The Centers for Medicare & Medicaid Services (CMS) Medicare Electronic Health Record (EHR) Incentive Program is divided into three stages, each intended to incentivize providers to demonstrate meaningful use (MU) of an EHR system through a progression of measures and objectives. Stage 1 established the foundation for the program by instituting requirements for the electronic capture of clinical data and by providing patients with electronic access to their health information. Stage 2 expands on Stage 1 by encouraging the use of health information technology for continuous quality improvement at the point of care and the exchange of information in a structured format. Stage 3 focuses on improving clinical outcomes. In 2019, MU will transition into the new Merit-based Incentive Payment System (MIPS) program as required under the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) enacted in 2015.
CMS released a modified version of Stage 2 (Modified Stage 2) requirements in 2015 in an effort to align the first two stages with Stage 3. The new regulation has changed the reporting requirements for providers participating in the EHR Incentive Program in 2016. This column discusses what surgeons need to know to successfully participate in the program.
What are the reporting requirements in 2016?
Surgeons who are participating in the EHR Incentive Program for the first time will report using the Modified Stage 2 requirements for 90 consecutive days. They will need to report on all measures as required, with special accommodations for measures that were not required previously for Stage 1 providers. Providers participating in their second year or beyond are required to report on Modified Stage 2 for the full calendar year. They will have to report on all measures as required. (See Table 1.)
Table 1. List of objectives and measures required for reporting 2016 MU
| Objective | Measure | Exclusion |
| Objective 1:
Protect patient health information |
Measure: Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI created or maintained in CEHRT in accordance with requirements under 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the EP’s risk management process. | |
| Objective 2:
Clinical decision support |
For providers to meet the objective they must satisfy both of the following measures:
Measure 1: Implement five clinical decision support interventions related to four or more clinical quality measures at a relevant point in patient care for the entire EHR reporting period. Absent four clinical quality measures related to a provider’s scope of practice or patient population, the clinical decision support interventions must be related to high priority health conditions. Measure 2: The provider has enabled and implemented the functionality for drug‐drug and drug‐allergy interaction checks for the entire EHR reporting period. |
Exclusion for Measure 2: Any provider who writes fewer than 100 medication orders during the EHR reporting period. |
| Objective 3:
Computerized provider order entry |
A provider, through a combination of meeting the thresholds and exclusions (or both), must satisfy all three measures for this objective.
Measure 1: More than 60 percent of medication orders created by the provider during the EHR reporting period are recorded using computerized provider order entry. Measure 2: More than 30 percent of laboratory orders created by the provider during the EHR reporting period are recorded using computerized provider order entry. Measure 3: More than 30 percent of radiology orders created by the provider during the EHR reporting period are recorded using computerized provider order entry. |
Exclusion for Measure 1: Any provider who writes fewer than 100 medication orders during the EHR reporting period.
Exclusion for Measure 2: Any provider who writes fewer than 100 laboratory orders during the EHR reporting period. |
| Objective 4:
Electronic prescribing |
Measure: More than 50 percent of permissible prescriptions written by the provider are queried for a drug formulary and transmitted electronically using CEHRT. | Exclusions: Any provider who meets the following criteria:
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| Objective 5:
Health information exchange |
Measure: Providers who transition or refer their patient to another setting of care or provider of care must (1) use CEHRT to create a summary of care record; and (2) electronically transmit such summary to a receiving provider for more than 10 percent of transitions of care and referrals. | Exclusion: Any provider who transfers a patient to another setting or refers a patient to another provider less than 100 times during the EHR reporting period. |
| Objective 6:
Patient-specific education |
Measure: Patient-specific education resources identified by CEHRT are provided to patients for more than 10 percent of all unique patients with office visits seen by the provider during the EHR reporting period. | Exclusion: Any provider who has no office visits during the EHR reporting period. |
| Objective 7:
Medication reconciliation |
Measure: The provider performs medication reconciliation for more than 50 percent of transitions of care in which the patient is transitioned into the care of the provider. | Exclusion: Any provider who was not the recipient of any transitions of care during the EHR reporting period. |
| Objective 8:
Patient electronic access (view, download, and transmit) |
Measure 1: More than 50 percent of all unique patients seen by the provider during the EHR reporting period are provided timely access to view online, download, and transmit to a third party their health information subject to the provider’s discretion to withhold certain information.
Measure 2: For an EHR reporting period in 2016, at least one patient seen by the provider during the EHR reporting period (or patient‐authorized representative) views, downloads, or transmits his or her health information to a third party during the EHR reporting period. |
Exclusion for Measure 1: Any provider who neither orders nor creates any of the information listed for inclusion as part of the measures except for “Patient Name” and “Provider’s name and office contact information.”
Exclusion for Measure 2: Any provider who meets the following criteria:
|
| Objective 9:
Secure messaging |
Measure: For an EHR reporting period in 2016, for at least one patient seen by the provider during the EHR reporting period, a secure message was sent using the electronic messaging function of CEHRT to the patient (or the patient‐authorized representative), or in response to a secure message sent by the patient (or the patient‐authorized representative) during the EHR reporting period. | Exclusion: Any provider who has no office visits during the EHR reporting period, or any provider who conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period. |
| Objective 10:
Public health reporting |
Providers in 2016 must meet two of the following three measures:
Measure Option 1 – Immunization Registry Reporting: The provider is in active engagement with a public health agency to submit immunization data. Measure Option 2 – Syndromic Surveillance Reporting: The provider is in active engagement with a public health agency to submit syndromic surveillance data. Measure Option 3 – Specialized Registry Reporting: The provider is in active engagement to submit data to a specialized registry. |
Exclusions for Measure 1: Any provider meeting one or more of the following criteria may be excluded from the immunization registry reporting measure if the provider:
Exclusions for Measure 2: Any provider meeting one or more of the following criteria may be excluded from the syndromic surveillance reporting measure if the provider:
Exclusions for Measure 3: Any provider meeting at least one of the following criteria may be excluded from the specialized registry reporting measure if the provider:
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What are the changes in reporting from 2015 to 2016?
There are very few changes in reporting from 2015 to 2016. Providers are expected to continue to report on the same Modified Stage 2 objectives and measures in 2016 that were required in 2015. Because major changes were made to the program in 2015, such as the elimination of Stage 1 and the consolidation of core and menu objectives, CMS offered measure or objective exceptions that allowed providers to skip reporting on a measure or objective without being penalized. CMS refers to these exceptions as “alternate exclusions.”
The Modified Stage 2 rule includes alternate exclusions in the following circumstances:
- A particular measure does not have a Stage 1 measure equivalent
- A previously optional measure is now required
- Additional technology, such as an upgraded certified EHR system, is required
Many of the alternate exclusions that were available in 2015 are no longer available in 2016. In 2016, alternate exclusions are available for two MU objectives: computerized provider order entry (CPOE) and public health reporting. Providers scheduled to be in Stage 1 (providers in their first two years of participation in the EHR Incentive Program) may claim an alternate exclusion for two measures under the CPOE objective. Providers who choose to use the alternate exclusion for the CPOE objective will not have to report their use of CPOE for laboratory or radiology orders. They also may use an alternate exclusion for the public health reporting objective for two measures. Because the measures were previously optional, providers are not required to submit syndromic surveillance data to a public health agency or submit data to a specialized registry. Providers are required to successfully report on the remaining objectives and measures in order to avoid a penalty. (See Table 2 for a list of alternate exclusions in 2016.)
Table 2. Alternate exclusions available for 2016 reporting
| Objective for 2016 | Measures for Providers in 2016 | Alternate Exclusions |
| Objective 3:
CPOE |
Measure 2: More than 30 percent of laboratory orders created by the provider during the EHR reporting period are recorded using computerized provider order entry.
Measure 3: More than 30 percent of radiology orders created by the provider during the EHR reporting period are recorded using computerized provider order entry. |
Alternate Exclusion for Measure 2: Providers scheduled to be in Stage 1 in 2016 may claim an exclusion for Measure 2 (laboratory orders) of the Stage 2 CPOE objective for an EHR reporting period in 2016.
Alternate Exclusion for Measure 3: Providers scheduled to be in Stage 1 in 2016 may claim an exclusion for Measure 3 (radiology orders) of the Stage 2 CPOE objective for an EHR reporting period in 2016. |
| Objective 10:
Public health |
Measure Option 2–Syndromic Surveillance Reporting: The provider is in active engagement with a public health agency to submit syndromic surveillance data.
Measure Option 3–Specialized Registry Reporting: The EP is in active engagement to submit data to a specialized registry. |
Alternate Exclusion for Measure 2: Providers may claim an alternate exclusion for Measure 2 (syndromic surveillance reporting) for an EHR reporting period in 2016.
Alternate Exclusion for Measure 3: Providers may claim an alternate exclusion for Measure 3 (specialized registry reporting) for an EHR reporting period in 2016. |
What is the best way for surgeons to meet the public health registry objective?
In the Modified Stage 2 regulation, CMS finalized a consolidated public health reporting objective that combined three separate registry reporting measures that were previously optional. Providers are asked to report immunization data to a public health agency, report syndromic surveillance data to a public health agency, or report data to a specialized registry to improve public health information. CMS believes these measures can help track the spread of infectious diseases, foodborne illnesses, and other issues that affect public health. Although the information is useful, in 2016 this objective caused concern for both providers with little time to identify registries and with state health organizations and medical associations that lack the infrastructure to accept data from certified electronic heath record technology (CEHRT).
To complete the objective, providers must be in “active engagement” with a public health agency to submit health data using CEHRT. Active engagement can be demonstrated through completed registration to submit data to a registry. To meet the public health registry objective, surgeons must attest to any combination of two of the following three measures:
- Measure 1—Immunization registry reporting: The provider or hospital is in active engagement with a public health agency (PHA) to submit immunization data.
- Measure 2—Syndromic surveillance reporting: The provider or hospital is actively engaged with a PHA to submit syndromic surveillance data.
- Measure 3—Specialized registry reporting: The provider or hospital is actively engaged to submit data to a specialized registry.
Measure 3 may be counted more than once to satisfy the requirement of two measures if more than one public health registry is available. Providers are encouraged to contact their specialty societies and state health departments to determine whether their registries meet the requirements for MU. Due to pending resolution of federal technical and administrative requirements, it is unclear which registries can meet Measure 3.
The American College of Surgeons strongly recommends that surgeons who cannot otherwise meet this objective choose the exclusion option on the attestation form. Any surgeon may be excluded from the specialized registry reporting measure if he or she meets at least one of the following criteria:
- Does not diagnose or treat any disease or condition associated with, or collect relevant data through, a specialized registry in their jurisdiction during the EHR reporting period
- Operates in a jurisdiction for which no specialized registry is capable of accepting electronic registry transactions in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period
- Operates in a jurisdiction where no specialized registry for which the surgeon is eligible has declared readiness to receive electronic registry transactions at the beginning of the EHR reporting period
Is there a blanket hardship exemption in 2016 like there was in 2015?
No blanket hardship exemption is available for the 2016 MU reporting period.
When does Stage 3 begin?
Starting in 2017, providers have the option of attesting to Stage 3 measures and objectives for the EHR reporting period using CEHRT that meets either the 2014 or 2015 certification criteria. All providers must attest to Stage 3 beginning in 2018.
