Released at the end of February, the proposed definition for Stage 2 meaningful use is making its rounds with analysis and commentary coming from a number of organizations around the country. The official public comment period for this Notice of Proposed Rule Making (NPRM) is open until May 7. The final version of the Stage 2 requirements is expected later this summer after CMS has had an opportunity to review comments and make revisions.
At a high level, here's a quick look at a few key features of the proposed new rule:
The requirements for Stage 2 do not become effective for Eligible Providers (EP) until calendar year (CY) 2014. Recall that CMS changed the first year of Stage 2 to 2014 for everyone in order to give vendors and early adopters time to prepare for and institute the new round of requirements. Keep in mind that all EPs begin with the Stage 1 set of requirements for their first two years of the program before moving into Stage 2, regardless of when they actually begin the program (attesters from 2011 being allowed three years of Stage 1 as a result of the CMS delay of Stage 2).
There will be 17 core objectives required for all EPs, with a menu set of five from which an EP must select three. So just as in Stage 1 there are 20 total requirements to meet. Also, exclusions no longer count toward meeting one of the menu objectives as they did in Stage 1. You'll have to provide data for the three menu items that you select. Finally, all denominators include all encounters at locations equipped with an EHR.
New and Familiar Objectives:
More detailed analysis on the entire NPRM will be available on WHITEC's website in the coming weeks, but here are several highlights worth noting:
The electronic exchange of summary of care really reinforces the need for and strength of health information exchange: for all transitions of care, where patient information is exchanged, more than 10% of the recipients need to be on a different vendor platform and have no organizational affiliation to the sender.
To boost patient engagement, providers must give online access to information to over 50% of their patients within 4 days of having the information themselves. Furthermore, more than 10% of patients must view, download, or transmit
Clinical Quality Measures:
Some big changes here. Though no longer articulated as a core objective, Clinical Quality Measure (CQM) reporting is still a requirement under Stage 2. There was also an earnest effort to demonstrate greater alignment of the measures among the government's various quality reporting programs.
The two primary considerations are whether to report as an individual EP or collectively with a group of EPs (defined as 2 or more EPs with a unique NPI working under one tax ID).
For individual EPs, there are two options.The first of those options actually has two versions (a and b) being proposed to the public and based on feedback, CMS will settle on only one of these.
Option 1a calls for reporting on 12 CQMs, with at least one being reported in each of 6 new domains that are based on the National Quality strategy. This option would give providers the most flexibility to choose measures from their scope of practice but result in the government getting smaller pools of quality data from a wider range of measures.
Option 1b calls for all EPs to report on 11 core CQMs and 1 menu CQM. This would limit the providers' flexibility in selection of measures but give the government a deeper pool of quality data in a few important measures (though this is likely to be countered to some degree by the larger number of zero denominators from specialists who find those measures outside of their scope of practice.)
Option 2 is pretty straightforward: EPs report CQMs under the Physician Quality Reporting System using data pulled from their Certified EHR Technology (CEHRT).
For group reporting, there are three options:
- Jointly reporting on 12 CQMs with at least 1 from each of the 6 domains
- Participating in an ACO while satisfactorily meeting the requirements of the Medicare Shared Savings Program, or
- Reporting via PQRS Group Practice Reporting Option (GPRO) option.
The chief financial motivator for practices, of course, are the incentives that are available to qualified providers who demonstrate meaningful use in their use of certified EHR technology (CEHRT). In 2015, those who've not achieved meaningful use will see penalties in the Medicare payments they receive. The penalties gradually accrue over subsequent years (1% in 2015, 2% in 2016, and so on) until a certain cap is reached. This could play out a couple of different ways depending on the national level of adoption:
Scenario 1: Assumes that less than 75% of EPs are meaningful users for CY 2018 and beyond. In this case, the penalty maxes out at 5%.
Scenario 2: Assumes that more than 75% of EPs are meaningful users for CY 2018 and beyond. In this case, the maximum penalty would be 3%.
Finally, in order to avoid 2015 penalty start, an EP must attest no later than Oct. 1, 2014. This means they must begin the 90 day EHR reporting no later than July 2, 2014.
An expanded definition of "Medicaid encounter" is being proposed that would include the following:
- Any encounter receiving medical assistance under 1905(b), including expansion populations
- Patients on panels seen within 24 months instead of just 12
- Permitting volumes to be calculated from the most recent 12 months, instead of on the CY
- Zero-pay Medicaid claims
In addition, as we saw in Stage 1, the proposal to extend the states' flexibility with the definition of Meaningful Use would be continued.
Adjustments to Stage 1:
Just when you might have thought that Stage 1 was finalized, we find that there are a few minor changes in store for those EPs who will be attesting under the Stage 1 requirements in 2014.
For CPOE, the denominator is now the total number of orders for the reporting period, rather than the pool of patients already having at least one medication order in their med list - originally intended as a "workaround' for providers still having a significant number of patient charts based on paper.
Where blood pressure, height, and weight measurements for the vitals requirement were previously limited at age 2, the blood pressure age limit is now 3 and there is no limit for the other two. Likewise, the scope of practice exclusion can be taken for blood pressure independently of the other two.
The test of HIE is removed, effective CY 2013.
Also, the two separate objectives for providing an electronic copy of health information on request and providing access to health information have been combined into a single objective that calls for the ability to view, download, and transmit that data.
Finally, the public health objective (immunizations, syndromic surveillance, etc.) now have the addition of "except where prohibited."