During an Oct. 29 webinar that reviewed the recently-released final rules of the meaningful use program, Centers for Medicare & Medicaid Services (CMS) Policy Lead for the program, Elisabeth Myers, provided some clarity on specific issues that have seemed to confuse the industry in recent weeks.
The session, hosted by Ann Arbor, Mich.-based College of Healthcare Information Management Executives (CHIME), focused mostly on the program’s Stage 2 modification rules from 2015-2017. Per the CMS final rules, eligible healthcare professionals can begin Stage 3 of the program in 2017, though they are required to start that stage in 2018.
With the release of the final rules earlier this month, industry stakeholders were most pleased that CMS adopted a 90-day reporting period for the current stages of the program, down from 365 days which was originally proposed. Indeed, in 2015, all providers can attest to an electronic health record (EHR) reporting period of any continuous 90-day period within the calendar year (hospitals have a 15-month period). In 2016, first-time participants may use an EHR reporting period of any continuous 90-day period between Jan. 1 and Dec. 31, 2016, though all returning participants must use the EHR reporting period of a full calendar year. Then, 2017 begins the optional Stage 3 year; providers who choose Stage 3 in this year may use a 90-day reporting period. “We are trying to make 2017 the transitional year with as much flexibility as we can,” Myers said.
Myers then went through the objectives for the Stage 2 modification rules, highlighting key changes from what was proposed that providers should be aware of. For one, Myers made note that e-prescribing is now a requirement for providers rather than just a menu objective. However, according to the rules, she added, there is an exception for Stage 1 eligible hospitals and critical access hospitals (CAHs) in 2015 and 2016. “We got feedback that there were issues in getting the technology in place and in time safely. That was a big red flag,” Myers said.
What’s more, for the health information exchange (HIE) objective, the modifications rule for 2016-2017 reads: “The eligible hospital or CAH that transitions or refers their patient to another setting of care or provider of care must— (1) use certified EHR technology (CEHRT) to create a summary of care record; and (2) electronically transmit such summary to a receiving provider for more than 10 percent of transitions of care and referrals. Clearing up any confusion, Myers said that the above is all one measure, not separate ones.
“We are just trying to clarify that you are creating a CCDA [Consolidated Clinical Document Architecture] and sending it electronically,” Myers said. “A certified EHR definitely allows for a broader range of mechanism, and we are trying to expand that further [by allowing] a secure email or a secure messaging function. You still have to create a document and submit it electronically, though.” By transmitting the CCDA electronically, Myers continued, there could be a third party that converts that summary of care document into another format. “We recognize there are problems on the other end at times, so a third-party party conversion mechanism is acceptable,” Myers said.
Another point of confusion after the final rules came out had to do with the patient electronic access objective, particularly around the second measure, which in 2015 and 2016, requires at least one patient to view, download or transmit (VDT) his or health data. This threshold increases to 5 percent in 2017, and 10 percent for Stage 3. This signals a change from the proposed rule, which had the threshold increase from 1 single patient to a lofty 25 percent in Stage 3. Many patient engagement supporters took issue with the proposed rule, asserting that requiring just one patient to VDT his or her health data is not nearly enough, and then jumping up to 25 percent, as was proposed, is too big a leap.
As such, Myers said that due to stakeholder feedback, in particular CHIME’s recommendations, CMS opted for a “phased-in approach.” Myers explained the agency’s thought process: “We thought this measure might need more time to mature, as well as the technology adoption rate needing more time to get saturated. We do believe that a provider influences that behavior, but statistics are showing that’s not only factor at hand. There is an adoption issue among patients as well,” she said.
Regarding the public health reporting objective, Myers said lots of stakeholder feedback was generated during the comment period, resulting in CMS making changes to the proposed rule. For years 2015-2017, the public health objective was narrowed down to four measures: immunization registry reporting; syndromic surveillance reporting; specialized registry reporting; and electronic reportable laboratory result reporting (for eligible hospitals/CAHs only).
For specialized registry reporting, Myers said that CMS found that there might be viable reasons why an eligible provider or critical access hospital might not be able to report. As such, she said, in two specific instances, providers can claim exclusion. One involves checking with your state to see if there is an endorsed registry available to report to. If not, an exclusion claim is acceptable. The second instance would involve checking with any national society you are a member of. If there isn’t an endorsed registry available there, you can claim exclusion. “Until we get to point where we have a useful and viable registry, it can really hard on providers to go out and find one,” Myers said.
Additionally, Myers did clear up one grey area regarding Stage 3. With the release of the rules on Oct. 6, CMS announced a 60-day public comment period to facilitate additional feedback about Stage 3 going forward, in particular with regards to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) that requires the establishment of a Merit-based Incentive Payment System (MIPS) and consolidates certain aspects of a number of quality measurement and federal incentive programs for Medicare physicians and other providers into one framework. There was some speculation about what that comment period was actually for and if the Stage 3 rule was indeed final. Myers said that despite the additional comment period, the Stage 3 rule is absolutely final; the comments from stakeholders will be addressed for future rules such as MACRA/MIPS.
This could be disconcerting to some providers, many who have thought that CMS set the bar too high with certain Stage 3 measures. For one, Pam McNutt, senior vice president and CIO of Dallas, Texas-based Methodist Health System, and a CHIME member who was part of the webinar, said that she continues to comment about how difficult it is for providers to be held accountable for the actions of others. “In Stage 3, providers are going to be held even more accountable for others’ actions when you have things such as patients entering data and having more access to portals,” she said. “And with transitions of care, you have to rely on providers on the other end viewing and doing things with the data. It’s not fair to hold providers accountable for others’ actions. I am disappointed that bars have been set extremely high for Stage 3. It’s a big leap from Stage 2, which has been gratefully reduced [from what was proposed],” McNutt said.