Stage 3 Proposed Rule: The Most Challenging Measures

CMS, HHS, and the Office of the National Coordinator for Health Information Technology recently released the proposed rule for the third stage of the government's EHR incentive program.

Though providers would need to meet fewer objectives in Stage 3 (there are only eight objectives included in the proposed rule), many of these objectives may be more challenging. The measures associated with them include higher percentage thresholds, as well as difficult new requirements.

Here are a few of the objectives and measures in the proposed rule that could be most challenging for physicians:

1. Patient-engagement related objectives. While many physicians are struggling to meet the patient engagement related objectives in Stage 2, Stage 3 ups the ante.

"In [the proposed rule] the engagement of patients has been multiplied four-fold," Beth Onofri, clinical market adviser at Kareo, a medical practice management software and medical billing services provider, told Physicians Practice in an e-mail. "[Patients] must communicate with their providers via secure messaging, they must download or transmit their health information, they must receive patient education through a portal or API, and they must add nonclinical health information to their records."

Here's a closer look at a few of the challenging patient engagement-related requirements included in the proposed rule:

• More than 25 percent of all unique patients seen by the provider must actively engage with the EHR made accessible by the provider. A provider may meet the measure by either having more than 25 percent of all unique patients (or patient authorized representatives) view, download, or transmit to a third party their health information; or by having more than 25 percent of all unique patients (or patient-authorized representatives) access their health information through the use of an ONC-certified API that can be used by third-party applications or devices.

• For more than 35 percent of all unique patients seen by the physician, a secure message must be sent to the patient using the electronic messaging function of the EHR, or in response to a secure message sent by the patient.

Those requirements may sound daunting, but don't panic just yet. Jason Fortin, senior adviser at Impact Advisors, a healthcare technology consulting firm, stressed that there's no guarantee that the 25 percent measure related to patient engagement will come to fruition in the final rule.

"I have to imagine it's going to go down because anyone that comments and reads that - no one is going to say, 'Oh, that feels like the right number,'" Fortin told Physicians Practice. "So hopefully it does go down."

Still, Fortin said, though the thresholds may decrease, it's likely that the measure will remain.

2. Health information exchange-related objectives. Physicians who are struggling with health information exchange (HIE) would need to make a big leap in Stage 3 under the proposed rule.  Here are a few of the more challenging HIE-related measures that physicians would need to attest to:

• For more than 50 percent of transitions of care and referrals, providers that transition or refer patients to another setting of care or provider of care would need to create a summary of care record using the EHR and electronically exchange the summary of care record.

• For more than 40 percent of transitions or referrals received and patient encounters in which the provider has never before encountered the patient, the provider would need to incorporate into the patient's record in the EHR an electronic summary of care document from a source other than the provider's EHR.

• For more than 80 percent of transitions or referrals received and patient encounters in which the provider has never before encountered the patient, the EP would need to perform clinical information reconciliation. The provider would choose two of the following three clinical information sets on which to perform reconciliations: medication, medication allergy, or current problem list.

3. New measures. The proposed rule also includes new measures that could pose unique challenges for physicians, said Fortin. For example:

• For more than 15 percent of all unique patients seen by the provider, patient generated health data or data from a nonclinical setting would need to be incorporated into the EHR.

Part of the challenge associated with the new proposed objectives is that it's unclear how challenging they will be until it is time to get started with Stage 3, said Fortin. For instance, though the Stage 2 requirements related to summary of care records and transitions of care may not have seemed particularly challenging at the outset, they turned out to be a huge problem for many physicians.

"... It didn't initially seem like it was going to be as difficult as it was," said Fortin. "Once you start implementing the capability and actually putting the work flows in and realizing some of the technical standards behind it you realize, 'Oh my gosh, this is actually going to be a real problem.' I think the new measures pose that level of uncertainty and that's what makes it tricky."