Meaningful Use Stage 3 Proposed Rule Detailed

The proposed rule aims "to create more transparency on cost and quality information, bring electronic health information to inform care and decision making, and support population health," says HHS Secretary Sylvia M. Burwell.

The Centers for Medicare & Medicaid Services on Friday afternoon released the proposed rule for Stage 3 of Meaningful Use.

The agency, in a media statement announcing the move, said the proposed rules "will give providers additional flexibility, make the program simpler, and drive interoperability among electronic health records, and increase the focus on patient outcomes to improve care."

"The flow of information is fundamental to achieving a health system that delivers better care, smarter spending, and healthier people," said US Department of Health and Human Services Secretary Sylvia M. Burwell in a statement. "The steps we are taking today will help to create more transparency on cost and quality information, bring electronic health information to inform care and decision making, and support population health."

The announcement was accompanied by the release of two documents: a 301-page proposed rule on requirements for hospitals and providers, and a 431-page proposed rule on new 2015 Edition EHR certification requirements. Public comment on both proposals is due by May 29.

Under the proposed rules, eligible professionals, eligible hospitals, and critical access hospitals would have to meet new criteria to qualify for Medicaid EHR incentive payments. Providers would also be required to meet new criteria to avoid Medicare payment adjustments based on program performance beginning in payment year 2018.

"This Stage 3 proposed rule does three things: it helps simplify the Meaningful Use program, advances the use of health IT toward our vision for improving health delivery, and further aligns the program with other quality and value programs," said Dr. Patrick Conway, MD, CMS acting principal deputy administrator and chief medical officer. "And, in an effort to make reporting easier for health care providers, we will be proposing a new Meaningful Use reporting deadline soon."

"ONC's proposed rule will be an integral component in the shared nationwide effort to achieve an interoperable health system," said Karen DeSalvo, MD, national coordinator for health IT. "The certification criteria we have proposed in the 2015 Edition will help achieve that vision through provisions that consider the range of health IT users and uses across the care continuum, including those focused on interoperable standards, data portability, improved transparency, privacy and security capabilities, and increased oversight through ONC's Health IT Certification Program."

Since the Meaningful Use program began in 2011, more than 433,000 eligible professionals and eligible hospitals, representing about 60% of eligible professionals in either the Medicare or Medicaid programs and about 95%of eligible hospitals, have received an incentive payment.

The Stage 3 proposed rule's scope is generally limited to the requirements and criteria for Meaningful Use in 2017 and subsequent years. CMS is considering additional changes to Meaningful Use beginning in 2015 through separate rulemaking.

Among the highlights of the proposed Meaningful Use Stage 3 rule:

• Starting in 2018, all providers will report on the same definition of Meaningful Use at the Stage 3 level, regardless of their prior participation.
• While Stage 3 will be the final Meaningful Use stage, ONC and CMS will continue to modify the program's requirements in subsequent years to achieve further aims of the program.
• Starting in 2017, hospitals and providers will attest on a calendar year reporting period. Currently, hospitals attest on a fiscal year reporting period. CMS says the change will simplify reporting. The agencies may still require hospitals to report in the October 1–December 31, 2016 period "depending on future rulemaking."
• Starting with Stage 3, providers are being required to implement five clinical decision support interventions related to four or more quality measures and report that as part of their Meaningful Use attestations. Such reporting is consistent with the intent of Stage 3 to move beyond process compliance toward improving clinical outcomes, using the care coordination and health information exchange technology made possible in Meaningful Use certified products.
• The proposed rule will further align Meaningful Use with other CMS quality reporting programs that use certified EHRs, such as Hospital Inpatient Quality Reporting (IQR) and the Physician quality Reporting System (PQRS).
• Medicaid providers demonstrating Meaningful Use for the first time will be able to report in any continuous 90-day period, instead of reporting in a calendar quarter.
• Providers may remain on 2014-Edition certified EHRs through 2017. If they wish, they may opt to move to 2015-Edition certified EHRs for the 2017 calendar year in order to begin attesting for Stage 3 a year early, while others opt to remain at Stage 2 in 2017. In 2018, Stage 3 attestation would be mandatory for all.
• While many menu options in Stage 2 become mandatory in the proposed Stage 3, numerous recommendations in the proposal provide various circumstances where providers may skip or fail certain objectives and still avoid certain downward payment adjustments.
• Responding to criticisms of Stage 2's requirement that patients need to view or download health records via patient portals, the agencies propose to certify certain application program interfaces (APIs) for certified EHRs which will enable patients to use third-party applications, such as PHRs, to view and download their medical record data, and thus allow providers to fulfill these requirements that way as well as via portals.

Critical and Cautious Reaction
While the weekend left little time for interested organizations to fully evaluate proposed rule, early reactions sounded a cautionary tone.

"They've kind of thrown the gauntlet down and said everybody will be there by 2018," says Russ Branzell, chief executive officer of the College of Healthcare Information Management Executives (CHIME). "The question is then, if you're delayed or you've had other problems or conversions, can people really make it? I'm mostly talking about the providers, not the hospitals. Can they really make it to Stage 3 by 2018? Or will they just give up, which we saw some pretty serious indications of giving up the last fiscal year for everybody."

Still, Branzell praises some flexibility introduced by the Stage 3 proposal. "You don't have to use a specific way of reporting transitions of care [and] coordination of care." He cites the failure of many public health information exchanges, despite five years of funding and development, as a reason for providing more flexibility on Meaningful Use's interoperability requirements.

In a statement, the American Medical Association said it is evaluating the proposed rules. The organization "hopes that policymakers have included recommendations from our blueprint to improve the Meaningful Use program for patients and physicians," said president-elect Steven J. Stack MD. "This includes making the program more flexible, removing requirements that are making it difficult for physicians to successfully participate, and increasing focus on the functional interoperability of EHRs. We want to see this program succeed and will continue ongoing dialogue with policymakers to ensure Meaningful Use delivers intended advances in patient care and practice efficiencies."

The American Hospital Association is taking a more negative stance.

"Hospitals are implementing electronic health records at a brisk pace in order to improve patient health and healthcare, but they must do so under the crushing weight of government regulations," stated Linda E. Fishman, AHA senior vice president of public policy analysis and development.

The proposed rule "demonstrates that the agency continues to create policies for the future without fixing the problems the program faces today," Fishman stated. "In January, CMS promised to provide much-needed flexibility for the 2015 reporting year, which is almost half over. Instead, CMS released Stage 3 rules that pile additional requirements onto providers. It is difficult to understand the rush to raise the bar yet again, when only 35% of hospitals and a small fraction of physicians have met the Stage 2 requirements."

AHA and CHIME urged CMS to release the 2015 flexibility rules immediately. Those rules, which CMS officials indicated are being written, would shorten the 2015 fiscal year reporting requirements for Meaningful Use from 365 days to 90 days.

The American College of Cardiology, in a statement, took issue with the proposed move to have all providers in 2018 start with Stage 3-level reporting, even if it was their initial year of participation.

"Implementing an EHR system in a physician practice or a hospital is not as simple as flipping a switch; it takes time, financial investment, careful consideration and planning, as well as education for all staff," said Kim Allan Williams Sr., MD, president of the 49,000-member medical society. "The program must take this learning curve into consideration."