Stage 2 Meaningful Use: Are you ready?

According to the U.S. Center for Medicare and Medicaid Services (CMS) records, some 3,570 optometrists have attested for Electronic Health Record (EHR) Incentives totaling close to $57 million. With incentives scheduled to decline in future years and penalties kicking in for practitioners who fail to adopt and attest to Meaningful Use for EHRs, more clinicians are looking to purchase and implement such systems. The biggest question on everyone's mind is: Are you ready for Stage 2 Meaningful Use requirements in 2014?

What are the stages of Meaningful Use?

To help make adoption and use of EHRs easier, in addition to receiving incentive payments, CMS established criteria for Meaningful Use in stages. Stage 1 is the easiest level to obtain; Stage 3 will be the most difficult. Each stage has a distinct purpose with the goal of advancing the overall health of our patients.

The goal of Stage 1 is to capture health data in a coded format. Stage 2 applies the data to patient care and expands the exchange of information between providers and other healthcare entities. Finally, Stage 3-the exact measures are still in preliminary stages-will focus on Clinical Decision Support (CDS) application during point of care to help improve healthcare outcomes and provide patients with self-management tools and their comprehensive health data.

The stage that a practice should be following depends on when a practice installed and first attested to using its EHR system. Up through 2013, all practices, whether on an existing EHR system or a new installation, are in Stage 1. The only difference is the length of time required to attest-90 days for practices just installing and attesting for the first time, or the entire calendar year for those practices that already attested to Meaningful Use in a previous year. In 2014, any practice that has attested to using an EHR in 2011 or 2012 will be required to follow Stage 2 Meaningful Use criteria. Practices installing and attesting to meaningful use of EHRs in 2013 and 2014 will still be under the updated Stage 1 Meaningful Use criteria and will report on Stage 2 criteria starting in 2015. Because the entire process becomes more complicated the longer a system is installed and used, CMS recently launched an online process calculator. Practitioners can input data about when their EHR was installed and when they first attested; the Web site will calculate and display the path to Meaningful Use and stage by calendar year. Go to http://cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Participation-Timeline.html.

Why should I implement EHR and report Meaningful Use?

Currently, successful reporting and attesting to Meaningful Use criteria results in an EHR incentive payment by CMS to the eligible practitioner, based on either submitted allowable Medicare charges or standard, set payment for the Medicaid incentive pathway. This incentive disappears in 2015 and becomes a payment reduction (penalty) for practitioners not successfully reporting EHR Meaningful Use criteria. Those practitioners who don’t successfully report criteria for patients seen in 2013 will receive an automatic 1% adjustment to CMS payments in 2015. This penalty increases to 2% in 2016 and 2017, then rises to 3% in 2018. The penalties can continue to increase up to 5% if 75% of practitioners nationally are not “meaningful EHR users.” This payment adjustment will be combined with other payment adjustments for not reporting PQRS and e-prescribing.  A 1% penalty could quickly grow to 3% in 1 year if a practitioner is not performing all three things: PQRS, e-prescribing, and Meaningful Use). The other point to consider: the longer a practitioner waits to attest to Meaningful Use, the harder the staged criteria become as evidenced by the recent changes.

Stage 1 has changed for 2013

Several criteria used to meet Meaningful Use Stage 1 have been updated for 2013.

First is the objective concerning CPOE (computerized physician order entry). Practitioners may elect to use alternate reporting criteria. Typically, reporting is based on a percentage of patients for which a medication has been prescribed electronically-30% for Stage 1. Instead, practitioners can now report based on the total number of scripts created during the EHR reporting period, rather than the number of unique patients.

For the objective related to recording vital signs, there are now optional criteria that may be used in 2013 (it becomes required for Stage 1 reporting in 2014). Blood pressure must be measured only for patients aged 3 years and older, and height and weight are required reporting for patients of all ages (compared with the current verbiage of the criteria that states all three measurements are required on patients aged 2 years and older). The exclusion still applies that if all 3 measures are not relevant to a specialty, then the practitioner is not required to report on this measure. Because CMS has not specifically addressed which specialties are exempt from this reporting measure, the decision is left to the discretion of the reporting practitioner.

For physicians waiting to implement EHRs until 2014 or later, they are still under Stage 1 criteria. However, another measure changes just for this group. Current criteria for an objective require providing an electronic copy of a patient’s health information within 3 business days of request. The revised objective requires online access to a patient’s health information without request within 4 business days of the information being made available to the provider.

The remainder of Stage 1 Objectives remains unchanged.

Differences between Stages 1 and 2

There are several key differences between Stage 1 and Stage 2 criteria. First, many Stage 1 Menu objectives (for example, optional-practice picks 5 of 10 to report) become Core (mandatory) in Stage 2. Stage 1 has 15 Core Objectives, and 5 of 10 Menu Objectives were required, 1 of which had to be related to public health. In Stage 2, 17 Core Objectives will be required and 3 of 6 Menu Objectives must be reported. Many Stage 2 Menu Objectives are new.

In general, compliance with new criteria for Stage 2 requires a patient portal. Also, every EHR system must be certified for 2014 Stage 2 Objectives. As such, providers will be required to update current systems to receive this new required functionality. It will be important for practices and providers to work closely with their software vendors to ensure that each installation is current and can meet Stage 2 Objectives.

What is different about Stage 2 Objectives?

For many objectives, the percentage of patients for which a provider must meet criteria and report on increases.

• CPOE requirement increases from 30% of medications/unique patients to 60% of medications, 30% of lab, and 30% of radiology orders.

• E-Rx Objective increases from 40% of medications to 50%.

• Recording demographics spikes from 50% to 80% of unique patients.

• Recording vital signs (if not excluded) goes from 50% to 80% of unique patients.

• Recording smoking status jumps from 50% to 80% of unique patients.

• Instead of implementing only 1 Clinical Decision Support (CDS), 5 CDSs must be implemented within the EHR system.

• Clinical summaries must be provided for 50% of office visits within 1 day, decreased from 3 business days).

• 55% of lab test results must be entered; the requirement is now a Core Objective.

• Patient reminders drop from 20% to 10%, mainly because the Objective status changes from Menu to Core.

Several Objectives from Stage 1 are still present, however, they have been combined with other Core Objectives. For instance:

• Performing drug-drug and drug-allergy checks.

• Maintaining an active problem list, medication list, and medication allergy list has been combined into a single Objective.

• Performing drug-formulary checks is part of the E-Rx Objective.

New Stage 2 Objectives

Several Stage 2 Objectives and Measures will require more effort by both the physician and staff, as well as the patient.

First, besides making health information available electronically to 50% of patients within 4 business days of the information being received by the physician, 5% of unique patients, or their authorized representative, must view, download, or transmit their health information to a third party. This Objective demonstrates the need for a patient portal in which the patient’s information can be securely uploaded and accessed by the patient. This portal will also need to keep track of which patients view and then transmit information to other persons.

Next, the transition of care Objective has been modified. Not only is it a Stage 2 Core Objective, but there are additional requirements besides providing a summary of care record for more than 50% of transitions of care. For 10% of these transitions and referrals, this information must be transmitted electronically either through Certified EHR Technology (CEHRT), or through a Health Information Exchange (HIE). Further, at least one of these electronic transmissions of the summary of care record must be either between EHRs designed by different developers or a successful test with the CMS-designated test EHR.

The final new Stage 2 Core Objective is secure patient messaging. A secure message must be sent using the electronic messaging function of certified EHR technology to 5% of unique patients. This is the other Objective that would require a patient portal.

What about Stage 2 Menu Objectives?

Five of the 6 Stage 2 Menu Objectives are new. Only 3 Menu Objectives must be successfully reported. Unfortunately, starting in 2014, a Menu Objective/Measure cannot be reported as an exemption. These new Objectives are:

• Enter at least one electronic progress note created, edited, and signed by the physician for more than 30% of unique patients.

• More than 20% of all scans and tests ordered by the practitioner resulting in an image are incorporated into the EHR. Every optometrist should consider reporting this measure given the amount of tests that ODs perform, such as visual fields, corneal topographies, and OCTs.

• Have structured data entered in the EHR for one or more first-degree relatives for more than 20% of all unique patients.

• Submission of cancer case information from CEHRT to a cancer registry.

• Submission of specific case information from CEHRT to a specialized registry.

Clearly, Stage 2 Meaningful Use increases both the amount of data collected on patients and its use for communicating and coordinating care with the patient and other providers.

The corollary is that the volume of data and its management will throw a burden on the provider and his or her office staff. Ultimately, though, once EHR protocol becomes routine, patients will begin to recognize better healthcare outcomes and greater shared responsibility in their well being.ODT

Dr. McCarty is director of clinic operations, health information, and IT at SouthEast Eye Specialists in Chattanooga, TN. E-mail him at zmccarty@southeasteye.com.

The Stages of Meaningful Use

The overarching goal of Meaningful Use is to optimize patient care.

To help make adoption and use of EHRs easier, CMS established criteria for achieving Meaningful Use in stages.

• Stage 1 [Difficulty: Simple] Capturing patient health data in a coded format.

• Stage 2 [Difficulty: Moderate] Apply data to patient care and enhance information exchange between providers and other healthcare entities.

• Stage 3 [Difficulty: High] Enhance healthcare outcomes and provide patients with self-management tools and comprehensive health data.