On Oct. 6, 2015, the Centers for Medicare and Medicaid Services (CMS) released the final rule for Stage 3 of its meaningful use (MU) program for electronic health records (EHRs), along with finalized modifications to MU Stages 1 and 2. The American Association of Orthopaedic Surgeons (AAOS), along with several other healthcare groups, had urged the administration to delay rulemaking for MU Stage 3 and reevaluate the program in light of recent changes to Medicare.

The AAOS and other groups noted that the MU Stage 3 rules were developed prior to and without consideration of the changes enacted by the Medicare Access and CHIP Reauthorization Act (MACRA). As a result, the software developed by vendors may lock in problematic technology.

The groups also noted that interoperable, useable, and clinically relevant EHRs are an essential foundation for the implementation of the Merit-Based Incentive Payment System (MIPS) program and Alternative Payment Models (APMs). And while health information technology (HIT) may be a fundamental component to improving the nation's healthcare system, a significant gap exists between the implementation of EHRs and the success of physicians in meeting MU objectives. In fact, approximately 80 percent of physicians are using EHRs but less than 20 percent have successfully participated in MU Stage 2.

Finally, because current HIT infrastructure does not provide for efficient electronic exchange of patient information, many physician groups are concerned that the MU program's ambitious and prescriptive timetables hinder—instead of help—physicians to provide quality care to their patients.

"We are disappointed that CMS did not listen to stakeholders and members of Congress who urged them to delay rulemaking for Stage 3 so that it would better align with the MIPS program and allow adequate time to prepare," stated Thomas C. Barber, MD, chair of the AAOS Council on Advocacy. "We certainly appreciate the recognition of concerns and added flexibility in the program, but rather than push forward with the next stage of meaningful use, CMS should first focus their attention on ensuring that providers can easily and efficiently share health information to support care delivery and new models of care.

"We will continue to advocate for meaningful use requirements that better align with upcoming programs, increase specialty specific quality measures, encourage interoperability, and expand hardship exemptions," pledged Dr. Barber.

According to AAOS President David D. Teuscher, MD, specialty physicians such as orthopaedic surgeons "face unique technology challenges, ranging from certification issues to collection of appropriate data, as well as the larger issues impacting all physicians such as interoperability and cost." Dr. Teuscher noted that the amount of time orthopaedic surgeons would spend trying to meet the proposed Stage 3 objectives would ultimately result in less time treating patients, thereby reducing patients' access to care.

Members of Congress expressed similar frustration. More than 100 legislators joined Reps. Tom Price, MD (R-Ga.); Renee Ellmers (R-N.C.); and David Scott (R-Ga.) in asking for a delay to align meaningful use with the forthcoming MIPS program. Additionally, Sen. Lamar Alexander (R-Tenn.) had repeatedly suggested a Stage 3 delay.

"The administration has a tin ear," stated Sen. Alexander after the release of the rules. "We asked: 'Why spend a year modifying rushed up mistakes? Why not spend a year getting it right in the first place?' They listened but they did not hear.

"They've missed a golden opportunity to develop bipartisan support in Congress and throughout the country for an electronic health records system that would genuinely help patients," he continued. "Instead, they've rushed ahead with a rule against the advice of some of the nation's leading medical institutions and physicians. Congress will carefully review this rule and has the option of fixing it through legislation or overturning it through the Congressional Review Act."

About the rules
Major provisions for the EHR Incentive Programs in 2015 through 2017 include the following:

• 10 objectives for eligible professionals (EPs), including one public health reporting objective—down from 18 total objectives in prior stages
• 9 objectives for eligible hospitals and critical access hospitals (CAHs), including one public health reporting objective—down from 20 total objectives in prior stages
• Clinical Quality Measures (CQM) reporting for both EPs and eligible hospitals/CAHs remains as previously finalized.

According to CMS, these changes are based on an evaluation of current programs and an identification of areas where modifications could be made to align with the long-term vision and goals for Stage 3. Objectives and measures of the 2015 through 2017 EHR Incentive Programs were restructured to align with Stage 3 and Stage 2 "patient action" measures were modified.

Major provisions for Stage 3 of the EHR Incentive Programs in 2017 and subsequent years are as follows:

• 8 objectives for EPs, eligible hospitals, and CAHs— In Stage 3, more than 60 percent of the proposed measures require interoperability, up from 33 percent in Stage 2.
• Public health reporting with flexible options for measure selection
• CQM reporting aligned with the CMS quality reporting programs
• Finalized use of application program interfaces that enable the development of new functionalities to build bridges across systems and provide increased data access. According to CMS, this will help patients have unprecedented access to their own health records, empowering individuals to make key health decisions.

The Stage 3 requirements are optional in 2017. All providers will be required to comply with Stage 3 requirements beginning in 2018, using EHR technology certified to the 2015 Edition. Objectives and measures for Stage 3 include increased thresholds, advanced use of health information exchange functionality, and an overall focus on continuous quality improvement.

In addition, the final rule adopts flexible reporting periods that are aligned with other programs to reduce the reporting burden for physicians. It also moves from fiscal year to calendar year reporting for all providers beginning in 2015. A 90-day reporting period is available for all providers in 2015, for new participants in 2016 and 2017, and for any provider moving to Stage 3 in 2017. All returning participants must use a full calendar year reporting period in 2016, 2017, and 2018.

Elizabeth Fassbender is the communications manager in the AAOS office of government relations. She can be reached at fassbender@aaos.org

Additional Information:
AAOS Letter to CMS