CMS: Sleek and simplified, stage 3 is ‘Meaningful Use for everyone’

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 - Robert Anthony
Robert Anthony, Deputy Director, Quality Measurement & Health Assessment Group 
Centers for Medicare & Medicaid Services

It’s T-minus two and a half years, give or take, on the liftoff of Meaningful Use stage 3. In 2018, every eligible hospital and eligible professional must attest to a single set of eight objectives—or suffer reduced Medicare/Medicaid reimbursements—in what is expected to be the final and definitive MU stage. The sweep-up will include healthcare providers who will be demonstrating their deployment of certified EHR technology for the very first time.

Some of the details still need to be tweaked, as comments on CMS’s proposed rule close on May 29. However, for all intents and purposes, stage 3 is already docked on the launch pad with steam billowing from the bleeder valves fore and aft.

The approach of the turning point helped fill the room when two CMS officials recapped MU’s recent past and sketched out its future at HIMSS15 in Chicago this April.

The good news that emerged for those who have lagged behind so far and fear they can’t catch up in time: CMS has built in some flexibility and, clearly, gone out of its way to simplify participation.

“We were thinking very much in terms of something that was simpler” when drafting the stage 3 proposed rule, said Robert Anthony, deputy director of CMS’s quality measurement and health assessment group. “We heard [the call for simplicity] from a variety of providers as you went through and implemented. We heard it from your vendors. We heard it from different stakeholder associations: Not only had Meaningful Use become rather complicated and large,” but also “once you started to implement Meaningful Use in concert with other requirements like PQR (physician quality reporting) or IQR (inpatient quality reporting) or value-based purchasing, it was just one of a number of complicated requirements.”

Anthony said 2017 will be, in fact, a “flexibility year.” Providers will attest to either a modified version of stage 2—with accommodations made for stage I providers—or, at their discretion, to the full version of stage 3.

Meanwhile, he added, flexibility will extend beyond dates and into doing, good news for the medical specialties. “We have heard you say that workflow differs from one setting of care to the next,” Anthony said. “Even within the same specialty, we see substantial variations within workflows. We wanted to focus on those elements that improve outcomes and quality of care for patients. Because ultimately that’s what this was meant to do.”

Eight easier objectives? 

One of the end goals of stage 3 is ensuring that the exchange of health information is truly interoperable, flowing freely (albeit securely) across platforms—and among and between providers and patients. Anthony suggested that keeping this broad capability in mind helped CMS identify measures to cut when they’re already covered by other EHR initiatives.

Describing an example, he pointed to smoking status. MU originally included this health factor, but “we’ve heard over and over again about quality measures that are part of the core set for PQRS that [tackle] the exact same thing. We took away those redundancies where we could find them.”

CMS is also looking to cut out recording measures that have “topped out,” meaning they have a very high performance rate and thus aren’t subject to substantial continued improvement. For example, providers have achieved Meaningful Use on problem lists, the sections of patients’ medical charts detailing key medical diagnoses and conditions, to the tune of 95%-plus.

In the end, CMS winnowed stage 2’s 20 or so performance indicators to just eight “advanced use” objectives for stage 3:

  1. Protection of electronic health information
  2. Electronic prescribing (eRx)
  3. Clinical decision support
  4. Computerized provider order entry (CPOE)
  5. Patient electronic access to health information
  6. Coordination of care through patient engagement
  7. Health information exchange
  8. Public health and clinical data registry reporting

“These eight core objectives focus on just a few major areas that both CMS and ONC thought were critical for establishing that electronic infrastructure that supports better care for patients,” Anthony said. “Some of these we had already started in Stage 2. I think a lot of these won’t take people by surprise.”

Dawn of the data-driven patient

Next up was Elisabeth Myers, policy lead for eHealth initiatives at CMS’s Center for Clinical Standards and Quality. She did a little deeper dive into the eight objectives, drawing special attention to items 5 through 8 after noting that the first four are not all that different from their respective iterations in stage 2—with one minor exception.

“With number 4, computerized provider order entry, the real change is that we are going from radiology orders to diagnostic imaging orders,” she said. “So it’s a larger category that incorporates a wider range of the types of orders that we want to see done with CPOE.”

Myers then highlighted aspects of the other objectives.

Patient electronic access to health information. Where the prior versions of MU stressed the concept of view, download and transmit, CMS is now taking a broader view of patient access. For example, the agency wants to offer providers the option of using an application programming interface that would allow data to be accessed in multiple ways using third-party applications. This will allow for some variety in how the technology itself can be used, she said.

At the same time, CMS wants the patient-access objective to encompass patients’ access to specific education resources, electronic as well as paper. “What we’re talking about here is providing meaningful access to useful health information about their own care,” Myers said. “Preventative options, potential risks—all of the things that help improve health literacy and help improve the patient’s engagement in the decision-making process for their healthcare.”

Coordination of care through patient engagement. The overarching goal here is “keeping the patient at the center of care and engaging the patient in communication, having an open channel in a communications continuum,” Myers said. Like some other objectives on the new, condensed list, this one offers providers the option of picking from a list of measures.

In this case, providers will choose to complete two of three: having patients review their health records, helping them exchange secure messages with the provider, and/or showing their interactions with their health records after generating their own data and incorporating it into the EHR.

Health information exchange. “The really key point here is that we are closing the loop. The stage 2 rule has a lot of information about sending,” Myers said. By contrast, stage 3 is “also about receiving.” It’s also about incorporating data through clinical information reconciliation, she added.

Public health reporting. “What we’ve proposed is, instead of having very specific, strict [language]—‘You must do exactly this even if it’s not relevant to you, and you must do it in exactly this way’—we’re trying to provide a public health suite,” Myers said. Essentially providers will report on the data that’s most applicable to their respective practices, patient populations and public health agencies. “We’re really trying to get to that meaningful exchange of public health and population health data,” Myers said.

Anthony summed up the exercise CMS put into simplifying Meaningful Use in stage 3 and, in the process, preparing it to enjoy a long, productive life. “We’ve essentially come down to a smaller set of objectives that focus on the essence of what we need to move forward with interoperability, enabling better patient care through the use of EHR technology,” he said. “If I had my way, stage 3 would have been called the ‘Meaningful Use for Everyone’ rule.”

And so the countdown to final liftoff begins.