The Future of Meaningful Use: CMS’s Stage 3 EHR Incentive Program Proposed Rule

In March and April 2015, the Centers for Medicare & Medicaid Services (CMS) proposed three rules that will reshape the Medicare and Medicaid Electronic Health Record (EHR) Incentive Program.

The Stage 3 proposed rule, published on March 30, 2015,¹80 Fed. Reg. 16732 (Mar. 20, 2015). alters the framework of the EHR incentive program, and seeks to promote interoperability of EHR technology and multidisciplinary approaches to patient care.

CMS also published a proposed rule that aims to modify Stages 1 and 2 of the program in 2015 and 2016 to align more closely with what it anticipates the program will be like in Stage 3,²80 Fed. Reg. 20346 (April 15, 2015). and the Office of the National Coordinator for Health Information Technology (ONC) published its proposed rule on 2015 Edition Health Information Technology (Health IT) certification criteria on March 30, 2015.³80 Fed. Reg. 16804 (Mar. 30, 2015).

This article focuses on the Stage 3 proposed rule and implications for providers if it is finalized. Stakeholders submitted comments to the proposed rule on May 29, 2015.

The Evolution of Meaningful Use

The EHR incentive program, known best as the meaningful use program for its requirement that providers demonstrate meaningful use of EHR technology, was established by the American Recovery and Reinvestment Act of 2009 (the program).⁴P.L. 111-5.

Initially, the program functioned as an incentive program, providing eligible professionals (EPs), eligible hospitals (EHs), and critical access hospitals (CAHs) (collectively referred to as providers) with financial bonuses for successfully attesting and demonstrating meaningful use of certified EHR technology (CEHRT).

Now, the program imposes reductions to Medicare payments otherwise due to providers. Starting on October 1, 2014, for eligible hospitals and CAHs, and January 1, 2015, for EPs, the program imposed penalties on providers who are not meaningful users of CEHRT.

EPs who are not meaningful users are now subject to a 2 percent Medicare payment reduction, which will increase up to 5 percent by 2018. Eligible hospitals and CAHs who are not meaningful users face Medicare payment reductions of up to 25 percent of the increase to the Inpatient Prospective Payment System (IPPS) payment rate.

The EHR program consists of three stages of meaningful use. Each stage has its own set of requirements that must be met in order to demonstrate meaningful use. The requirements become more rigorous as EPs proceed through the stages.

For each stage, providers must meet several objectives by reporting on associated measures.

In Stages 1 and 2, providers are required to meet and report on required core objectives and a series of menu set objectives that they choose.

Stage 3 of Meaningful Use

Today, providers are complying with different stages of meaningful use—some are in Stage 1, others in Stage 2, and some have yet to begin attesting. When finalized, Stage 3 is expected to be the final stage of the program. CMS appears to have two primary objectives for the program:

1. streamline the program; and
2. promote widespread and involved use of certified EHR technology.

Streamlining Meaningful Use

CMS proposes to streamline the meaningful use program by making several changes.

First, CMS proposes that all providers will be required to meet Stage 3 requirements starting in 2018, regardless of their previous stage of participation. Providers will have the option to begin attesting under Stage 3 in 2017.

By 2018, CMS envisions that all providers will be attesting to the same meaningful use objectives and using the 2015 Edition of certified EHR technology.

Several stakeholders have expressed concern regarding the mandate to use 2015 CEHRT technology. Several commenters reflected on the widespread vendor problems associated with the 2014 Edition technology which prompted CMS to implement a hardship exception specifically for vendor issues with 2014 Edition technology. Commenters note that similar delays in implementation may occur if CMS requires that all providers use 2015 Edition technology.

Second, by 2018, all providers will report and be subject to adjustment on a calendar year (CY) basis. Previously, eligible hospitals reported based on the fiscal year (FY).

Third, CMS proposes to eliminate the system of core and menu set objectives, and replace it with a single set of eight required objectives and associated measures.

Some objectives are tailored based upon provider type (e.g., EP, or eligible hospital, or CAH), and some require that providers attest to all associated measures but need only meet the requirements of a subset of objectives.

CMS streamlined the measures by removing “topped out” measures—those measures it believes have achieved sufficient utilization that the policy objective for including them has been met.

Also, CMS conferred with the HIT Policy Committee to identify eight policy areas that “represent the advanced use of EHR technology and align with the program’s foundational goals and overall national health care improvement goals.”⁵80 Fed. Reg. at 16743.

The eight key policy areas/objectives proposed are:

1. protect patient health information;
2. electronic prescribing (eRx);
3. clinical decision support (CDS);
4. computerized provider order entry (CPOE);
5. patient electronic access to health information;
6. coordination of care through patient engagement;
7. health information exchange (HIE); and
8. public health and clinical data registry reporting.

Although Providers generally support CMS’s proposal to streamline meaningful use requirements, many feel strongly that they should not be held accountable for patient interaction with EHRs. Thus, objectives requiring patient engagement measured by the percentage of patients that view, download, or transmit health information electronically have met strong resistance.

Providers also comment that CMS should reconsider CDS intervention measures. One problem with EHRs is the number of alerts they send to physicians.

For example, many physicians receive an alert each time a CDS is triggered, each time a document is added to the EHR, and every time there is a potential drug-drug or drug-allergy problem.

Many physicians complain that they get “alert fatigue” and risk missing important alerts because they are overwhelmed by less important ones. Although CMS attempts to streamline the meaningful use requirements, there are still a significant number of objectives and measures that are likely to lead to alert fatigue if EHRs do not become more sophisticated and triage alerts or only provide them at critical times (such as at patient visits).

Promoting Widespread, Integrated Use of EHR Technology

CMS’s ultimate goal is that all providers will use EHRs in a standardized way to facilitate interaction between and among providers, patients, and other health representatives. CMS furthers this objective in three ways. First, CMS proposes significantly higher compliance rates for several of the measures from the Stage 2 requirements. Coupled with increasing penalties for failing to successfully attest to meaningful use, EPs, eligible hospitals, and CAHs will no doubt feel pressure to devote substantial efforts to implementing and interacting with CEHRT.

Second, CMS proposes that paper-based formats will no longer be allowed for the purposes of meeting Stage 3 objectives and measures. In the past, CMS allowed providers to meet objectives for providing patient education resources, summary of care documents, and transitions or referrals of care documents in paper-based formats. CMS recognizes that paper-based formats may still be preferred or necessary in certain circumstances, but proposes that in order to be considered a meaningful user of EHR technology, all actions must be met through electronic interaction with the EHR.

Third, CMS also proposes a handful of new measures to promote interoperable systems, including:

• the option to provide patient access to health information through an ONC certified application program interface (API); and
• incorporating patient-generated data or data from non-clinical settings into the EHR.

Use of APIs will facilitate patient interaction with EHRs, and will also allow providers to interact with one another more easily. Several EHRs have been working with healthcare organizations to create a platform that allows developers to create applications that work in various EHRs.⁶See Eric Wicklund, EHR Vendors Extending Platforms with Apps and APIs, HealthcareITnews.com, http://www.healthcareitnews.com/news/ehr-vendors-extending-platforms-apps-apis (Apr. 3, 2015).

ONC’s proposed rule on 2015 Edition certified technology also takes steps to promote interoperability, particularly for EHR Program objectives and measures. For example, ONC proposes to standardize the language used to transmit e-prescriptions. Measures like this promote interoperability between provider EHRs but also between provider and pharmacy systems. Similar initiatives for non-clinical settings of care, like physical therapy, enhance multidisciplinary approaches to patient care.

Many providers support the use of EHRs and applaud CMS’s efforts to promote interoperability of EHR technology.

However, many comments to the proposed rule emphasized that the technology is not sufficiently advanced to support the functions CMS proposes to require.

As noted above, many industry groups and individuals are concerned that requiring the 2015 Edition certified EHR technology will result in technological challenges, citing problems with provider experience with the 2014 Edition.

In order for the meaningful use program to be successful in the future, EHRs must be more user-friendly and interoperable. While recognizing the potential of EHRs, many providers feel that current technology is still more of a burden than a benefit. EHRs are very expensive, particularly for smaller practices, and often do not adequately interface with a practice’s needs.

Program requirements to provide patient information electronically, have a significant portion of patients view or download their health information through EHRs, and receive, incorporate, and send health information to other providers through the EHR is nearly impossible without interoperable technologies. There are over 6,000 EHRs available to providers for the meaningful use program according to ONC’s complete listing of certified Health Information technology.⁷See Certified Health IT Product List, Office of the National Coordinator (May 29, 2015), available at http://oncchpl.force.com/ehrcert?q=chpl.

However, each system has a different interface, customizability for a provider’s needs, and ability to work with other EHR vendors and technologies. The API measure proposed by CMS and development of interoperable platforms and applications may assist with integrated use of EHRs.

Conclusion

Overall, the Stage 3 Meaningful Use proposed rule is a step in the right direction for a unified EHR program. However, it is unclear whether streamlining EHR requirements is enough to overcome technological challenges faced by providers. Stage 3 will not succeed if EHRs are unable to facilitate meaningful use.