AAOS Now

Published 11/1/2014
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Howard Mevis

Bar Raised for Stage 2 Meaningful Use

Orthopaedic surgeons may well consider Sept. 4, 2014, as a “date that will live in infamy.” On that date, the Centers for Medicare & Medicaid Services (CMS) Office of the National Coordinator for HIT (ONC) published final regulations for meeting Stage 2 meaningful use criteria for electronic medical records (EMRs).

Although the regulations were touted as providing “additional flexibility” in meeting the requirements, they also present significant hurdles and create substantial additional burdens for eligible providers (EPs).

For example, under Stage 1 meaningful use criteria, EPs could attest for a period of 90 consecutive days; the final rules for Stage 2 ask for a full year of attestation (365 days), beginning Jan. 1, 2015.

This is a significant increase from the 2014 requirements. During 2014, EPs who had completed Stage 1 could satisfy Stage 2 with just 90 days of attestation. As of Aug. 25, 2014, ONC reported 143 eligible hospitals and 3,152 eligible providers had attested to Stage 2.

“No one expected the Stage 2 final rule to require 365 days attestation,” said Jonathan Schaffer, MD, a member of the Academy’s Practice Management Committee EMR team. “The Academy’s view was that a 90-day attestation for Stage 2 was a more practical approach. EPs were more likely to succeed and demonstrate their continued backing for the meaningful use program.

“This longer attestation period means that all EPs will struggle to meet meaningful use, and the incentive payments physicians were counting on to offset EMR implementation costs are now doubtful,” he concluded.

“The 2015 attestation requirement represents a disincentive to participate in the program and reduces the likelihood that orthopaedic surgeons will report on clinical quality measures, too. Instead of simplification, we get confusion, and the momentum from Stage 1 is lost,” noted Richard Dell, MD, another member of the EMR team.

Vendors get a break
At the same time, ONC maintained 2014 requirements for the EMR industry. It dropped the controversial 2015 certification criteria and opted for a more flexible version.

“This change helps because EMR vendors have not been able to get updated software to the market for 2014 attestation,” said Dr. Dell. However, he also noted that it is now too late to attest in 2014 using 2011 certified software.

“The time available after the initial publication of the Stage 2 rule was too short to make the required software coding changes to enable their EHR products to be certified to the 2014 edition of EHR certification criteria,” said Dr. Dell. As a result, according to the final rule for those seeking to attest in 2015, “all eligible providers need to adopt, implement, or upgrade to 2014 Edition certified EHR technology.”

What happens if an orthopaedic surgeon does not meet the meaningful use requirements? Medicare payment penalties begin in 2015 if an EP has not attested for Stage 1. The penalties increase over time up to a 5 percent deduction from reimbursement.

Is legislative relief possible?
On Sept. 16, 2014, legislation was introduced in the U.S. House of Representatives calling on CMS to revert to the 90 consecutive day requirement for Stage 2 meaningful use. The proposed Flexibility in Health IT Reporting (Flex-IT) Act of 2014 (H.R. 5481) is sponsored by Rep. Renee Ellmers (R-N.C.) and Rep. Jim Matheson (D-Utah). With the Congress meeting in lame duck session following this month’s election, the likelihood of passage is unknown.

“Orthopaedic surgeons and other physicians need to advocate for this legislation. The office of government relations for the American Association of Orthopaedic Surgeons (AAOS) is communicating with members of Congress about the need for this legislation, and member support is valued,” noted AAOS Medical Director Will Shaffer, MD.

Meaningful use plan
What do the final regulations mean for Meaningful Use Program incentive payments?
Table 1 shows the current schedule of payment adjustments.

Stage 2 retains the core and menu structure for meaningful use objectives. Although some Stage 1 objectives were either combined or eliminated, most Stage 1 objectives are now core objectives under Stage 2 criteria.

Orthopaedic practices are required to meet 17 core objectives to achieve meaningful use as well as three out of six menu objectives. Details of these objectives can be found on the ONC website (www.healthit.gov). For many of these objectives, the threshold that orthopaedic practices must meet to qualify under Stage 2 has been raised. For example, under Stage 1 meaningful use, computerized physician order entry (CPOE) was required only for medication orders. Under Stage 2, CPOE is required for medication, laboratory, and radiology orders.

In addition, the threshold for each of these uses is higher. Whereas Stage 1 required CPOE use for at least 30 percent of unique patients with at least one medication, Stage 2 now requires the physician to use CPOE for more than 60 percent of medication, 30 percent of laboratory, and 30 percent of radiology orders placed during the EHR reporting period.

Most of the new objectives introduced for Stage 2 are menu objectives. As in Stage 1, many of the Stage 2 objectives have exclusions that enable providers to achieve meaningful use without having to meet objectives outside of their normal scope of clinical practice.

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

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