In 2010 the Centers for Medicare and Medicaid Services (CMS) established incentive programs to encourage eligible professionals and hospitals to implement health information technology. The primary focus of these programs is the implementation of electronic health record systems and their "meaningful use" (MU). This multi-year program will roll out in several phases, or "stages." Stage 1 meaningful use is defined by the Medicare and Medicaid Programs Electronic Health Record Incentive Program Final Rule (July, 2010). A Correcting Amendment was issued to fix a set of typographical errors (December, 2010). That rule is supported by a Final Rule for Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology (July, 2010).
A critical component of the CMS Rule is a set of public health objectives related to reporting, with corresponding measures and standards, which eligible professionals and hospitals will be expected to support if the public health agencies in their jurisdictions are capable of exchanging data electronically. Each of the Stage 1 public health objectives is discussed in detail on a separate page accessible from the links to the right.
Here are some additional important facts about Stage 1:
- EPs can participate in either the Medicaid or Medicare EHR incentive program, but not both (though they can switch once); eligible hospitals may participate in both.
- The reporting year schedule and timetable is complicated - it differs for the two programs, and for EPs and hospitals.
- For the Medicaid incentive program, participants need only demonstrate in the first year that they have adopted, implemented, or upgraded certified EHR technology through self-attestation. Achievement of Meaningful Use can be a substitute for this attestation but this is not required in the first year. From a public health agency's standpoint, this means that EPs may defer their testing and submission of public health data to the second year. However, for the Medicare incentive program, participants must achieve Meaningful Use for a consecutive 90 day period within the program year (calendar year for EPs; Federal FY for hospitals), including the first year of the program.
- For the Medicaid incentive program, state Medicaid offices have some flexibility to define the terms of their program, both more stringent (e.g., define specific requirements for certain reporting) and less stringent (e.g., define exemptions for certain reporting). See your state Medicaid office website for more details.
- Unsuccessful tests of interoperability still qualify EP/hospitals for meaningful use, however an unsuccessful test needs to be re-attempted in the second year. A successful test does not need to be re-attempted even if the public health agency has not yet allowed the EP/hospital to begin routine submission of data.
- If there are multiple EPs in an organization using the same EHR system, only one interoperability test needs to be performed to qualify the entire organization at each location where the organization operates.
- Regional Extension Centers (REC) should be encouraged to include appropriate interfaces to public health in any negotiated EHR system vendor contracts, and RECs should provide clear documentation of public health interface and data transport requirements.
Stage 2 Meaningful Use
In August, 2012, CMS released the Final Rule for Stage 2 Meaningful use, and ONC released a corresponding Final Rule for the related standards and implementation specifications. Here are some highlights:
- Any proposed changes to the three Stage 1 objectives are included on their respective pages (links are to the right).
- The implementation of Stage 2 criteria is being delayed a year until 2014, with a three month reporting period for Stage 2 compliance.
- State Medicaid programs have some flexibility with respect to public health measures so long as they do not require EHR functionality that is not already required. For example, states can move measures from the Menu Set to the Core Set, or make a measure more stringent, with CMS permission.
- Two additional public health measures - the capability to identify and report cancer cases or cases to a specialized registry other than cancer - were added to the menu set for EPs but not EHs.
- CMS added the phrase "except where prohibited" to ensure that the objectives persist even where not required by a jurisdiction, so long as they are not prohibited.
- If an EP/EH meets the criteria for exclusion from a public health menu set measure, the item no longer counts towards the number of menu set items necessary to meet meaningful use.
- A failed test will no longer meet the respective objective.
- While no specific transport methods are proscribed for public health measures, the rule states that EPs and EHs will be expected to use the transport means stipulated by the public health agency to which they report. Public health agencies can require a transport mechanism that is not found in the ONC Final Rule (namely Direct and/or SOAP-based web services as defined by the NwHIN project).
- Public health agencies are now expected to provide documentation (does not have to be a "letter" but can be any "written communication" including electronic communications) to EPs and EHs affirming their ability to successfully submit data to be used during attestation.
- CMS anticipates creating a "centralized repository" of public health agencies and the status of their capability to receive ongoing submissions of public health data. Public health agencies will need to make sure that their capability to receive data is documented in this repository - failure to do so will allow EPs and EHs to claim exclusion from public health measures.
- Though HL7 v2.3.1 will no longer be supported for certification of EHR technology, an EP or hospital which used it for Stage 1 will be able to continue to use it in Stage 2 for ongoing immunization or syndromic surveillance submission if the public health agency continues to accept it.
- Since public health objectives are now found in both the Core Set and Menu Set, the specific requirement that a public health objective be included in Menu Set selection has been dropped.
- Exclusions from public health measures have been further clarified (see individual pages).
- The nature of "ongoing submission" has been further clarified to include registration by the EP/EH with the public health agency within 60 days of the start of the reporting period and active participation in on-boarding requirements of the agency. Once that is completed, submission of data during normal business operations must continue through the reporting period.
- EPs can now include unpaid claims in their calculation of eligibility, so it may be easier for public health agencies who do not bill Medicaid or Medicare for services to become eligible for the program.