Stay Up-To-Date on Meaningful Use Requirements

Joel V. Brill, MD, AGAF, AGA CPT/RUC Advisor
Lawrence R. Kosinski, MD, MBA, AGAF, Chair, AGA Practice Management & Economics Committee

On Sept. 4, CMS posted the final rule on the Electronic Health Record Incentive Program — Stage 2 (42 CFR Parts 412, 413, and 495) in the Federal Register. The rule specifies the stage two criteria that eligible professionals, eligible hospitals and critical access hospitals must meet in order to qualify for Medicare and/or Medicaid electronic health record (EHR) incentive payments.

What does this rule mean for gastroenterologists?

  • New criteria — Starting in 2014, providers participating in the EHR incentive programs who have met stage one for two or three years will need to meet new meaningful use stage two criteria.
  • Improvements in patient care — stage two includes new objectives designed to improve patient care through better clinical decision support, care coordination and patient engagement.
  • Saving money, time, lives — With this next stage, CMS hopes EHRs will further save our health-care system money, save time for doctors and hospitals, and save lives.

Eligibility Issues

here have been no significant changes to the principles of eligibility. CMS intends to assure its taxpayers that only providers who are truly participating receive incentive funds. Therefore, half of outpatient encounters (at least 50 percent of eligible professional outpatient encounters) must occur at locations equipped with certified EHR technology. Denominators are based on outpatient locations; numerators include all patient encounters performed where certified EHR technology is in use. Both numerator and denominator include ASCs.   

One note of change:

If you are a hospital-based provider and can demonstrate that you fund the acquisition, implementation and maintenance of certified EHR technology, including supporting hardware and interfaces needed for meaningful use without reimbursement from an eligible hospital or critical access hospital in lieu of using the hospital’s certified EHR technology, you can be determined to be non-hospital-based and potentially receive an incentive payment.

Changes to Stage One

Computerized physician order entry (CPOE) — Currently, the denominator is comprised of unique patients with at least one medication in their medication list. This can now be replaced with the number of orders during the EHR reporting period.

Vital signs — The current rule is for all patients aged two or older to include blood pressure and height/weight. The new change allows for patients aged three or older for blood pressure, but no age limit for height/weight.

Testing of health information exchange — The current rule stated that one test of electronic transmission of key clinical information was required. This has been eliminated starting in 2013. 

E-Copy and online access — The current rule states that eligible professionals must provide patients with an e-copy of health information upon request. This has been changed to “provide patients the ability to view online, download and transmit their health information.” 

Stage Two Core Measures

The previous 15 core measures have been replaced by 17 core measures.

Core Objective

Measure

CPOE

Use CPOE for more than 60% of medication, 30% of laboratory and 30% of radiology

E-Prescribing (eRx)

eRx for more than 50%

Demographics

Record demographics for more than 80%

Vital signs

Record vital signs for more than 80%

Smoking status

Record smoking status for more than 80%

Interventions

Implement five clinical decision support interventions + drug/drug and drug/allergy

Labs

Incorporate lab results for more than 55%

Patient lists

Generate patient list by specific condition

Preventative reminders

Use EHR to identify and provide reminders for preventive/follow-up care for more than 10% of patients with two or more office visits in the last two years

Patient access

Provide online access to health information for more than 50% with more than 5% actually accessing

Visit summaries

Provide office visit summaries for more than 50% of office visits

Educational resources

Use EHR to identify and provide education resources more than 10%

Secure messages

More than 5% of patients send secure messages to their eligible professional

Medication reconciliation

Medication reconciliation at more than 50% of transitions of care

Summary of care

Provide summary of care document for more than 50% of transitions of care and referrals with 10% sent electronically and at least one sent to a recipient with a different EHR vendor or successfully testing with CMS test EHR

Immunizations

Successful ongoing transmission of immunization data

Security analysis

Conduct or review security analysis and incorporate in risk management process

E-Prescribing (eRx)

eRx for more than 50%

Demographics

Record demographics for more than 80%

Vital signs

Record vital signs for more than 80%

Smoking status

Record smoking status for more than 80%

Interventions

Implement five clinical decision support interventions + drug/drug and drug/allergy

Labs

Incorporate lab results for more than 55%

Patient lists

Generate patient list by specific condition

Preventative reminders

Use EHR to identify and provide reminders for preventive/follow-up care for more than 10% of patients with two or more office visits in the last two years

Patient access

Provide online access to health information for more than 50% with more than 5% actually accessing

Visit summaries

Provide office visit summaries for more than 50% of office visits

Educational resources

Use EHR to identify and provide education resources more than 10%

Secure messages

More than 5% of patients send secure messages to their eligible professional

Medication reconciliation

Medication reconciliation at more than 50% of transitions of care

Summary of care

Provide summary of care document for more than 50% of transitions of care and referrals with 10% sent electronically and at least one sent to a recipient with a different EHR vendor or successfully testing with CMS test EHR

Immunizations

Successful ongoing transmission of immunization data

Security analysis

Conduct or review security analysis and incorporate in risk management process

There are five very significant issues to expand on in this table:

  • Although in stage one CPOE only included medications, this has now been expanded to include orders for laboratory and radiology.
  • The clinical decision support (CDS) requirement has been markedly expanded. You now need five CDS tools to report on.
  • Lab results are now required to be incorporated digitally in at least 55 percent of the entries.
  • Online access to health information is now required for more than 50 percent of your patients and you must document that more than 5% of them have done so. This means that if you do not have a portal in place, you better get one implemented as soon as possible. This applies to the secure messaging requirement as well.
  • You must now be able to send a patient summary electronically to at least 10 percent of your PCPs and at least one of them must be using a different EHR. This will require the use of Continuity of Care Documents (CCDs).

Menu Set Measures

Eligible professionals must select three out of the following six menu set items, which have replaced the five of 10 menu set measures.

Menu Objective

Measure

1. Imaging results

More than 20% of imaging results are accessible through certified EHR technology

2. Family history

Record family health history for more than 20%

3. Syndromic surveillance

Successful ongoing transmission of syndromic surveillance data

4. Cancer

Successful ongoing transmission of cancer case information

5. Specialized registry

Successful ongoing transmission of data to a specialized registry

6. Progress notes

Enter an electronic progress note for more than 30% of unique patients

Objectives two and six should be easily selected. If you submit data to the AGA Digestive Health Outcomes Registry® from your certified EHR, you will be able to satisfy objective five.

Clinical Quality Measures
Although reporting clinical quality measures (CQMs) is no longer a core objective of the EHR incentive programs, all providers are required to report on clinical quality measures in order to demonstrate meaningful use. In addition, all providers must select clinical quality measures from at least three of the six HHS National Quality Strategy (NQS) domains: patient and family engagement, patient safety, care coordination, population and public health, efficient use of health-care resources, and clinical processes/effectiveness. 

Stage 1 Requirement Stage 2 Requirement

Complete six out of 44

  • Three core or three alternate core
  • Three menu

Complete nine out of 64 total clinical quality measures
Choose at least one measure in three NQS domains

Recommended core CQMs include:

  •  Nine CQMs for the adult population
  • Nine CQMs for the pediatric population
  • Prioritize NQS domains

Requirements for Patient Action

CMS initially proposed two new core objectives (providing patients online access to health information and secure messaging between patient and provider) with measures that would require patients to take specific actions in order for a provider to achieve meaningful use and receive an EHR incentive payment. For both objectives, the threshold was set at 10 percent of patients.  CMS finalized the proposed measures, but reduced the thresholds to 5 percent for both objectives. The new measures are as follows:

  • More than 5 percent of patients must send secure messages to their EP.
  • More than 5 percent of patients must access their health information online.

Focus on Electronic Information Exchange

Stage two requires that a provider send a summary of care record for more than 50 percent of transitions of care and referrals.  The rule also requires that a provider electronically transmit a summary of care for more than 10 percent of transitions of care and referrals. At least one summary of care document must be sent electronically to a recipient with a different EHR vendor or to a CMS-designated test EHR.

Quality Measure Reporting 

The year 2014 represents CMS’s commitment to aligning quality measurement and reporting among programs, including the Hospital Inpatient Quality Reporting Program, Physician Quality Reporting System, Children's Health Insurance Program Reauthorization Act and accountable care organization programs. Alignment includes:

  • Choosing the same measures for different program measure sets.
  • Coordinating quality measurement stakeholder involvement efforts and opportunities for public input.
  • Identifying ways to minimize multiple submission requirements and mechanisms.

Group Reporting Option

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

Stage Two Timing

In the stage one meaningful use regulations, CMS established an original timeline that would have required Medicare providers who first demonstrated meaningful use in 2011 to meet the stage two criteria in 2013. The stage two rule gives providers more time to meet stage two criteria. A provider who attested to stage one of meaningful use in 2011 would attest to stage two in 2014, instead of in 2013.  Therefore, providers are not required to meet stage two meaningful use before 2014. The table below demonstrates the progression of meaningful use stages based on the first year a provider participates in the program. 

CMS also introduced a special three month EHR reporting period, rather than a full year of reporting, for providers attesting to either stage one or stage two in 2014 in order to allow time for providers to implement newly certified EHR technology. In future years, providers who are not in their initial year of demonstrating meaningful use must meet criteria for 12-month reporting periods.

1st
Year

Stage of Meaningful Use

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

2021

2011

1

1

1

2

2

3

3

TBD

TBD

TBD

TBD

2012

 

1

1

2

2

3

3

TBD

TBD

TBD

TBD

2013

   

1

1

2

2

3

3

TBD

TBD

TBD

2014

     

1

1

2

2

3

3

TBD

TBD

2015

       

1

1

2

2

3

3

TBD

2016

         

1

1

2

2

3

3

2017

           

1

1

2

2

3

Payment Adjustments

Eligible providers who are meaningful EHR users in 2013 will avoid a payment adjustment in 2015. If eligible providers first meet meaningful use in 2014, they will avoid the 2015 payment adjustment if they are able to demonstrate meaningful use at least three months prior to the end of the calendar year and meet the registration and attestation requirement by Oct. 1, 2014.

CMS also finalized the exceptions to these payment adjustments; the four categories include:

  • The lack of availability of internet access or barriers to obtaining information technology infrastructure.
  •  A time-limited exception for newly practicing eligible professionals or new hospitals that will not otherwise be able to avoid payment adjustments.
  •  Unforeseen circumstances such as natural disasters that will be handled on a case-by-case basis.
  • (Eligible providers only) Exceptions due to a combination of clinical features limiting a provider's interaction with patients or, if the eligible professional practices at multiple locations, lack of control over the availability of certified EHR  technology at practice locations constituting 50 percent or more of their encounters

Please contact Deborah Robin, AGA senior director for quality, or Elizabeth Wolf, AGA director of regulatory affairs, if you have any questions about the requirements. For additional information on the stage two rule, review the CMS tipsheet