On April 10, 2015, CMS released a proposed rule that would dramatically change the Stage 1 & 2 Medicare and Medicaid (EHR) Incentive Program for this year and until Stage 3 is mandated. We commented on the proposed rule in our blog “Stage 1 and Stage 2 Meaningful Use Makeover – 5 Things You Need to Know”.

The rule proposes to:

  1. Reduce the Reporting Period to 90 DaysMeaningful Use Stage 3
  2. Relax the Most Difficult Patient Engagement Measures
  3. Simplify the Attestation Process by Removing Measures
  4. Deprecate the Concept of Core and Menu Measures

In addition to the above captioned changes, CMS is proposing a mysterious change to perhaps the most difficult Stage 2 objective – the Electronic Exchange of Summary of Care documents (PHRs / CCDA documents).

The existing Summary of Care objective is a multi-part objective. Measure 1 of the objective sets a threshold for the exchange of paper versions of the summary of care. Measure 2 sets a threshold for the electronic exchange of summary of care.

In the proposed rule, Measure 1 (paper exchange) is being eliminated and CMS is proposing to retain and update only the second measure (electronic exchange) of the existing Stage 2 objective for Summary of Care for meaningful use in 2015 and through 2017.

The Objective: The EP who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care provides a summary care record for each transition of care or referral and transmits the record electronically.

The reasoning behind this measure (per CMS) is that exchange of summary of care documents also know as PHRs or CCDAs helps to assure that the lines of communication between providers caring for the same patient are open and that providers can operate with better information and therefore more effectively coordinate the care they provide.

The purpose of this objective is to ensure a summary of care record is provided to the receiving provider when a patient is transitioning to a new provider or has been referred to another provider while remaining in the care of the referring provider.

Per CMS the proposed update to the measure seeks to increase flexibility for providers with regard to the electronic transmission of the summary of care. Currently, the measure specifies the manner in which the summary of care must be electronically transmitted. In the current rule providers must electronically transmit the summary of care using CEHRT (Certified Electronic Health Record Technology) to a recipient. The method used by most providers to electronically transmit the summary of care via CEHRT is the new Direct secure email system.

Direct adoption been slow because the ecosystem that supports Direct is immature and lacks certain provider directory exchange standards. Until the Direct secure email ecosystem has more time to mature, the electronic submission of Summary of Care records will be challenging for most providers.

CMS proposes to update this measure to state simply that a provider would be required to create the summary of care record using CEHRT and transmit the summary of care record electronically (not specifically via CEHRT).

This subtle change CMS is proposing regarding Summary of Care that excludes CEHRT from the electronic transmission standard remains a mystery. What is the practical implication of electronic transmission using CEHRT vs electronic transmission not using CEHRT? Does this mean Fax is allowed? What is the non-CEHRT electronic method CMS alludes to? If CEHRT is no longer required how can vendors provide a numerator value to the EP?

CMS remains tight-lipped on this subtle change, they must because they are not allowed to clarify during the comment period. I know because I asked! It is clear they purposely left this part of the proposed rule vague, but why?

The new Stage 1 and 2 proposed rule offers providers the flexibility they need to succeed in 2015 but only if the electronic transmission of Summary of Care documents threshold is changed or if the word electronic is defined in a manner that does not mandate the use of Direct.

CMS promised more flexibility regarding the electronic transmission of summary of care records, but if we want to unravel the mystery the most you can do at this point is to send your comments to CMS, cross your fingers, hold your breath, and wait till the Final Rule is published in July.

To calculate the percentage of the measure, CMS and ONC have worked together CMS-3311-P 68 to define the following for this objective: Denominator: Number of transitions of care and referrals during the EHR reporting period for which the EP or eligible hospital’s or CAH’s inpatient or emergency department (POS 21 or 23) was the transferring or referring provider. Numerator: The number of transitions of care and referrals in the denominator where a summary of care record was created using Certified EHR Technology and is exchanged electronically. Threshold: The percentage must be more than 10 percent in order for an EP, eligible hospital or CAH to meet this measure. Exclusion: Any EP who transfers a patient to another setting or refers a patient to another provider less than 100 times during the EHR reporting period. Alternate Exclusions and Specifications for Stage 1 Providers for Meaningful Use in 2015 CMS propose that providers scheduled to demonstrate Stage 1 of meaningful use for an EHR reporting period in 2015 may claim an exclusion for Measure 2 of the Stage 2 Summary of Care core objective, as there is not an equivalent Stage 1 measure. The measure related to the electronic transmission of a summary of care record in the Summary of Care core objective requires an electronic summary of care document to be sent for transitions and referrals and is only applicable for Stage 2. There is not an equivalent objective and measure in Stage 1. CMS note that for an EHR reporting period beginning in 2016, all providers must attest to the complete objective and meet the specifications and threshold for the both Stage 2 measures in order to successfully demonstrate meaningful use. CMS-3311-P 69 Alternate Exclusion: Provider may claim an exclusion for the measure of the Stage 2 Summary of Care objective which requires the electronic transmission of a summary of care document if for an EHR reporting period in 2015 they were scheduled to demonstrate Stage 1, which does not have an equivalent measure. There are no alternate specifications for this objective. We invite public comment on this proposal.

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