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Understanding the Meaningful Use Final Rule

By Rahul Patel
Physicians EHR, Inc

On July 28, 2010, the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator (ONC) published the Stage 1 criteria for the meaningful use final rule that is aimed to help improve health outcomes, increase safety, and contain health care costs through increased use of certified electronic health record (EHR) technology. Through this rule, providers will be eligible to receive Medicare and/or Medicaid incentive payments by displaying meaningful use of certified EHR technology. This article will elaborate mainly upon the details of the final rule, provider eligibility, and expected timeframes.

Background

Enacted as part of the American Recovery and Reinvestment Act (ARRA), the Health Information Technology for Economic and Clinical Health (HITECH) Act propels the adoption of EHRs by providing financial incentives under Medicare and Medicaid to hospitals and eligible professionals (EP) who demonstrate meaningful use of certified EHR technology. In January 2010, CMS delivered a Notice of Proposed Rulemaking (NPRM) and reviewed the over 2,000 received comments on the proposed meaningful use ruling. Along with input from federal advisory committees, these comments were given thorough consideration as the final rule was developed. On July 13, 2010, the Stage 1 criteria for the final rule was released by the CMS and ONC with publication occurring on July 28, 2010.

What is the Final Rule?

Meaningful use is built upon three pillars, as specified by ARRA: (1) the use of certified EHR technology in a meaningful manner; (2) the use of certified EHR technology for electronic exchange of health information to improve quality of health care; and (3) the use of certified EHR technology to submit clinical quality measures. These three pillars drive the approach to meaningful use which is to use data capture and sharing to advance clinical processes and ultimately improve patient outcomes.

For Stage 1 criteria of meaningful use, the originally proposed rule required that eligible professionals meet all 25 objectives (23 for hospitals) in reporting meaningful use of EHRs. The final rule relaxes the conditions some by dividing the objectives into a "core" group of required objectives and a "menu set" of objectives from which providers can choose to defer up to five (5) requirements. This approach incorporates accountability in adopting basic measures of meaningful EHR use but also maintaining flexibility to satisfy the varying needs of a provider on the path to comprehensive EHR usage. EPs will now be required to meet fifteen (15) core objectives and select (5) from the menu set. Hospitals must meet fourteen (14) core objectives and select (5) from the menu set. The deferred menu set objectives must be met to reach full meaningful use; however, a specified timetable has not yet been determined. Stage 2 and 3 of meaningful use are expected to be implemented in 2013 and 2015, respectively.

The following table, adopted from the CMS' EHR Incentive Programs website, displays the core and menu set objectives for both EPs and hospitals:

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Eligible Professionals (Physicians) CORE OBJECTIVES Computerized physician order entry (CPOE) E-Prescribing (eRx) Report ambulatory clinical quality measures Implement one clinical decision support rule Provide patients with electronic copy of health information upon request Provide clinical summaries for patients for each office visit Drug-drug and drug-allergy interaction checks Record demographics Maintain updated problem list of current and active diagnoses Maintain active medication list Maintain active medication allergy list Record and chart changes in vital signs Record smoking status for patients ages 13 and older Capability to exchange key clinical information among providers of care and patient-authorized entities electronically Protect electronic health information MENU SET (Choose 5) Drug-formulary checks Incorporate clinical lab test results as structured data Generate lists of patients by specific conditions Send reminders to patients per patient preference for preventive/follow-up care Provide patients with timely electronic access to their information Use certified EHR technology to identify patient-specific education resources and provide to patient, if appropriate Medication reconciliation Summary of care record for each transition of care or referrals Capability to submit electronic data to immunization registries/systems* Capability to provide electronic syndromic surveillance data to public health agencies*

Hospitals CORE OBJECTIVES Computerized physician order entry (CPOE) Drug-drug and drug-allergy interaction checks Record demographics Implement one clinical decision support rule Maintain updated problem list of current and active diagnoses Maintain active medication list Maintain active medication allergy list Record and chart changes in vital signs Record smoking status for patients ages 13 and older Report clinical quality measures to CMS/states Provide patients with electronic copy of health information upon request Provide patients with an electronic copy of their discharge instructions at time of discharge, upon request Capability to exchange key clinical information among providers of care and patient-authorized entities electronically Protect electronic health information MENU SET (Choose 5) Drug-formulary checks Incorporate clinical lab test results as structured data Generate lists of patients by specific conditions Record advance directives for patients 65 years or older Capability to submit electronic data to immunization registries/systems* Use certified EHR technology to identify patient-specific education resources and provide to patient, if appropriate Medication reconciliation Summary of care record for each transition of care or referrals Capability to submit electronic data to immunization registries/systems* Capability to provide electronic syndromic surveillance data to public health agencies*

*At least 1 public health objective must be selected

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Eligibility for Professionals

All eligible professionals must have a National Provider Identifier (NPI) to register via the EHR Incentive Program website. Medicare EPs must also be enrolled in the CMS Provider Enrollment, Chain and Ownership System (PECOS) to receive incentives.

The eligibility rules vary between Medicare, Medicare Advantage, and Medicaid for EPs. Given acceptable demonstration of meaningful EHR use, each eligible professional may qualify for an incentive payment even if they are a part of a group practice. However, each EP is only eligible for one incentive payment per year, regardless of how many locations they may provide services. EPs that perform greater than 90% of their services in a hospital inpatient or emergency room setting (hospital-based) will not quality for Medicare or Medicaid incentive payments.

A Medicare EP is defined as a doctor of medicine or osteopathy, doctor of dental surgery or dental medicine, doctor of podiatry, doctor of optometry or a chiropractor who is not hospital-based. Eligible professionals can participate for five (5) years through the end of the program in 2016 with the last year to begin participation in 2014.

In addition to providing at least twenty (20) hours/week of patient care services, a Medicare Advantage EP must either be employed by a Medicare Advantage organization, or employed by a partner of a Medicare Advantage organization, where they provide at least 80% of that organization's Medicare patient care services to enrollees of the MA establishment.

A Medicaid EP is defined as a physician, nurse practitioner, certified nurse-midwife, dentist, or physician assistant who provides services in a PA-led Federally Qualified Health Center or Rural Health Clinic.  Eligible professionals can participate for 6 years through the end of the program in 2021 with the last year to begin participation in 2016. To qualify for incentive payments, a Medicaid EP must not be hospital-based and must meet certain Medicaid patient volume criteria (30% or more; 20% if pediatrician).

At the Kansas City meeting of Regional Extension Centers (RECs), CMS confirmed that providers filing Medicaid as a secondary payer and meet the 30% threshold may elect to file as a Medicaid eligible provider.

For eligible professionals that practice at multiple locations, at least 50% of patient care must occur in locations where certified EHR technology is available. Meaningful use would be based only off of patient encounters that occur in these locations.

The following table, adopted from the CMS EHR Incentive Program website, displays key differences between the Medicare and Medicaid programs:

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Medicare EHR Incentive Program Can participate as soon as the federal program launches Reimbursement penalties begin in 2015 for those that do not display MU Must show MU in Year 1 Maximum incentive is $44,000.00 for EPs (up to $48,400.00 if practicing in a Health Provider Shortage Area) Uniform MU objectives

Medicaid EHR Incentive Program Can participate only if state implements No penalties Can qualify for payment for adopting, implementing, upgrading or demonstrating meaningful use of certified EHR technology in Year 1 Maximum incentive is $63,750.00 for EPs States may require additional core objectives

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Other Key Notes

Clinical Quality Measures

Eligible professionals are required to report on three (3) core clinical quality measures and select an additional three (3) clinical quality measures to report from a different set than the core list. EPs must also submit their aggregate clinical quality measure number, denominator, and exclusion data to CMS to demonstrate meaningful use.

Exclusions

Some meaningful use objectives may not apply to certain eligible professionals and such exclusions would not count against the required fulfillment of objectives. For example, chiropractors who do not e-prescribe would not be expected to meet that objective as they would not have any eligible patients.

Important Dates

Action Item	(Expected) Date
Enactment of American Recovery & Reinvestment Act (ARRA) Enactment of Health Information Technology for Economic and Clinical Health (HITECH) Act under ARRA	Feb 2009
Publication of Medicare & Medicaid Electronic Health Record Incentive Program Notice of Proposed Rulemaking (NPRM)	Jan 13, 2010
60-day comment period on NPRM	Jan 13 – Mar 15, 2010
Meaningful Use Final Rule released and published	July 2010
Begin registration for EHR Incentive Program Earliest Medicaid program launch date for participating states	Jan 2011
Incentive payments begin	May 2011
Last day for EPs to register and attest to receive incentive payment for Calendar Year 2011	Feb 29, 2012
Stage 2 of Meaningful Use expected	2013
Medicare reimbursement adjustments begin for EPs that are not compliant with meaningful use Stage 3 of Meaningful Use expected	2015
Last year to receive Medicare EHR incentive payment Last year to begin participation in Medicaid EHR Incentive Program	2016
Last year to receive Medicaid EHR incentive payment	2021

 

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References   
"Overview EHR Incentive Programs." Centers for Medicare & Medicaid Services. Web. 28 July 2010.

"Secretary Sebelius Announces Final Rules To Support ‘Meaningful Use’ of Electronic Health Records." United States Department of Health and Human Services. Web. 28 July 2010.