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CMS releases stage 2 meaningful use criteria for EHR, gives vendors and practitioners additional time

Dermatologists who have yet to adopt and implement electronic health record (EHR) technology and attest to meaningful use have been given additional time to meet both stage 1 and stage 2 attestation criteria and earn bonus payments. The Centers for Medicare and Medicaid Services (CMS) released its proposed final rule on stage 2 of meaningful use on Feb. 23. Dermatologists now have until October 2014 to implement EHR technology in their practices, thanks to a November 2011 delay by CMS in deference to vendors. This will help practitioners avoid Medicare reimbursement penalties beginning in 2015 with a 1 percent cut for non-attesting physicians.

Dermatologists who wish to attest to meaningful use must begin the process by Oct. 1 of this year in order to make themselves eligible for the full $44,000 bonus from the federal government. (To read more about the attestation process, see sidebar, "Attesting to meaningful use.")

Time to prepare

With this delay of stage 2 until 2013 for all providers, according to New York dermatologist Mark Kaufmann, MD, who speaks on EHR and meaningful use at American Academy of Dermatology meetings, early adopters receive an opportunity to earn incentive money for essentially streamlining existing practices. 

“They’ve delayed the implementation of stage 2 for everyone, so the people who really benefit are physicians like myself who attested in 2011. If you attested in 2011, you were originally supposed to start stage 2 in 2013. In 2011, I did three months of meaningful use, and in 2012, I’ll do a full year. In 2013, instead of having to step up to stage 2, I’ll do another year of stage 1,” Dr. Kaufmann said. “What that means is that one could potentially get three years’ worth of incentive money — $38,000 of the $44,000 you are eligible to receive — all without even going to stage 2.”

According to CMS data, 518 dermatologists find themselves in this scenario, having already attested for 2011. They will have 18 more months to work with their vendors and consider the move to stage 2.[pagebreak]

While the delay signals a willingness on the part of CMS to meet the market halfway, according to EHR consultant Margret Amatayakul, the release of proposed stage 2 criteria demonstrates the continued determination of the government to push universal EHR adoption within a well-defined timeframe.

“If you’re a physician who has put off getting an EHR because of uncertainty or concerns about the future, I think that these rules serve as a signal to say that CMS is serious about this. I think that meaningful use is probably here to stay, and CMS is really putting a lot of effort into increasing adoption,” Amatayakul said. “When you combine EHR with bundled payments and ACOs, it’s clear that this is the way CMS wants to go. Hopefully, stage 2 will encourage more people to seriously think about how EHR has become the state of practice, another part of doing business.”

Barbara Duck, a health IT expert who wrote one of the earlier EHR programs in the late 1990s, and who runs the health care blog The Medical Quack, said that the delay should induce physicians to adopt and attest to meaningful use as soon as possible. She said that the relative inexpensiveness of software-as-a-service EHR technology, where physicians pay a monthly fee for access to an EHR system hosted centrally by a vendor, should add to the inducement for physicians to adopt, as it allows them to reduce cost and eliminates the need for an office-based server and the related hardware.

“The longer you put adoption off, the worse it’s going to be. I would say at least get started under stage 1. I recommend looking into software-as-a-service for physicians worried about cost. There is certified software that is dirt cheap. You can get a lot more stimulus money back than what you have to put out for the system,” Duck said. “You don’t have to go all-out and spend a great deal of money. You get a very reasonable rate on a certified, functional EHR without committing to the hardware. If you’re worried about the rapid changes, why put more out of pocket than you have to?”[pagebreak]

Changes in stage 2

The proposed stage 2 criteria require that physicians meet 17 core objectives and three of five menu objectives (see sidebar, right), as well as reporting on an increased number of quality measures. Significantly, it also increases the required use of computerized physician order entry (CPOE) transactions for medications from 30 percent of patients to 60 percent. While the use of electronic prescribing has been rising steadily for years, stage 2 will require physicians to prescribe through certified electronic systems for more than half of their patients.

While Dr. Kaufmann said that many of the proposed expansions to the meaningful use program under stage 2 aren’t necessarily aimed at or beneficial to dermatologists, there are some items that jump out as hopeful for the specialty. For example, the new schedule provides more breathing room, he said — physicians have two years to move from stage 1 to stage 2 and avoid penalties, a change from the single year the original timetable would have allowed. (See sidebar below for information on bonuses and penalties by year.)

In addition, he said, the vital signs requirements are slightly more reasonable, especially for dermatologic surgeons. Under stage 1, he said, some dermatologists and dermatologic surgeons found capturing the required vital signs — the blood pressure, height, and weight of each patient — an unnecessary use of time that made participation in the meaningful use program more difficult. While dermatologists seeking to earn meaningful use payments still must capture these data points, and will continue to have to do so through 2012, this will ease somewhat in 2013. Dermatologists will only have to capture one of the three data points — blood pressure, height, or weight — and will only have to do so for 50 percent of patients.

Amatayakul said that what’s most clear in stage 2 is the need for physicians to seriously commit to making one’s EHR system fit the practice for the long term.

“The stage 2 proposed measures, in some cases, show even more of the same things we saw in stage 1, but there are also some new aspects to pay attention to. What is clear is that physicians are going to realize that you can’t just go by the seat of your pants and hope to meet the requirements. You have to get a decent system and work with that vendor over time,” Amatayakul said. “For people who did make the investment, the thing to do right now is make sure that they are in touch with their vendor. I still have some pretty serious concerns about the number of vendors that have been certified and how many of those vendors are so new to the field. Are they stepping up to the point that the dermatologists can actually use the products? Dermatologists need to make sure their vendor has a plan and know that they will be well taken care of.”

The proposed stage 2 rule is expected to be finalized during summer 2012, following a 60-day public comment period. 

Reporting measures

The proposed rule regarding stage 2 meaningful use criteria released by CMS in February indicates that physicians will have to ramp up the level of their EHR reporting in order to continue to earn meaningful use bonus payments when stage 2 criteria take effect. Stage 1 required the reporting of 15 core measures, while Stage 2 requires 17 core measures to be reported. Stage 1 required users to report five of 10 menu set measures, while Stage 2 will require reporting of three out of five menu set measures. Stage 1 required users to report at least six clinical quality measures, while Stage 2 will require them to report at least 12.

EHR Stage 2 requirements

EHR standards will increase noticeably under the proposed rule released by CMS Feb. 23. Many formerly optional measures will become requirements, and 20 functionality objectives must be met to avoid penalties.

Core Set (must meet all 17)

  • Computerized physician order entry for medication and lab orders
  • Electronic prescribing
  • Patient demographics
  • Smoking status
  • Clinical decision support
  • Chart patient vital signs over a period of visits
  • Incorporate clinical lab results into patient records*
  • Generate lists of patients by condition
  • Reminders for preventative and follow-up appointments*
  • Patient portal access
  • Clinical patient summaries
  • Identify patient education resources*
  • Secure messaging with patients
  • Medication reconciliation*
  • Send summary of care records for referrals and transitions of care*
  • Data transmission to immunization registries*
  • Privacy and security
* Previously menu set item, now required

Menu set (meet three of five)

  • Access imaging results
  • Record patient family history
  • Transmit electronic syndromic surveillance data to public health agencies
  • Report cancer cases to state registries
  • Report non-cancer cases to state registries

Attesting to meaningful use

At present, 518 dermatologists have attested to meaningful use under the stage 1 criteria to qualify for bonus incentives. Both New York dermatologist Mark Kaufmann, MD, and Charlotte, N.C., dermatologist Mark Darst, MD, have completed the stage 1 meaningful use attestation process. They spoke with Dermatology World to share their experiences with attestation.

Mark Darst, MD

We attested in early 2012, but we won’t expect to see any money until later this year. I don’t know how long it will take to see cash, but I have colleagues in South Carolina who attested and received their payments last year. My EHR has a meaningful use dashboard built in, so everything that I need to track is there in a snapshot. I can log on and look at, say the last three months, and it will give me a snapshot of what I did as far as meeting meaningful use. It demonstrates visually what measures I’m meeting or failing short of over a period of time that I select, so that I can adjust my processes as needed.

It was a little cumbersome to set up just because you have to make sure that everything is mapped properly to show up as data that’s recognizable to CMS under meaningful use. CMS wants the data recorded in a specific structured form. Getting that mapped took a little time, but once it was, we were good to go. It collects our patient data automatically in correctly structured form.

I can recoup a lot of the investment of the EHR based on stage 1, and based on that, I can make a decision on whether I really want to attest to stage 2, or take the penalty.”

Mark Kaufmann, MD

When you are ready to attest, CMS has a meaningful use attestation calculator ( It allows you to enter your numerators and denominators, and gives you a preview of your answer — either you passed or you didn’t.

You then go through actual attestation — entering the certification number of your EHR and answering all the meaningful use questions, basically — and everywhere that there is an exclusion available, it asks you if you qualify for the exclusion.”



Reporting measures
EHR Stage 2 requirements
Attesting to meaningful use