The Centers for Medicare and Medicaid Services (CMS) on April 10 released a proposed rule aligning Stage 2 of the Electronic Health Record (EHR) Incentive Program, with the recently proposed Stage 3 rule. The Stage 2 rule contains the proposed criteria that eligible professionals, eligible hospitals and critical access hospitals would need to meet in order to qualify for EHR incentive payments and avoid penalties for non-participation. In this newly proposed rule CMS attempts to reduce the reporting burden, eliminate redundant and duplicative reporting, better align the objectives and measures of meaningful use, and focus Stages 1 and 2 of the EHR Incentive Program on advanced use of EHR technology.  Most notably, this proposed rule would change the Medicare and Medicaid Incentive Program reporting period in 2015 to a 90-day period aligned with the calendar year rather a full-year reporting period, which the ACC has called for in numerous letters to the federal government. Public comments on the proposed rule are due to CMS by June 15. The ACC is working with members to develop a response and intends to submit comments by the deadline. The ACC has online resources available for Stage 1 and Stage 2.

This proposal to modify Stage 1 and Stage 2 comes on the heels of a proposed rule outlining Stage 3, the proposed final stage, of the program. CMS stated that the analysis conducted during the planning process for Stage 3 provided insights on progress towards program milestones and overall performance on Stage 1 and Stage 2 objectives and measures. This analysis prompted CMS'response to stakeholder concerns about program complexity and reporting burdens. Because of this, CMS is proposing a number of changes to both the EHR reporting period and the overall construct of the program, and allows for an easier transition from Stage 1 or Stage 2 to Stage 3 of the program.

Reporting Periods

For 2015, eligible professionals would be allowed to attest to an EHR reporting period of any continuous 90-day period within the calendar year. CMS states that this 90-day EHR reporting period for 2015 would allow providers additional time to address any remaining issues with the implementation of technology certified to the 2014 Edition and to accommodate the changes to the objectives and measures of meaningful use proposed in this rule.

All providers would move to an EHR reporting period based on the calendar year beginning in 2015 and continuing through 2016 onward. This aligns with the provision outlined in the Stage 3 proposed rule to move all providers to an EHR reporting period of one full calendar year beginning in 2017 with a limited exception for Medicaid providers demonstrating meaningful use for the first time.

In 2016, CMS is proposing that eligible professionals, eligible hospitals and Critical Access Hospitals that are demonstrating meaningful use for the first time may use an EHR reporting period of any continuous 90-day period during the 2016 calendar year. However, all returning participants would use an EHR reporting period of the full 2016 calendar year. In 2017, all providers, both new and existing participants, would use an EHR reporting period of one full calendar year as proposed in the Stage 3 proposed rule.

CMS'proposed rule would also apply for the Medicaid EHR Incentive Program, including the proposed changes to the EHR reporting period in 2015 and 2016, and the objectives and measures required to demonstrate meaningful use in 2015 through 2017.

Clinical Quality Measures

In 2015 (and for providers demonstrating meaningful use for the first time in 2016) providers may attest to any continuous 90-day period of clinical quality measure (CQM) data during the calendar year through the Medicare EHR Incentive Program registration and attestation site; or electronically report CQM data using the established methods for electronic reporting. In 2016 and subsequent years, providers beyond their first year of meaningful use may attest to one full calendar year of CQM data or they may electronically report their CQM data using the established methods for electronic reporting.

Program Structure Modifications

CMS is proposing to require all providers to attest to a single set of objectives and measures beginning with an EHR reporting period in 2015. These objectives and measures would leverage existing objectives and measures of meaningful use. Since this change may occur after providers have already begun their work toward meeting meaningful use in 2015, the agency is proposing accommodations within individual objectives for providers in different stages of meaningful use, including retaining the different specifications between Stage 1 and Stage 2.

The following is a list of objectives and measures from meaningful use Stages 1 and 2 that CMS has identified as either redundant, duplicative or topped out:

Eligible Professionals	Eligible Hospital/Critical Access Hospital
Record Demographics	Record Demographics
Record Vital Signs	Record Vital Signs
Record Smoking Status	Record Smoking Status
Clinical Summaries	Structured Lab Results
Structured Lab Results	Patient List
Patient List	Summary of Care (Measure 1—Any Method; Measure 3—Test)
Patient Reminders	eMAR
Summary of Care (Measure 1—Any Method; Measure 3—Test)	Advanced Directives
Electronic Notes	Electronic Notes
Imaging Results	Imaging Results
Family Health History	Family Health History
	Structure Labs to Ambulatory Providers

CMS notes that many of these objectives and measures include actions that may be valuable to providers and patients and the agency encourages providers to continue to conduct these activities if it suits their practice and the preferences of their patient population. The agency insisted that the removal of these measures is in no way intended as a removal of endorsement of these best practices or to discourage providers from conducting and tracking these activities for their own quality improvement goals.

CMS is proposing that the structure for Meaningful Use for 2015 through 2017 would be nine required objectives for eligible professionals using Stage 2 and eight required objectives for eligible hospitals and critical access hospitals using Stage 2, with alternate exclusions and specifications for Stage 1 providers in 2015.

The current stage structure, retained objectives, and proposed structure is as follows:

	Current Stage 1 Structure	Retained Objectives	Proposed Structure
Eligible Professional	13 core objectives 5 of 9 menu objectives including 1 public health objective	6 core objectives 3 menu objectives 2 public health objectives	9 core objectives 1 public health objective (2 measure options of 5)
Eligible Hospital/Critical Access Hospital	11 core objectives 5 of 10 menu objectives including 1 public health objective	5 core objectives 3 menu objectives 3 public health objectives	8 core objectives 1 public health objective (3measure options of 6)
	Current Stage 2 Structure	Retained Objectives	Proposed Structure
Eligible Professional	17 core objectives including public health objectives 3 of 6 menu objectives	9 core objectives 0 menu objectives 4 public health objectives	9 core objectives 1 public health objective (2 measure options)
Eligible Hospital/Critical Access Hospital	16 core objectives including public health objectives 3 of 6 menu objectives	7 core objectives 1 menu objective 3 public health objectives	8 core objectives 1 public health objective (3 measure options)

The proposal eliminates the distinction between core and menu objectives, and further proposes that all retained objectives and measures would be required for the program. The now required objectives from Stages 1 and 2 are:

• Stage 1 Menu (all): Perform Medication Reconciliation
• Stage 1 Menu (all): Patient Specific Educational Resources
• Stage 1 Menu (all):  Public Health Reporting Objectives (multiple options)
• Stage 2 Menu (Eligible Hospitals and Critical Access Hospitals Only): Electronic Prescribing

The proposed changes to individual objectives and measures for Stage 2 of meaningful use are summarized as follows:

• Changes the threshold from the Stage 2 Objective for Patient Electronic Access measure number 2 from "5 percent" to "equal to or greater than 1".
• Changes the threshold from the Stage 2 Objective Secure Electronic Messaging from being a percentage-based measure, to yes/no measure stating the "functionality fully enabled".
• Consolidates all public health reporting objectives into one objective with measure options following the structure of the Stage 3 Public Health Reporting Objective
• Changes the eligible hospital electronic prescribing objective from a "menu" objective to a mandatory objective with an exclusion available for certain eligible hospitals and critical access hospitals

There are two objectives for eligible professionals and one objective for eligible hospitals and critical access hospitals which specifically contain measures requiring a provider to track patient action. CMS is proposing to modify these measures as follows:

• For Patient Action to View, Download, or Transmit Health Information, the proposed rule removes the 5 percent threshold from the eligible professional Stage 2 objective. Instead, the rule requires that at least one patient seen by the provider during the EHR reporting period views, downloads, or transmits his or her health information to a third party. For CMS, this would demonstrate that the capability is fully enabled and workflows to support the action have been established by the provider. This same measure applies to eligible hospitals and critical access hospitals and requires that at least one patient discharged from the hospital during the EHR reporting performs the same action.
• For secure electronic messaging using certified EHR technology, CMS is proposing to convert the measure for the Stage 2 objective from the 5 percent threshold to a yes/no attestation to the statement: "The capability for patients to send and receive a secure electronic message was enabled during the EHR reporting period.

These changes are intended to allow providers to work toward meaningful patient engagement through health IT using the methods best suited to their practice and their patient population.

Certification

This rule is not proposing changes to the individual certification requirements for the objectives and measures of meaningful use for an EHR reporting period in 2015 through 2017. Until a transition to EHR technology certified to the 2015 Edition is required (proposed in the Stage 3 proposed rule beginning with an EHR reporting period in 2018), CMS is proposing that providers would continue to use EHR technology certified to the 2014 Edition for an EHR reporting period in 2015, 2016 and 2017. As outlined in the Stage 3 proposed rule, providers may upgrade early to EHR technology certified to the 2015 Edition for an EHR reporting period prior to 2018.

Keywords: Centers for Medicare and Medicaid Services, U.S., Certification, Cost of Illness, Demography, Electronic Health Records, Family Health, Goals, Hospitals, Meaningful Use, Medicaid, Medicare, Medication Reconciliation, Motivation, Patient Participation, Public Health, Quality Improvement

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