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First Look at CMS' Meaningful Use Rule

December 31, 2009
by David Raths
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New Year’s Eve probably isn’t the best time to do a thoughtful analysis of a new 556-page proposed rule from the Centers for Medicare and Medicaid Services and a 136-page interim final rule from the Office of the National Coordinator for Health Information Technology. But since the HHS offices met their deadline of publishing the rules before the end of the year, I thought it would be worthwhile to offer a first impression of what stands out as new and significant. No doubt, the publications will be fodder for further debate early in 2010.

I think the most important thing to look at is how the CMS proposed rule governing the EHR incentive programs differs from the Health IT Policy Committee’s recommendations for providers and hospitals to meet meaningful use Stage 1 guidelines in 2011.

First, however, it is interesting to note that CMS is proposing that the earliest start date for EHR reporting period be the first day of the payment year. (It could have allowed an EHR reporting period to begin as early as July 3, 2010. That would have allowed an eligible hospital to successfully demonstrate meaningful use on Oct. 1, 2010, the first day of fiscal 2011. But because the final rule won’t be published until after March 2010, with the final rule effective 60 days after its publication, CMS decided this did not allow enough time for HHS, the vendor community, or the provider community to take advantage of an earlier start date.)

Now, on to some highlights of the ways the CMS rule follows and ways it differs from HIT Policy Committee recommendations. First, it specifies percentage target measures for each meaningful use criterion. As the CMS document notes, “The HIT Policy Committee did recommend some measures; however, they did not explicitly link each measure to an objective. Therefore, the proposed measures set forth below are a significant departure from the recommendation of the HIT Policy Committee.”

• CMS requires 80 percent CPOE use in Stage 1 by providers but only 10 percent by hospitals, the latter measure recommended by the policy committee. CMS also proposes that for Stage 1, the definition of CPOE will not include the electronic transmittal of orders to the pharmacy, laboratory, or diagnostic imaging center.

• CMS proposed to drop the Policy Committee’s recommendation to include “Record advance directives” as an objective of the Stage 1 criteria of meaningful use.

• CMS will not propose including the objective “Document a progress note for each encounter.” It states: “Documentation of progress notes is a medical-legal requirement and a component of basic EHR functionality, and is not directly related to advanced processes of care or improvements in quality, safety, or efficiency.”

• The HIT Policy Committee suggested that providers implement one clinical decision support rules relevant to specialty or high clinical priority. CMS has bumped that number up to five clinical decision support rules.

• At least 50 percent of all clinical lab tests results ordered by a provider or by an authorized provider of the eligible hospital must be incorporated into an EHR as structured data. CMS says it invites comment on whether this 50 percent is feasible for the Stage 1 criteria of meaningful use. (I have heard many people express concern about this one.)

• I have written before that there is quite a divergence of opinion about whether making data available to patients should be part of Stage 1. The policy committee recommended that it should be and CMS agreed. Its Stage 1 measure: 80 percent of all patients who request an electronic copy of their health information are provided it within 48 hours. Hospitals will have to get their patient portal projects revved up.

The ONC’s interim final rule makes for interesting reading, too. I’ll just note a few things here having to do with certification. First, ONC had started down the road of identifying how certifying bodies other than CCHIT could be recognized. Now it has decided to proceed with a separate notice and comment rulemaking early next year to establish the policies for the certification of HIT and the process a certification body will need to follow to become an authorized certification body, as determined by ONC.

ONC also noted that it would have to become flexible in its certification to take into account certifying EHR Technology assembled from swappable “EHR modules,” such as those designed to enable electronic health information exchange.

Another change is that ONC will require certified EHR technology to be capable of encryption.

There’s much more to both documents, and I will be writing more next week. It will be interesting to see the public comments roll in as well. Happy New Year!

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