which data is collected by the jurisdiction's immunization registry or immunization information system during the EHR B. The EP operates in a jurisdiction for which no immunization registry or immunization information system is capable of receiving electronic immunization data in the specific standards required for Certified EHR Technology at the start of their EHR reporting period. The EP operates in a jurisdiction Any EP who has no office visits during the EHR 5
MENU MEASURES IN STAGE 2 (**denotes a new measure) #1** MEASURE More than 40 percent of all scans and tests whose result is an image ordered by the EP during the EHR reporting period are accessible through Certified EHR Technology (New) EXCLUSION Any EP who does not perform diagnostic interpretation of scans or tests whose result is an image during the EHR #2** More than 20 percent of all unique patients seen by the EP during the EHR reporting period have a structured data entry for one or more first- degree relatives (New) Any EP who has no office visits during the EHR #3 #4** #5** Successful ongoing submission of electronic syndromic surveillance data from Certified EHR Technology to a public health agency for the entire EHR reporting period ( was a single test) Successful ongoing submission of cancer case information from Certified EHR Technology to a cancer registry for the entire EHR reporting period (New) Successful ongoing submission of specific case information from Certified EHR Technology to a specialized registry for the entire EHR reporting period (New) A. The EP is not in a category of providers who collect ambulatory syndromic surveillance information on their patients during the EHR B. The EP operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data in the specific standards required for Certified EHR Technology at the start of their EHR C. The EP operates in a jurisdiction for which no public health agency is capable of accepting the version of the standard that the EP's Certified EHR Technology can send at the start of their EHR A. Does not diagnose or directly treat cancer; or B. Operates in a jurisdiction for which no public health agency is capable of receiving electronic cancer case information in the specific standards required for Certified EHR Technology at the start of their EHR A. Does not diagnose or directly treat any disease associated with a specialized registry; or B. Operates in a jurisdiction for which no registry is capable of receiving electronic specific case information in the specific standards required under Stage 2 at the beginning of their EHR reporting CLINICAL QUALITY MEASURES IN STAGE 2 TBD 6