The core proposed meaningful use rule was issued by the Centers for Medicare and Medicaid Services and specifies the criteria that eligible professionals and hospitals must meet to qualify for incentive payments. The Office of the National Coordinator issued a proposed rule laying out the EHR capabilities and standards that are necessary for EHRs to be certified as meeting Stage 2 MU requirements.
In both proposed rules, federal officials made concerted efforts to make some meaningful use criteria more flexible.
For example, the proposal for "gap certification" means EHR vendors only need to get new capabilities certified under Stage 2-they do not have to recertify continuing capabilities already certified under Stage 1.
A new provision, which received loud applause at the recent HIMSS Conference, is that providers don't have to buy a new certified EHR that includes functions not covered under meaningful use. They can meet meaningful use by using a certified Complete EHR, a modular EHR or a combination of Modular EHRs.
Further, clinical quality measures in Stage 2 will align with other reporting programs, including PQRS, ACOs, medical homes, NCQA and Joint Commission, among others. Group reporting of quality measures-not individual but including all physicians in a practice, for instance-is permitted under the proposed rule, a welcome change from Stage 1.
However, some stakeholders are finding other criteria unsettling. For instance:
* The rule calls for eligible professionals to provide more than 50 percent of patients the ability to view online, download and transmit their health information within four business days of the information being available to the EP; and within 36 hours of discharge for hospitals. But that's only half the battle, as more than 10 percent of patients actually have to view, download or transmit. How is that supposed to happen?
* Under Stage 1, the licensed professional whose judgment creates the order (the physician) must personally use the CPOE function. But physicians want to be caregivers and not documenters, says Shefali Mookencherry, principal consultant at Hayes Management Consulting in Newton Center, Mass. So, CMS in proposed Stage 2 is asking for comment on whether other licensed professionals can actually enter an order and be the first-time generator of the order after receiving a verbal, written or electronic communication from the physician. Some states, Mookencherry notes, permit the pharmacist to be the first generator of an order if the pharmacist has an agreement with the physician. But other states may not permit someone besides the physician to generate the first order, regardless of what meaningful use says.
* While federal officials tout Stage 2 as a big leap forward in health information exchange, some others see it as an incremental step. The data exchange set forth in Stage 2 is primarily point-to-point using secure e-mail technology, as most state HIEs and many regional ones aren't operational or ready for more advanced types of exchange, says Debra White, partner in the law firm Manatt, Phelps & Phillips.
* Capturing demographic information as structured data would rise from more than 50 percent in Stage 1 to more than 80 percent in Stage 2. While CMS has found that many Stage 1 attesters have easily passed 50 percent, it can be tough. Preferred Health Partners, a multi-specialty group practice in Brooklyn with 170 physicians, has found it difficult to capture race and ethnicity information in a region with a huge immigrant population, says Joel Taylor, CIO. "People don't want to give up that information-they don't know why or where you're going to use it."
A revealing table
While focused on Stage 2, the CMS proposed rule makes some changes to Stage 1 criteria in 2013 and sets the table for a possible Stage 4. In the rule, "Table 2: Stage of Meaningful Use Criteria by First Payment Year," shows the progress through Stages 1 through 3 depending on when a provider starts, and lists "TBD" (to be determined) from 2018 through 2021. Then comes this sentence: "If there will be a Stage 4 of meaningful use, we expect to update this table in the rulemaking for Stage 3."
That language tells attorney White at Manatt, Phelps & Phillips that vendor innovation and provider adoption of EHRs under meaningful use is slower than federal officials anticipated. Because of that, the program may not be tracking to spend its available funds as originally believed, so money could remain for a fourth stage.
Or, White speculates, Stage 4 could be done without the carrot of incentive payment but just the stick-a reimbursement penalty for not complying.
Preferred Health Partners expects to attest for the first time to Stage 1 meaningful use in 2012. The practice has a total of 750 employees and an I.T. staff of 15, and it is finding Stage 1 to be a challenge. Many Stage 1 objectives remain in Stage 2 as proposed, but at a higher threshold. "Think how scary this will be for small practices," says CIO Taylor.
Taylor likes EHR meaningful use; he thinks it's where the industry needs to go. But there's plenty in the Stage 2 proposed rules that gives him pause. Consider:
* The more than 50 percent threshold for collecting the smoking status of patients 13 years of age or older moves to more than 80 percent under Stage 2. CIO Taylor figures if a practice can get to 50 percent, it can get to 80, but 50 percent isn't that low a threshold to begin with. "We're 60 percent primary care physicians and the training and tracking of this objective is difficult."
* Stage 1 requires implementation of one clinical decision support rule. Stage 2 seeks to expand not just use of decision support but to ensure proper interventions are taken. For instance, an alert could be issued when a physician in a group practice is seeing a patient with a large body mass index, recommending the patient is sent to the dietician following the office visit. This means having comprehensive decision support incorporated into an EHR, configuring it with lab results, problem and medication lists, and other health status indicators, and presented at relevant points in the workflow, Taylor says. "The bottom line is, the language is vague from a technological perspective."