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Reimbursement and Practice Management

EHR Meaningful Use – Stage Two

The anticipated publication of the Final Rule outlining the Stage 2 Meaningful Use criteria came on September 4, 2012. Core criteria are essential to understand to avoid future penalties.

In this Pulse article, you will learn how to:

  • Describe the meaningful use objectives for the government’s stage two of the EHR Incentive Program
  • List the hardship criteria for eligible professionals who cannot meet the stage two objectives
  • Identify the current time frames associated with incentives and penalties for EHR Meaningful Use

The highly anticipated publication of the Final Rule outlining the Stage Two Meaningful Use criteria came on September 4, 2012. For participants in the government’s Electronic Health Record (EHR) Incentive Program, there is now a pathway to reach the program’s next stage successfully. Given that penalties will soon be imposed – as of January 1, 2015 – on non-participating physicians, this Final Rule is essential to understand.

Although the incentive program was passed into law in 2009, it didn’t officially get underway until 2011. During the interim, the government determined that phasing in the criteria would be the best approach. While this transition may feel drawn out at times, the intended goal of the EHR Incentive Program – an electronic record for every patient that allows interoperability and connectivity among providers to improve communication and quality of care – could not be achieved in one step. Three stages – data capturing, advanced clinical processes, improved outcomes – were formulated, although the government defined only the initial stage when launching the program.

Physicians and other eligible professionals (EPs) still have time to gain bonus payments, and avoid the penalties of reduced Medicare reimbursement. The window of opportunity, however, is shutting. Participants in the Medicare EHR Incentive Program can still achieve $39,000 worth of payments – only $5,000 less than the program’s maximum for the EPs who attested to successful participation before the fall of 2012. If you begin in 2013, you can comply with Stage One rules in 2013 and 2014.

The Final Rule confirmed that penalties – in the form of lower Medicare reimbursement – will be imposed starting in 2015, on the basis of the EPs participation status in 2013. EPs can still avoid the penalty in 2014, but only if they are first-time participants who register by July 1, 2014, and successfully attest to meaningful use by the end of September 2014.

Exceptions to the penalties will be granted for EPs who fall into at least one of five categories:

  1. Cannot get Internet access or face other barriers to IT infrastructure
  2. Are new EPs in the first two years of practice
  3. Experience natural disasters or other unforeseen circumstances
  4. Have limited interaction with patients, or
  5. Practice at multiple locations but cannot control EHR availability at all locations

Unless one of the five exceptions applies, the government will require EPs to continue demonstrating meaningful use every year to avoid penalties in subsequent years. The take-away is that it’s not just good enough to participate for one year – regardless of what stage of meaningful use you plan to complete next, do not neglect the reporting process each year.

While the penalties are not significant – one percent of Medicare reimbursement – remember that this payment adjustment will be applied to all of your Medicare business. Furthermore, the penalties don’t stop at one percent; they’ll climb by an additional one percent each year, up to five percent.

Clinical quality measures (CQMs) are at the forefront of Stage Two, with the government announcing that it no longer considers CQMs as criteria for meaningful use. Indeed, CQMs are meaningful use. That change allows EPs participating in both the EHR Incentive Program and the Physician Quality Reporting System (PQRS) to merge their reporting of CQMs for meaningful use and PQRS measures into one submission. Although not available at the time of this publication, CMS also announced that it will soon post a list of the CQMs on the main web page of its EHR Incentive Program.

Having removed the CQMs as criteria to achieve meaningful use, 20 other criteria are presented in Stage Two. The government retains the "core/menu" structure from Stage One, but now sets out 17 core objectives to meet, plus three more to select from a menu of six objectives. Some Stage Two criteria remain the same – electronic prescribing, for example – but the measure is increased to 80 percent of permissible prescriptions, significantly more than the 50 percent required in Stage One.

Perhaps the most controversial criteria are two new ones that require your patients to act: five percent of patients must view online, download or transmit their health information to a third party, and five percent of patients must send secure messages to their EP. In the face of significant criticism of these criteria when first proposed last winter, the government pushed back in the Final Rule, asserting: "...we continue to believe that EPs are in a unique position to strongly influence the technologies patients use to improve their own care, including viewing, downloading and transmitting their health information online."

For a list of the new objectives and measures, see “Stage 2 Meaningful Use Criteria” below.

The Final Rule also outlines some changes to the entire program. In order to achieve the higher Medicaid bonus of $63,750, 30 percent or more of the EP’s patient volume must be Medicaid patients. The government clarified that this count could include CHIP programs, Title 21 – even encounters where Medicaid coverage was present but Medicaid did not actually pay (often the case for Medicare/Medicaid-covered patients). Furthermore, the look-back period to determine the 30 percent of patient volume threshold is now the previous 12 months, instead of the 12 months of the previous calendar year.

For Medicaid participants, the government requires only to be “adopting, implementing or upgrading to certified EHR technology” during their initial year of participation to achieve the bonus payment – a much lower bar than attesting to the meaningful use of a certified EHR. The Final Rule clarified, however, that Medicaid participants who are actively adopting, implementing or upgrading, but haven’t proven meaningful use by September 2014, will indeed be subject to the Medicare penalties.

A separate, yet corresponding Final Rule released at the same time as the Stage Two rule concerns requirements for EHR systems that vendors must meet in order to maintain certification in the government program. Continued certification will hinge on the vendor’s ability to upgrade its products to enable EPs to perform these new meaningful use measures. Be prepared to upgrade your system in the coming 12 to 18 months, and allow time to train yourself and your staff to use it. All EPs can participate for three months in 2014, not just those in Stage Two. This timeframe, the government claims, will allow all practices to upgrade to the newest version of the EHR.

With the release of the Stage Two Final Rule, the government takes another giant step to carry out the American Recovery and Reinvestment Act of 2009, which encourages the use of technology in healthcare. Now it is up to thousands of physicians and other healthcare professionals to make the most of this opportunity and avoid future reimbursement penalties. For that to happen, you need to be informed, active and resourceful. Start today by planning for how you and your practice will gear up to meet this next stage of meaningful use.

Stage 2 Meaningful Use Criteria

Core Criteria (all required)

  1. Use CPOE >60% of medication, >30% lab and >30% radiology orders
  2. E-Rx >50%
  3. Record demographics >80%
  4. Record vital signs >80%
  5. Record smoking status >80%
  6. Implement 5 clinical decision support interventions & drug/drug & drug/allergy checks
  7. Incorporate lab results as structured data >55%
  8. Generate patient list by specific condition
  9. Use EHR to identify and provide >10% with reminders for preventive/follow-up
  10. Provide online access to health information >50% with >5% actually accessing
  11. Provide office visit summaries in one business day >50%
  12. Use EHR to identify and provide patient-specific education resources >10%
  13. More than 5% of patients send secure messages to their EP
  14. Medication reconciliation >50% of transitions of care
  15. Provide summary of care document >50% of transitions of care and referrals with 10% sent electronically; one test to another EHR vendor or the CMS test EHR
  16. Successful ongoing transmission of immunization data
  17. Conduct or review security analysis and incorporate in risk management process

Menu-based Criteria (3 out of 6)

  1. More than 10% of imaging results are accessible through EHR
  2. Record family health history as structured data >20%
  3. Record electronic progress notes >30%
  4. Successful ongoing transmission of syndrome surveillance data
  5. Successful ongoing transmission of cancer case information
  6. Successful ongoing transmission of data to a specialized registry

United States