On August 23, 2012, the final Meaningful Use Stage 2 rules were published. Coupled with the earlier publication of the proposed Stage 3 rules, healthcare in the United States for the foreseeable future is being redefined. What we are seeing is the steady evolution of healthcare not only into the electronic age but also into the realm of cyber-medicine with the growing requirement for provider and patient to be linked by Internet. These new rules also emphasize a renewed appreciation for the importance of quality metrics, and for a provider (EP and hospital alike), one must be able to consistently demonstrate that milestones in care are being met or the money simply won’t be there.
Reading through the nearly 700 pages of the rules, there is much to applaud and also much that merits further discussion. When ONC put the rules together, the authors realized that implementing Stage 2 rules will require a significant amount of work and clearly this would tax the resources of both hospitals and eligible providers (EP). Thus in 2014 all providers will only have to contend with a 3-month reporting period. The rules now also allow for “batch reporting” for EP attestation. This eliminates the requirement that each EP report individually enter data into a separate file and thus reduces the work and simplifies the process for a hospital or group to validate EP compliance.
Not all is good for EPs. Stage 2 now requires that EPs meet all 17 Core requirements and 3 of the 6 Menu Objectives. The rules are also more stringent in the numerators needed to meet the measure. These are summarized as follows:
In comparing this to the Stage 1, Stage 2 does not require more objectives be met. Rather, while the total number remains at 20, EPs must now meet 17 core objectives (2 more) but only 3 menu objectives (2 less). Similarly, eligible hospitals and critical access hospitals (CAHs) must meet a total of 19 objectives in the new stage 2 rules; 16 core objectives (previously 14 in stage 1) and 3 of 6 menu objectives (as opposed to 5 of 10 in Stage 1).
Perhaps the most important change with respect to these objectives is that while an EP or hospital can claim Menu Objective exclusions, beginning in 2014 this will no longer qualify for meeting an objective. In other words, if you cannot measure something, then you have effectively limited the list of choices but still must meet the total number of objectives.
Not only must a hospital or EP invest resources to meet the requirements but also they must be certain that their systems can meet the requirements for patient engagement. Stage 2 rules are built on the concept that not only must healthcare have access to the internet, but that there will a growing reliance on patients to use the internet to interact with their providers. For example, EPs must be able to send secure messages to at least 5% of their patients. There is also the expectation that 5% or more of patients will access their health care information securely online. Admittedly, 5% is a low number and there are allowable exceptions based on internet access. This is, however, the first step in defining how healthcare information will flow across the internet in the future.
The Stage 2 rules do offer the provider a degree of simplification in reporting quality measures. Currently, the 4 major programs (HIQRT, PRQS, CHIPRA, and ACO) all have different measurement standards. Beginning in 2014, CMS will look to align both measures and reporting across all these organizations so that when implemented, hospitals and providers will be able to:
- Select the same measures for different programs
- Simplify submission requirements to minimize multiple submissions
- Better coordinate quality measure involvement for data gathering including public input
CMS is also seeking to align CQM and HHS priorities. All providers must now select three of six CQMs from the HHS National Quality Domains. These are:
The impact of this change is significant for both providers and CMS. In theory both hospitals and EPs see a reduction in the effort needed to gather data and also to report this information. It also should reduce disparities in data priorities since there would be harmonization in data requirements.
For CMS, this should simplify and unify the various quality measure programs. CMS also expects this will result in higher quality care, better outcomes and lower cost through the unification of healthcare improvement programs. If CMS is successful in bringing this process to fruition, then we should all expect this to be a win-win outcome from the revised Stage 2 rules.
The biggest changes come after 2014. EPs and hospitals will now have to report on more CQMs taken from a larger pool. Beginning in 2014 EPs will have to report on 9 out of 64 CQMs whereas prior to 2014, they had only to report on 6 out of 44. It is also recommended that they look to report 1 measure in each of the 3 NQS domains. Hospitals will also see an increase going from 15 CQMs to 16 CQMs and also 1 measure in each of the 2 NQS domains.
So while we seeing a simplification in reporting by aligning the various measures, providers will see an increase in the number of measures they will need to follow. It remains to be seen how each will affect the other, but in the short term, both EPs and hospitals will most likely see an increase in the total amount of work needed to report to CMS beginning in 2014.
The Stage 2 final rules go into the payment adjustments for hospitals and EPs. The intent for both these groups is that in order to maximize payment, the Meaningful Use requirements must be met by the defined deadlines across all the required measures. Because these adjustments are based upon the previous year’s reporting, there is tremendous pressure to meet the program’s objectives early so as not to be penalized later. There are hardship exceptions, but for the majority of EPs and hospitals, best to be ahead of the curve rather than to have to catch up later. Medicare and Medicaid requirements are discussed, however for the most part the changes relating to both make the process simpler rather than more complicated.
Where the rule changes fall short rests with a fundamental deficiency in how Meaningful Use is constructed. Meaningful Use is focused around acute care and it does an admirable job of looking how care is provided and that quality landmarks are being addressed in a consistent manner. The problem lies not in the immediate future, but how medical demographics are changing in the US.
By 2020, 12 million Americans will require long term care and by 2050, it is estimated this number will grow to 27 million. It is also estimated that by 2050, 19.4 million Americans will be 85 years or older with many requiring long term, non acute care. What this means is that while in 2012 we are focusing on acute care, we are ignoring the fact that we need to expand Meaningful Use to address the needs of this rapidly growing segment of the healthcare population.
The HITECH act only pays cursory attention to this trend. There is essentially no money to prepare for the electronic documentation of care for this group nor are there any measures comparable to CQMs that address the needs or quality of care in long term care.
As CMS prepares to open the discussion on Stage 3 rules to public comment, perhaps this would be the proper venue to engage in a discussion on what is needed to build a comprehensive program for looking at the totality of care in the US. Stage 2 addresses both the adult and pediatric populations, but somehow sidesteps the issues that are unique to long term care.
Yes, the final Stage 2 rules are comprehensive and while there are certain criticisms that can be made, one should recognize that the revisions provide simplification while addressing the deficiencies that existed in Stage 2 proposed rules. As we move ahead and start to prepare for Stage 3, we should use this as an opportunity to recognize that healthcare is a continuum and Meaningful Use must address every level in this process. Our national healthcare goal should be that no matter where care is provided, the best and most appropriate tools for administering and monitoring the delivery and quality of care are consistently being used by all providers.