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November 19, 2012

Meaningful Use — The Next Go-Round
By Robert J. Murphy
For The Record
Vol. 24 No. 21 P. 22

The stage is set for healthcare organizations to earn their keep in version two of the watershed rule.

In August, the Centers for Medicare & Medicaid Services (CMS) released its final rule for stage 2 of meaningful use. The rule specifies the criteria that eligible professionals, eligible hospitals, and critical access hospitals must meet to participate in the EHR incentive program.

In a nutshell, the CMS’ intent is to expand the meaningful use of certified EHRs as part of a broader effort to build the kind of HIT infrastructure necessary to improve patient care and enhance efficiency. The stage 2 rule expands on stage 1 with numerous measures believed to advance these goals and encourage greater participation from practitioners and hospitals.

An earlier iteration of the stage 2 rule underwent modest changes on the path to the final rule. It’s worth reviewing the stipulations of the final stage 2 rule and examining how it differs from stage 1 as well as the earlier proposed stage 2 rule.

Meaningful Use Objectives
Perhaps the first step for healthcare organizations is to get a handle on the new rule’s deadlines and milestones. The CMS’ original timeline for stage 1 established a schedule that would have required Medicare providers that first demonstrated meaningful use in 2011 to meet the stage 2 criteria in 2013.

Stage 2 gives providers a little more leeway to meet its criteria. Those who attested to stage 1 in 2011 may now attest to stage 2 in 2014. At the very least, this takes some pressure off providers scrambling to attest to stage 2 by next year.

Looking at the actual meaningful use objectives, stage 2 largely subsumes those of stage 1 while adding a few more. And there are some changes compared with stage 1. For example, the core objective from stage 1 calling for the “exchange of key clinical information” has been replaced by what is thought to be a more robust “transitions of care” core objective in stage 2.

What’s more, the final stage 2 rule adds outpatient lab reporting to the menu for hospitals and recording clinical notes as a menu option for both eligible providers and eligible hospitals. (As the terms suggest, a core objective is mandatory, while providers and hospitals may choose a certain number of menu items to fulfill the requirement.)

Altogether, the final stage 2 rule stipulates 20 measures for eligible professionals (17 core measures and three menu options) and 19 measures for eligible hospitals and critical access hospitals (16 core measures and three menu options).

Among the most significant features of the stage 2 final rule are the following:

Two new core objectives: One, which is meant for eligible professionals, stipulates that practitioners must use secure electronic messaging to communicate with patients about pertinent health information. The other new core objective, which pertains to eligible hospitals and critical access hospitals, requires these entities to automatically track medications from order to administration.

“The bottom line is that the majority of the changes happened on one specific part of the proposed rulemaking: clinical core measures,” says Anand Shroff, chief technology and product officer at Health Fidelity, a company focused on unlocking the value of unstructured clinical data.

Group reporting: This component looks to make reporting easier for individual practitioners in a group practice by permitting group practices to submit attestation data for all their doctors in a single file.

Patient engagement: These objectives are based on the need for patients to play a greater role in their own care. One provides patients with online access to their health information, while the other calls for secure messaging between patients and providers. The initial threshold for both objectives was 10% of a practice’s patients, but providers objected. After taking the complaints into consideration, the CMS has reduced the threshold to 5%.

“This [objective] is pretty fascinating because that means hospitals and providers must put that information out there, but then patients have to actually do something with it,” says Timothy Kelly, vice president of marketing at Dialog Medical, a patient education software vendor.

The CMS also included exclusions for this objective based on a provider’s access to broadband Internet. All the same, the CMS considers these objectives achievable and believes that electronic access to clinical information will promote patient engagement.

Electronic exchange of summary-of-care documents: The CMS initially proposed two ambitious measures for this objective in stage 2. One required that providers send a summary-of-care record for more than 65% of care and referral transitions. However, in the final rule, the threshold was reduced to 50%.

A second measure stipulated that providers electronically transmit a summary of care for more than 10% of care and referral transitions and that it be sent electronically to a provider with no affiliation with an organization or vendor. The intent here is to promote electronic exchange outside established vendor or organization networks. Eventually, the CMS plans to eliminate the organizational and vendor limitations.

Clinical Quality Measures
The core and menu objectives for stage 2 may be further delineated into so-called clinical quality measures. Key areas to examine include the measures themselves and the requirements that have been established to report the clinical quality measures to the CMS. As with the core objectives, providers and hospitals must adhere to a selection of menu items.

Overall, the final rule states that eligible providers must report on nine of 64 clinical quality measures, while eligible hospitals and critical access hospitals are required to report on 16 of 29 total clinical quality measures.

Requirements extend further. All providers must select from three of six healthcare policy domains from Health and Human Services’ National Quality Survey: patient and family engagement, patient safety, care coordination, population and public health, efficient use of healthcare resources, and clinical processes/effectiveness.

Data Reporting
It’s one thing to capture and aggregate massive amounts of clinical data. It’s quite another to arrange to transmit this data to the CMS and other interested parties.

“You’re going to have to have electronic health records that can send these reports directly to a receptive technology at CMS,” says Karen Bell, chair of the Certification Commission for Health Information Technology. “And they’re actually going to be piloting that in the coming year, but it will be mandatory in 2014.”

The final rule for stage 2 demands that, beginning in 2014, Medicare providers beyond one year of demonstrating meaningful use must report their clinical quality measures electronically to the CMS. Eligible practitioners can report these measures in one of two ways: through the Physician Quality Reporting System for patient data or the CMS portal to submit aggregate data.

Medicare Payment Cuts
With the duplicity of the most seasoned politicians, the CMS refers to its proposed reimbursement reductions as Medicare payment “adjustments.” However they are presented, the reductions will take effect in 2015.

The final stage 2 rule devises a process in which payment reductions will be determined by an EHR reporting period prior to 2015. Eligible practitioners and hospitals that demonstrate meaningful use by 2013 will avoid payment reductions in 2015. Not only that, providers that exhibit meaningful use in 2014 will avoid the penalty if they register and attest to meaningful use by July 1, 2014.

Hardship Exceptions
The CMS established a set of so-called hardship exceptions that give rise to exclusions from certain obligations. One has to do with infrastructure. This means providers must verify that they’re in an area lacking sufficient Internet access or otherwise facing insurmountable barriers to obtaining infrastructure.

Another circumstance considered a hardship is being a new practitioner. The rule sets aside a two-year exemption for these newcomers to get up to speed. It stands to reason they would not have had time to implement an EHR while adapting to a new practice.

Then there’s unforeseen circumstances, the all-purpose grab bag of mishaps and misfortunes, including natural disasters.

A final exemption to at least part of the meaningful use law concerns scope of practice. Maybe a practice does not conduct face-to-face or telemedicine interaction. Any number of factors may prevent patient follow-up. There’s also a break for multiple-location physician practices in which there’s a question of who controls the practice’s EHR.

The Rule’s Ramifications
Clearly, the medical and hospital lobbies pushed back against earlier stage 2 proposals considered unfavorable to their interests. As a result, some regard the final rule to be watered down. Yet anyone who wants this initiative to move forward must recognize that in politics, perfect is the enemy of good.

Prominent medical and industry associations have voiced objections. “Not surprisingly, the biggest nonsupporter of the announcement is coming from the [American Medical Association] because physicians in particular are unfairly burdened by decreasing reimbursements, increasing costs, meeting ICD-10 compliance, accountable care, and other pressures from all the changes in the healthcare industry,” says Fred Pennic, founder of HIT Consultant.

While Pennic finds plenty to like about the final rule for stage 2 meaningful use, he also has his criticisms. One has to do with disruptive workflow changes. Another is what he considers the complicated reporting of clinical quality measures. Pennic also envisions challenges in meeting the requirements for patients to view and download their clinical information, not to mention transmitting summary-of-care records in the event of a transition in care. Finally, he believes some physicians find certain measures are beyond their control.

Pennic’s not the only industry expert who finds fault with an aspect of stage 2. “I am not happy about the approach that the EHR companies are taking toward it, which is making doctors’ lives harder,” Shroff says. “That is not the intent of the ruling. The intent of the law is to make sure providers capture critical information that would improve the quality of care and perhaps, in some cases, reduce costs. The intent was never to double or triple the visit time so that the provider revenue goes down.”

Lipstick on a Pig
It may be the case that the ultimate aims—to improve patient care and reduce costs—of recent healthcare initiatives extend to such a wide community that policy makers and politicians obtain merely a blinkered view of the whole scene. The abiding belief is that the meaningful use program offers widespread and long-term benefits.

“I think we’ll look back on this as something [about which] we will be extremely pleased that we made this investment at this time,” Kelly says.

— Robert J. Murphy is a freelance medical journalist in Philadelphia.