Changes to the MeaningfulUse Incentives Stage2 Rule

As for the Standards Rule, I've gone through the Incentives rule and tried to highlight the major changes.  This time, I put the executive summary up front.

Executive Summary

• 3-month/90-day reporting period (Medicare/Medicaid) added in 2014 for Stage 1 or Stage 2 Meaningful Users to allow time for implementation.
• Hospital-based EPs can be designated non-hospital if they pay for their own EHR.
• Menu-sets objectives have to be meaningful to you, you cannot pick one just because it offers you an exclusion.
• There are hardship exceptions allowed.
• EPs in an HPSA can receive a 10% bonus payment.
• CPOE is reduced to 30% for lab and radiology (remains at 60% for meds).
• Many exceptions now include "fewer than 100 events" 
• View/Download/Transmit and Secure Messaging reduced to 5% from 10%, and exceptions given for < 3Mbs Broadband availability.
• Public Health reporting exceptions granted for lack of availability, not using the MU Standards, or not able to enroll at the start of the reporting period.
• Added Progress Note Menu objective for EPs and Hospitals.
• Added Lab Reporting Menu objective for Hospitals
• Changed EMAR to be applicable for 10% of med orders.
• Changed CDS to be 5 interventions for 4 CQMs, and allows for use of high priority conditions if those CQMs are not available.

General

They've added a 3-Month/90-day reporting period for Medicare/Medicaid providers who attest in 2014 to either Stage 1 or Stage 2.  If Medicare, the 3-month period must be aligned to a quality reporting quarter.  If Medicaid, any 90-day period will do.  Essentially, this give providers an extra 9 months to become compliant.  This change avoids creating a funnel problem according to CMS's Rob Anthony.  I agree.  It will make transitioning given the MU Stage 2 deadlines much easier for providers and for vendors trying to meet the requirements.

CMS also added a provision for a hospital-based EP (one who furnishes more than 90% of his services in an inpatient or emergency room setting), the option to request (through an administrative process) to be identified as a non-hospital-based EP if they fund the acquisition, implementation, and maintenance of their own EHR (including software, hardware and interfaces).  The HITECH Act limits who is eligible for MU under the law, and the regulations cannot change that, but this is one area where CMS has some leeway.

Beginning in 2014, an excluded menu set objective cannot be used to meet the meaningful use requirements, unless all other menu set objective can also be excluded.  You have to pick the ones you can meet, unless you cannot pick enough.

CMS added provisions and a process for hardship exceptions for certain cases.

They added a 10% incentive bonus for EPs who furnish 50% or more of there services in a Health Professional Shortage Area (HPSA) (see §495.102)

Objectives for EPs

Core Objectives for EPs

CPOE: Instead of 60% of medication, laboratory or radiology orders, it is now only 30% for lab and radiology orders (still at 60% for meds).

Formulary:  Reduced from 65% of orders to 50%.

CDS: Implement five CDS Interventions for 54 CQMs.  If 4 CQMs aren't available to the provider, then CDS must be related to high priority conditions.

Drug/Drug&Allergy Checks: Exclusion added for providers writing < 100 prescriptions.

Generate Patient Lists:  Denominator changed to patients who have had two (rather than one) or more visits in a 24 month period.

View/Download/Transmit: Changed from 10% to 5% of patients seen in the period.  Exclusion criteria changed bandwidth requirement from 4Mbps to 3Mbps.

Provide Clinical Summaries: Change 24 hours to 1 business day, and added "patient authorized representative".

Medication Reconciliation: Reduced from 65% to 50%.

Transitions of Care: Summary record provided to 50% (was 65%) of patients for transfers of care, where more than 10% are either: 1) electronically transmitted by the EHR, or 2) transmitted via an NwHIN exchange participant under NwHIN Governance rules  AND where at least one exchange is either with a different vendor, or tested using a CMS designated test EHR. Changed the exclusion to include providers to transition or refer fewer than 100 times.

Transmission of Immunization Data to Public Health:  Clarified exclusions:  Provider does not immunize, or No Immunization registry exists, or it does not use certified EHR standards, or provider cannot be enrolled at the start of the provider's reporting period.

Secure Messaging: Changed the numerator from 10% to 5%.  Added an exclusion for the case where less than 50% of patient encounters are in a county without at least 3Mbs broadband service.

Menu Objectives (Choose 3)

(Note, this isn't a complete list of menu objectives, just changes to them)

Imaging: The image and report on it are available from the EHR for more than 10% (was 40%) of tests whose results are images.  Exclusions: Now includes (A) Orders fewer than 100 tests, or (B) has no access to images at the start of the reporting period.

Submission of Syndromic Surveillance Data: Added exclusion for no agency with capability to accept the data.

Cancer Registry: Added exclusions for No agency has a registry, or they do not support the standards.

Other Registry: Added exclusions for No agency or national specialty society has a registry, or they do not support the standards.

Progress Notes:  Added a new objective for EPs:

(6)(i)  Objective.  Record electronic notes in patient records. (ii) Measure.  Enter at least one electronic progress note created, edited, and signed by an EP for more than 30 percent of unique patients with at least one office visit during the EHR reporting period. The text of the electronic note must be text-searchable and may contain drawings and other content.

Objectives for Hospitals

In general, the changes for hospitals mirror similar changes for EPs.

Core Objectives

CPOE: Instead of 60% of medication, laboratory or radiology orders, it is now only 30% for lab and radiology orders (still at 60% for meds).

CDS: Implement five CDS Interventions for 54 CQMs.  If 4 CQMs aren't available to the provider, then CDS must be related to high priority conditions.

View/Download/Transmit: Changed from 10% to 5% of patients seen in the period.  Exclusion criteria changed bandwidth requirement from 4Mbps to 3Mbps.

Transitions of Care: Summary record provided to 50% (was 65%) of patients for transfers of care, where more than 10% are either: 1) electronically transmitted by the EHR, or 2) transmitted via an NwHIN exchange participant under NwHIN Governance rules  AND where at least one exchange is either with a different vendor, or tested using a CMS designated test EHR. Changed the exclusion to include providers to transition or refer fewer than 100 times.

EMAR: Changed from EMAR is used in at least one ward during the period to EMAR is in use for more than 10% of medication orders produced.  Added an exclusion for hospitals with fewer than 10 patients per day.

Menu Objectives (choose 3)

(Note, this isn't a complete list of menu objectives, just changes to them)

Imaging: The image and report on it are available from the EHR for more than 10% (was 40%) of tests whose results are images. 

ePrescribe electronically for Discharge Rx: Added refills as well as new or changed Rx to the numerator.

Progress Notes:  Added a new objective for Hospitals:

(5)(i)  Objective. Record electronic notes in patient records. (ii) Measure. Enter at least one electronic progress note created, edited and signed by an authorized provider of the eligible hospital’s or CAH’s inpatient or emergency department (POS 21 or 23) for more than 30 percent of unique patients admitted to the eligible hospital or CAH’s inpatient or emergency department during the EHR reporting period.  The text of the electronic note must be text-searchable and may contain drawings and other content.   

Lab Reports: Added a new objective for Hospitals:

(6)(i) Objective. Provide structured electronic lab results to ambulatory providers. 

(ii) Measure. Hospital labs send structured electronic clinical lab results to the ordering provider for more than 20 percent of electronic lab orders received.