View source for Meaningful Use Stage 2 for Eligible Professionals (EP) for the Medicare EHR Incentive Program

'''MEANINGFUL USE STAGE 2 FOR ELIGIBLE PROFESSIONALS FOR THE MEDICARE EHR INCENTIVE PROGRAM'''




'''BACKGROUND:'''

On February 17, 2009 the $787 Billion American Recovery and Reinvestment Act (ARRA), often referred to as the “Economic Stimulus”, was signed into law by President Barack Obama.  A part of this law was the HITECH Act (Health Information Technology for Economic and Clinical Health Act), whose purpose was to increase the use of Electronic Health Records (EHR) by physicians (called Eligible Professionals, or EPs in the law) and hospitals.  HITECH set aside $22 Billion for this goal, including $18 Billion for financial incentives through the Medicare and Medicaid reimbursement systems for physicians and hospitals to adopt EHR’s.  Individual physicians and certain other medical providers were eligible to receive as much as $44,000 in incentive money over 5 years from the Medicare EHR Incentive Program.  In order to earn these financial incentives, physicians and hospitals had to use EHR’s certified by the Office of the National Coordinator (ONC) for Health Information Technology, and were required to use them in a “meaningful” way (1,2).  The Center for Medicare Services (CMS) in conjunction with the ONC developed specific criteria for this “Meaningful Use”, and divided the criteria into three separate stages.  Stage 1 of Meaningful Use, which went into effect in 2011, required Eligible Professionals to demonstrate they were using the basic functionalities of the EHR, including capturing patient data electronically and sharing the data with either other healthcare professionals or the patient. 

 
'''STAGE 2 MEANINGFUL USE- CORE AND MENU OBJECTIVES:'''

The ONC and CMS published proposed criteria for Stage 2 Meaningful Use on March 7, 2012 with a subsequent 60-day period for public comment.  The final criteria were incorporated in the Stage 2 Final Rule, which was issued on August 23, 2012 (3).  The Stage 2 criteria first go into effect for EP’s in 2014.  The criteria for Stage 2 emphasize using the EHR for advanced clinical processes.  These include health information exchange between healthcare providers, and increasing patient engagement in their own care by giving patients online access to their health information in the EHR.  In Stage 1, EP’s had to meet 15 mandatory “Core Objective” Meaningful Use criteria, and had to choose and meet another 5 out of 10 “Menu Objective” criteria.  In Stage 2, EP’s have to meet 17 mandatory “Core Objective” criteria, and must choose 3 out of 6 “Menu Objective” criteria to meet.  In Stage 2 compared to Stage 1, there is one new Core Objective, and five new Menu Objectives.  Eight of the Stage 1 Core Objectives were eliminated from Stage 2, but most of these were incorporated into new or revised Stage 2 criteria.  The same is true of the Stage 1 Menu Objectives which were eliminated.  On the whole, the Stage 2 criteria are more stringent than those in Stage 1.  Despite the fact that EP’s must satisfy the same total number of objectives in Stage 2 as in Stage 1 (twenty), most of the thresholds (percentages) that EP’s must achieve to satisfy those objectives are higher in Stage 2 (4).  


'''SUMMARY OF STAGE 2 MEANINGFUL USE CRITERIA (Adapted from Refs. 4 and 5) AND COMPARISON WITH STAGE 1'''


'''STAGE 2 CORE OBJECTIVES'''

'''1. CPOE'''
           STAGE 2 MEASURE:  Use CPOE for >60% of medication, >30% of laboratory, and >30% of radiology orders
           COMPARISON WITH STAGE 1:  >30% of patients have at least one medication on their medication list entered by CPOE
'''2.  Electronic Prescribing'''
           STAGE 2 MEASURE:  >50% of all permissible prescriptions are compared to at least 1 drug formulary and transmitted electronically
           COMPARISON WITH STAGE 1:  >40% of permissible prescriptions transmitted electronically
'''3.  Demographics'''
           STAGE 2 MEASURE:  >80% of all patients have demographics recorded as structured data
           COMPARISON WITH STAGE 1:  >50% of patients have demographics recorded as structured data
'''4.  Vital Signs'''
           STAGE 2 MEASURE:  >80% of patients have BP (for patients 3 yo and over) and height and weight (for all ages) recorded as structured data
           COMPARISON WITH STAGE 1:  >50% of patients 2 yo or over have BP, height, and weight recorded as structured data
'''5.  Smoking Status'''
           STAGE 2 MEASURE:  >80% of patients 13 yo or over have smoking status recorded as structured data
           COMPARISON WITH STAGE 1:  >50% of patients 13 yo or over have smoking status recorded as structured data
'''6.  Clinical Decision Support (CDS)'''
           STAGE 2 MEASURE:  Implement 5 CDS interventions related to 4 or more clinical quality measures, and enable drug-drug and  drug-allergy interactions checks in the EHR
           COMPARISON WITH STAGE 1:  Implement 1 clinical decision support rule
'''7.  Lab Results'''
           STAGE 2 MEASURE:  >55% of clinical lab test results are incorporated in the EHR as structured data
           COMPARISON WITH STAGE 1:  >40% of clinical lab tests results are incorporated in the EHR as structured data
'''8.  Patient List'''
           STAGE 2 MEASURE:  Generate at least 1 report listing patients with a specific condition
           COMPARISON WITH STAGE 1:  The same
'''9.  Reminders for Preventive Care'''
           STAGE 2 MEASURE:  Use EHR to identify and provide reminders for preventive/follow-up care for >10% of patients with 2 or more office visits in the last 2 years
           COMPARISON WITH STAGE 1:  Send a reminder for preventive/follow-up care to >20% of patients 65 yo or older or 5 yo or younger
'''10.  Patient Electronic Access to Their Health Information'''
           STAGE 2 MEASURE:  >50 of patients have online access to their health information within 4 business days, and >5% actually access it or transmit it to a 3rd party
           COMPARISON WITH STAGE 1:  >50% of patients who request an electronic copy of their health information are provided it within 3 business days
'''11.  Clinical Summaries for Patients'''
           STAGE 2 MEASURE:  Clinical summaries provided within 1 business day to patients for >50% of all office visits 
           COMPARISON WITH STAGE 1:  Clinical summaries provided within 3 business days to patients for >50% of all office patients
'''12.  Provide Patient Education Resources'''
           STAGE 2 MEASURE:  Use the EHR to identify patient-specific education resources, and provide these to >10% of patients
           COMPARISON WITH STAGE 1:  The same
'''13.  Secure Electronic Messaging With Patients'''
           STAGE 2 MEASURE:  >5% of patients send a message to their provider using the electronic secure messaging function of the EHR 
           COMPARISON WITH STAGE 1:  Not included in Stage 1
'''14.  Medication Reconciliation'''
           STAGE 2 MEASURE:  The provider performs medication reconciliation using the EHR for >50% of transitions of care from another setting or provider
           COMPARISON WITH STAGE 1:  The same
'''15.  Summary of Care Record'''
           STAGE 2 MEASURE:  Send for >50% of transitions of care and send electronically for >10%.  Must send at least 1 summary to recipient with a different EHR, or else successfully test sending at least 1 summary to a CMS-designated test EHR
           COMPARISON WITH STAGE 1:  The provider sends a summary of care for >50% of transitions of care to another setting or provider or a referral
'''16.  Immunizations'''
           STAGE 2 MEASURE:  Successful ongoing submission of electronic immunization data to an immunization registry or information system
           COMPARISON WITH STAGE 1:  At least 1 test of submitting electronic immunization data to an immunization registry, and follow-up submission if the test is successful
'''17.  Security Risk Analysis'''
           STAGE 2 MEASURE:  Conduct or review a security risk analysis including addressing the encryption/security of data, implement security updates, and correct deficiencies
           COMPARISON WITH STAGE 1:  The same


'''STAGE 2 MENU OBJECTIVES (must select 3 of 6)'''


'''1.  Syndromic Surveillance'''
           STAGE 2 MEASURE:  Successful ongoing submission from the EHR of electronic syndromic surveillance data to a public health agency
           COMPARISON WITH STAGE 1:  >=1 test of submission from EHR of electronic syndromic surveillance data to a public health agency; follow-up submission if test successful
'''2.  Imaging Results'''
           STAGE 2 MEASURE:  >10% of imaging results (pictures and reports) are accessible through the EHR
           COMPARISON WITH STAGE 1:  Not included in Stage 1
'''3.  Family Health History'''
           STAGE 2 MEASURE:  >20% of patients have a structured data entry for the family health history of one or more first-degree relatives
           COMPARISON WITH STAGE 1:  Not included in Stage 1
'''4.  Cancer Registry Reporting'''
           STAGE 2 MEASURE:  Successful ongoing electronic submission of cancer cases from the EHR to a cancer registry
           COMPARISON WITH STAGE 1:  Not included in Stage 1
'''5.  Specialized Registry Reporting'''
           STAGE 2 MEASURE:  Successful ongoing electronic submission of specific case information from the EHR to a specialized (non-cancer) registry
           COMPARISON WITH STAGE 1:  Not included in Stage 1
'''6.  Progress Notes'''
           STAGE 2 MEASURE:  Create at least 1 electronic progress note in the EHR for >30% of patients
           COMPARISON WITH STAGE 1:  Not included in Stage 1
 

'''STAGE 2 CLINICAL QUALITY MEASURES (CQMs):'''

These have changed from the current Stage 1 CQM requirements.  Currently in Stage 1, EPs have to report on 3 core CQMs.  If they are unable to report on any of these because the CQM is outside the scope of the EP’s practice, they must choose a corresponding number of additional CQMs from a list of 3 alternate core CQMs.  In addition to reporting on 3 core CQMs, the EP must also choose 3 additional CQMs from a list of 38.  The Stage 1 CQM requirements will be changing in 2014 and thereafter to match the Stage 2 requirements outlined below.
In Stage 2, the EP must report on 9 of 64 CQMs.  CMS recommends that EPs report on 9 core adult CQMs or 9 core pediatric CQMs, although this is not required.  CMS chose the recommended core CQMs based on the following criteria: conditions that contribute to the morbidity and mortality of Medicare and Medicaid beneficiaries; conditions that are public health priorities; conditions common to health disparities; conditions that disproportionately increase healthcare costs; measures that would allow quality of care to be measured in new dimensions; and measures that include patient or caregiver engagement (6).   The CQMs chosen for reporting must cover at least 3 of the National Quality Strategy domains of the Department of Health and Human Services.  These domains are:
1)	Patient and Family Engagement
2)	Patient Safety
3)	Care Coordination
4)	Population and Public Health
5)	Efficient Use of Healthcare Resources
6)	Clinical Processes/Effectiveness
Part of the reason for the increase in number of CQMs for EPs to choose from is so that there will be more of them relevant to specialist physicians.  One of the complaints lodged against the Stage 1 CQMs is that not enough of them were relevant to or reportable by specialists.  
Starting in 2014, EPs beyond the first year of demonstrating Meaningful Use will need to electronically report their CQMs to Medicare.  In addition to the current reporting by individual EPs, there will also be an option for reporting as a medical group or clinic using the Physician Quality Reporting System (PQRS) tool.  This will allow the group to meet both the Medicare EHR Incentive Program and PQRS reporting requirements at the same time (7).


'''REPORTING STAGE 2 CRITERIA AND CQMs:'''

For 2014 only, EPs only have to demonstrate meeting Meaningful Use Core and Menu Objectives as well as reporting CQMs for one quarter (3 months) of the calendar year.  This is so that EPs who have to upgrade to 2014 Certified EHR technology will have time to implement their new systems.  In order to meet Stage 2 Meaningful Use requirements, EPs will have to use EHR systems certified for 2014 standards (7).
The earliest that the Stage 2 criteria will be effective is in calendar year 2014 for EPs. Table 2 below illustrates the progression of meaningful use stages from when a Medicare provider begins participation in the program.


'''STAGE 2 TIMELINE (7):'''

Providers who were early demonstrators of meaningful use in 2011 will meet three consecutive years of meaningful use under the Stage 1 criteria before advancing to the Stage 2 criteria in 2014. All other providers would meet two years of meaningful use under the Stage 1 criteria before advancing to the Stage 2 criteria in their third year.



'''CONTROVERSIES ABOUT STAGE 2 CRITERIA:'''

The American Medical Association (AMA) and many state and specialty medical societies have submitted comments to CMS criticizing the Stage 2 criteria.  They saw them as being overly demanding and unrealistic, and putting an unreasonable burden on physicians.  They criticized the increases in the minimum thresholds necessary to meet the criteria.  They also criticized the all-or-nothing nature of the criteria, whereby if a doctor barely missed meeting even a single criterion, this would disqualify him/her from getting any EHR incentive money whatsoever, and would cause financial hardship by making it difficult for him to pay for an expensive EHR system he had already bought.  This would treat physicians who had made a good-faith effort to implement an EHR the same as ones who had made no effort.  The critics also pointed out that physicians have little or no direct control over several contingencies that determine whether they can meet some of the Stage 2 criteria.  For example, for the laboratory results objective, if the labs in the area don’t have interfaces with the physician’s EHR or other health information exchange technology, the physician cannot meet the criterion.  For the objective that at least 5% of patients view their health information electronically, and also for the one requiring that at least 5% securely electronically message their doctor, the doctor has to depend on the patient to initiate these actions.  The doctor can encourage the patients to do so, but if they ignore him, then the doctor will fail to meet the criteria and will forfeit the EHR incentive money.  The critics advocate that there should be more opportunities for physicians to get exclusions from meeting objectives such as these that they don’t have control over, and also from objectives that are irrelevant to their practice or specialty.  Another criticism of Stage 2 is that CMS and the ONC haven’t done an adequate study of Stage 1 of Meaningful Use, to determine if the objectives chosen have resulted in any improvement in the quality of care, and to see whether the objectives and criteria have discouraged some doctors from adopting EHRs because they were too rigid and burdensome (8). 
     


'''REFERENCES:'''

'''1.'''  Hitech Answers.  EHR incentive program [Online]. 2012 [cited 2013 March 8]; Available from: URL:  http://www.hitechanswers.net/ehr-incentive-program/
'''2.'''  Hitech Answers.  About the HITECH Act: HITECH Act summary [Online]. 2009 [cited 2013 March 8]; Available from: URL:  http://www.hitechanswers.net/about/about-the-hitech-act-of%202009/
'''3.'''  Centers for Medicare and Medicaid Services, Department of Health and Human Services.  Medicare and Medicaid programs; Electronic Health Record incentive program- Stage 2.  Final rule [Online]. Federal Register 2012 Sep 4;77(171), Part II.  Available from: URL: http://www.gpo.gov/fdsys/pkg/FR-2012-09-04/pdf/2012-21050.pdf
'''4.'''  Centers for Medicare and Medicaid Services, Department of Health and Human Services.  Stage 1 vs. Stage 2 comparison table for Eligible Professionals- resources for Eligible Professionals [Online]. 2012 August [cited 2013 March 8]; Available from: URL: https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage1vsStage2CompTablesforEP.pdf
'''5.'''  Don’t get too comfortable, Stage 2 Meaningful Use requirements have arrived. Michigan Medicine [serial online]2012 Sep-Oct 111(5):18-19. Available from: URL: https://www.msms.org/AM/Template.cfm?Section=Michigan_Medicine&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=22414
'''6.'''  Centers for Medicare and Medicaid Services, Department of Health and Human Services.  2014 Clinical Quality Measures tipsheet [Online]. 2012 August [cited 2013 March 7]; Available from: URL: https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/ClinicalQualityMeasuresTipsheet.pdf
'''7.'''  Centers for Medicare and Medicaid Services, Department of Health and Human Services. Stage 2 overview tipsheet [Online]. 2012 August [cited 2013 March 7]; Available from: URL: https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2Overview_Tipsheet.pdf
'''8.'''  Meaningful use stage 2: A recipe for failure. American Medical News [Online]. 2012 Jun 11 [cited 2013 March 9]; Available from: URL: http://www.amednews.com/article/20120611/opinion/306119958/4/





Submitted by Arvin Mirow, M.D.
[[Category:BMI512-WINTER-13]]