The Centers for Medicare and Medicaid (CMS) is overhauling the Electronic Health Records (EHR) Medicare and Medicaid program for hospitals. In a proposed rule that would apply starting in 2019, the federal agency is making significant changes to objectives and measures for calculating EHR incentive payments and reductions. The Trump Administration’s new approach attempts to reduce the regulatory burden by making the EHR markers more flexible. At the same time, the proposed rule focuses on promoting interoperability of health data between providers and giving patients greater access to their health information. CMS is seeking comments on various aspects of the proposal, and comments must be received by 5:00 pm EST on June 25, 2018.

Background on Meaningful Use Program and EHR Certifications

Established under the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH), the Meaningful Use Program incentivizes adoption and use of EHRs for health care providers participating in Medicare and Medicaid. Between January 2011 and January 2018, Medicare EHR incentive payments have totaled over $24.8 billion and Medicaid EHR incentive payments have totaled more than $12.6 billion.

EHR incentives under HITECH were intended to encourage health care providers to adopt and use EHRs to support a number of CMS’s specified objectives. To receive EHR incentive payments in each stage of the HITECH Meaningful Use Program, practitioners and hospitals must attest that they used certified EHR technology and satisfied the applicable Meaningful Use Program objectives and measures. As a meaningful EHR user, hospitals must also electronically report certain clinical quality measures (CQMs). Beginning in CY 2017, CMS established 16 CQMs that must be electronically reported. The Meaningful Use Program requires hospitals to retain documentation supporting their demonstration of Meaningful Use for six years.

The bipartisan Medicare Access and CHIP Re-authorization Act of 2015 (MACRA) implemented the Merit-based Incentive Payment System (MIPS), which replaced the Medicare EHR Meaningful Use Program for eligible clinicians. Notably, MACRA did not replace the EHR Meaningful Use Program for Medicare eligible hospitals, critical access hospitals, and dual-eligible hospitals. Through the Inpatient Prospective Payment System (IPPS) proposed rule, released on April 27, 2018, CMS is introducing significant changes to the current EHR incentive program for hospitals.

CMS Proposal to Revamp EHR Program for Hospitals

Under the Bipartisan Budget Act of 2018, CMS is no longer required to impose more stringent measures of meaningful use of EHR over time. Accordingly, CMS is proposing replacing the Meaningful Use Program with the Promoting Interoperability Program (PI Program). The proposed, new PI Program encourages interoperability of data between providers and aims to improve patient accessibility to health information. With regard to Medicaid-only eligible hospitals, CMS is not requiring states to adopt the new PI Program.

Among other proposed changes, beginning with the reporting period in CY 2019, hospitals would be required to use the 2015 Edition of certified electronic health record technology (CERHRT). In addition, the proposal would modify the reporting periods in 2019 and 2020 – permitting EHR reporting of any continuous 90-day period to be sufficient. Under the proposed rule, CMS would score each hospital on several performance measures but allow hospitals “to emphasize measures that are most applicable to their care delivery.”

Some of the major proposed changes under the PI Program include:

  • Implementing performance-based scoring: The proposed performance-scoring methodology is based on a total PI score of 100. Each measure is assigned a maximum number of points but there is no required thresholds for reporting. Hospitals would submit a numerator and a denominator data for each performance measure, which is translated to a performance rate for that measure. The performance rate would apply to the total possible points for that measure. Hospitals must report on all required measures across all four objectives in order to earn any score at all. A score of 50 PI points would meet the “meaningful use” payment.
  • Reduction to four objectives: The current structure of the Stage 3 Meaningful Use Program requires hospitals to report six objectives that include 16 measures scored on a pass/fail basis. The proposed rule eliminates two objectives aimed at patient engagement. The proposed PI Program would also reduce the total number of required measures across the objectives from 16 to 6. The PI Program scoring will be based on the four objectives:
    1. e-Prescribing,
    2. Health Information Exchange,
    3. Provider to Patient Exchange and
    4. Public Health and Clinical Data Exchange.
  • E-Prescribing objective includes two new opioid measures: As part of the federal response to the opioid crisis, CMS introduces two new measures to the e-Prescribing objective that are based on electronic prescribing and monitoring Schedule II opioids:
    • Query for Prescription Drug Monitoring Program (PDMP) measure is based on query of a PDMP by a provider using CEHRT for prescription drug history prior to transmission of a Schedule II opioid prescription; and
    • Verify Opioid Treatment Agreement measure is based on whether a hospital sought to identify the existence of a signed opioid treatment agreement and incorporates it into CEHRT when the total duration for an opioid prescription is at least 30 cumulative days within a 6-month look-back period.
  • Health information exchange objective: The proposed rule would adopt the existing health information objective with several important changes. For example, hospitals would no longer be able to seek exclusions from the existing three measures associated with the Health Information Exchange (HIE). Second, the agency’s proposed, new methodology would remove, reshuffle, and combine existing HIE measures to emphasize interoperability of care records and reduce redundancy, complexity, and provider burdens. The rule introduces a proposed new measure, Support Electronic Referral Loops by Receiving and Incorporating Health Information, and permits hospitals to seek an exclusion for the new measure. The new measure would combine the two existing measures to focus on the exchange of the health care information, and streamline and simplify reporting. CMS is also considering another potential new measure, Health Information Exchange Across the Care Continuum, that would give providers a wider range of options in selecting measures.
  • Provider to patient exchange objective: This proposed modified objective makes significant changes to existing framework with the goal of improving access and exchange of patient health information, patient centered communication, and coordination of care using CEHRT. The proposal would remove the following four measures of usage that the agency believes are too burdensome for provides to report:
    • Patient-Specific Education;
    • Secure Messaging;
    • View, Download or Transmit; and
    • Patient Generated Health Data.
  • Potential removal of the public health and clinical data registry reporting objective and measures: The agency has proposed removing this objective no later than CY 2022.

The PI Program, including its new objectives and measures, for CY 2019 and 2020 are summarized in the following chart:

Objectives Measures Maximum Points
e-Prescribing e-Prescribing 10 points (CY 2019)or 5 points (CY 2020)
Query of Prescription Drug Monitoring Program (PDMP) **optional/bonus in CY 2019** 5 points
Verify Opioid Treatment Agreement **optional/bonus in CY 2019** 5 points
Health Information Exchange Support Electronic Referral Loops by Sending Health Information *exclusion available in CY 2019* 20 points
Support Electronic Referral Loops by Receiving and Incorporating Health Information 20 points
Provider to Patient Exchange Provide Patients Electronic Access to Their Health Information 40 points (CY 2019)or 35 points (CY 2020)
Public Health and Clinical Data Exchange Syndromic Surveillance Reporting (Required) Choose one or more additional: Immunization Registry Reporting Electronic Case Reporting Public Health Registry Reporting Clinical Data Registry Reporting Electronic Reportable Laboratory Result Reporting 10 points

CMS Wants Feedback About Possible Changes to the Conditions of Participation

CMS is also requesting stakeholder feedback through a Request for Information on the possibility of revising Medicare Conditions of Participation (COP) for hospitals. Specifically, CMS may add certain requirements related to interoperability of health data in its COPs as a way to increase electronic sharing of data between hospitals and other providers.

As noted above, CMS is seeking comments on various aspects of the proposed PI Program. Comments must be received by 5:00 pm EST on June 25, 2018. If CMS does not adopt the new, proposed PI Program, it would maintain the current Step 3 Meaningful Use Program found in 42 C.F.R. § 495.24.