The CMS and HHS' Office of the National Coordinator for Health Information Technology issued their much-anticipated final meaningful-use information technology regulations
that hospitals and physicians must follow to tap into some $27.3 billion in financial incentives authorized by the stimulus act.
The rule gives providers something to cheer. The CMS backed away from a controversial all-or-nothing rule requiring physicians to meet a list of 25 criteria and hospitals a list of 23 criteria to be eligible to receive a subsidy for electronic health-records systems. Instead, hospitals must meet 19 criteria and physicians 20 under a formula that includes 15 mandatory quality measures for doctors and 14 for hospitals with a choice of five others from a 10-item “menu.”
“While challenges remain, the final rule provides a better approach to the ‘real-world' issues faced by practices as they move toward 'meaningful use' of EHRs,” said William Jessee, president and CEO of the Medical Group Management Association, in a news release.
“After reviewing the comments, we agree that requiring that (eligible professionals), eligible hospitals, and (critical-access hospitals) satisfy all of the objectives and their associated measures in order to be considered a meaningful EHR user would impose too great a burden and would result in an unacceptably low number of EPs, eligible hospitals, and CAHs being able to qualify as meaningful EHR users in the first two years of the program,” the rule states.
“After consideration of the public comments received, we are establishing a core set of objectives with associated measures and a menu set of objectives with associated measures,” the rule continued. “In order to qualify as a meaningful EHR user, an EP, eligible hospital, or CAH must successfully meet the measure for each objective in the core set and all but five of the objectives in the menu set. With one limitation, an EP, eligible hospital, or CAH may select any five objectives from the menu set to be removed from consideration for the determination of qualifying as a meaningful EHR user.”
The rules were announced during a news conference whose speakers included HHS Secretary Kathleen Sebelius, new CMS Administrator Donald Berwick, National Coordinator for Health Information Technology David Blumenthal, and Surgeon General Regina Benjamin,
The goals behind meaningful EHR use are said to be improving the quality, safety and efficiency of healthcare services; reducing healthcare disparities; engaging patients and their families; improving the coordination of care; improving population and public health; and ensuring the privacy and security of personal medical information.
Another item providers were concerned with was the proposed rule demanding that, for a 90-day period during the first year of the program, hospitals run 10% of their orders through a computerized physician order entry system to qualify for the subsidy, while physicians were required to use CPOE for 80% of their orders. In comment letters, provider groups often cited a 2008 study that found only 4% of physicians were using CPOE.
The final rule cuts this back a bit.
“Our intent in the proposed rule was to capture orders for medications, laboratory or diagnostic imaging,” the rule stated. “However, after careful consideration of the comments, we are adopting an incremental approach by only requiring medication orders for Stage 1. First, this supports the objectives of e-prescribing, drug-drug and drug-allergy checks. Second, this requirement will improve patient safety because of the alignment of ordering medications in a structured data format will enable providers to create registries of patients for potential medical recalls, participate in surveillance for potential sentinel events and life-threatening side effects of new medications. Third, other measures involving transitions of care documents and summary of care document will require the entry of an active medication list.”
In addition to reducing what needed to be run through CPOE, the final rule establishes an across-the-board 30% requirement.
“For stage 1, we are finalizing a threshold for CPOE of 30 percent for EPs, eligible hospitals, and CAHS,” the rule stated. “We believe this relatively low threshold, in combination with the limitation to only medication orders, will allow hospitals and EPs to gain experience with CPOE. However, as providers gain greater experience with CPOE, we believe it is reasonable to expect greater use of the function.”
“Improvements sought by MGMA contained in the final rule include a reduction in the originally unrealistic thresholds related to e-prescribing, administrative transactions and computerized physician order entry, among others,” Jessee said.
The CMS first issued its proposed rules
on Dec. 30, and reports that it received more than 2,000 comments before the comment period closed on March 15.
Since then, little was known about how the final rules were developing. In an interview yesterday, Steven Waldren, director of the American Academy of Family Physicians' Center for Health IT, said Blumenthal didn't reveal much at an April meeting of the Physicians' EHR Coalition, except that the final version of the rules would be much different than originally proposed.
“He alluded that there were a lot of changes that the group would like a lot and that the group would not like,” Waldren said, adding that one his major concerns was the all-or-nothing nature of the rules.
“That's quite a bit of a challenge for docs and creates a lot of risk because if you miss one measure, you don't get anything,” he said.
The proposed rules were considered aggressive by many, Waldren said, “but we also need to get the ball rolling.”
Waldren said he would prefer making the initial requirements easier than pushing back the start of the program, and he used the analogy of an escalator to describe how he would like to see the rules amended.
“Instead of slowing down the escalator, don't make the first step so high,” he said.
While the EHR subsidies were included in legislation that was meant to stimulate the economy, there were many who said it had the opposite effect as providers put off making IT purchases until some clarity emerged on meaningful use. Last fall, this led some vendors to guarantee that their products
would meet the meaningful-use rules even though it wasn't established what those rules would be.
Athenahealth, a vendor most known for its revenue-cycle management products, just launched its web-based EHR in 2007, and it raised the bar by guaranteeing that its customers would receive a subsidy or they would receive free service for up to six months.
Athenahealth spokesman John Hallock said yesterday that their product would work as promised.
“We're pretty confident in our ability—whatever changes there are, if any—to make any updates if we need to,” he said.
Hallock added that the Athena Clinical EHR is now used by more than 2,000 providers and accounts for about 8% of the company's business, but he added that 54% of its new business now includes providers who use both the EHR and the revenue-management products. “In the last year and a half, we have seen a very big uptick,” he said.
Though people are looking for a short-term surge in IT adoption from the stimulus-law subsidies, Hallock said the focus should be on the long term.
“This is all going to play out—not next month or next week—but over a series of years,” he said. “Ambiguity is not a bad thing. When things change, you change with them.”
Waldren offered similar thoughts.
“With any huge change, you'll have some waste,” he said. “But we'll also get some folks who can take advantage and do great things with the technology.”
Provider groups hailed the move on e-prescribing.
"While challenges remain, the final rule provides a better approach to the 'real-world' issues faced by practices as they move toward 'meaningful use' of EHRs," said William Jessee, president and CEO of the Medical Group Management Association, in a news release. "Improvements sought by MGMA contained in the final rule include a reduction in the originally unrealistic thresholds related to e-prescribing, administrative transactions and computerized physician order entry, among others."