History of the Program
In 2010 the Centers for Medicare and Medicaid Services (CMS) established incentive programs — now called the Promoting Interoperability (PI) Programs — to encourage eligible professionals (EP) and eligible hospitals/critical access hospitals (EH/CAH) to implement health information technology. The primary focus of these programs is the implementation of electronic health record systems and their “meaningful use” (MU). This multi-year program will roll out in several phases, or “stages.”
Stage 1 meaningful use was defined by the Medicare and Medicaid Programs Electronic Health Record Incentive Program Final Rule (July, 2010). A Correcting Amendment was issued to fix a set of typographical errors (December, 2010). That rule is supported by a Final Rule for Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology (July, 2010).
In August, 2012, CMS released the Final Rule for Stage 2 Meaningful use, and ONC released a corresponding Final Rule for the related standards and implementation specifications. A revised timetable was released in August 2014 (also see final rule).
Current Program Status
In October, 2015, CMS released the Final Rule (and Corrections and Clarifications) for Stage 3, which included a consolidation of the previous Stage 1 and Stage 2 programs for 2015-2017 in order to move all participants more quickly to a less confusing, uniform program. This interim period is sometimes referred to as the “Modification Period” (or “Mod Period”) by CMS and ONC. In addition, though Stage 3 begins for everyone in 2018, participants can adopt Stage 3 measures as early as 2017. ONC released a corresponding Final Rule related to 2015 Edition HIT Certification criteria at the same time.
During the Mod period, participants can continue to use 2014-certified EHRs but the program is consolidated and streamlined. In 2018, participants are required to use 2015 certified EHRs and move to Stage 3. The definition of certified EHR technology was moved from the ONC Rule to the CMS Final Rule for simplicity.
In October 2016 CMS introduced the Merit-based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) by issuing a Final Rule. This program replaces the CMS EHR Incentive Program/Meaningful Use for clinicians who bill Medicare Part B only.
A critical component of the CMS Rule is a set of public health objectives related to reporting, with corresponding measures and standards, which eligible professionals and hospitals will be expected to support if the public health agencies in their jurisdictions are capable of exchanging data electronically. Each of the public health objectives is discussed in detail on a separate domain area page accessible from the links on the upper right.
Here are some highlights:
- EPs can participate in either the Medicaid or Medicare EHR incentive program, but not both (though they can switch once); EH/CAHs may participate in both.
- Stage 1 public health objectives changed in Stage 2, and have now changed again during both the Mod Period and Stage 3. All public health-related measures are now consolidated under a single objective with choice of measures provided among a number of categories. For the Mod Period, EPs need to select two measures, and EH/CAHs need to select three measures. For Stage 3, the number of measures for EH/CAHs increases to four.
- For the Medicaid incentive program, state Medicaid offices have some flexibility to define the terms of their program, both more stringent (e.g., define specific requirements for certain reporting) and less stringent (e.g., define exemptions for certain reporting). See your state Medicaid office website for more details.
- Multiple providers within the same practice can perform just one test for all eligible providers (see CMS FAQ).
- While no specific transport methods are proscribed for public health measures, the rule states that EPs and EHs will be expected to use the transport means stipulated by the public health agency to which they report. Public health agencies can require a transport mechanism that is not found in the ONC Final Rule (namely Direct and/or SOAP-based web services as defined by the NwHIN project).
- Regional Extension Centers (REC) should be encouraged to include appropriate interfaces to public health in any negotiated EHR system vendor contracts, and RECs should provide clear documentation of public health interface and data transport requirements.
- Health Information Exchanges (HIE) can often be leveraged to facilitate transport of messages from providers to public health agencies. If the HIE is helping by transforming messages from an unsupported format to HL7 v2 the HIE software needs to be ONC Certified EHR Technology (see CMS FAQ). The eHealth Exchange is one such network, but not all public health agencies may yet be connected to it (see CMS FAQ).
- Public health agencies are expected to provide documentation (does not have to be a “letter” but can be any “written communication” including electronic communications) to EPs and EHs affirming their ability to successfully submit data to be used during attestation.
- CMS has created “centralized repository” of public health agencies and the status of their capability to receive ongoing submissions of public health data in the form of a downloaded spreadsheet. Public health agencies will need to make sure that their capability to receive data is documented in this repository – though failure to do so will not allow EPs and EHs to claim exclusion from public health measures. In September 2016 CMS announced the initiation of this repository and requested that public health agencies register their readiness for 2017 by completing an online form. Public health agencies must still take it upon themselves to post their readiness to support each public health measure, and do so at least six months before the start of the reporting period (usually January 1). The CDC MU Public Health Reporting Taskforce has provided some additional guidance.
- HL7 v2.3.1 is no longer be supported for certification of EHR technology since all participants must possess an EHR system certified at least under 2014 criteria.
- EPs can include unpaid claims in their calculation of eligibility, so it may be easier for public health agencies who do not bill Medicaid or Medicare for services to become eligible for the program.
- If an EP/EH meets the criteria for exclusion from a public health measure, the item does not count towards the number of items necessary to meet meaningful use. Exclusions from public health measures that had been clarified for Stage 2 (see individual pages and CMS FAQ) have been revised additionally for the Mod Period and Stage 3. Some special exclusion rules were clarified for 2015 in a CMS FAQ.
- The notion of “ongoing submission” of data to public health from earlier rule making has been revised and clarified to now be referred to as “active engagement” with a public health agency. Participants can be in one of three active engagement steps:
- Completed Registration to Submit Data
- Testing and Validation
Participants need only register once with a public health agency, and registration during a prior stage of MU is perfectly acceptable. Participants who are just beginning with Stage 1 in 2015 can meet the requirements either by submitting a test message or by moving into production during the reporting period (see FAQ).
- For MACRA participants, all possible public health measures are optional. Attestation for participants is a simple “yes/no” rather than a measure of volume. The immunization measure provides a higher score if selected than the others. Under the proposed CY 2018 Updates, if reporting to an IIS is not possible, other public health measures may be used instead (p. 173). In addition, it is proposed that participants can continue to use older, 2014 CEHRT into 2018.
- For Medicare eligible hospitals and CAHs and dual-eligible hospitals, a slight change was made in November 2016 that lowered the reporting requirements for public health measures for both the Modified 2017 Stage 2 and Stage 3.
- In the Summer of 2017 CMS made additional modifications for 2018. They shortened the reporting period from one year to any continuous 90-day period. In addition, participants are now free to use either 2014 CEHRT, 2015 CEHRT, or a combination of the two. Finally, participants have clear guidance about an exception in the event that their CEHRT becomes decertified.
- For 2019 it is expected that all participants use 2015 CEHRT only. CMS has indicated that the EHR need only be certified on the last day of the reporting period so long as the functionality is in use for the entire reporting period.
Finally, CMS has issued updated guidance (in addition to its original guidance) on when state costs related to promoting Health Information Exchange (HIE) can be matched at the 90 percent HITECH administrative rate to support the coordination of care and transitions of care requirements in Meaningful Use modified Stage 2 and Stage 3. PHII provides a Planning Toolkit for Preparing to Access CMS 90-10 Funding for Public Health.
Much more information is available in the CMS FAQs as well as other resources identified on this page. Additional CMS FAQs have addressed issues like CEHRT installation timetable, registration of intent to submit data (and another), and CMS’ desire to protect providers from the cost of software changes. CDC is offering technical assistance to states through a special team accessible via e-mail.
The MU PH Reporting Requirements Task Force has released a MU2 PHA Readiness Guidance Recommendations Document to help guide public health agencies prepare for Stage 2. A Stage 3 2017 Guide is also available along with a new summary table.