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Is the Stage 3 Proposed Rule Too Aggressive? Industry Experts React

March 23, 2015
by Gabriel Perna and Rajiv Leventhal
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After a weekend to read through the approximately 300 pages that make up the Centers for Medicare and Medicaid Services’ (CMS) proposed rule for Stage 3 of meaningful use, industry  experts are starting to share their detailed opinions on it.

Overall, the reaction to CMS’ Stage 3 proposals is mixed. While some are concerned that CMS is upping the stakes considerably and establishing a single set of objectives and measure, tailored to eligible providers (EPs), eligible hospitals (EHs), and critical access hospitals (CAHs), which will be required in 2018, others are appreciative of the elements of flexibility that exist within the rule.

Higher Thresholds

Erik Dahl, who analyzes whether or not a healthcare organization has hit on the meaningful use measures as part of his role as an IT auditor at Chan Healthcare, a consulting firm in Clayton, Mo that is a subsidiary of Crowe Horwath LLP., says it’s clear that CMS is trying to build in some flexibility, with how providers can report in 2017. For one, Stage 3 attestation is not required and for those who do attest, there are options on what certified electronic health record technology (CEHRT) can be used. However, he is concerned with some of the benchmarks that he says are “aggressive.”

Specifically, Dahl mentions the requirement from CMS that proposes 25 percent of the EH, EP or CAH’s patient view, download, or transmit their information. This is up from the 5 percent requirement in Stage 2. He says that many providers see this as something that’s beyond their control. “Can they encourage patient engagement? Absolutely. I think many providers are doing that. To jump from 5 to 25 percent…I don’t know if that’s a symptom of this being the last stage of meaningful use,” he says.

 Naomi Levinthal, consultant, research and insights at The Advisory Board Company (Washington D.C.), says that the jump from getting 5 percent of patients to view, download, and transmit their data to the proposed 25 percent threshold in Stage 3 is a “game-changer.” Levinthal calls it “overestimation of the industry’s readiness,” while Bruce Eckert, national practice director, strategic advisory group at Beacon Partners (Boston), says that while all of the early word was that there would be a big emphasis on patient engagement, the level and amount of patient engagement envisioned by the proposal surprised him.

Naomi Levinthal

Jason Fortin, senior advisor at Impact Advisors, was floored by the jump to 25 percent. He said the threshold is really high, and even a counter-balance with the use of application programming interfaces (APIs), won’t make this a realistic number for most providers. “One of out of four patients is not going to actively engage with their health record. In some communities, they might get there. In most, they won’t,” he said.

Better received is the requirement which asks providers to send a message to 35 percent of their patents, Dahl says, because it’s more in their hands. Levinthal agrees, saying, “Right now, the threshold is 5 percent, but you can’t count provider-initiated messages,” she says. “This is a great example of where the threshold is higher, but the number is actually easier to achieve. So I see it as a step in the right direction.”

However, the patient-generated health data (PGHD) requirement, which asks providers to incorporate PGHD into the EHR for 15 percent of its patients is a huge question mark for most.  “Are we really to the point where the technology is going to support that measure by 2017 and 2018?” Dahl wondered. Fortin agrees with this assessment, saying that it’s impossible to know what integration of PGHD and clinical data will look like, since it’s not a widespread capability today.

Eckert also feels it’s a stretch, despite the fact that industry is headed in a direction of more patient involvement and interaction. “These are certainly challenging percentages, though CMS has backed off some of those thresholds in years past.  There is no guarantee if that this time though,” says Eckert. “Keep in mind that policymakers are looking ahead to 2018, so it’s a ways out in the future, and they want to intentionally making it challenging to help drive the industry towards more patient involvement. Technology is also evolving that way. But this percentage seems like it’s one of those that’s too much, too soon,” he says. Levinthal adds that it seems like the thresholds are “a huge step forward instead of just a little step forward.”

Bruce Eckert

The health information exchange measures require providers to include a summary of care record and an electronic exchange of the summary of record in their EHR for 50 percent of referred patients or higher; an electronic summary of care document to be incorporated into the EHR for 40 percent of patient being referred; and clinical information reconciliation for 80 percent of patients or higher. Dahl predicts these “aggressive” thresholds will be an area of concern for most providers.

On the positive side of interoperability, CMS was applauded for including open APIs as a requirement for 2015 CEHRT. “With this rule, members of Premier remain hopeful that we will finally create strong policies that incent use of standard APIs to enable interoperability among disparate systems in healthcare. With interoperability standards, providers will be in a much better position to manage population health across the care continuum and support advanced payment initiatives such as shared savings and bundled payment,” stated Amanda Forster, vice president of public relations, at Premier, the Charlotte-based group purchasing organization.




Some may think Stage 3 is tough on provifers, but even tougher is the vendor certification requirements. In fact there a few new tests (or test components) that don't seem to be related to provider MU attestation but sustem developers will still need to comply to get products certified.