On August 27, 2012, the Centers for Medicare & Medicaid Services (CMS) published the 672-page Final Rule that specifies the Stage 2 criteria that eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) must meet to continue to participate in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs.

In addition to the Stage 2 Final Rule, CMS announced changes to Stage 1 objectives, measures, and exclusions for EPs, eligible hospitals, and CAHs. Stage 1 changes specific to eligible hospitals and CAHs will take effect as early as Oct. 1, 2012. Changes specific to EPs will take effect Jan. 1, 2013, and other changes are slated to take effect in 2014. All providers must achieve meaningful use under the Stage 1 criteria before moving to Stage 2.

Good news, bad news
While Stage 1 was focused largely on data input, Stage 2 raises the bar by focusing on improved clinical processes. Thomas C. Barber, MD, chair of the AAOS EHR Project Team, noted that the new rules “create a whole new ballgame for orthopaedic surgeons seeking meaningful use payments.”

Although early adopters were given an extra year before advancing to Stage 2, all other providers—including those who qualify in 2012—have just 2 years of meaningful use under the Stage 1 criteria before advancing to the Stage 2 criteria.

“The good news is that early adopters (providers who began to meet Stage 1 requirements in 2011) now have until 2014 before they have to meet the Stage 2 requirements,” said Dr. Barber. “The bad news is a new expectation that patients have online access to their medical record and use secure email to provide their physician with medical information.”

In addition to requirements for online patient engagement and information exchange, the Office of the National Coordinator for Health Information Technology within CMS took the opportunity to expand the number of core and menu measurements and to increase reporting related to clinical quality measures.

Stage 2 highlights
The following are highlights of Stage 2 for EPs:

• The Final Rule confirms 2014 as the earliest effective date for Stage 2.
• For 2014 only, providers who are beyond the first year of demonstrating meaningful use will have a 90-day reporting period to allow time to upgrade certified EHR technology to the 2014 edition.
• EPs must meet or exclude all 17 core measures and must meet—not “meet or exclude”—3 of the 6 menu measures. (Unlike Stage 1, exclusions of menu measures do not count unless the EP cannot find 3 relevant menu measures.)
• All Stage 1 menu measures except syndromic surveillance become core measures.
• Five new menu measures have been added: access to imaging results, family history, progress notes, reporting to cancer registries, and reporting to specialized registries.
• Stage 2 increases most Stage 1 thresholds.
• Computerized Physician Order Entry is expanded to include lab and radiology orders in addition to prescriptions.
• The following two new core objectives have been added:
• EPs will have to ensure that more than 5 percent of the patients they see actually view, download, or transmit their health information.
• EPs will have to ensure that more than 5 percent of the patients they see send them a secure email message containing clinical information (not just a request for an appointment).
• Clinical summaries of office visits must be available to patients within 1 day, instead of the 3-day timeframe in Stage 1.
• The Stage 1 measure requiring a test of the ability to exchange clinical data with another provider has been dropped effective 2013, in favor of a more robust 2014 Stage 2 requirement for ongoing exchange of a significantly more extensive data set.
• EPs will report on 9 of 64 Clinical Quality Measures (CQM); after the EPs’ first incentive year, the CQM data must be submitted electronically, rather than by attestation.
• To streamline the reporting process, Stage 2 offers opportunities for batch reporting by group practices and for consolidated CQM reporting for Physician Quality Reporting System and Meaningful Use.
• The definition of “hospital-based” physicians has been modified to create an application process for physicians to demonstrate that they alone fund their EHR systems and are eligible to receive the incentive payments directly.
• Penalties and hardship exemptions are defined, establishing Oct. 1, 2014, as the latest date by which an EP can attest for the first time and avoid a 1 percent payment adjustment in 2015.

More information
October 3, 2012, is the last day for eligible professionals to begin their 90-day reporting period to demonstrate Stage 1 meaningful use for the Medicare EHR Incentive in 2012 and qualify for an incentive payment of up to $18,000 (maximum payment of $44,000). Providers who first demonstrate Stage 1 meaningful use in 2013 can qualify for a first-year incentive payment of $15,000 and a maximum payment of $39,000; those who first demonstrate Stage 1 meaningful use in 2014 can qualify for a first-year incentive payment of $12,000 and a maximum payment of $24,000 (Fig. 1). Payment adjustments will begin in 2015 for providers who are eligible but decide not to participate.

According to Dr. Barber, the EHR Project Team is working with staff to create a Stage 2 meaningful use toolkit to help orthopaedic surgeons meet these new requirements. At the same time, the Stage 1 toolkit is being revised based on the changes reported in the Stage 2 rule.

Jackie Ryan is the manager of the AAOS practice management group. She can be reached at ryan@aaos.org

For links to a detailed list of changes to Stage 1, instructions on how to get started participating in the Medicare or Medicaid EHR Incentive Programs, and resources available through the AAOS Practice Management website, see the links below or visit www.aaos.org/pracman

Additional Resources:
EHR Incentive Program from CMS
CMS Stage 1 Changes Tipsheet
CMS Stage 2 Overview Tipsheet