Wednesday, July 14, 2010

Summary of Meaningful Use Incentives Changes

I finished my review of the Meaningful Use Incentives rule. My review was focused specifically on how the measures in that rule are tied to the standards rule (which I reviewed yesterday here), and so I only had to read about 250 of the 864 pages. I specifically did not cover quality measures, or many of the administrative details.  I also do not go into detail on the percentage measure revisions, or into the quality measures.  If you are looking for other details such as these, I recommend that you read the article in the New England Journal of Medicine, John Halamka's summary, Inga (HISTalk's) summary, or many of the other summaries available on the web.
Note that page numbers in the text below are from the PDF on display and will not correspond to the page numbers when these are finally published in the Federal Register:
  • Definitions of Certified EHR Technology and Qualified Electronic Health Record in this rule are the same as, and therefore reference the definitions of those terms in the Standards Rule (see Page 22).
  • You can stop being a meaningful user in the middle, and resume where you left off (see page 24 through 26), up until 2015. After that, all bets are off.
  • Your first reporting period is 90 days long in your first reporting year (page 28), and you start at the Stage 1 criteria for two years, then move to Stage 2 criteria (page 39). After 2014, it isn’t indicated what will be done about getting everyone to the same level of meaningful use, but that is the stated goal.
  • States are not allowed to request more stringent criteria than what can be certified in Stage 1. If you are a vender of an EHR product, you should consider certifying for optional criteria, because states would be allowed to require it for Medicaid users (page 50). Even so, if a hospital is eligible under Medicare, then it is deemed to be Medicaid eligible, even if its EHR technology does not support additional state requirements (also page 50).
  • The rule takes the approach that there are core measures which must be implemented by all, some core measures which must be implemented by all EPs, others which must be implemented by all Hospitals, and then a menu of other requirements of which some number are required to be implemented. Therefore, the incentives are no longer a set of all-or-nothing requirements. From an EHR product perspective, products will probably need to support more of the “menu” requirements because different users of those products will want to select different requirements from the “menu”.
  • Some requirements may not be applicable to a provider. Failure to meet these requirements will not go against the providers eligibility for incentive payments. However, note that the Incentives rule indicates which requirements are permitted to be treated this way (page 61 to 62).
  • The incentive eligibility has been linked to the standards rule in many places. The phrase “We further specify that in order to meet this objective and measure, [EP/Hospital/CAH] must use the capabilities Certified EHR Technology includes as specified and standards at 45 CFR 170.3XX(x).” Basically, this phrase says that to be eligible, you must use the Certified EHR Technology to meet the objective and not some other technology, and that you must do so in the way specified by the standards identified in the certification criteria.
  • Because eligibility and claims are no longer certification criteria in the Standards Final Rule, they are also no longer required to be used to obtain incentive payments.
  • The NPRM required tracking of “Insurance Type”. However, given that there are no established standards to identify types of insurance, the requirement to track this information for patients was removed from the Incentives rule.
  • The NPRM required tracking of Race and Ethnicity. The final incentives rule clarifies that this tracking should be consistent with OMB guidance for gathering information about race and ethnicity. See yesterday’s post in the Standards rule for a link to those guidelines.
  • Hospitals must capture whether or not an advance directive is available for patients over 65. This is a new requirement for the Incentives rule.
  • The use of Clinical Decision Support in the NPRM required implementation of 5 rules. This was reduced to 1 rule so that implementations could focus on good implementation of clinical decision support. The description of clinical decision support has been modified to avoid bad examples.
  • In cases where providers are required to either give patients data, or make it accessible online, the time frames have been altered. Instead of 2 or 4 days, they have been changed to business days (Monday through Friday excluding Federal and State holidays), and in one case, increased from 2 to 3 days (See page 161 and 175). In addition, it was indicated that it is not appropriate to charge patients for clinical summary provided for an office visit (Page 179) since that would be enabled by the Certified EHR Technology and should be of minimal expense to the provider (Hit the print button…)
  • Some measures included a required test (e.g., for reporting information to public health for surveillance, immunizations or lab results; or electronic exchange of data with other providers). For these measures, the test need not include actual patient data, but could use test data. Also, the test need not be “successful”. On this, my advice would be to show appropriate due diligence in your attempts to ensure that the test passes.
Finally, my last comment is simply to reiterate in my own words what I found on page 219.
Meaningful Use will not be cancelled. It is law. The regulation implements what is already required under law. For this, I’m not sorry!
Having plowed through the regulations in two days, I have to say that the final results are much improved over the original regulation text delivered earlier this year. I am pleased with the final results, and proud to have been a participant in this regulatory process. The rules are not perfect, but they are certainly good enough to provide for dramatic improvements in healthcare.

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