The Health Information Technology for Economic and Clinical Health (HITECH) Act passed in 2009 provided funds to reimburse physicians for the purchase and meaningful use of an electronic health record (EHR) system. Once the regulations were put in place, physicians and hospitals around the country began to purchase certified systems and make the transition from paper to electronic patient files.

But when the Centers for Medicare & Medicaid Services (CMS) released the requirements that physicians must meet to qualify for meaningful use Stage 1 incentive payments, it was clear that qualifying would not be easy.” In particular, specialists such as orthopaedic surgeons would be challenged to qualify.

To obtain government payments for Stage 1 meaningful use, an orthopaedic surgeon had to document meeting criteria for 15 core and five out of 10 menu objectives. The criteria were heavily weighted to primary care, requiring orthopaedic surgeons to document patient information normally not required in an orthopaedic practice.

On March 7, 2012, the proposed rules for meeting Stage 2 meaningful use were published in the Federal Register. Even though CMS decided to delay implementation of Stage 2, the response from the medical community ranged from “Are you kidding me?” to “This is really going to be difficult.”

The American Association of Orthopaedic Surgeons (AAOS) has submitted comments on the proposed Stage 2 requirements and “signed on” to comments submitted by the American Medical Association and the American College of Surgeons. The following is a summary of the key Stage 2 requirements on the horizon.

Key criteria
Stage 2 criteria focus on improving care transitions and patient engagement. For care transitions, orthopaedic surgeons will most likely use a health information exchange (HIE), which can direct movement of secure patient information between disparate health organizations. Unfortunately, not all states have HIEs, and those that are currently operational are expensive to use.

The proposed requirements for patient engagement will require orthopaedic practices to provide patients with the ability to view online, download, and transmit their health information. Practices must also prove that at least
10 percent of their patients are actually accessing healthcare information on EHR systems.

CMS proposes to maintain the same core and menu structure for Stage 2, orthopaedic surgeons will have to meet 17 core objectives and three of five menu objectives, or they may seek to qualify for an exclusion of some items. Although CMS has stated that each objective/measure was evaluated for its applicability to all eligible professionals (EPs) and eligible hospitals, it also recognized that in some situations, it might be impossible for an EP or eligible hospital to meet the measure. Thus, the rule includes certain defined exclusions. If an exclusion applies, the EP or eligible hospital would not have to meet that objective/measure in order to be deemed a meaningful user.

From options to requirements
Some criteria that were optional for Stage 1 meaningful use will be required for Stage 2 meaningful use. Among the proposed changes are the following:

• changes to the denominator of computerized provider order entry (CPOE) (optional in Stage 1; required for Stage 2)
• changes to the age limitations for vital signs (optional in Stage 1; required for Stage 2)
• elimination of the “exchange of key clinical information” core objective from Stage 1 in favor of a “transitions of care” core objective that requires electronic exchange of summary of care documents in Stage 2 (effective Stage 2)
• replacing the objective to “provide patients with an electronic copy of their health information” with one that requires providers to provide patients with the ability to “view online, download, and transmit” health information (effective Stage 2)

Impact on orthopaedic practices
What do these key requirements mean to orthopaedic surgeons? The transitions of care core objective requires that orthopaedic offices have the ability to transfer data electronically from the office to a hospital or another physician caring for the patient, using the EHR system. If the practice’s EHR system does not interface with the other provider’s EHR system, an HIE can be used, but this will result in a cost to the practice and an expense that cannot be recaptured. A secure patient portal to provide patients access to their medical record and a way to communicate with the provider will also be required. But what happens when patients don’t use computers?

It’s an issue the AAOS raised in a comment letter to Marilyn Tavenner, CMS’s acting administrator. To illustrate the difficulties some surgeons might face, AAOS shared the story of Gabriel L. Dassa, DO, an orthopaedic surgeon in solo practice in Bronx, N.Y. His patient population is predominantly (about 70 percent) indigent and low-income Medicaid and Medicare beneficiaries. His patients do not have access to a computer to use patient portals and will not likely seek health information reports from him.

Dr. Dassa will probably not achieve the Stage 2 requirement for at least 10 percent of patients to access their protected health information and use secure messaging online. Although he can electronically link to the hospital, he cannot exchange patient information electronically with most other physicians in the area, because they have not purchased EHR systems. Dr. Dassa might qualify for exclusion of some Stage 2 requirements; if not, he faces payment adjustments for Medicare reimbursement beginning in 2015.

More requirements
The proposed rule does include new requirements designed for specialists, primarily focused on imaging results, use of cancer registries, and the capability to identify and report specific cases to a specialized registry. For orthopaedic surgery, the requirement to report cases to a specialized registry increases the value of the recently formed American Joint Replacement Registry.

Just as in Stage 1, CMS proposes that EPs be required to report on specified clinical quality measures to qualify for incentive payments under the Medicare and Medicaid EHR Incentive Programs. The clinical quality measures that directly link to orthopaedic practice focus on osteoporosis and back pain. These conditions are not normally encountered in practices focused on adult reconstruction, sports medicine, pediatric orthopaedics, or orthopaedic trauma.

By statute, Medicare payment adjustments are required to take effect in 2015. However, CMS is proposing to adjust the rule. If an EP achieves Stage 1 meaningful use in 2013, no payment adjustment would be made. Anyone who first demonstrates Stage 1 meaningful use in 2014 would avoid the penalty if the attestation requirement were met by October 3, 2014.

Between now and then
Stage 2 does not begin immediately and some modifications to the rule are likely, particularly in the area of measure reporting. CMS expects to release the final rule after a review of comments later this year. The AAOS EHR Project Team and staff will create a Stage 2 meaningful use toolkit to help orthopaedic surgeons navigate the requirements.

Orthopaedic surgeons can still obtain payments for Stage 1 meaningful use if they apply and submit data documenting meaningful use. To qualify, orthopaedists must meet Stage 1 criteria for a period of 90 consecutive days during the calendar year. Oct. 3, 2012, is the last day for EPs to begin the 90-day reporting period for calendar year 2012. As of March 2012, although about 44,000 physicians have received Stage 1 payments, fewer than 1,000 orthopaedic surgeons have qualified.

Howard Mevis is the director of the AAOS department of electronic media, evaluation programs, course operations & practice management group. He can be reached at mevis@aaos.org

Additional Resources

• Toolkit
• Health Information Technology
• How to attain meaningful use