Meaningful use stage 2 dropped late in the summer, as the ONC and CMS officials released final rules, respectively, for vendors to tailor electronic health record systems for certification, and for health care providers to reap Medicaid and Medicare incentive checks for implementation of those systems.
The big message here is the push on standards-based exchange and interoperability.
Farzad Mostashari, M.D.,
national HIT coordinator
The final rules came loaded with answers from stakeholder comments collected since the proposed rule debuted earlier this year, with many adjustments made for the benefit of specialist physicians. Another highlight: Compliance includes encryption of HIPAA-protected data at rest.
The Centers for Medicaid and Medicare Services (CMS) rule also extends deadlines for stage 2 attestation for 2011's early adopters. Originally, the hospitals that have already been through stage 1 would have had to attest in 2013, but that's been extended to 2014. This means eligible professionals (EPs) and hospitals will have to complete their 90-day reporting period in that year. (This chart explains the full compliance schedule.)
The reasoning behind that extension not only was to give relief to providers, but also to give software vendors more time to meet certification criteria, according to representatives from CMS and the Office of the National Coordinator for Health Information Technology (ONC) in a conference call with reporters. The meaningful use rule, too, adds that commenters sought relief because its deadlines came on top of ICD-10 implementation schedules and health care reform implementation deadlines, too.
"The changes that you see [in the final rules] reflect that we are listening," said Farzad Mostashari, M.D., national HIT coordinator.
He added that the new criteria are a shift in focus for the health IT field. Stage 1 pushed clinical data collection and bare-bones clinical decision support, while meaningful use stage 2 focuses more on sharing patient data between providers, with public health agencies and with patients themselves.
That includes getting vendors in on the act and writing features into their software to enable secure, standardized data exchange via the Web. That standardization took efforts from volunteers across the health care sector to consolidate hundreds -- and even thousands -- of ways to represent certain data sets, such as lab results and medication lists. "The big message here is the push on standards-based exchange and interoperability," Mostashari said.
6,100 stakeholder comments draw answers, clarifications
On the provider side, CMS has paid more than $6.6 billion in electronic health record (EHR) incentives to about 128,000 eligible professionals and 3,600 hospitals. Along the way to attesting to stage 1 meaningful use, providers pointed out problems and inconveniences in the process that CMS addressed in stage 2. Examples from the 672-page stage 2 document include:
- Batch processing for physician groups to submit attestation information all at once, instead of one by one as stage 1 required -- which some physician groups claimed was onerous.
- Edits to stage 1 requirements to harmonize them with exceptions/alternative compliance methods written into stage 2. For instance, there's a new exclusion to the e-prescribing meaningful use objective for providers who neither operate a pharmacy within their organization nor have one within 10 miles accepting electronic prescriptions at the start of his/her reporting period. Since stage 2 doesn't introduce the rule -- instead it expands stage 1's threshold from 40% to 50% -- CMS needed to change the original stage 1 rule as well. If they hadn't, as the commenters put it, "it would create a strange scenario where an EP might have to electronically prescribe during their 2 years of stage 1 and then meet an exclusion in stage 2."
- Adjusting thresholds of compliance. Using computerized provider order entry (CPOE) systems for lab and radiology orders is new to stage 2, but the proposed rule requires these new items to be at the 60% threshold just like medication orders, which debuted in stage 1 at 30%. Reflecting on stakeholder comments, CMS lowered lab and radiology CPOE requirements to 30% each.
Specialists accommodated in meaningful use stage 2
Specialty physicians sometimes have a difficult time complying with meaningful use, which has been described as "primary care centric." Rob Anthony, Office of E-Health Standards and Services health insurance specialist, said stage 2 meaningful use accommodates specialists by adjusting objectives that would create hardships for compliance.
For example, surgeons and psychiatrists will be able to adjust for the controlled substances they prescribe electronically. Since controlled substances can't count toward meaningful use e-prescribing thresholds, those prescriptions won't count toward the physician's total (the denominator) and therefore will no longer skew reporting during the attestation process to make it appear as if a smaller percentage of patients' meds were prescribed electronically.
Moreover, Anthony continued, "We did introduce some hardship exclusions specifically for payment adjustments [penalties for providers who aren't meaningful use compliant] in regard to certain specialties that we knew would have particular challenges – and that we heard from the public have had very difficult hurdles to get over for meaningful use – and [those] specifically [are] in [areas] of pathology, anesthesiology and radiology."
Mostashari also said regulators added optional "menu" meaningful use compliance objectives that cater to specialties based on feedback from specialist physicians in the period between the release of stages 1 and 2. These include reporting data to cancer registries or professional society registries, image viewing and collecting family health history.
Along the same lines, the rules now accommodate rural providers who have difficulties obtaining Internet access, a hardship that would make transmitting patient summary of care documents, e-prescribing data, public health reports and other mandates difficult. They may request one-year exceptions from penalties for up to five years, which CMS will review on a case-by-case basis. The agency also added an "extreme circumstances" exception for providers who experience compliance barriers through no fault of their own, such as hospital shutdowns, their EHR vendors going out of business, or natural disasters that knock out the EHR system during a reporting period.
"This really represents the culmination of a two-year-long process of laying out the next step in that escalator, that roadmap that is taking us from paper to a modernized health care system that really meets the promise of improving quality, safety, efficiency and care coordination," Mostashari said.
More information -- including the complete text of both the CMS and ONC final rules -- can be obtained at the HealthIT.gov meaningful use stage 2 page. Also, Mostashari's Twitter account, @Farzad_ONC, featured a steady stream of stage 2 snippets – including the ideas he liked that didn't make it into the final rule.