The CMS and HHS' Office of the National Coordinator 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.
Providers appeared most interested in learning whether the CMS would modify a proposed rule mandating an all-or-nothing, “pass-fail” approach dictating that, in order to receive a subsidy, doctors must meet, in its entirety, a list of 25 requirements and hospitals must meet a similar list of 23, and the CMS appeared to have been receptive.
“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.
A change on 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.”
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.”
Easier first steps urged
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 product would meet the meaningful-use rules even though it wasn't established what those rules would be.