July 14, 2010
Health care providers will have two years to implement Stage 1 programs on electronic medical records no matter when they start
The federal government has, in many ways, lowered the bar for physicians and hospitals to receive reimbursement for implementing electronic medical records (EMRs), while also retaining the fundamental measures to maintain quality of care and safety, experts say.
The U.S. Centers for Medicare and Medicaid Services (CMS) on Monday released its final version of so-called meaningful use rules. Those rules will be used by the government to determine whether EMR qualify implementations for billions of dollars in incentives.
William Connelly, an attorney specializing in health care in the Washington office of law firm Manatt, Phelps & Phillips LLP, said the changes that the CMS made to the quality-of-care metrics were significant. The CMS reduced the number of quality metrics from 90 to 44, and physicians only need report electronically on three.
For example, if a patient has diabetes, the health care provider—be it a physician or a hospital—is required to report that it is in fact taking blood pressure readings on that patient. Or if a patient has had a heart attack, the provider must report that it has prescribed an aspirin regimen. Part of the reason why the CMS dropped so many of the requirements in the first phase of meaningful use rules is that the agency itself has no way to receive reports electronically much of the time, Connelly said.
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The new rules were finalized after a three-month public comment period during which more than 2,000 recommendations were received by the U.S. Department of Health and Human Services on its preliminary "notice of proposed rule making" effort. The final document is 864 pages long.
In the final rules, CMS does little to promote the electronic exchange of EMRs between hospitals and among states. "There wasn't much to promote health information exchange in the proposed rule, but they scaled it back even further in the final rule," Connelly said.
He added that state health information exchanges will likely be addressed in Phases 2 and 3 of the rules. Phase 2 is expected as early as this fall. There has yet to be a date set for the release of Phase 3 of the rules.
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One thing the CMS had no flexibility with in its rules was the 2015 deadline for implementing EMRs. The timetable for meeting the standards was set in stone by the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. The HITECH Act mandates that health care entities must implement EMRs by 2015 or face monetary penalties in the form of reductions in Medicare reimbursements.
"I think there's a lot of folks that are all of a sudden realizing that they're in a real predicament. What I sense from talking to other organizations is that they didn't take this quite as seriously as they should have," said Bill Fawns, director of IT services at Kern Medical Center in Bakersfield, Calif.
[EDITOR: Fawns is CIO of Kern County and interim CIO of Kern Medical Center.]
In November, Kern Medical Center plans to deploy an OpenVista EMR system from Medsphere Systems Corp. Kern Medical has a 222-bed acute-care teaching hospital that serves a community of approximately 650,000 and cares for 16,000 inpatients annually.
"Our approach to meaningful use has been to throw it back to our vendor. So contractually we obligated our vendor to deliver meaningful use however the requirements turn out," Fawns said.
He said one of the greatest challenges with deploying an EMR system has been setting up a wireless infrastructure in a hospital campus that has a mixture of new and old buildings. Another big challenge is pushback from the hospital staff.
"We're a teaching hospital, so on one end of the spectrum we have residents born with a computer in their hand and so they look at this as an opportunity to move forward; on the other side of the spectrum are the physicians [who] are in their 60s and the very idea of signing onto a computer is a big question mark to them," Fawns said.
While he sympathizes with organizations struggling with implementing EMRs, Fawns said he has mixed feelings about health care providers that complain about the 2015 deadline the government has set.
"We're aggressively going after this. Part of me thinks other organizations could have done that too," he said. "My guess is there will be enough cries that deadline will be extended. But even if it's left as it is now, it is enough time if they want to get serious about an EMR."
Segal said the 2015 deadline is not as dire as it appears. While HHS wanted all entities to achieve Stage 3 meaningful use by 2015, that stirred up concerns among some health care providers who then voiced their concerns—and those concerns were heard.
"In some cases, if you started EMRs later, you were needing to move through each stage in one year. That didn't logically take into account the time needed to progress from one stage to another," Segal said.
The final rules state that reimbursement payments for Medicare providers may begin no sooner than October for eligible hospitals, and no sooner than January 2011 for eligible health care professionals. The rules allow providers to begin EMR deployments in 2012, 2013 or 2014, and they grant the providers two full years to fully implement Stage 1 standards, Segal said.
Health care providers only need to record 90 days of EMR information to report to the CMS to qualify for reimbursement payment, instead of a full year as the preliminary rules required.
"The good news is... if you're able to start demonstrating meaningful use Jan. 1, 2011, then around April 1 they would be able to... in effect get the money early, which is very useful for covering the cost of doing an upgrade or acquisition," Segal said. "The flip side is you can start later in the year and still get the money."
In another change from its original proposed rules, the CMS also modified its requirement for the percentage of patients who must be sent electronic reminders for care management. Instead of 50% of all patients 50 years of age or older, the Stage 1 rules state that 20% of all patients 65 and over must receive electronic reminders, Segal said.
The CMS also added two new items to the final rules: Health care providers will have to provide patient-specific educational resources in EMRs, and they will have to electronically record advance directives, which include living wills and durable powers of attorney for health care, Segal said.
Another area of the proposed rules that drew heavy criticism and was removed in the final meaningful use standards was the section covering revenue cycles and practice management, which included rules for submitting bills or checking patient eligibility electronically.
"Those could have caused complications," Segal said. "In many cases, people don't have a stand-alone EMR that doesn't include revenue cycle functionality."
"One of the good things that happens as you move from a proposed rule to a final rule is people identify all sorts of ambiguities," Segal said. "But also based on comments, CMS sought to get a better balance between the ambition of moving the health care world forward and the practicalities of what could be achieved."