On March 30, the Centers for Medicare & Medicaid Services (CMS) published a proposed rule (CMS Proposed Rule) detailing the policies it will introduce during Stage 3 of the Medicare and Medicaid Electronic Health Record (EHR) Incentive Program. In tandem with CMS’s publication, the Office of the National Coordinator for Health Information Technology (ONC) also published a proposed rule (ONC Proposed Rule) providing a new edition of health information technology (HIT) certification criteria. The proposed rules are intended to work together in streamlining the establishment of an interoperable nationwide health information infrastructure.

Stage 3 of the EHR Incentive Program

CMS plans to implement two significant changes during the third—and likely final—stage of the EHR Incentive Program.

First, CMS would eliminate the tiered stage system.  In previous iterations of the EHR Incentive Program, providers would attest to different stages sequentially based on their first year of payment. For example, a provider whose first payment year was in 2015 would have been required to attest to meaningful use at the Stage 1 level for 2015 and 2016, followed by the Stage 2 level for 2017 and 2018, and finally the Stage 3 level for 2019 and beyond. Under the CMS Proposed Rule, however, beginning in 2018, all providers—even first time participants in the EHR Incentive Program—will be required to attest to meaningful use at the Stage 3 level.

Stage 3 would consist of eight objectives and their associated measures, with some objectives having multiple measures. While providers would be required to attest to all measures, they would not be required to meet the threshold of every measure for each objective. For example, the CMS Proposed Rule contains three measures for the Health Information Exchange objective:  (1) creating a summary of care using certified electronic health record technology and then electronically exchanging that summary for more than 50 percent of transferred, referred, or new patients; (2) receiving and implementing summary of care documents from a source other than the provider’s EHR system for more than 40 percent of transferred, referred, or new patients; and (3) performing a clinical information reconciliation for more than 80 percent of transferred, referred or new patients.  Providers would be required to attest to all three measures.  But they only would have to meet the percentage threshold for two of the three measures to satisfy the objective.

Second, the Proposed Rule suggests changes to the EHR Incentive Program’s mandated reporting periods. The reporting period for Medicare eligible professionals (EPs), eligible hospitals, and critical access hospitals would transition from a 90-day period to a calendar-year period. Medicaid EPs, eligible hospitals, and critical access hospitals attempting to demonstrate meaningful use in their first year, however, would remain on the 90-day reporting period.

Lastly, the CMS Proposed Rule has a number of provisions that seek to promote interoperability. A number of objectives have measures requiring the electronic transmission of health data. But these objectives, by themselves, do not necessarily require or increase interoperability. First, many measures are optional. Second, the rules do not appear to require transmission between different types of HIT modules. For example, as discussed above, the Health Information Exchange objective would require providers to electronically send or receive (or electronically send and receive) a certain percentage of summary case records for transferred, referred, or new patients. If two separate provider groups are using an HIT module developed by the same company, however, they could transmit the requisite amount of summary case documents to satisfy this objective without interoperability. Nonetheless, the CMS Proposed Rule would make one step towards interoperability—the adoption ONC’s proposed 2015 criteria for certified HIT as a requirement to participate in Stage 3 of the EHR Incentive Program.

2015 Edition HIT Certification Criteria

The ONC Proposed Rule makes more direct strides at promoting interoperability.

First, HIT modules would need to conform to the latest editions of code sets so that data could be more easily exchanged across platforms.

Second, HIT modules would be required to adopt C-CDA Release 2.0. The C-CDA standard is the single standard permitted for transmission of summary care records. ONC also recognizes, however, that not all systems would be able to update to C-CDA Release 2.0 at the same time. Therefore, HIT modules would need to transmit and parse summary care records in both C-CDA R1.1 and C-CDA R2.0 in order to mitigate any interoperability problems that may arise as the newest version of C-CDA is adopted asynchronously.

Third, the ONC Proposed Rule seeks to make HIT more user-focused and user driven. Users would need to be able to configure and set a number of functions and be able to export patient summaries independent of developer assistance (with the exception of the initial training/orientation). The same would apply for the export and import of CQM data.

Finally, the ONC Proposed Rule would establish a new certification criterion: the ability to respond to requests for patient data from other applications. ONC defines application as “any other type of system or software that is not the data source responding to the requests for data.” A HIT module would be required to have an application programming interface capable of responding to a request for data contained in the Common Clinical Data Set and returning the requested data in a designated format.

The comment periods on both proposed rules close on May 29, 2015.