On Feb. 23, CMS released the long-awaited notice of proposed rule-making that details Stage 2 of the Electronic Health Record Incentive Program, advancing the next set of criteria that hospitals and health care providers must meet to continue successfully demonstrating meaningful use of EHR systems.
While proposals for the next phase of core and menu set requirements largely mirror the direction set by the Health IT Policy Committee's summer 2011 recommendations, they are, on the whole, more aggressive. This is unsurprising given that everything that is included in the final rule -- due out summer 2012 -- must be initially addressed in the NPRM and vetted in a public comment period.
Stage 1 focused on the adoption and implementation of certified EHR technology and the capture of critical, structured data elements. With Stage 2, CMS aims to advance clinical processes for continuous quality improvement. CMS has retained its basic framework for a core and menu set of measures. While the number of overall objectives does not increase, providers should note that CMS has subsumed a number of Stage 1 measures -- such as the problem list, medication list and medication allergy list -- into other Stage 2 objectives to make room for new requirements.
If approved in a similar format to the proposed rule, these new measures will serve as the impetus for providers to advance along the following vectors:
Information Exchange: In Stage 1, CMS required no more than a test of information exchange capabilities. In Stage 2, providers will move to widespread use through the new transitions of care objective. CMS proposes that providers transmit the summary of care record electronically in 10% of instances. Additionally, all population and public health objectives now will require ongoing submission, regardless of whether they are part of the core or menu set.
Patient Engagement: CMS is eliminating the requirement to provide patients with an electronic copy of their health information in favor of an objective similar to the Stage 1 requirement that Eligible Professionals provide patients with electronic access to their health data. In Stage 2, both EPs and Eligible Hospitals will be required to support infrastructure that allows patients to view, download and transmit their health information. EHs will be required to provide this access within 36 hours of discharge. Even more striking, CMS will require providers to engage their patients in viewing their health information. EHs will need to show that patients viewed, downloaded or transmitted this information in 10% of instances to meet the requirement, introducing an outcomes measure to the program. This will no doubt be one of the more highly debated aspects of the NPRM in public comment.
High-Quality, Real-Time Data Capture: While a great deal of data -- such as problems, medications and medication allergies -- were captured in a structured format in Stage 1, the data were not widely leveraged. CMS is suddenly putting this data into production. The continuous use of these data and the constant viewing of them by patients and clinicians will force providers to better manage the timeliness in which information is captured, its comprehensiveness and its accuracy.
In addition to bringing forth new proposed core and menu set criteria, CMS has used the NPRM to adjust and clarify the program, addressing issues ranging from updated Stage 1 criteria to payment adjustments (more commonly known as the penalty phase of the program).
CMS clarified that providers will receive two years in each stage, regardless of which year they enter the program. CMS also has proposed an exception that would allow providers who successfully attested to meaningful use in 2011 to remain in Stage 1 for a third year, through 2013. This change is to accommodate the late release of the final Stage 2 rule relative to the initially proposed 2013 start of the Stage 2 reporting period for these providers.
While CMS has put forth many lofty and aggressive requirements for Stage 2, there are areas where the market expected CMS to put forth proposals that it did not. These include:
Emergency Department Adoption: In Stage 1, CMS provided two methods for ED volume calculation, the "All ED" and "Observation Services" methods. The great majority of providers opted for the observation services method, which limits volume calculation to patients who are ultimately admitted to the inpatient setting and patients who receive observation services. There was concern that CMS would abandon the observation services method in an effort to drive greater adoption of certified EHR technology in the ED. The NPRM alleviates this concern as CMS intends to continue with these two methods for ED volume calculation in Stage 2.
Electronic Physician Notes: The Policy Committee had recommended that CMS put forth an electronic note requirement. For hospitals, this would require a note maintained by a physician, nurse practitioner or physician's assistant to exist for 30% of patient days. The requirement would force EHs to engage physicians in meaningful use efforts more significantly than in Stage 1, where providers relied heavily on nursing staff to achieve required meaningful use measures. Ultimately, CMS chose not to propose this requirement in the NPRM.
Specialists: The Policy Committee and its Meaningful Use Work Group engaged in a good deal of discussion regarding the applicability of the meaningful use program to specialists. The Meaningful Use Work Group is currently evaluating a number of options to address this issue, such as a separate set of requirements for specialists focused on issues like care coordination. While CMS continued to detail exclusions for these specialists from Stage 2 criteria, it did not put forth a new methodology for more effectively bringing specialists into the fold in the NPRM.
In parallel, ONC has issued a sister NPRM on standards, implementation specifications and certification criteria for EHR technology. The rule, called the 2014 edition, represents an entirely new methodology for certifying EHR technology. It aims to give providers more flexibility in terms of what aspects of the certified EHR system they are required to implement as a function of the stage they are in, the exclusions they face and the menu set criteria they have chosen to defer. ONC also identifies a steep increase of required standards for clinical content; standardized vocabulary; accessibility; data capture; and export, transport, and privacy and security in this proposed rule.
In truth, the majority of providers find the prospect of Stage 1 attestation daunting. But with a steep ramp up to Stage 2 and the promise of additional and more complex stages, all should take stock of Stage 2 proposals to determine how to best lay the groundwork for success moving forward.
The Advisory Board Company's Protima Advani and Tony Panjamapirom contributed to this article.