"Meaningful use" final rule offers some flexibility

Physicians now can defer up to five EMR objectives in the first two years and still qualify for Medicare or Medicaid financial incentives.

By — Posted July 19, 2010

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The final "meaningful use" rule for electronic medical record adoption gives physicians and hospitals some flexibility in meeting certain objectives to qualify for billions in federal incentives.

The American Medical Association and other physician organizations had expressed concern earlier this year when a proposed rule outlined what should constitute meaningful use of paperless records. They said the plan asked adopters to do too much too quickly and would undermine the government's goal of establishing a nationwide EMR system.

Officials with the Centers for Medicare & Medicaid Services said they took those comments into account as they drafted the final rule, unveiled July 13. The Office of the National Coordinator for Health Information Technology also issued a final rule the same day outlining the standards and criteria EMR vendors need to follow for their products to become certified for meaningful use.

The final CMS rule divides the initial 25 meaningful use objectives into two categories: a core group of 15 objectives that physicians and hospitals must meet, and a "menu set" of 10 procedures from which they can choose any five to defer in 2011-12, the first round of the incentive program. CMS also softened some requirements to make them easier to achieve.

David Blumenthal, MD, the national health information technology coordinator, and Marilyn Tavenner, the CMS principal deputy administrator, on July 13 posted a commentary about the final rule on the New England Journal of Medicine website.

"Concerns about the pace and scope of implementation of meaningful use led us to adopt a two-track approach regarding the objectives that allow practices and hospitals to quality for incentive payments in the first two years of the program," they wrote.

Each objective has an accompanying measure to determine if a physician met the goal. For instance, one core objective -- that a doctor use an EMR to conduct computerized physician order entry for medication orders -- requires that more than 30% of a doctor's patients taking at least one medication have at least one drug ordered through CPOE.

Billions in incentives await

The meaningful use regulations specify only the objectives physician and hospital EMRs must achieve in payment years 2011 and 2012. Additional objectives will be added in future years.

CMS will reward meaningful EMR users with incentive money that was made available through the economic stimulus package enacted in early 2009. Eventually, that money will start phasing out, and physicians who have not adopted paperless systems will start facing Medicare penalties.

As much as $27 billion may be expended in incentive payments, according to CMS. Eligible physicians who meet all required objectives could receive as much as $44,000 over five years from Medicare, or $63,750 over six years from Medicaid. Hospitals may receive millions of dollars for meaningful use under both Medicare and Medicaid, the agency said.

Other key changes in the final rule:

  • A new EMR objective on providing electronic patient education resources.
  • A new definition of a hospital-based professional as one who performs a substantial amount of services in an inpatient hospital setting or emergency department only.
  • A stipulation that critical access hospitals are considered acute care hospitals when it comes to the Medicaid bonus program.

Greater flexibility appreciated

The AMA had signed onto a March letter to CMS outlining problems with the proposed meaningful use rule, along with the American College of Physicians, the American Academy of Family Physicians, the American College of Surgeons and many others. The Association said it would review the final rule carefully to ensure that the new requirements allow enough greater flexibility.

"The AMA is committed to [EMR] adoption that streamlines the clinical and business functions of a physician office and helps provide high-quality care to patients," said AMA Secretary Steven J. Stack, MD. "It is critical that barriers to implementation are removed so physicians can successfully adopt new technology."

The Medical Group Management Assn., which also signed the letter, said the agency made some progress on the flexibility front.

"While challenges remain, the final rule provides a better approach to the real-world issues faced by practices as they move toward meaningful use" of EMRs, said William Jessee, MD, MGMA president and CEO. Dr. Jessee said improvements sought in the final rule included a "reduction in the originally unrealistic thresholds related to e-prescribing, administrative transactions and computerized physician order entry, among others."

The Federation of American Hospitals said it supported the final rule.

"The rule recognizes many of the practical concerns ... [about] the proposed rule and should help provide the impetus for hospitals to advance the use and dissemination of health information technology for improved patient care," said Chip Kahn, the federation's president and CEO.

Some policy observers said the rule will provide the incentives necessary to spur EMR adoption.

"These regulations provide a promising foundation for encouraging the effective use of health information to improve patient care," said Mark B. McClellan, MD, PhD, director of the Engelberg Center for Health Care Reform and a senior fellow at the Brookings Institution in Washington, D.C.

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What physicians need to do

For the first round of Medicare and Medicaid EMR bonuses in 2011-12, physicians must meet 15 core objectives and at least five of 10 "menu set" items. Each objective has a measure to determine if an EMR was used to perform the function for an appropriate number of opportunities:

Core set (must meet all)

  • Record patient demographics
  • Record vital signs/chart changes
  • Maintain current and active diagnoses
  • Maintain active medication list
  • Maintain active allergy list
  • Record adult smoking status
  • Provide patient clinical summaries
  • Provide electronic health information copy on demand
  • Generate and transmit prescriptions electronically
  • Use computerized physician order entry for drug orders
  • Implement drug-drug/drug-allergy interaction checks
  • Be capable of electronic clinical information exchange
  • Implement one clinical decision support rule
  • Protect patient data privacy and security
  • Report clinical quality measures to CMS or states

Menu set (can defer up to five for 2011-12)

  • Implement drug formulary checks
  • Incorporate clinical lab test results
  • Generate patient lists by condition
  • Identify patient-specific education resources
  • Perform medication reconciliation between care settings
  • Provide summary of care for transferred patients
  • Submit electronic immunization data to registries
  • Submit electronic epidemiology data to public health agencies
  • Send care reminders to patients
  • Provide timely patient electronic access to health information

Source: Centers for Medicare & Medicaid Services

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External links

"The 'Meaningful Use' Regulation for Electronic Health Records," New England Journal of Medicine, July 13 (link)

"Finding My Way to Electronic Health Records," by Surgeon General Regina Benjamin, MD, New England Journal of Medicine, July 13 (link)

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