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ONC ponders idea of meaningful use Stage 4

Most health care workers know about meaningful use stages 1, 2 and 3, but policymakers might be thinking about meaningful use Stage 4.

A reference to meaningful use Stage 4 in the notice of proposed rulemaking for Stage 2 might have health care providers wondering about regulators' plans for adding more compliance mandates. Officials admit that adding a fourth stage to meaningful use is a possibility, but they are warning doctors not to start planning on it -- at least not yet.

Given that the HITECH Act doesn't provide specifics for executing a staged approach to the program and doesn't specify an end date, adding more meaningful use stages would be allowed under the law.

The idea of a Stage 4 for meaningful use emerged in the notice of Stage 2 proposed rulemaking. A table that outlines the time frame under which payment adjustment will be implemented is followed by this sentence: "If there will be a Stage 4 of meaningful use, we expect to update this table in the rulemaking for Stage 3."

A spokesperson for the Office of the National Coordinator for Health IT, or ONC, said this is not an indication that regulators are currently considering adding a fourth stage. Given that the HITECH Act doesn't provide specifics for executing a staged approach to the program and doesn't specify an end date, adding more meaningful use stages would be allowed under the law, he said.

The incentive portion of the meaningful use program must be completed by 2015, as specified by the HITECH Act, but the HHS secretary will have significant latitude in enforcing meaningful use rules beyond that. This could involve continued payment adjustments that are linked to new meaningful use stages. The secretary could decide to make regulations for avoiding payment adjustments more stringent over time.

If a new meaningful use stage is added, the Health IT Policy Committee could be ready with recommendations. The group is developing recommendations for Stage 3 now. It's holding on to policy recommendations that it feels could further the goals of the meaningful use program but that the health care industry might not be ready to comply with by 2016, said Dr. Paul Tang, vice chair of the committee.

Right now, the recommendations are categorized as Stage 4 "placeholders." This doesn't mean that the committee will formally recommend them should a fourth stage emerge, Tang said. The committee agreed to table the proposals until ONC decides a fourth round of rulemaking will be implemented.

More on meaningful use of EHR systems

See what's included in the proposed Stage 2 regulations

The HIT Policy Committee's thoughts on Stage 3 regulations

Read the latest news on the HITECH Act

Slides from a presentation delivered at an August 8 meeting of the ONC's Meaningful Use Workgroup listed some potential Stage 4 placeholders. One updates a Stage 2 rule for medication reconciliation, adding that eligible professionals must perform reconciliations of medication contraindications when they receive patients from other care settings. Other proposals would require that doctors be able to maintain interdisciplinary problem lists and to receive external "medication fill" histories to confirm that patients pick up their prescriptions.

All regulations under consideration for Stage 3 must fit within a set of predefined criteria, Tang said. Rules must support new coordinated models of care, address national health priorities, be broadly applicable, promote advancements that cannot be driven by market forces, be achievable by 2016 and be feasible. The rules being considered for Stage 3 that get bumped into the Stage 4 placeholder category are ones that don't meet one or more of these criteria. Most likely they are not seen as achievable or feasible by 2016, Tang said.

It still could be some time before regulators conclude whether further meaningful use stages will be necessary. The final Stage 2 rules are yet to be published, and advisory committees are only just starting to lay out proposals for Stage 3. Stage 4 talks won't come any time soon -- if at all.

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