Recently there has been a growing discontent regarding meaningful use. The provider community is unhappy, members of Congress are up in arms, and even JASON, a group of scientists convened to provide council to the government on science and technology, has joined the fray. During the first quarter of this year, less than 1,000 eligible professionals attested for Stage 2. What’s more troubling is they used only eight different EHRs. There is a growing sense that ONC is moving too fast, and some would say moving in the wrong direction. On the Friday before Labor Day, just before the close of business on the East Coast, CMS released the final rule we mentioned in this blog in May. Today we will devote our attention to that rule and attempt to clarify the impact it will have on nephrologists.
Stage 3 delay
First the easy part: Stage 3 has officially been delayed until 2017. Among nephrologists, the only folks impacted will be those who started early. If your first year to attest was 2011 or 2012, you will now report Stage 2 in 2016 as opposed to Stage 3 as originally planned. The new schedule is displayed in the table below.
Table 1: Stage of meaningful use criteria by first payment year
What about 2014?
The real news in this rule is the potential impact it creates for nephrologists in 2014. The rule is 90 pages long, a short story compared to what we usually see from CMS. The bulk of the rule explains the impact these changes will have on the approach providers take in 2014. As you may recall, CEHRT is “Certified EHR Technology”. If you are not using CEHRT, you cannot attest for meaningful use. The original certification most EHR vendors labored through a couple of years ago is now referred to as 2011 Edition CEHRT. 2011 Edition CEHRT is capable of supporting the Stage 1 objectives, but it technically expired on December 31, 2013.
Among other things, this rule puts 2011 CEHRT on life support, allowing customers to use it through the end of 2014. The provisions of this rule not only impact nephrologists still using a 2011 Edition EHR, but they also impact certain nephrologists using 2014 Edition CEHRT who are scheduled to report Stage 2 this year. The table below will serve as a guide to help explain the new options you may face as a result this rule.
Table 2: Options for attestation in 2014
I am going to ignore the column labeled “Using 2011 & 2014 Edition CEHRT to do:”, as my read of this rule suggests large complex health systems (like hospitals) are the intended audience for this option, and there is only so much ground one can cover in a single blog post. It is important to recognize the options in this rule depend on how CMS defines key phrases from the final rule (as highlighted in the following statement): “The options outlined in this final rule may be used only by providers who are unable to fully implement 2014 Edition CEHRT for an EHR reporting period in 2014 due to delays in the availability of 2014 Edition CEHRT.”
At a very high level, nephrologists impacted by the provisions in this rule will find themselves in one of two scenarios:
- Your EHR vendor has not yet completed the 2014 certification process, or
- You have a 2014 Edition CEHRT in place, but you face other barriers that have prevented full implementation.
Let’s examine each in turn.
EHR vendor has not completed the 2014 certification process
The first scenario above is the easiest one to understand. If your EHR vendor has not achieved 2014 Edition CEHRT, you clearly “are unable to fully implement 2014 Edition CEHRT for an EHR reporting period in 2014 due to delays in the availability of 2014 Edition CEHRT.” If that’s the case, regardless of whether you are scheduled to face the Stage 1 or Stage 2 objectives in 2014, this rule will permit you to use your existing 2011 Edition CEHRT and report the Stage 1 objectives during one of the 2014 reporting periods. One of the driving forces behind this rule is a large number of EHR vendors who achieved the initial 2011 edition certification have not been able to achieve the 2014 certification. Prior to this rule, those EHR customers had no opportunity to participate in 2014.
Basically CMS is saying they are not going to penalize you because your vendor is not ready. If you are still using the EHR you used for Stage 1 last year, you can use it again this year and report the Stage 1 objectives again (as it is not equipped to report Stage 2). This rule is a game changer for practices in this boat.
2014 Edition CEHRT is in place but other barriers stand in your way
Some nephrologists will find themselves in the second scenario. The impact here is largely limited to those who are scheduled to report Stage 2 this year (you started in 2011 or 2012). Your vendor has completed the 2014 Edition Certification and the EHR is installed, but something stands in your way. The rule identifies two specific barriers, which if present, would permit you to use the 2014 Edition CEHRT to report the Stage 1 objectives instead of the Stage 2 objectives you were originally scheduled to report. Those two barriers are:
- Inability to train your staff or put new workflows in place in time to meet Stage 2 in 2014, or
- Lack of local targets prepared to receive an electronic summary-of-care document.
The first barrier is based on timing. If you have had 2014 Edition CEHRT in place since January of this year, CMS will have a tough time believing there was not enough time to train the people in your practice and adopt the necessary new workflows to meet Stage 2 in 2014. On the other hand, if you went live with the 2014 Edition CEHRT last month, there is a good chance you will not have time to meet the Stage 2 objectives in 2014 due to staff training and/or workflow challenges. If that is the case, you can use the 2014 Edition CEHRT to report the 2014 Stage 1 objectives. If you pursue this path, during your attestation you will be required to attest to the fact that you were unable to fully implement 2014 Edition CEHRT.
The second barrier requires a bit of explanation. One of the Stage 2 Core objectives requires that for at least 10% of the transitions of care or referrals you make, a copy of the patient’s summary of care moves electronically to the new health care provider. Every 2014 Edition CEHRT is capable of creating and sending a summary of care electronically, and they are all capable of receiving one electronically. In spite of this, many physicians around the country are discovering the vast majority of the physicians or hospitals they are trying to reach electronically are unable to receive their patient’s summary of care.
CMS recognizes this limitation in the published final rule and has created a narrow exception with regard to the summary of care measure during the 2014 reporting period. If you find yourself in this position (the providers you are trying to send a summary of care to electronically are unable to receive it), you may forgo the Stage 2 objectives in 2014 and report the Stage 1 objectives using your 2014 edition CEHRT. If you pursue this path, during your attestation you will be required to attest to the fact that you were unable to fully implement 2014 Edition CEHRT. Also note, CMS will expect you to maintain documentation that supports your inability to successfully complete the electronic transfer of summary-of-care documents during the 2014 reporting period.
Too little, too late?
So where does this leave us? We are roughly three weeks away from the start of the 4th quarter, the last reporting period for 2014. CMS has now added a bit of complexity to the equation. The intent of this final rule is to expand the options available for those unable to fully implement 2014 edition CEHRT. In my experience, the majority of nephrologists are in this boat. But CMS has left us with a very short runway. Practices will need to quickly digest this rule and determine how it impacts their approach in 2014.
There is still time to take the path best suited for your practice, but time is truly of the essence. Do you intend to take advantage of this new provision because you were unable to fully implement 2014 edition CEHRT? Drop us a comment and join the conversation.
hassan shahin says
Two questions:
When did acumen become 2014 CEHRT certified?
How about eCube and the 50/50 rule, how does that affect my ability to do MU2?
Terry Ketchersid, MD, MBA, VP, Clinical Health Information Management says
Hello Hassan,
Acumen acheived the 2014 certification in December of 2013. The 50/50 rule is unchanged. If half of your outpatient enounters during the reporting period occur in a location not equipped with CEHRT, you are not eligible to participate in the program. If the deployment in those venues of care is outside of your direct control, you may file for a hardship exception. Alternatively, you may wish to access certified technology like Acumen from within that venue of care and include those patient encounters.
Cathleen M. Randolph says
Since our outpatient clinics are not equipped with Certified EHR Technology (eCube does not count last I recall), we’ll apply for the hardship exception for 2014.
Kristine Hovde says
Firstly, I appreciate your blog and insight into this rule as it is confusing and a game changer. Right now I am on the fence about which option to recommend to our physicians.
There are two variables that could impact our decision. #1 If we elect to report Stage 1 instead of starting Stage 2 will there be a reimbursement and if so, how much will it be? #2 If we go ahead with Stage 2 this year what will the reporting period be in 2015 and 2016? I certainly don’t expect you to know those answers but it would be nice if CMS provided them.
My original plan was to claim the exclusion from the Summary of Care objective because our providers will not have transferred or referred over 100 patients during the fixed quarter reporting period. One of my concerns is that we can only claim the exclusion one time and therefore would have to meet it in 2015 regardless of what the reporting timeline is.
If we choose to report on Stage 1 this also worries me:
“Also note, CMS will expect you to maintain documentation that supports your inability to successfully complete the electronic transfer of summary-of-care documents during the 2014 reporting period”.
How do you document physician offices that don’t know what a direct email address is or do not have one because they are in their first year of Stage 1? Saving screen shots wouldn’t work because there is no direct email address to enter. We have literally had zero luck in getting anyone to provide this and it isn’t from a lack of trying.
Any additional input or suggestions would be appreciated!! Thank you.
Terry Ketchersid, MD, MBA, VP, Clinical Health Information Management says
Great questions. Regarding the incentive payment, it is based on your reporting year, not on the Stage you report, so you will receive the same incentive this year if you report Stage 2 or use this new provision to report Stage 1. The reporting periods for 2015 and 2016 will be the entire calendar year unless one of those years is your first year to report in which case it will be any continuous 90 days within the year. The exclusion piece raises an interesting point. The way I have read this rule, technically you will not know how many referrals or transitions of care you have until you reach the end of the reporitng period, and this special provsion recognizes you are unlikely to get to the end of the RP if you cannot locate “targets” for the electronic summary of care. The documentation piece is very important because I think we will see an increasing number of audits over time. I’d certainly capture scrren shots from your EHR perhaps where you search for the targets email address. I’d ask your local hospital(s) for a note about their readiness (or lack there of) to receive the summaries electronically. ,I’d also check to see if the local medical society has any knowledge of regional penetration of 2014 CEHRT and/or readiness for electronic transmission. The documentation is in case you are audited and remember we are being told to hang on to such documentation for 6 years. Thx for your comment Kristine.
Kristine Hovde says
Dr. Ketchersid, Thank you so much for the prompt response. Your knowledge and suggestions are extremely helpful.
Regards,
Kristine
gail seiken says
I failed to fulfill requirements for meaningful use 1 last year, despite having successfully completed it for the two previous years. My understanding is that I should have applied for hardship this year since I fall under the 50:50 rule, however I missed that deadline. Am I subjected to penalty in 2015 for this year, or do I have other options?
Terry Ketchersid, MD, MBA, VP, Clinical Health Information Management says
Hi Gail, very sorry to hear the news. If I understand your situation correctly, it sounds like you were successful with Stage 1 in 2011 and 2012, but not in 2013. The deadline for filing for the hardship exception for that year has passed (July 1, 2014). If all of this is an accurate interpretation of your circumstance, then unfortunately CMS will apply the 1.0% downward adjustment to your 2015 Medicare Part B Fee for Service work. There is no other recourse that I am aware of. Let me know if I misunderstood your question.
Anne Horan says
I have been looking extensively for one of your above responses. We attested to Stage 1 in 2012 and 2013. We are not prepared to attest to Stage 2 for 2014 so we will be attesting again to stage 1. Do we attest for the full year of 2014 or 3 months? Also I wanted to make sure I understand that the incentive money is NOT based on attesting to the correct stage but just the fact that we are continuing to meet Meaningful Use Requirements? Thank you in advance!
Terry Ketchersid, MD, MBA, VP, Clinical Health Information Management says
Hi Anne, If you qualify for one of the opportunities described in the late breaking “flexible” rule, you will indeed be able to report Stage 1 in 2014 and the reporting period is a calendar quarter (not the entire year). And yes, the incenvtive is paid based on the year you report, not the stage you report so if your are successful in 2014 you will collect the year 3 incentive based on the content of your note.