With the issuance of September’s Stage 2 Final Rule under the Medicare and Medicaid EHR Incentive Programs, the march toward establishing “meaningful use” of EHR systems continues in medical practices and facilities across the health care spectrum.
At first blush, the new ruling—which introduces new clinical quality measures reporting mechanisms for practitioners—may seem to slow down the pace of that march for optometrists. But while the update does push back Stage 2’s timeframe for establishing meaningful use from 2013 to 2014, experts advise optometrists to stay on track for becoming meaningful users of EHR by next year.
Change on the Menu
Stage 2 begins in 2014, a year later than the 2009 American Recovery and Reinvestment Act originally required—or two years after a provider first achieves requirements for Stage 1.
While eligible providers, including optometrists, can start to earn Stage 1 incentive payments as late as 2014 under the Medicare EHR Incentive Program, and 2016 under the Medicaid EHR Incentive Program, Medicare will begin to impose penalties on those not achieving meaningful use by 2015.
While the Stage 1 meaningful use criteria were met with criticism for being essentially primary care-based, National Health Information Technology Coordinator Farzad Mostashari, M.D., Sc.M., has described the Stage 2 rule as being “potentially more relevant to specialists.”
Most notably, the rule makes the optional menu items from Stage 1 mandatory, adding a requirement for patient engagement and allowing medical groups to attest to meaningful use for multiple providers at one time, while raising the bar for meeting other mandatory items in Stage 1. For instance, providers are now required to enter medication orders electronically for at least 60% of their patients, whereas Stage 1 only required providers to do so 30% of the time.
And, under patient reporting demographics for Stage 1, demographics only had to be reported for more than 50% of unique patients—defined as patients seen multiple times during a given reporting period but only counted once. In Stage 2, that number has gone up to 80%.
In addition, under Stage 1, more than 80% of all unique patients seen must have at least one entry—or an indication that the patient is not currently prescribed any medication—recorded as structured data. This measure is no longer a separate objective under Stage 2, and has been incorporated into the Stage 2 measure of summary of care record.
While some thresholds have been raised, others have been added that hold optometrists accountable for patient utilization of information. For example, providers must now offer online access to health information and secure messaging for only 5% of patients, as opposed to the 10% of patients that had previously been proposed. In response to a federal advisory board, the final certification rule also adds a requirement that all personally identifiable health data must be encrypted while at rest.
Also worth noting is that the Stage 1 core set measure for recording vital signs has changed for 2013, adds Jeff Grant, president and founder of HealthCare Management & Automation Systems, a practice management and IT consulting firm in Shell, Wy. “Essentially, this change separates blood pressure from height and weight, which means, for example, that optometrists can exclude height and weight if they believe blood pressure is relevant but height and weight are not.”
“CMS recognized that the whole idea of using vital signs for anyone other than primary care physicians was a bit questionable,” Mr. Grant adds. “So, Stage 2 created some flexibility that wasn’t there before. Stage 1 didn’t take specialties into account.”
Do the Math
In a nutshell, meaningful use criteria are divided into groups of core objectives that all providers must complete. In total, individual providers must now meet 17 core measures for meaningful EHR use, as well as choosing from a menu of six additional measures.
On the surface, the differences between Stage 1 and Stage 2 criteria may seem numerous, but providers must still essentially meet the same number of requirements, says Jay W. Henry, O.D., M.S., a partner at Hermann & Henry Eyecare, in Pickerington, Ohio. “The obvious comparison would be going from 15 core and five-out-of-10 menu objectives in Stage 1 to 17 core and three-out-of-six menu objectives for Stage 2,” he says.
This move adds some new objectives, removes others and combines many Stage 1 objectives into single objectives in Stage 2.
“Now, some of the core objectives have exemptions or exclusions, and if a provider meets an exemption, he wouldn’t need to complete that objective, but would get credit for it,” Dr. Henry explains. “In Stage 1, that meant that you must either complete, or meet, an exclusion to those 15 core items.
From the menu set, providers could select the five that they wanted to complete out of the 10 available to choose from,” says Dr. Henry. “However, one of the two public health measures still had to be completed. In the end, providers were going to complete or get credit for 20 objectives.”
Under Stage 2, however, the 17 core objectives must now be completed or exempted from, and providers must choose three of the six menu items, but “in the end, you are still reporting on 20 objectives. The truly important part of this is understanding what these new 20 objectives are, how they have changed—including the new quality measures—and how they will impact you clinically,” Dr. Henry explains.
No Surprises
The provisions within the Stage 2 final rule shouldn’t come as a great shock to optometrists who have been following the meaningful use incentive program’s progress, Mr. Grant says. “We knew this was coming,” he says. “What the update does is somewhat change the timeline. The original law indicated that Stage 2 would be for 2013. So this is a nice reprieve, to have an extra year at Stage 1.”
And, while the Stage 2 final rule mandates that the next phase won’t take hold until 2014, optometrists will still be impacted in the upcoming year, he says.
For example, practices that attest for the 2013 payment year will avoid the 2015 penalty payment. Those that don’t attest for next year, however, will see Medicare reimbursements decreased by 1% when the penalties take effect in 2015. As such, providers must continue to attest in 2013.
This requirement, says Mr. Grant, will be the same for providers who attested in 2011 or 2012, and whose reporting period is the full calendar year, or those for whom 2013 is the first payment year and have a reporting period of only 90 days. It’s worth noting, he adds, that Stage 2 includes a special provision for eligible professionals demonstrating meaningful use for the first time in 2014. In other words, providers attesting no later than Oct. 1, 2014 would avoid the 2015 penalty.
Clear Communication
For EHR vendors, numerous changes must be made so that their EHR systems support the new and combined Stage 2 objectives. This may require adding some new features, such as secure messaging and electronic submission of clinical quality measures, as well as making workflow changes to meet the changed objectives, says Philip J. Gross, O.D., partner at Vision Quest Eye Care Center, in Dover, Del.
“More importantly, EHR vendors will need to support multiple rules simultaneously,” he says. For instance, some optometrists will start their first year as meaningful users in 2014. Therefore, these optometrists will be under the Stage 1 rules, while others will be starting their third year of meaningful use, and thus will be held to the Stage 2 rules.
“This is going to create much more complexity for the EHR vendors, as well as create more time needed for design and engineering to support these multiple simultaneous tracking and reporting systems,” Dr. Gross says.
Optometry practices must be careful to make sure the vendors providing their EHR systems are on top of the certification process.
“Doctors need to be communicating with software vendors to ensure that they’re certified in a timely manner,” he says. “No vendor could not be certified, or else they would cease to be in business. But optometrists need to make sure that their vendor is certified in a timely enough fashion so as not to jeopardize their status as a meaningful user in 2014.”
No Time Like the Present
Consistent communication with vendors about their certification is just one piece of the process for optometrists gearing up for meaningful use by 2014, however. “The first step for optometrists is to choose a certified EHR system that they’re comfortable with,” says Dr. Henry. “Optometrists should demo the product and be sure they like how the information goes into the EHR and what it looks like once it is in there.” For example, evaluate how easy previous results such as past refractions or past posterior segment results can be viewed, and how they can adapt to the workflows that the EHR uses.
Once the system is in place, it’s important for optometrists to understand that, given the new changes that have just been released, the first two years that a practice participates in meaningful use will always be in Stage 1, Dr. Gross adds.
After that, you will move to the newer Stage 2 rules and objectives. Still, optometrists should register for the EHR incentive program as early as possible in the year they plan to participate, Dr. Gross says. “Then, any problems with registration can be addressed before the due date of March 1 the following calendar year.” (For instance, participants in 2012 must register and attest before March 1, 2013).
“Finally,” says Dr. Gross, “once the objectives for the EHR reporting period are completed, the practice needs to attest before March 1 of the following calendar year as well,” he explains.
Indeed, Mr. Grant says “there’s really no reason for anyone to put off” working toward meaningful use of an electronic health record until 2014, tempting as it may be.
“2012 is pretty much over,” he says. “To ensure the maximum incentive possible that’s remaining—and to prevent incurring the penalties that begin in 2015—optometrists should work hard to become meaningful users in 2013.”
