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.

By Charles Fiegl amednews staff — Posted Sept. 3, 2012

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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.

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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)

Source: Stage 2 Meaningful Use Final Rule, Centers for Medicare & Medicaid Services, Aug. 23 (link)

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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: “Electronic Health Records: Number and Characteristics of Providers Awarded Medicare Incentive Payments for 2011,” Government Accountability Office, July 26 (link)

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