The Stage 3 Meaningful Use preliminary recommendations

July 18, 2013

Proposed recommendations for Stage 3 Meaningful Use (MU) criteria have prompted some concerns from national provider associations. Stage 3 criteria—slated to go into effect in 2016— are intended to begin the transition from a setting-specific focus to a collaborative, patient and family-centric approach. Provider associations that have commented on the proposal say the criteria are premature, because there is limited experience even with the Stage 1 criteria, and question whether electronic health record (EHR) systems have sufficiently evolved to support measures that emphasize interoperability.

The recommendations were issued by the Health Information Technology Policy Committee (HITPC), a federal advisory committee that advises the U.S. Department of Health and Human Services (HHS), in November 2012. They follow closely the final Stage 2 regulations, published in September 2012. The recommendations address three main areas: MU objectives and measures, quality measures, and privacy and security.

Many of the recommendations build on the Stage 2 objectives, either by increasing the threshold percentage to show MU or by changing what was a menu objective in Stage 2 to a core objective in Stage 3. Several of these recommendations specifically address the role of laboratories in the MU of EHR technology.

For example, one of the Stage 2 measures requires that more than 30 percent of laboratory orders are recorded by computerized physician order entry (CPOE). The preliminary recommendation for Stage 3 is to raise this threshold to more than 60 percent. In a second example, in Stage 2 more than 55 percent of clinical lab test results that are either in a positive/negative affirmation or numerical format must be incorporated into the EHR technology as structured data. For Stage 3, HITPC recommends that the threshold be raised to more than 80 percent. In another example, one of the Stage 2 menu measures for eligible hospitals is that hospital labs send structured electronic lab results to the ordering provider for more than 20 percent of electronic lab orders received. For Stage 3, HITPC recommends that the threshold be raised to more than 80 percent.

HITPC requested comments on these preliminary recommendations, including feedback on a number of specific topics. The comment period closed January 14, 2013.

Various organizations submitted comments in response to the preliminary recommendations, including the American Hospital Association (AHA), American Medical Association (AMA), and the College of Healthcare Information Management Executives (CHIME). These organizations all expressed concern over a rushed adoption of Stage 3 criteria. Many providers have not yet adopted EHR technology and participated in Stage 1 of the EHR incentive program, and no provider will be required to meet the Stage 2 criteria for MU until 2014. The organizations stressed that Stage 3 requirements should not be drafted when there is limited information about the success of Stage 1 and very little experience implementing Stage 2. The organizations suggested that further evaluation first occur to provide an evidence-based approach to Stage 3 criteria. AHA further suggested that Stage 3 begin in fiscal year 2017 instead of fiscal year 2016.

The organizations also expressed concern that both Stage 2 and Stage 3 focus on health information exchange (HIE), and yet interoperability of EHR systems continues to be a concern. For example, CHIME encouraged “the time frames for Stage 3 to be linked to and preceded by proven HIE capabilities.”

The College of American Pathologists (CAP) also submitted comments. CAP noted that the majority of Stage 1 and Stage 2 MU objectives do not apply to the practice of pathology, and that this trend continues in the Stage 3 preliminary recommendations. CAP also noted that, for pathologists in non-hospital settings, the Stage 2 final rule includes a temporary hardship exception from the downward payment adjustments imposed on providers who do not demonstrate MU beginning in 2015. (Hospital-based pathologists are not eligible for MU incentive payments, and thus the exception also does not apply.) CAP urged that pathologists be provided permanent relief from MU requirements, because the majority of pathologists use laboratory information systems (LISs) which are tailored specifically to the practice of pathology, and not certified EHR technology, and which focus on documentation related to patient encounters. Further, CAP noted that in order to meet the Stage 2 and Stage 3 criteria, most eligible professionals and hospitals will need to rely on data that pathologists and laboratories generate. CAP commented that MU incentive payments or other funding mechanisms should be established to cover associated interface requirements for laboratories, to help achieve the goal of interoperability.

It will be interesting to see whether HHS responds to these organizations’ concerns by officially delaying the drafting of Stage 3 Meaningful Use requirements until more information can be gathered from Stage 1 and Stage 2 experiences. It will also be interesting to see if HHS pushes back the start date of Stage 3 to 2017, as suggested by AHA. There is precedent for such an action, because HHS pushed back the start date of Stage 2 from 2013 to 2014 in response to concerns that providers would not be able to meet Stage 2 requirements within the original timeframe. Those who have further input will have the opportunity to submit comments again when HHS releases its proposed regulations for Stage 3.

Amy M. Joseph is an attorney with Hooper, Lundy & Bookman, P.C., a full-service law practice dedicated solely to the representation of healthcare providers. Her practice involves a broad range of business, transactional, and regulatory aspects of the healthcare industry.