Tomorrow, HHS will publish the notice of proposed rulemaking (NPRM) for Stage 2 of the CMS EHR incentive program in the Federal Register. ONC provided us with an early look late last month. Concurrently the companion proposed rule for vocabulary and standards was published. Each is accompanied by a 60-day public comment period, after which the powers that be will consider the feedback and ultimately publish the final rule. Folks in the know believe we will see the final rule in the July/August timeframe. It is important to understand this because what I am discussing this week, and likely in the weeks ahead, is speculation at this point. But the proposed rule does provide us with insight into the direction this program is moving.
What’s the impact on nephrology?
There is actually quite a bit. First, our old friend the “50% rule” remains in play. Together with several other stakeholders from the renal community, I had the pleasure last August to be involved in a face to face conversation with ONC and CMS representatives. During that meeting we suggested an alternative to the 50% rule that would have reduced the impact this has on nephrologists and would permitted more of us to participate in this program without bringing a certified EHR into the dialysis facility (or into the access center). Alas our recommendations were not heeded in the NPRM. If you find yourself in a practice environment in which more than half of your patient encounters occur outside of the office setting, as a nephrologist you will have two choices: take the EHR into the dialysis unit or do not participate in the program.
Why is this important? Although some might take issue with me, the stage 1 meaningful use objectives are not that difficult to meet in the office setting. However, the moment you leave an environment where the care team works for you and has direct access to your practice’s EHR, things get a little complicated. This challenge will be magnified in 2014 if the proposed Stage 2 objectives make it into the final rule.
Report 20 objectives
At first glance one might wonder what all the fuss is about. Eligible professionals, who include nephrologists, will need to report 20 stage 2 meaningful use objectives—17 core measures and 3 from a menu of 5. If this sounds familiar, it should. The stage 1 requirement also includes reporting 20 objectives (15 core and 5 from a menu of 10). But that’s where the similarity ends. ONC has combined several stage 1 objectives into a single stage 2 objective. For example, drug-drug/drug-allergy becomes part of the clinical decision support objective. In another interesting approach, the problem list, the med list and the allergy list are no longer individual objectives. But maintenance of these three items will be required to meet some of the new stage 2 objectives.
In addition, the targets for many of the stage 2 objectives have been raised. For example, the NPRM proposes an 80% target for the vital signs, demographics and tobacco use objectives. Perhaps most challenging for the nephrologist is the proposed change to the CPOE objective. The NPRM adds lab and radiology tests to medications and proposes to raise the target to 60% of these orders created during the reporting period. Finally, there are two new objectives where success is almost completely dependent on patient behavior (patients sending secure electronic messages and accessing information on line).
What’s not here?
Absent from the NPRM is something the HIT Policy Committee (HITPC) had supported in its recommendation to ONC. The NPRM does not contain an objective that effectively examines the electronic capture of the patient encounter. That’s right, as with stage 1, the nephrologist can satisfy the stage 2 objectives without creating an electronic progress note. ONC also vetoed the HIT Policy Committee’s recommendation to sunset the menu. The original proposal from HITPC called for converting all stage 1 menu objectives to stage 2 core objectives. ONC decided instead to keep the menu to provide some flexibility in the program, which I think is laudable.
Comment period
Other areas in the proposal will make their way into this blog in the weeks ahead. The 60-day comment period begins March 7. We plan to submit a formal comment and you should as well. Or send us your comments. We will be happy to post them here.
Randy Gertner says
Terry,
Thanks for the update. I knew this was out there, but waited for your commentary to summarize everything. I order labs an radiology studies on a regular basis through Acumen, but I don’t believe it is “captured” for MU purposes. I created a POC “e-z lab form” and the staff knows to fax it to the lab. I guess from a systemic standpoint this process will need to formalized in a MU data capture format. The same applies to my ordering of radiology studies. Many of our patients are indigent, and do not have access to the internet. This might make the patient dependent measures more challenging—>hopefully those will be menu items, or perhaps have an exclusion. Alternatively, perhaps there is a way to guide the patient in our office with our computer system to meet this objective (if that is allowed and in the spirit of the rule) Looking forward to the coming posts on this topic.
JW says
Terry,
Fantastic analysis as always. One thing that stood out when reading the proposed rule was the fact that in Stage 2, all measures apply to all patients (previously some measures could be limited to those patient records maintained in the certified system).
However, the rule also says EP’s practicing at multiple locations only need to include patients seen at locations with certified EHR Technology in their calculations.
These two statements seem to be in opposition; do you have any insight on this particular issue?
Terry Ketchersid, Vice President and Medical Officer at HITSG says
JW,
Good points. My read is they dropped the option of including everyone or only those patients whose records were maintained in the certified EHR becuase it generally confused the issue. That option seemed to make the most sense for objectives like eRx. The provider could report the eRx objective on only the patients maintained in the certified EHR, or they could expand the denominator to include all prescriptions written (hospital discharges for example, patients not known to the practice prior to that hospital stay, but for whom the doc used the eRx tool).
The second statement regarding multiple locations is directly related to what I have been calling the “50% rule”. If you see 70% of your patients at the main office where the EHR resides, but see the other 30% at a location where the certified EHR is not present, you can still participate but you would only report the patients in the main office in this example. The challenge for nephrologists has been the role of the dialysis encounters in this calculation. My impression from communications with CMS has been that if the dialysis encounters are required to meet the 50% hurdle, those patient’s records must be maintained in the certifed EHR and must be counted in order for the nephrologist to accurately report the meaningful use program. That impression has not changed based on my reading of the stage 2 NPRM.
We made a suggestion to ONC several months ago which would have eased the burden on nephrologists (and other medical subspecialists as well), but unfortunately that suggestion did not makes it’s way into the NPRM.