Much of the pushback for the Stage 3 Meaningful Use final rule stems from the experience of meaningful use eligible professionals (EPs) and hospitals (EHs) in Stage 2 meaningful use, which led many to call for and eventually receive concessions from the Centers for Medicare & Medicaid Services that drastically reduced meaningful use requirements.*
NB. The recently issued propose rule for MACRA implementation will end meaningful use for physicians in 2017.
Despite the resistance, tens of thousands of meaningful use eligible providers successfully demonstrated meaningful use in Stage 2 meaningful use and data about their performance is available in various public use files (PUFs) which give insight into the challenge of meeting this stage's objectives.
Before taking a deep dive into this data, a review of Stage 2 meaningful use objectives is necessary as its requirements have changed dramatically since its initial publication in 2012.
Similar to Stage 1 Meaningful Use, Stage 2 meaningful use required EPs and EHs to satisfy similar but different data collection and reporting activities.
At the time of its original publication, meaningful use EPs were responsible for meeting 17 core objectives and 3 of 6 menu objectives. EHs had 16 core objectives and 3 of 6 menu objectives to satisfy. As for clinical quality measures, EPs were required to report on 9 out of 64; EHs were required to report on 16 out of 29 CQMs.
An important component of Stage 2 meaningful use as originally planned was health information exchange, in the sense of provider-to-provider, provide-to-public health agency, and provider-to-patient health data exchange. The idea of shifting the locus of control out of the provider's hands and into the hands of patients eventually became a powerful impetus behind a call to reduce meaningful use requirements in Stage 2 meaningful use.
The most significant modifications to Stage 2 meaningful use were a reduced reporting period in 2015 from 365 to 90 days, the replacement of the 5-percent threshold for view/download/transmit (VDT) with one patient, the consolidation of all public health reporting objectives, the elevation of EH electronic prescribing objective from menu to required, and the alignment of the reporting schedule for both meaningful use EPs and EHs based on the calendar year.
The final rule for these meaningful use modifications was published in October 2016 and many meaningful use eligible providers are still working out their implications for meaningful use reporting beginning this month and extending through the end of February.
Stage 2 Meaningful Use for Eligible Providers
The public use files (PUFs) provided by CMS represent a treasure trove of information relative to how meaningful use eligible providers performed on each Stage 2 meaningful use measure either core or menu.
The most recent PUF contains data on 59560 Medicare physicians across 17 core measures and 6 menu measures.
The first measure (CM21) focused on computerized-physician order entry and comprised three components for which EPs had to exceed 60 percent for medications, 30 percent for labs, and 30 percent for radiology orders during the meaningful use reporting period.
By and large, meaningful use EPs were very successful with this measure, well above 90 percent across the board. That being said, many opted for the exclusion — "any EP who writes fewer than 100 medication, laboratory, radiology, or laboratory orders during the EHR reporting period" — and more so for the second and third parts, laboratory and radiology, respectively.
Electronic prescribing (CM22), though a longstanding feature of health IT dating back decades, was a significant enough challenge for many EPs. The average were a few hairs under 90 percent and the number of exclusions for providers unable to perform more than 50 percent of e-prescribing for permissible prescriptions reached nearly 20 percent.
The core measure for demographics (CM23), vital signs (CM24), smoking status (CM25) provided little difficult for these eligible providers.
The most recent PUF contains data on 59560 Medicare physicians across 17 core measures and 6 menu measures.
Clinical decision support (CM26) , however, proved otherwise. This two-part measure proved difficult for its second requirement — "Measure 2: The EP has enabled and implemented the functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period." The number of exclusions taken by EPs (8363; 14%) speak to problems incorporating this functionality fully into physician workflows.
Recording clinical lab test results (CM27) and generating patient lists (CM28) were straightforward tasks for EPs, but patient reminders (CM29) were not. Under the latter, EPs were tasked with using "clinically relevant information to identify patients who should receive reminders for preventive/follow-up care and send these patients the reminders, per patient preference," and only a small portion were able to have success.
Similar difficulties faced EPs relative to the VDT requirements for Core Measure 30. The first measure requiring providers to make online access available to more than 50 percent of patients within 4 business days led to low levels of success, but the 5-percent threshold for VDT did not.
Providing clinical summaries (CM31) was an objective manageable for most EPs, but providing patient-specific education resources (CM32) proved less so. On its own, the latter was only core measure for which the average performance score dipped south of 80 percent. (More on menu measures in a moment.) Meanwhile, performing medication reconciliation (CM33) saw high average reporting scores.
As the data show, providing summary care records to patients led to many an exclusion being taken. To review, here is a run-down of the core measure's three parts.
First, EPs had to provide a summary of care record for more than 50 percent of transitions of care and referrals.
Second, EPs had to provide a summary of care record for more than 10 percent of such transitions and referrals "either (a) electronically transmitted using CEHRT to a recipient or (b) where the recipient receives the summary of care record via exchange facilitated by an organization that is a NwHIN Exchange participant or in a manner that is consistent with the governance mechanism ONC establishes for the NwHIN."
Third, EPs must conduct one or more "successful electronic exchanges of a summary of care document" with a recipient who has EHR technology that was developed designed by a different EHR technology developer than the sender's EHR technology."
So was it A, B, or C that proved the most challenging? The answer is A. The dismal performance score of 40.45% speaks to the difficulty even successful meaningful users had in providing summary of care records for care transitions or referrals. It then comes as no surprise that 51446 out of a possible 59650 sought an exclusion here.
The remaining core measures — submitting electronic data for immunization (CM35), protecting electronic health information (CM36), and using secure electronic messaging (CM37) — all led to high marks for meaningful use EPs.
Source: Xtelligent Media
As compared to meaningful use core measures, menu measures led most EPs to experience some difficulty in succeeding at three of an available six options.
Three menu measures saw high figures for EPs — imaging results (MM21; 80.79%), recording patient family health history (MM22; 72.13%), and recording electronic notes (MM26; 98.52) — but the others not so much.
Leading to the lowest percentages was the identification and reporting of cancer cases (MM24; 10.70%). As part of this measure, EPs were responsible for submitting cancer case information from their certified EHR technology to a public health central cancer registry in an ongoing fashion throughout the entire EHR reporting period, and it was a yes/no question.
Next up was a similar measure of identifying and reporting specific cases to a specialized registry (MM25; 19.90%). Again, a yes/no question that led to most meaningful use EPs coming up short.
And finally there was the submitting of electronic syndromic surveillance data to public health agencies (MM23; 30.57%).
What do these meaningful use menu measures all have in common? That's right, the objective assumes the ability of an external recipient to receive EP meaningful use data and frequently.
Stage 2 Meaningful Use for Eligible Hospitals
Compared to their physician counterparts, meaningful use eligible hospitals (EHs) stand to gain millions of dollars in EHR incentives from CMS. That being said, they have the luxury of many fewer exclusions when trying to satisfy meaningful use requirements.
In Stage 2 meaningful use, EHs were tasked with meeting 16 core measures and 6 menu measures. The most recent PUF contains data on 1835 hospitals.
A quick look at the figures reveals a good amount of success for these organizations in meeting most the measures required of them in this second stage of the EHR Incentive Programs.
EH performance percentages for the first measure of CPOE (CM21) were lower than their counterpart's figures, but still well above the thresholds for this three-part measure. What's more, EHs had no recourse to exclusions.
The next handful of EH core measures — CM22 through CM27 — speak to very high levels of success for these eligible providers. Noteworthy is the success of EHs in satisfying the requirement for clinical decision support (CM25) which proved more difficult for EPs (their CM26).
The VDT requirement for EHs, however, did not share a similar fate. The problem was not related to sharing health data with discharged patients within 36 hours (CM28, Measure 1; 85.92%) but the matter of enabled more than 5 percent of discharged patients to access health information electronically.
In Stage 2, EHs were tasked with meeting 16 core measures and 6 menu measures. The most recent PUF contains data on 1835 hospitals.
Surely, the meaningful use modifications made to Stage 2 last October should go a long way toward address the patient engagement challenges for these providers.
The remaining meaningful use core measures (CM29-CM36) for EHs were layups for these providers, with one notable exception. As part of the objective for transition of care summaries (CM31), EHs had to satisfy three measures. It was the second that proved most challenging — providing "a summary of care record for more than 10 percent of such transitions and referrals either (a) electronically transmitted using CEHRT to a recipient or (b) where the recipient receives the summary of care record via exchange facilitated by an organization that is a NwHIN Exchange participant or in a manner that is consistent with the governance mechanism ONC establishes for the nationwide health information network."
Juxtaposed to EP Stage 2 figures, EHs could likely teach other eligible providers how to succeed on mean measures.
For the first menu measure involving advance directives (MM21), EHs saw almost unanimous success at a rate of 97.88 percent. Nearly as high was their performance with imaging results, a figure that is more than 10 percentage points higher than one registered by EPs. Conversely, the latter outstripped their counterparts came in nearly 10 percentage points less for recording electronic notes (EH MM25; EP MM26).
All in all, even the lowest performance points registered by EHs came in much higher than those put up by EPs for the remaining menu measures.
Recording patient family health history (MM23) was not a slam dunk for EHs but the average score was still three times larger than the 20 percent baseline.
E-prescribing (MM24) was also wrought with challenges, but it do came in nearly five times above the threshold of 10 percent.
And lastly, structured electronic lab results for ambulatory providers was an achievable objective for many a hospital, which only had to exceed 20 percent.
What's the significance?
When the modifications to Stage 2 meaningful use came out in October, they were joined by the final rule for Stage 3 Meaningful Use and its requirements, which came as a surprise to many industry stakeholders.
The experience of Stage 2 meaningful use, one full of many stops and starts, has soured some on the EHR Incentive Programs as a whole. One cautionary tale is that of getting the right EHR technology in place in time.
That was a concern voiced by Methodist Health System Senior Vice President and CIO Pamela McNutt in late 2015 at the College of Healthcare Information Management Executives (CHIME) Fall Forum.
"They have given a 90-day adoption period for Stage 3 but only if you want to be an early adopter in 2017," she told EHRIntelligence.com. "When you think about the vendor cycles, it's going to take vendors and most healthcare organizations a long time to ramp up — well in to the 2018 year. They really need to go back to a 90-day reporting period any time anyone enters one of the new stages. It's difficult to be ready for a full year of measuring your success."
"When you think about the vendor cycles, it's going to take vendors and most healthcare organizations a long time to ramp up — well in to the 2018 year."
In many ways, Stage 3 meaningful use will be unlike either preceding stage as a result of collapsing all requirements into eight categories for both EPs and EHs. However, in important ways it remains the same, such as its requirements for patient engagement.
As currently constructed, the Stage 3 meaningful use final rule requires meaningful use eligible providers to support VDT for more than 80 percent of patients. Additionally, these providers must provide more than 35 percent of patients with online-accessible patient-specific educational resources. That represents a significant departure from Stage 2 meaningful use in both its original and modified forms.
Another requirement likely to cause headaches is the third objective for transitions and summaries of care that rely on more robust health information exchange.
The EHR Incentive Programs have done wonders for increasing EHR adoption since their inception in 2011. But their legacy may end up being one of ridicule rather than praise if the current opinion of meaningful use is not addressed.
Opinions already range from the programs having no purpose beyond 2016 to being replaced by provision from the Medicare Access and CHIP Reauthorization Act by proponents of meaningful use. Still others only see promise in Stage 3 if and when recommended changes are made to its requirements.
Whatever credit the EHR Incentive Programs built up in Stage 1 meaningful use may ultimately be undone by the experiences of Stage 2 meaningful use.