Final Stage 2 rule offers delay, new measures

A timeline delay, new core measures and an electronic reporting mandate are the highlights of the meaningful use Stage 2 final rule, published Aug. 23 by the Centers for Medicare & Medicaid Services.

“The changes we’re announcing today will lead to more coordination of patient care, reduced medical errors, elimination of duplicate screenings and tests and greater patient engagement in their own care,” said Health and Human Services' (HHS) Secretary Kathleen Sebelius in a statement.

Although listed last in the rule's summary of major provisions, a delay in the Stage 2 timeline probably is the most important to eligible providers (EPs). In the Stage 1 final rule, CMS established that any provider who first attested to Stage 1 criteria in 2011 would begin using Stage 2 criteria in 2013. This final rule delays the onset of those Stage 2 criteria until 2014, “which we believe provides the needed time for vendors to develop certified EHR technology [CEHRT].”

For 2014 only, providers that are beyond the first year of demonstrating meaningful use (MU) will have a three-month quarter reporting period to allow up to nine additional months to upgrade certified EHR technology to the 2014 edition.

The agency also is introducing a special three-month EHR reporting period, rather than a full year of reporting, for providers attesting to either Stage 1 or Stage 2 in 2014. That reporting period is designed to “allow time for providers to implement newly certified CEHRT,” according to the rule. “In future years, providers who are not in their initial year of demonstrating meaningful use [MU] must meet criteria for 12-month reporting periods.”

“The three-month reporting period allows providers flexibility in their first year of meeting Stage 2 without warranting any delay for Stage 3.” CMS is committed to keeping implementation of Stage 3 on schedule, the rule also said. The schedule calls for implementation by 2016.

The CMS final rule also provides a flexible reporting period for 2014 to give providers sufficient time to adopt or upgrade to the latest EHR technology certified for 2014.

According to the final rule, EHRs must support display of image results, which could be accomplished via a single sign on link to a PACS. "Image results. Electronically indicate to a user the availability of a patient’s images and narrative interpretations (relating to the radiographic or other diagnostic test[s]) and enable electronic access to such images and narrative interpretations," the document read.

Nearly all of the Stage 1 core and menu objectives included in the proposed rule are being finalized for Stage 2. The test of “exchange of key clinical information” core objective from Stage 1 is eliminated in favor of a more robust “transitions of care” core objective in Stage 2; and the “Provide patients with an electronic copy of their health information” objective is also eliminated because it was replaced by the “electronic/online access” core objective.

The final rule adds “outpatient lab reporting” to the menu for hospitals and “recording clinical notes” as a menu objective for both eligible professionals (EPs) and hospitals. There will be 20 measures for EPs (17 core and 3 of 6 menu) and 19 measures for eligible hospitals and CAHs (16 core and 3 of 6 menu).

CMS finalized two new objectives in the core measures: Use of secure electronic messaging to communicate with patients on relevant health information and automatic tracking of medications from order to administration using assistive technologies in conjunction with an electronic medication administration record (eMAR).

CMS finalized the ability to use a batch reporting process for meaningful use, which will allow groups to submit attestation information for all of their individual EPs in one file.

CMS proposed two new core objectives (providing patients online access to health information; secure messaging between patient and provider) with measures that require patients to take specific actions in order for a provider to achieve meaningful use and receive an EHR incentive payment. In response to comments expressing concern about meeting those objectives, CMS lowered the threshold from 10 percent of patients to 5 percent for both measures.

“In addition, CMS is introducing exclusions based on availability of broadband in a provider’s practice area,” according to its fact sheet. “CMS believes that the patient utilization thresholds are achievable and that the ability to access clinical information electronically promotes patient engagement.”

Rather than the ambitious measures proposed surrounding electronic exchange of summary of care documents, CMS is requiring providers to send a summary of care record for 50 percent of its patients rather than more than 65 percent. And, CMS finalized its requirement that providers electronically transmit a summary of care for more than 10 percent of transitions of care and referrals, but eliminated the requirement that the summary of care be electronically sent to a provider with no organizational or vendor affiliation. Instead, CMS is requiring at least one instance of exchange with a provider using EHR technology designed by a different EHR vendor or with a CMS-designated test EHR.

The rule includes lab reporting for hospitals as a menu objective, which gives hospitals the flexibility to select other objectives for meeting MU and receiving the incentive payment.

CMS has modified the regulations on “hospital based” so that EPs who can demonstrate that they fund the acquisitions, implementation and maintenance of CEHRT, including supporting hardware and interfaces needed for MU without reimbursement from an eligible hospital or CAH —and use such CEHRT at a hospital, in lieu of using the hospital’s CEHRT—can be determined non-hospital based and receive an incentive payment. Determination will be made through an application process.

The rule finalized that:

• EPs must report on 9 out of 64 total clinical quality measures (CQMs); and
• Eligible hospitals and CAHs must report on 16 out of 29 total CQMs.

In addition, all providers must select CQMs from at least 3 of the 6 key healthcare policy domains from the HHS’ National Quality Strategy:

• Patient and Family Engagement
• Patient Safety
• Care Coordination
• Population and Public Health
• Efficient Use of Healthcare Resources
• Clinical Processes/Effectiveness

The rule finalizes that, beginning in 2014, all Medicare providers that are beyond the first year of demonstrating meaningful use must electronically report their CQM data to CMS. (Medicaid EPs and hospitals that are eligible only for the Medicaid EHR Incentive Program will report their CQM data to their state.) EPs can electronically report CQMs either individually or as a group use the Physician Quality Reporting System or the CMS Portal.