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.
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.