It’s that time of the year when kids of all ages are gearing up to return to school. As we were traveling through time-tested rituals at casa Ketchersid, I found myself wondering what to write about this week. Next thing you know my inbox was inundated with a variety of messages surrounding the CMS EHR Incentive Program’s Stage 2 Final Rule and ICD-10. Voilà, a blog post is born! Actually, based on the required reading for this class, it’ll be several posts.
The double-spaced version of the Stage 2 final rule consumes over 670 pages. HHS received over 6,100 comments during the 60-day comment period and they address a number of them in the document. Adding to the excitement is the companion final rule for the Standards and Implementation Specifications which weighs in at a paltry 470 pages. By comparison the ICD-10 document is a virtual chip shot at just north of 200 pages. Needless to say there is enough here to keep us busy for a while. Today let’s focus on the components of the stage 2 final rule which will impact nephrologists sooner than later.
Not surprisingly, the bulk of the Stage 2 document addresses the second stage of the meaningful use framework. However, the document brings some changes to the Stage 1 criteria as well. Some of these will impact nephrologists, others may not.
Slightly Less Homework than Expected (the good news)
Thankfully the majority of the changes that impact Stage 1 fall into the good news bucket. First and foremost, the troublesome core objective that requires exchanging clinical information electronically with another provider will be removed from the Stage 1 core set starting in CY 2013. Per ONC this objective not only created substantial confusion among providers, but the desired functionality will be captured in a new Stage 2 objective.
On a more technical note, reporting clinical quality measures (CQMs) will be removed from the list of core objectives starting in 2013. Before you get too excited about this, it is important to recognize this change merely reflects a move by ONC to set the expectation that reporting CQMs is a fundamental requirement of meaningful use. That is to say, you will still be required to report CQMs, but your reporting them will not count as a core objective. This little tidbit is likely to create a bit of confusion when you attest for 2013…stay tuned.
If you practice nephrology out in the sticks, in 2013 the e-prescribing core objective will have a new exclusion that may apply. If there are no pharmacies that accept eRx within a 10-mile radius of your practice, you can elect this exclusion for the eRx objective. I doubt there are many nephrologists in this category, but one never knows.
They have made some minor changes to the vital-signs objective, which are optional in 2013. These changes in effect separate BP from height and weight for providers who are willing to attest to the fact that collecting one or the other is outside of their scope of practice. I find it difficult to believe a nephrologist would not consider blood pressure to be within their scope of practice, but some might make the case for height and weight (BMI).
Early to Bed, Early to Rise (the not-so-good news)
The final rule for Stage 2 brings some unwelcome signals from ONC regarding Stage 1. Thankfully there are only a few items to consider here. The first is trivial, but I point it out as I think it reflects the perspective ONC takes. For 2013, providers reporting the CPOE objective in the core set may chose from one of two ways to define the denominator. Providers may continue to calculate the denominator as they do today (unique patient encounters with patient that have a medication on their med list) or they can use the new denominator: all medication orders written by the provider during the reporting period. The later is the denominator favored by ONC. We and apparently others argued in our comments to CMS that this would create a substantial burden on the provider. Thankfully they seemed to have listened, and instead of dropping the unique patient encounter it remains an option moving forward.
The more troubling issue from my perspective is our old friend the “50% rule.” We and others argued in our comment that this component of eligibility should be modified because of the unintended consequence it creates for nephrologists in the dialysis facility. Unfortunately this perspective did not influence ONC as the rule was not substantially changed. I say “substantially” because in this version ONC has made some clarifications regarding what they mean by an encounter and what they mean by the phrase “equipped with certified EHR technology.” Their encounter definition clearly includes all patient encounters in a dialysis facility. Further they state that the practice of capturing information in one location (like a dialysis facility while making rounds) then later entering the information at another location (like back in your office) will be unacceptable starting in 2013. They make their case using the example of CPOE. In our world it goes something like this; I write an order in the dialysis chart and later to meet meaningful use I add the order to my certified EHR. ONC would argue this defeats one of the principal purposes of CPOE, which is to serve up context-specific clinical decision support at the time the order is created. This should not create an issue in Stage 1 as CPOE is looking only at med orders and most systems are using eRx as a proxy. But stay tuned, as we will have more to say about the impact this will bring when Stage 2 arrives in 2014.
2014 May Be the Year to Consider an Early Graduation
There will be much more to come over the next few weeks as people begin to digest Stage 2. Let’s also not forget to circle September 30, 2014, on the calendar. With the impending ICD-10 transition deadline identified, some may find this to be an attractive retirement date. For those of you anxious to dive into the Stage 2 specifics, take a look at this fact sheet from CMS. I will be tackling some of these objectives in the weeks ahead. Report cards will be in the mail before you know it. Let us know how you would grade ONC by posting a comment here.
RG says
Thanks for the update Terry. It sounds like stage 2 is going to be hard. A quick glance reveals that “trasnsition of care” will need to be well defined. Does that mean a patient in our dialysis unit that comes back from the hospital? Also, the ordering of labs and radiology will be a new process. The electronic copy of the information also will present some administrative burdens, because it does not look like we can claim an exclusion if no one asks for it. Also complicating matters is that our VA dept of health does not accept immunizations with the current technology. In short, we have a lot of work to do. On the posivtive side, we have time on our side. Please continue to orient us little by little. Before we know it, stage 2 will be here and we need to be ready.