On Oct. 6, the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) released two final rules that align all three stages of the Electronic Health Record (EHR) Incentive Program (also known as "Meaningful Use"). In addition to finalizing program requirements for the 2015-2017 reporting periods, the rules combine Meaningful Use into one single stage. According to the agencies, the alignment aims "to advance electronic health records with added simplicity and flexibility." The ACC will continue to work with CMS to determine how Meaningful Use will align with the new Merit-Based Incentive Payment System which will go into effect in 2017. Although the rules are final, the ACC is working with members to develop a response and will formally weigh in during the 60-day comment period.

The modifications to reporting years 2015-2017 and the Stage 3 rule, when proposed, were separate. With the new final rule, all providers are required to attest to a single set of objectives and measures beginning with an EHR reporting period in 2015. These objectives and measures leverage existing objectives and measures of meaningful use and the distinction between core and menu objectives was eliminated. Since this change occurred after providers began their work toward meeting meaningful use in 2015, the agency provided alternative exclusions and exclusions as accommodations within individual objectives for providers in different stages of Meaningful Use. In order to simplify the number of objectives, CMS has removed objectives and measures that the agency believes are redundant, duplicative or "topped out." With the new final rule, CMS now references the requirements for the 2015-2017 reporting period as "Modified Stage 2."

2015-2017 Objectives

1. Protect Patient Health Information
2. Clinical Decision Support
3. Computerized Physician Order Entry
4. Electronic Prescribing
5. Health Information Exchange
6. Patient Specific Education
7. Medication Reconciliation
8. Patient Electronic Access
9. Secure Messaging (eligible professionals only)
10. Public Health Reporting

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): Electronic Prescribing

CMS made two key changes to the Modified Stage 2 thresholds:

1. For Patient Action to View, Download, or Transmit (VDT) Health Information, the final rule adopts the removal of 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 in 2015 and 2016 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. For 2017 the threshold increases to more than 5 percent of unique patients.
2. For secure electronic messaging using certified EHR technology, CMS finalized converting the measure for the Stage 2 objective from the 5 percent threshold in 2015 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." For 2016, it requires at least one patient seen by the eligible professional during the EHR reporting period, a secure message was sent using the electronic messaging function of certified EHR technology (CEHRT) to the patient (or patient authorized representative), or in response to a secure message sent by the patient (or patient-authorized representative) during the EHR reporting period. For 2017 the threshold is increased to 5 percent of unique patients.

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

In order to further clarify what is required of program participants in 2015, various frequently asked questions (FAQ) documents have been released by CMS. Below are five FAQs to note:

• FAQ 12817 — Relating to Modified Stage 2's Objective 5 — Health Information Exchange — Further explains which transfers of care or referrals may be counted in the numerator for the measure when a third party is involved.
• FAQ 12821 — Relating to Modified Stage 2's Objective 8 — Patient Electronic Access (VDT) and Objective 6 — Patient Specific Education — Further clarifies how to count contributions of information to a shared portal or to a patient's online personal health record (PHR) when the patient accesses the information on the portal or PHR?
• FAQ 12825 — Relating to Modified Stage 2's Objective 8 — Patient Electronic Access (VDT) and Objective 6 — Patient Specific Education — Further clarifies which providers can include a patient portal/messaging interaction in their numerator.
• FAQ #12985 — Relating to Modified Stage 2's Objective 10 — Public Health Reporting — Further clarifies that alternate exclusions to the measures in the public health reporting objective are available for providers in 2015 based on the changes to the public health reporting objective. Providers for whom the alternate exclusion is applicable will be presented that option in the attestation system.
• FAQ 13409 — Relating to Modified Stage 2's Objective 10 — Public Health Reporting — Further clarifies how to report on the objective if the provider planned on being in Stage 1 in 2015.

A full list of finalized objectives and measures for the 2015-2017 reporting periods [PDF] is available.

Stage 3
Stage 3 is the last stage of Meaningful Use and its requirements are optional in 2017 and mandatory for all participants in 2018, regardless of when they started the program. The pass/fail approach of the program remains; however, the core and menu set structure is removed and replaced with objectives and measures. CMS identified key policy areas representing advanced use of EHR technology that align with the foundational goals such as those in the CMS National Quality Strategy. The eight objectives are:

• Protect Electronic Health Information
• Electronic Prescribing
• Clinical Decision Support
• Computerized Provider Order Entry
• Patient Electronic Access to Health Information
• Coordination of Care through Patient Engagement
• Health Information Exchange
• Public Health Reporting

In the above list, eligible professionals are required to attest to the numerators and denominators of all measures associated with an objective; however, for certain objectives physicians only need to meet the thresholds for some of the measures. These objectives include:

• Objective 6 — Coordination of Care through Patient Engagement — providers must meet the threshold for two out of the three measures
• Objective 7 — Health Information Exchange — providers must meet the thresholds for two out of the three measures
• Objective 8 — Public Health Reporting — eligible professionals must report on three measures and eligible hospitals (EHs)/critical access hospitals (CAHs) must report on four measures

The Stage 3 measures include drastic increases which prove difficult to meet come 2018. These measures require that:

• 80 percent of patients be provided access (via view/download/transmit or an application programming interface) to their electronic health information
• 35 percent of patients be provided patient-specific educational resources and electronic access to those materials
• 10 percent of patients actively engage with the EHR
• A secure message was sent for 25 percent of patients
• Patient generated health data or data from a non-clinical setting is incorporated into the CEHRT for more than 5 percent
• For more than 40 percent of transitions or referrals received and patient encounters in which the provider has never before encountered the patient, the eligible professional, EH or CAH receives or retrieves and incorporates into the patient record an electronic summary of care document
• For more than 80 percent of transitions or referrals received and patient encounters in which the provider has never before encountered the patient, the eligible professional, EH or CAH performs a clinical information reconciliation

A full list of finalized objectives and measures for Stage 3 Meaningful Use [PDF] is available.

2015 CEHRT Rule
The ONC rule focuses on enabling interoperability, as well as a more flexible certification program that supports developer innovation and provides access to data in an actionable format. The rule also intends to facilitate the accessibility and exchange of electronic health information by including enhanced data portability, provider directories, testing conformance to health IT standards, transitions of care, and API capabilities (which is expected to improve interoperability as well as access to data in an actionable format) as part of the 2015 Edition Base EHR definition. ONC's rule also suggests new and updated vocabulary and content standards for the structured recording and exchange of electronic health information.

Patient safety is also emphasized in the rule by applying enhanced user-center design principles to health IT; enhancing patient matching; requiring relevant electronic health information to be exchanged (i.e., unique device identifiers); improving the post-market surveillance of certified health IT; public disclosures for product costs, such as implementation and use; and making more information about certified products publicly available and accessible (including improvement in the Certified Health IT Product List). ONC has also increased the transparency requirements vendors must follow regarding the functionalities and design limitations of their products. In addition, the rule makes the privacy and security of data and personal health information a priority, by ensuring relevant privacy and security capabilities and by addressing the exchange of electronic sensitive health information through the Data Segmentation for Privacy standard.

Keywords: Centers for Medicare and Medicaid Services, U.S., Certification, Decision Support Systems, Clinical, Disclosure, Electronic Health Records, Electronic Prescribing, Health Records, Personal, Meaningful Use, Medicaid, Medical Informatics, Medical Order Entry Systems, Medicare, Medication Reconciliation, Patient Participation, Patient Safety, Privacy, Public Health, Referral and Consultation

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