CMS Meaningful Use Definition Impact on Rural Providers

By: Alex Olson | 1/06/10

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by Louis Wenzlow, Rural Wisconsin Health Cooperative CMS Rule: Meaningful Use Definition Impact on Rural Providers Under the American Recovery and Reinvestment Act (ARRA), eligible physicians and hospitals must reach a certain threshold of EHR adoption (called "meaningful EHR use") in order to earn CMS incentive payments. In July, the ARRA-established HIT Policy Committee recommended a wide range of meaningful use objectives for CMS to consider in the development of a proposed HIT incentive rule. Released on December 30^th, the proposed rule largely follows the Policy Committee's recommendations. So how will the proposed rules meaningful use requirements impact rural providers? How long will providers have to achieve the meaningful use thresholds? And are these timing requirements reasonably achievable by small and rural providers? CMS Proposed Definition of Meaningful Use Consistent with HIT Policy Committee recommendations, the CMS proposed rule creates 3 stages between 2011 and 2015 over which providers will need to meet increasingly stringent meaningful use requirements. The proposed rule identifies the requirements associated with Stage 1. Providers that reach Stage 1 meaningful use by the end of 2012 will maximize the value of their incentive. Providers that meet Stage 1 requirements by 2014 can still receive some level of incentive (see next section for detail regarding how this works). The definition of Stage 1 meaningful use in the CMS proposed rule is similar to the definition established by the HIT Policy Committee in July. The major differences are:

• 2 HIT Policy Committee recommended requirements (record advance directives, and provide access to patient-specific educational resources) have been removed
• The HIT Policy recommendation to implement 1 clinical decision support rule has been increased to 5
• The information exchange requirement has been qualified so that it is allowable to exchange unstructured information, and the requirement can be met through a test of an EHRs "capacity" to exchange
• Specific measures have been defined for each one of the 20+ requirements
• Numerous quality measures have been defined (I will be dealing with how the quality measures impact rural providers in a separate analysis)

See CMS's Table 2: Stage 1 Criteria for Meaningful Use (Page 103-108 of the proposed rule: http://www.federalregister.gov/OFRUpload/OFRData/2009-31217_PI.pdf) for a detailed list of requirements. As with the HIT Policy Committee recommendations, the greatest challenge in the CMS proposed rule for rural providers is the Stage 1 requirement to implement computerized provider order entry (CPOE). CPOE is a capstone implementation that is generally (and for good reason) implemented many years after other building blocks of a complete EHR have been laid. How Long Do Providers Have to Achieve Meaningful Use? Consistent with the HIT Policy Committee recommendations, the CMS proposed rule employs the concept of "payment year," so that providers that become eligible in later years will still only have to meet Stage 1 requirements, if only for their first payment year. This will give early stage adopters at least some timing flexibility, though it will not do anything to make Stage 3 requirements reasonably attainable. All providers will need to reach Stage 3 requirements by 2015.

• Eligible professionals and hospitals whose first payment year is 2011 must meet stage 1 requirements in 2011 and 2012, stage 2 requirements (not yet defined) in 2013 and 2014, and stage 3 requirements (not yet defined) in 2015.
• Eligible professionals and hospitals whose first payment year is 2012 must meet stage 1 requirements in 2012 and 2013, stage 2 requirements in 2014, and stage 3 requirements in 2015.
• Eligible professionals and hospitals whose first payment year is 2013 must meet stage 1 requirements in 2013, stage 2 requirements in 2014, and stage 3 requirements in 2015.
• Eligible professionals and hospitals whose first payment year is 2014 must meet stage 1 requirements in 2014, and stage 3 requirements in 2015
• Eligible professionals and hospitals whose first payment year is 2015 must meet stage 3 requirements in 2015

Is Meaningful Use Achievable for Small and Rural Providers? Many small and rural providers are at the beginning stages of EHR adoption. For most of these early-stage providers, meeting Stage 1 meaningful use requirements by the end of 2012 would likely be unachievable. The provision to allow providers to meet Stage 1 requirements by 2014 (if 2014 is their 1^st payment year) is therefore welcome and critically important.  However, many providers who meet Stage 1 requirements in later years will likely find meeting Stage 2 and 3 requirements (assuming Stage 2 and 3 requirements are consistent with the HIT Policy Committee's recommendations for those stages) unachievable within the time frames allowed. These providers will therefore receive reduced incentives and eventually be subjected to penalties. Conclusion I believe that it's fundamentally unfair to set a single meaningful use standard for all providers. The result of a single-standard strategy is that providers who already have EHRs (and therefore don't need assistance) will get the lion's share of the incentives; whereas disadvantaged providers at low stages of adoption (who particularly need the assistance) will be much less likely to get help. This is like starting a 40 yard dash with some runners at the starting line, others at the twenty, and still others standing past the finish line, and only those that finish in 4 seconds get a prize. For whatever reasons, CMS and ONC have structured the incentive program in a way that will dramatically expand the digital divide between our country's EHR haves and have-nots. Given that many studies have shown that rural providers have significantly lower EHR adoption rates than general hospitals, as well as additional barriers to EHR implementation (such as lack of capital, minimal HIT staffing levels, and reduced EHR system ROI), this will disproportionately negatively impact rural providers.