EHR standards get
tougher under finalized meaningful use stage 2
Federal officials soften some proposed requirements and
officially delay the deadline to upgrade to the next electronic health record
phase, but doctors wanted more leeway.
Washington
Starting as early as 2014, physician practices will be required to achieve more
difficult objectives to demonstrate meaningful use of electronic health records
to earn federal bonuses and prevent future penalties.
The Centers for Medicare & Medicaid Services finalized
its requirements for stage 2 of the EHR incentive program in an Aug. 23
regulation. The final rule mandates that doctors meet a larger number of core
objectives — and stricter guidelines for some of those objectives already in
place — during the next part of the three-stage program. Physicians also must
adopt and demonstrate meaningful use of EHR systems by Oct. 1, 2014, or be
assessed a 1% penalty from Medicare.
Doctors who successfully adopt early enough can earn up to $44,000 over five
years from Medicare, or up to $63,750 over six years from Medicaid.
Demonstrating meaningful use of a paperless record will become required
annually to prevent penalties that will take effect starting in 2015. CMS
reports that about 55,000 physicians had earned Medicare incentives through
June 2012 under the less-stringent stage 1. Slightly more than 34,000 had
earned Medicaid bonuses.
Several organizations representing physicians and other participants have
urged CMS to design the program to be more flexible so it encourages even
greater EHR use. Organized medicine groups, including the American Medical
Association, had called for the administration to soften the stage 2 meaningful
use requirements that it outlined in a proposed rule issued in February.
The AMA “has provided ongoing input since the inception of
the EHR incentive program and has urged greater flexibility to make the program
more reasonable and achievable for physicians,” said AMA Board Chair Steven J.
Stack, MD. “In a comment letter submitted by the AMA and 100 state and
specialty medical societies in May, recommendations were outlined to eliminate
physician roadblocks and encourage greater physician participation.”
The Association and the other societies that signed onto the comment letter
were reviewing the final rule, Dr. Stack said. He said he hoped the review
would find changes that promote adoption and meaningful use of EHRs by
physicians.
Stages 1 and 2 each require meeting 20 total objectives, but stage 2 makes
mandatory some EHR measures that are optional for stage 1, such as whether the
electronic systems can incorporate clinical laboratory test results. Other
measures stay the same but have higher thresholds, such as a requirement that
EHRs send more than 50% of applicable prescriptions electronically, up from
more than 40%. The number of required core set measures goes up to 17 in stage
2 from 15 in stage 1. Physicians also must choose and comply with three out of
six additional “menu” set measures, as well as report at least nine clinical
quality measures.
Some additional time
granted
The effective date of stage 2 has been one of the most
contentious issues for the program. After physicians and others complained that
early adopters of paperless systems would be forced to meet the more stringent
requirements sooner than those who waited a year, the White House floated a
plan in late 2011 to set the earliest possible stage 2 deadline for doctors to
2014 instead of 2013. The final rule released in August makes that delay official.
Physicians who earned EHR bonuses in 2011 and 2012 would be
required to meet stage 2 requirements starting in 2014. Doctors who start
achieving meaningful use in 2013 or later would report under stage 1 rules for
two years before moving onto stage 2, regardless of whether they incur any
noncompliance penalties for being late adopters. Despite the effective delay
for early adopters to 2014, a significant majority of comments on the proposed
version of the rule said that deadline still was too aggressive. “Some
commenters suggested that the time was insufficient regardless of resource
constraints, while others suggested that currently vendors of [EHR systems]
lack the necessary capacity to make the necessary upgrades to their products
and implement them for their customers in time,” CMS acknowledged in the final
rule.
The physician organizations specifically asked that CMS
delay the start of stage 2 until 2015. The agency rejected the request, saying
it “would have a ripple effect through the timeline of stages.” However, CMS
did give physicians some more time to make the necessary changes to their
systems by requiring only a three-month reporting period in 2014, meaning EHRs
would not necessarily need to be upgraded by the start of the year.
Reporting periods for meaningful use will be three months
long regardless of what stage an eligible professional is following, said Rob
Anthony, a health specialist with the CMS Office of E-Health Standards and
Services, during an Aug. 24 seminar. Also beginning in 2014, a physician group
can submit a meaningful use attestation for all of its eligible professionals
in one file, saving the practice from entering each individual’s information
separately.
Demonstrating meaningful use during stage 2 will rely on
patients interacting with physicians and EHR systems online. For instance, CMS
had proposed that eligible physicians send a secure EHR-based message to at
least 10% of unique patients. Another proposed measure directed doctors to
provide half of their patients with the ability to view online information
about their care and ensure that a minimum of 10% did so.
Many commenters objected to these measures, because
physicians would be held accountable for patient inaction on a measure. The AMA
and other medical societies recommended the patient measures be made optional,
but CMS did not follow the advice.
“While we recognize that [eligible professionals] cannot
directly control whether patients use electronic messaging, we continue to
believe that [eligible professionals] are in a unique position to strongly
influence the technologies patients use to improve their own care, including
secure electronic messaging,” CMS said. The agency did, however, reduce the
reporting thresholds for those measures from 10% to 5% in the final rule. CMS
also will exclude physicians from the requirements when they practice in areas
without sufficient Internet access.
Some organizations reviewing the final rule lauded the
agency for including some additional flexibility for incentive program
participants.
“Extending the start for stage 2 until 2014 was a necessary
step to permit medical groups sufficient time to implement new software,” said
Susan Turney, MD, president and CEO of the MGMA-ACMPE, the entity formed by the
merger of the Medical Group Management Assn. and the American College of
Medical Practice Executives. “Permitting group reporting will reduce
administrative burden, as will lowering the thresholds for achieving certain
measures such as mandatory online access and electronic exchange of summary of
care documents.”
Doctors can seek
penalty exemptions
Agency officials carved out several hardship exceptions to
the noncompliance penalties, and some will require the reporting physician to
complete an application prior to the penalty’s assessment. The exemptions are
available for physicians who:
* Have
insufficient Internet access for any 90-day continuous period between Jan. 1,
2013, and July 1, 2014.
* Are new to
Medicare.
* Encounter
extreme circumstances outside the physicians’ control, such as practices
closing, natural disasters, EHR vendors going out of business and similar
scenarios.
* Practice in
multiple locations and have a lack of control over the availability of EHR
systems.
* Have a lack of
face-to-face visits or other patient interactions, or the need to provide
follow-up care.
In 2014, CMS also will align reporting for the clinical
quality measures component of meaningful use with the Medicare physician
quality reporting system so doctors are not facing two different reporting
standards. PQRS, a separate program from the EHR initiative, will penalize
physicians starting in 2015 for not reporting certain quality measures to the
government.
ADDITIONAL
INFORMATION:
What EHR upgrades
will be required?
Stage 2 of the federal electronic health record initiative
will include 17 core measures and six additional “menu” objectives, from which
a physician would choose at least three. Doctors must use their EHR systems to
meet requirements for at least 20 measures, including all 17 in the core set.
Core set
* Use computerized
physician order entry (more than 60% medication, 30% lab and 30% radiology
orders)
* Prescribe
permissible drugs electronically (more than 50%)
* Record patient
demographics (more than 80%)
* Record and chart
changes in vital signs (more than 80%)
* Record smoking
status (more than 80%)
* Use clinical
decision support (at least five interventions)
* Incorporate
clinical lab results into EHR (more than 55%)
* Generate lists
of patients by specific conditions (at least one list)
* Identify
patients who need reminders for preventive or follow-up care (more than 10%)
* Provide at least
half of patients with access to health information (more than 5% use access)
* Provide clinical
summaries for patients within one business day (more than 50%)
* Identify
patient-specific education resources (more than 10%)
* Communicate with
patients on relevant health information (more than 5%)
* Perform
medication reconciliation during care transitions (more than 50%)
* Send summaries
of care during referrals (more than 50%)
* Submit
electronic data to immunization registries (ongoing submissions during
reporting period)
* Protect EHR information
Menu set
* Access imaging
results through EHR (more than 10%)
* Record patient
family health histories (more than 20%)
* Record
electronic notes (more than 30%)
* Submit
electronic syndromic surveillance data to public health registries (ongoing
submissions)
* Identify and
report cancer cases to a public health registry (ongoing submissions)
* Identify and
report noncancer cases to a specialized registry (ongoing submissions)
Specialty physician
use of EHRs
In 2011, nearly 510,000 physicians were eligible for
Medicare electronic health record incentives, but only about 50,000 were
awarded bonuses during the first year of the initiative. The Government
Accountability Office found that about 14% of general practice physicians and
8% of specialists earned incentive payments for EHR meaningful use.
|
Specialty
|
Portion awarded
EHR bonus |
|
Gastroenterology
|
18.1%
|
|
Cardiology
|
16.6%
|
|
Pulmonary disease
|
16.3%
|
|
Urology
|
15.7%
|
|
Endocrinology
|
15.6%
|
|
Otolaryngology
|
14.1%
|
|
Neurology
|
11.9%
|
|
Surgery
|
9.3%
|
|
Oncology
|
8.6%
|
|
Dermatology
|
8.4%
|
|
Obstetrics-gynecology
|
8.2%
|
|
Physical medicine
|
7.3%
|
|
Ophthalmology
|
6.5%
|
|
Psychiatry
|
1.9%
|
|
Radiology
|
1.5%
|
Source: http://www.ama-assn.org/amednews/2012/09/03/gvl10903.htm
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