A First Look at the Stage 2 Final Rule

Like most people involved in the implementation of electronic health records and the journalists who write about them, I spent the evening of Aug. 23 poring over 600 very dense pages of CMS jargon to try to discern the flavor of the meaningful use Stage 2 final rule. My guess is that depending on your provider organization’s experience with Stage 1, you might have quickly scanned the index looking for specific topics such as “clinical quality measures” or “summary of care records” to see how you will be affected.

Obviously the thing is just too big to digest in one sitting, so Healthcare Informatics will have updates over the next week or so, including reactions from CIOs, CMIOs and consultants once they have had a chance to review the language.

But as someone who has followed the work of the Health IT Policy Committee pretty closely the last few years, I thought I would offer a first look at a few key items that CMS chose to alter from the proposed rule. (In cases where they finalized the proposed rule with no changes, CIOs sort of knew what to expect. By the way, my first impression is that they didn’t make as many alterations between proposed and final rule with Stage 2 as they did with Stage 1. In some cases they lowered thresholds from 10 percent to 5 percent, but I don’t see that as a huge shift. If you have to do something for 5 percent of patients, you still have to make the technology investment and make it work. So provider and vendor advocacy groups may not be too happy with the outcome.)

Here are a few of the significant changes I noticed right away:

Stage 2 Reporting Period: CMS will not delay Stage 2 until 2015, as some had suggested, but instead will use a three-month EHR reporting period in 2014 as the first year any provider would attest to Stage 2. It agreed with commenters that the use of a shorter EHR reporting period in 2014 is necessary to allow sufficient time for vendors to upgrade their technology and for providers to implement it.

Patients View, Download and Transmit Their Health Information: This is the one that drew the most negative comments from provider organizations. Many made the claim that they shouldn’t be held accountable for what their patients do. But CMS stuck to its guns, by insisting on the importance of making health information readily available to patients after a visit. It did acknowledge the difficulty of working with some patient populations by lowering the threshold from 10 percent to 5 percent. Providers will be scrambling to get their portal technology in place!

HIE Crossing Vendor and Organizational Boundaries: With the goal of furthering interoperability, the proposed rule sought to ensure that providers were exchanging health data with users of other EHR vendor systems and with other organizations. But CMS decided that “making the determinations for the numerator was infeasible particularly in regard to the organizational and vendor limitations. Therefore, we are removing the organizational and vendor limitations from this measure solely due to the burden of making these determinations for measurement.” Instead it will require providers to conduct one or more successful data exchange tests with a “CMS designated test EHR” during the EHR reporting period.

Secure Electronic Messaging: The proposed rule was to use secure electronic messaging to communicate with more than 10 percent of unique patients on relevant health information. In the final rule, CMS lowered the threshold to 5 percent and added a “broadband exclusion” for rural areas with limited broadband access.

Summary of Care Documents: CMS lowered the threshold slightly from 65 percent in the proposed rule. In the final rule, 50 percent of transitions of care must involve sending a summary of care record.

eMAR: CMS finalized the rule that more than 10 percent of medication orders be tracked using an electronic medication administration record (eMAR). But it also established exclusions for very small hospitals with inpatient census of fewer than 10 patients. “We are also concerned that very small hospitals may have local technical support and training issues that may make an automated eMAR solution actually less effective than other approaches. We also believe that very small hospitals will have fewer health care professionals involved in the process of medication administration and fewer patients for whom duplicative orders could present an issue, which would also make an eMAR solution less effective. Therefore, we believe these hospitals would not benefit from eMAR as much as larger facilities and are finalizing an exclusion for these hospitals.”

Medication Reconciliation: The proposal was to raise the measure on performing medication reconciliation during transitions of care to 65 percent. CMS noted that because most providers chose to defer this measure in Stage 1, and the lack of robust data in support of the proposed threshold, they lowered the threshold to 50 percent.

CPOE: CMS finalized the threshold for CPOE use in Stage 2 at 60 percent. It will also require that more than 30 percent of laboratory orders and more than 30 percent of radiology orders are recorded using CPOE. CMS also clarified that orders entered by credentialed medical assistants will count toward meeting this requirement.

Clinical Quality Measures: There’s a great deal of detail in the CQM section. One important point is that the proposed rule had called for hospitals to meet 24 CQMs beginning in 2014. CMS decided that would be too great an implementation burden and lowered the total to 16. It also will allow for group reporting by physician groups.

As I said, we’ll have more details, analysis and reaction over the next several days. What are some important things I missed on first glance?

Here's a pictorial view of the major changes seen in the final rule of meaningful use Stage 2.