posted by Kevin Heubusch
Jan 20, 2010 11:46 pm
AHIMA Meaningful Use White Paper Series
Paper no. 2
The first paper in the series offered a general overview of the notice of proposed rulemaking on meaningful use, published by the Centers for Medicare and Medicaid Services on January 13, 2010. This paper begins a more detailed, two-part review of the proposed rule.
The meaningful use program established by ARRA is initially an incentive program, not an entitlement program. No healthcare organization-provider or hospital-is required to apply for or participate in the program for the first five years.
To receive incentive payments an entity or provider must participate in Medicare Fee-for-Service, Medicare Advantage, or a state Medicaid program, with some restrictions. Beginning in 2016, however, the program becomes punitive. ARRA established that providers in Medicare programs will be penalized if they do not meet the meaningful use requirements.
The NPRM includes several key definitions (pp. 1847–50):
- “Qualified electronic health record” is defined in a separate rule on EHR certification issued the Office of the National Coordinator for Health IT (see paper 1): “an electronic record of health-related information on an individual that (A) Includes patient demographic and clinical health information, such as medical history and problem lists; and (has the capacity to: (i) provide clinical decision support ; (ii) to support physician order entry; (iii) to capture and query information relevant to health care quality; and (iv) to exchange electronic health information with and integrate such information from other sources.”
- “Certified EHR technology” is also defined in the certification rule: “A Complete EHR or combination of EHR Modules, each of which: (1) Meets the requirements included in the definition of a Qualified EHR; and (2) has been tested and certified in accordance with the certification program established by the National Coordinator as having met all applicable certification criteria adopted by the Secretary.”
- “Payment year” defines the first year of payment either on a fiscal or calendar year depending on the type of program or provider. Once a provider becomes eligible in the first year, the subsequent years all follow the fiscal or calendar year.
- “EHR reporting period” is the time period for which providers must report their meaningful use. In the first year, this period is proposed as minimum of 90 days of meaningful use within a payment year. In the following years, the reporting period is the full year, based on the belief that once a certified EHR is in use, the provider will continue to use the system.
- “Meaningful EHR user” is an “EP [eligible professional] or eligible hospital who, for an EHR reporting period of a payment year, demonstrates meaningful use of certified EHR technology in the form and manner consistent with [CMS’] standards. These standards would include use of certified EHR technology in a manner that is approved by [CMS].”
Meaningful Use Definition
Congress established the broad framework for meaningful use within ARRA:
- Use of certified EHR technology in a meaningful manner;
- Certified EHR technology connected in a manner that provides for the electronic exchange of health information to improve the quality of care; and
- Use of certified EHR technology to submit information on clinical quality measures.
The definition of meaningful use is a series of criteria designed to meet Congress’s requirements for use of certified EHR technology (pp. 1859–70).
CMS notes that given the on-going advancement in EHR technology and standards, as well as change in quality measurement and other healthcare-related reporting, the meaningful use definition should mature over time. Accordingly, CMS proposed three stages of criteria over the initial years of the program, 2010 through 2015.
The NPRM includes proposed requirements for stage 1 criteria only, which will initially cover 2011 and 2012. Future regulations will be proposed to cover stages 2 and 3. Within the NPRM, CMS requests comments and suggestions for requirements in these future stages.
Rather than peg the criteria stages to calendar years, CMS proposes that they be based on the year a provider joins the program. This flexibility allows providers to enter the program in a staggered approach that accommodates those who may not be ready to join the program in the first year. Thus a provider who enters the program in 2012 would still use the stage 1 criteria (and be eligible for the highest incentive payments). Otherwise, it was felt that the increasingly strict criteria would discourage late adopters from ever joining.
Table 1 from the NPRM illustrates this staged approach. As shown, the later a provider joins the program, the faster it must meet the stage 3 criteria.
In defining the stage 1 criteria, CMS considered the industry input it received as well as the recommendations of the Health IT Policy Committee, an advisory group established under HITECH, to describe outcomes, care goals, objectives, and measures. CMS suggests that stage 1 focus on electronically capturing health information in a coded format and using that information to track key clinical conditions which can then be communicated for coordination of care, decision support, quality reporting, public health, and patient communication.
CMS did not accept all of the policy committee’s recommendations. It explains its modifications within the NPRM. Table 2 is a matrix of outcomes, care goals, objectives, and measures that appear within the NPRM. The criteria and their measurement will be covered in future papers in this series.
Submission of Clinical Quality Measures
Congress’s second requirement is clinical quality measurement reporting. CMS proposes that the measures changes over time, reflecting the evolution of technology and reporting methodology as well as the transformation of quality of care measures. Most of the measures discussed for stage 1 are not new, so the task is one of collecting the data from the EHR and reporting the measures electronically (also the subject of future white papers).
There are a number of measurements grouped to medical specialties; however, it appears that not all medical specialties accept CMS’s categorization or the measures assigned to their categories. Readers should expect considerable debate and comment on these categories before the final rule is adopted.
Demonstration of Meaningful Use and Data Collection
The NPRM proposes the means for collecting data to demonstrate meaningful use as well as the exchange of data between Medicare and Medicaid to run the program (pp. 1903–4). CMS advocates for uniformity and simplicity in this process and suggests that Medicaid programs follow its lead.
Hospital-based Eligible Professionals
This controversial section (pp. 1904-7) states that certain “hospital-based eligible professionals are not eligible for the Medicare incentives payments” and may not be eligible for Medicaid incentives based on the “hospital setting” as defined under current Medicare reimbursement policy and based on an assumption that these professionals utilize the hospital EHR rather than their own. This includes out-patient facilities.
This section also sets a standard for professionals who spend part of their time delivering services in a hospital setting at 90 percent. CMS suggests states use some of the same methods to determine professional eligibility.
In discussing eligible professionals, CMS notes that the incentive payments are passed on total inpatient services and a “hospital with a large outpatient department will not receive a higher incentive payment as a result of their outpatient services.” Stage 1 criteria for hospitals apply only to a hospital’s inpatient setting, leading CMS to raise a concern that hospital investment in their outpatient primary care sites is “likely to lag behind their investment in their inpatient EHR systems.” CMS encourages comment on this section.
CMS requests considerable comment in this section. Concern has already been raised regarding segments of the provider community such as long-term care that are not covered by ARRA but are certainly a part of the continuity of care needed in healthcare.
As noted, CMS is working under the parameters set by ARRA and a desire to keep from any double-dipping for incentive payments. However, if concerns to support outpatient care and adequate inclusion can be addressed, it is possible that the program could be modified for greater inclusion within ARRA’s constraints.
Interaction with Other Programs-e-Prescribing
CMS notes (p. 1907) that the incentive program conflicts with the e-prescribing incentive program under MIPAA, the Medicare Improvements for Patients and Providers Act. Eligible providers who accept the EHR incentive will therefore be ineligible to receive the e-prescribing incentive payment during the same period.
Paper 3 in the series continues this overview of the meaningful use program with a look at the incentive payments and program requirements.
Download this paper as a PDF.
AHIMA. "Meaningful Use: Provider Requirements." (AHIMA report, January 21, 2010).