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Most Challenging Stage 3 Meaningful Use Requirements

While eligible providers must satisfy requirements across eight categories for Stage 3, three in particular stand out as potential pain points.

By Kyle Murphy, PhD

- As many as two years separate eligible providers from Stage 3 Meaningful Use, but several of the requirements for eligible professionals and hospitals in the final stage of the EHR Incentive Programs are already causing concerns.

Stage 3 Meaningful Use requirements

In finalizing the rule for Stage 3, the Centers for Medicare & Medicaid Services (CMS) sought to streamline meaningful use requirements and settled on eight categories of objectives. Many build off measures appearing in previous stages and now carry increased thresholds for successfully demonstrating meaningful use.

The similarities between this and previous stages of the EHR Incentive Programs extend to the concerns certain objectives raise about the ability of providers to achieve them because doing so depends on the actions of others, most notably patients.

While eligible providers must satisfy requirements across eight categories, three in particular stand out as potential pain points as evidenced by the comments addressed as part of the Stage 3 final rule.

Here's a review of what should be the most challenging Stage 3 requirements.

READ MORE: Recapping Recommended Changes to Meaningful Use Requirements

Leading the least, not surprisingly, is the fifth objective having to do with patient access to health information.

The objective comprises two measures and three possible exclusions:

Objective: The EP, eligible hospital or CAH provides patients (or patient-authorized representative) with timely electronic access to their health information and patient-specific education.

Measure 1: For more than 80 percent of all unique patients seen by the EP or discharged from the eligible hospital or CAH inpatient or emergency department (POS 21 or 23):Show citation box

(1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and

READ MORE: CMS Finalizes 2018 Meaningful Use Requirement Flexibilities

(2) The provider ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the API in the provider's CEHRT.

Measure 2: The EP, eligible hospital or CAH must use clinically relevant information from CEHRT to identify patient-specific educational resources and provide electronic access to those materials to more than 35 percent of unique patients seen by the EP or discharged from the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period.

Exclusions: A provider may exclude the measures if one of the following apply:

  • An EP may exclude from the measure if they have no office visits during the EHR reporting period.
  • Any EP that conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may exclude the measure.
  • Any eligible hospital or CAH will be excluded from the measure if it is located in a county that does not have 50 percent or more of their housing units with 4Mbps broadband availability according to the latest information available from the FCC at the start of the EHR reporting period.

One concern regarding this objective centers on the use of application programming interfaces (APIs) about which many commenters sought clarification, with some worried that API use would be tantamount to setting up another patient portal. CMS, however, dismissed these comments by articulating how APIs differ from patient portals and referring providers to 2015 Edition EHR certification rule and its breakdown of third-party, API-enabled applications. But commenters noted a lack of mature APIs as potential detrimental to their successful use.

Another concern raised by commenters was the difficulty in getting certain types of patients or geographies to satisfy the requirement. The exclusions address these concerns, but the requirements themselves still represent a significant jump over those in Stage 2 — that is, one patient.

READ MORE: CHIME Seeks 5 Changes to Stage 3 Meaningful Use Requirements

Another patient-centered meaningful use requirement drawing criticism is the sixth objective —  Coordination of Care Through Patient Engagement. This, too, comprises two measures and three potential exclusions:

Objective: Use CEHRT to engage with patients or their authorized representatives about the patient's care.

Measure 1: During the EHR reporting period, more than 10 percent of all unique patients (or their authorized representatives) seen by the EP or discharged from the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) actively engage with the electronic health record made accessible by the provider and either:

(1) View, download or transmit to a third party their health information; or

(2) access their health information through the use of an API that can be used by applications chosen by the patient and configured to the API in the provider's CEHRT; or

(3) a combination of (1) and (2).

Measure 2: For more than 25 percent of all unique patients seen by the EP or discharged from the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period, a secure message was sent using the electronic messaging function of CEHRT to the patient (or the patient-authorized representative), or in response to a secure message sent by the patient or their authorized representative. For an EHR reporting period in 2017, the threshold for this measure is 5 percent rather than 25 percent.

Exclusions: A provider may exclude the measures if one of the following apply:

  • An EP may exclude from the measure if they have no office visits during the EHR reporting period. Show citation box
  • Any EP that conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may exclude the measure.
  • Any eligible hospital or CAH will be excluded from the measure if it is located in a county that does not have 50 percent or more of their housing units with 4Mbps broadband availability according to the latest information available from the FCC at the start of the EHR reporting period.

Similar to the fifth objective, commenters expressed doubts about satisfying this requirement as a result of the makeup of their patient populations, notably elderly and rural patients. Whereas CMS did not dedicate as much space to allaying these concern, the federal agency did so in response to objections of holding providers accountable for patient action.

"We disagree that this proposed measure holds providers accountable for patient action, as the Stage 3 proposed measure specifically puts the control over communications in the hands of the provider," the final rule states. "For this measure, we proposed to include provider-initiated communications, provider-to-provider communications if the patient is included, and allows the provider to count any patient-initiated communication if the provider responds to the patient."

The third objective likely to prove a challenge deals with health information exchange and comprises three measures:

Objective: The EP, eligible hospital, or CAH provides a summary of care record when transitioning or referring their patient to another setting of care, receives or retrieves a summary of care record upon the receipt of a transition or referral or upon the first patient encounter with a new patient, and incorporates summary of care information from other providers into their EHR using the functions of CEHRT.

Measure 1: For more than 50 percent of transitions of care and referrals, the EP, eligible hospital or CAH that transitions or refers their patient to another setting of care or provider of care: (1) Creates a summary of care record using CEHRT; and (2) electronically exchanges the summary of care record.

Measure 2: For more than 40 percent of transitions or referrals received and patient encounters in which the provider has never before encountered the patient, the EP, eligible hospital or CAH incorporates into the patient's EHR an electronic summary of care document.

Measure 3: For more than 80 percent of transitions or referrals received and patient encounters in which the provider has never before encountered the patient, the EP, eligible hospital, or CAH performs a clinical information reconciliation. The provider must implement clinical information reconciliation for the following three clinical information sets:

(1) Medication. Review of the patient's medication, including the name, dosage, frequency, and route of each medication.

(2) Medication allergy. Review of the patient's known medication allergies.

(3) Current Problem list. Review of the patient's current and active diagnoses.

The final rule contains a length series of comments and responses between commenters and CMS. Primarily, the former voiced concerns about a lack of interoperability and its effect on meeting increased HIE requirements. Others noted limitations preventing other providers from receiving transitions of care documents because of a lack of HIE capabilities. Still others pointed to a lack of national and regional health IT infrastructure for finding electronic provider contact information (i.e., registries).

Stage 3 is scheduled to begin for all Medicare providers in 2018.

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