On March 20, 2015, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule for implementing Stage 3 of the Medicare and Medicaid Electronic Health Record Incentive Programs (the Meaningful Use Program). Overall, in Stage 3 CMS intends to simplify reporting requirements, reduce program complexity, focus on advanced use of electronic health record (EHR) technology, and align the Meaningful Use Program quality reporting with other CMS quality reporting programs that use certified electronic health record technology (CEHRT).
To reduce complexity, CMS proposes to replace the "core" and "menu set" objectives used in Stages 1 and 2 with a single set of meaningful use objectives and associated measures to which eligible professionals (EPs), eligible hospitals (EHs), and critical access hospitals (CAHs) must attest, starting no later than 2018, in order to receive Medicaid incentive payments and to avoid Medicare downward payment adjustments under the Meaningful Use Program. (As a reminder, Medicare incentive payments end in 2016, and Medicaid providers are not subject to payment adjustments under the Meaningful Use Program.)
Notably, the thresholds for the proposed Stage 3 objectives and measures are significantly higher than those required for Stage 2 attestations, reflecting CMS' expectation that providers will be engaging in more sophisticated uses of EHR technology by 2018. As CMS seeks public comment on a wide range of proposed Stage 3 features, and because comments submitted will form the basis for the final Stage 3 rule, the extent to which each of the proposed simplifications and heightened thresholds will be enacted remains to be seen.
Specific features of the Stage 3 proposed rule include the following:
- Attesting to Stage 3 objectives and measures will be optional for all providers in 2017 but mandatory for all providers in 2018 and thereafter. In other words, beginning in calendar year 2018, all providers will be participating in Stage 3, regardless of their stage in 2017.
- To meet Stage 3, CMS will require all providers (except Medicaid providers in their first year of demonstrating meaningful use) to report on a calendar year EHR reporting period beginning in 2017. Such annual reporting will align with other CMS quality reporting programs.
- Medicaid EPs and EHs that demonstrate meaningful use for the first time in 2017 or thereafter would have to attest for an EHR reporting period of any continuous 90-day period in the calendar year in order to receive an incentive and to avoid subsequent payment adjustments under the Medicare program. Except for these two categories of providers, CMS proposes to eliminate the 90-day EHR reporting period for new meaningful EHR users beginning in 2017 and instead require a full-year reporting period in 2017.
- In addition, starting in 2018, all providers will be required to use EHR technology that is certified to ONC's 2015 Edition of Health Information Technology Certification Criteria ("2015 Edition") for a full calendar year. Use of the 2015 Edition in 2017 is optional.
- To attest to Stage 3—whether in 2017, 2018, or thereafter—all providers must use CEHRT that is certified to the 2015 Edition.
- In Stage 3, CMS will "retire" objectives and measures that are redundant or duplicative or that have been "topped-out" (measures that are no longer useful in gauging provider performance because they are so widespread).
- Providers will no longer be permitted to include paper-based formats or take manual actions to meet certain objectives and measures.
- Providers in states that permit electronic prescribing of controlled substances may now include prescriptions for controlled substances in the measures to meet the electronic prescribing objective.
- Providers may include patient-authorized representatives in the numerators in the Coordination of Care through Patient Engagement and Patient Electronic Access objectives.
- Providers may engage with patients using application program interfaces (APIs), which are programming protocols which providers can enable to offer patients access to their health information through third-party applications. Such third-party applications offer more flexibility than many patient portals; in fact, some permit individuals to access portions of their health information directly from the provider's CEHRT. As with patient portals, however, CMS is proposing that providers may not charge patients a fee for using an API.
- Clinical quality measure (CQM) reporting periods for Stage 3 will be aligned with other Stage 3 reporting requirements noted above (including the exception for Medicaid providers demonstrating meaningful use for the first time).
- In 2017, providers may either electronically submit CQM data or attest to CQMs, but electronic submission will be required in 2018 and thereafter unless electronic reporting is not feasible.
- Future rulemaking for CQMs for EPs will be included in the Medicare Physician Fee Schedule rulemakings, and future rulemaking for CQMs for EHs and CAHs will be included within the Inpatient Prospective Payment System framework.
- Starting in 2015, states will be required to report quarterly to CMS information about each Medicaid provider that has successfully attested in a payment year, whether or not the provider has been paid for that payment year.
- Although CMS expects Stage 3 to be the final stage of the Meaningful Use Program framework, it acknowledges that it may address changes in technology and clinical care standards in future rulemaking.
Stage 3 Proposed Objectives and Measures
Stage 3 focuses on the advanced use of EHR technology in order to promote improved patient outcomes and health information exchange. To achieve these aims, CMS proposes the following eight main objectives (and their associated measures) for Stage 3 attestation in 2017 and subsequent years. These objectives combine objectives and measures from earlier stages of the Meaningful Use Program. For Objectives 6 and 7, CMS proposes to require providers to attest to results for numerators and denominators of all measures associated with the objectives, but providers would only need to meet the percentage thresholds for two of the three measures. If providers are unable to meet a particular measure, they must qualify for one of a variety of exclusions for that measure.
Objective 1. Protect Patient Health Information – Protect ePHI created or maintained by CEHRT through implementation of appropriate technical, administrative, and physical safeguards.
Measure: Conduct or review a security risk analysis, including addressing the security (including encryption) of data stored in CEHRT, implement security updates as needed, and correct identified security deficiencies as part of the risk management process.
Objective 2. Electronic Prescribing – EPs must generate and transmit permissible prescriptions electronically, and EHs and CAHs must generate and transmit permissible discharge prescriptions electronically.
Measure (EP): More than 80% of all permissible prescriptions written by the EP are queried for a drug formulary and transmitted electronically using CEHRT.
Measure (EH/CAH): 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.
Objective 3. Clinical Decision Support – Implement clinical decision support (CDS) interventions focused on improving performance on high-priority health conditions.
Measure 1: Implement five CDS interventions related to four or more CQMs at a relevant point in patient care for the entire EHR reporting period. Absent four CQMs related to an EP, EH, or CAH's scope of practice or patient population, the CDS interventions must be related to high-priority health conditions.
Measure 2: The EP, EH, or CAH has enabled and implemented the functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period.
Objective 4. Computerized Provider Order Entry – Use Computerized Provider Order Entry (CPOE) for medication, laboratory, and diagnostic imaging orders directly entered by a licensed healthcare professional, credentialed medical assistant, or a medical staff member credentialed to and performing the equivalent duties of a credentialed medical assistant who can enter orders into the medical record per state, local, and professional guidelines.
Measure 1: More than 80% of medication orders created by the EP or authorized providers of the EH's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using CPOE;
Measure 2: More than 60% of laboratory orders created by the EP or authorized providers of the EH's or CAH's inpatient or emergency department during the EHR reporting period are recorded using CPOE; and
Measure 3: More than 60% of diagnostic imaging orders created by the EP or authorized providers of the EH's or CAH's inpatient or emergency department during the EHR reporting period are recorded using CPOE.
Objective 5. Patient Electronic Access to Health Information – The EP, EH, or CAH provides access for patients to view online, download, and transmit their health information, or retrieve their health information through an API, within 24 hours of its availability.
Measure 1: For more than 80% of all unique patients seen by the EP or discharged from the EH or CAH inpatient or emergency department:
(i) The patient or authorized representative is provided access to view online, download, and transmit health information within 24 hours of its availability to the provider; or
(ii) The patient or authorized representative is provided access to an ONC-certified API that can be used by third-party applications or devices to provide patients or their representatives access to health information within 24 hours of its availability to the provider.
Measure 2: The EP, EH or CAH 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 EH or CAH inpatient or emergency department during the EHR reporting period.
Objective 6. Coordination of Care through Patient Engagement – Use communications functions of CEHRT to engage with patients or authorized representatives about the patient's care.
Measure 1: During the EHR reporting period, more than 25% of all unique patients seen by the EP or discharged from the EH or CAH inpatient or emergency department actively engage with the electronic health record made accessible by the provider. An EP, EH, or CAH may meet the measure by either:
(i) More than 25% of all unique patients (or their authorized representatives) seen by the EP or discharged from the EH or CAH inpatient or emergency department during the EHR reporting period view, download, or transmit to a third party their health information; or (ii) More than 25% of all unique patients (or their authorized representatives) seen by the EP or discharged from the EH or CAH 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.
Measure 2: For more than 35% of all unique patients seen by the EP or discharged from the EH or CAH 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 authorized representatives), or in response to a secure message sent by the patient (or authorized representative.
Measure 3: Patient-generated health data or data from a non-clinical setting is incorporated into the CEHRT for more than 15% of all unique patients seen by the EP or discharged by the EH or CAH inpatient or emergency department during the EHR reporting period.
Objective 7. Health Information Exchange – The EP, EH, or CAH provides a summary of care record when transitioning or referring their patient to another setting of care, retrieves a summary of care record upon the first patient encounter with a new patient, and incorporates summary of care information from other providers into their EHR using the functions of CEHRT.
Measure 1: For more than 50% of transitions of care and referrals, the EP, EH, or CAH 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.
Measure 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, EH, or CAH incorporates into the patient's EHR an electronic summary of care document from a source other than the provider's EHR system.
Measure 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, EH, or CAH performs a clinical information reconciliation.
Objective 8. Public Health and Clinical Data Registry Reporting – The EP, EH, or CAH is in active engagement with a public health agency or clinical data registry to submit electronic public health data in a meaningful way using CEHRT, except where prohibited, and in accordance with applicable law and practice. "Active engagement" may be met by (1) completing registration to submit data to the agency or registry, (2) testing and validating the electronic submission of data, or (3) electronically submitting production data to the agency or registry.
Measure 1: Immunization Registry Reporting – The EP, EH, or CAH 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.
Measure 2: Syndromic Surveillance Reporting – The EP, EH, or CAH 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 EHs and CAHs (POS 23).
Measure 3: Case Reporting – The EP, EH, or CAH is in active engagement with a public health agency to submit case reporting of reportable conditions.
Measure 4: Public Health Registry Reporting - The EP, EH, or CAH is in active engagement with a public health agency to submit data to public health registries.
Measure 5: Clinical Data Registry Reporting - The EP, EH, or CAH is in active engagement to submit data to a clinical data registry.
Measure 6: Electronic Reportable Laboratory Result Reporting – The EH or CAH is in active engagement with a public health agency to submit electronic reportable laboratory results.
Of the six possible measures for Objective 8, EPs would be required to choose from measures 1 through 5 and would have to successfully attest to any combination of three measures, whereas EHs and CAHs would have to choose from measures 1 through 6 and would have to successfully attest to any combination of four measures (which could include, for example, reporting to four different clinical data registries).
CMS estimates that between 2017 and 2020, the total cost to the federal government of the Meaningful Use Program will be $3.7 billion. Consistent with its past practice of substantially underestimating the time and financial resources required to comply with the administrative requirements of its regulations, CMS forecasts that it will take individual EHs, CAHs, and EPs a total of six hours and 52 minutes annually to attest to Stage 3 and to submit CQMs, and it calculates the total cost of such attestations and CQM submissions for all EHs and CAHs nationwide as $2,135,204 and for all EPs nationwide as $385,834,395.
The proposed rule will be published in the Federal Register on March 30, and comments on the proposed rule are due no later than May 29, 2015. CMS responds to comments in its final rulemakings and often notes, in finalizing features suggested in proposed rules, that it received no comments on those features. Accordingly, interested providers should consider submitting comments on areas of concern in the proposed rule.