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Stakeholders Plead for Flexibility in Stage 3 Meaningful Use

Stage 3 meaningful use is still coming under fire for its lack of flexibility, onerous reporting requirements, and swift timetable.

By Jennifer Bresnick

- CMS may be getting more flak than it bargained for when it opened up the final Stage 3 meaningful use regulations for public comment.  Dozens of irate physicians and a slew of professional societies have eagerly voiced their opinions about the scope and timing of the last phase of the EHR Incentive Programs, and the results have been resoundingly negative.

Stage 3 meaningful use

The American Medical Association, CHIME, the American College of Cardiology, and Congressional leaders have all argued that Stage 3 meaningful use is simply too rigid, too difficult, too process-oriented, and slated to arrive too soon for an industry overwhelmed with an avalanche of competing initiatives and a health IT landscape insufficiently mature for their needs.

The professional societies responding to the regulations are careful to point out that they believe the Triple Aim is still a worthy goal for the healthcare system, and that meaningful use has helped the industry make progress towards improved patient care. 

But Stage 3 may be more of a barrier than a catalyst for innovation, says the AMA in a letter addressed to Acting CMS Administrator Andy Slavitt, due chiefly to the program’s lack of flexibility, untenable pass/fail requirements, and the high number of objectives that lie outside of the attester’s control.

“Physicians are incredibly frustrated with the MU program and the impact it has on the design of EHRs,” the writes AMA CEO James L. Madara. “The AMA has raised substantial concerns about the effect of the MU program on the practice of medicine and the innovation of technology."

READ MORE: EHRs, Value-Based Care Constrain Personalized Medicine Progress

“Yet, Stage 3, as currently drafted, continues to restrict innovations in technology for patients and physicians and creates barriers in moving to the new Merit-Based Incentive Payment System (MIPS) and alternative payment models (APMs).”

“For example, MU measures currently define patient engagement in a narrow manner without recognizing the vast opportunities of new technologies,” he continues. “Similarly, the MU program’s pass-fail structure is at odds with moving towards measuring and assessing care improvement. Since the future of value-based reimbursement depends upon leveraging health IT, we believe the MU program must be reassessed.”

The American College of Cardiology also believes that meaningful use has lost its way.  The program should be “refocused” on interoperability, usability, and patient outcomes, and must also provide a much higher degree of flexibility for providers who are likely to be unable to meet “unrealistic” benchmarks.

“The finalized requirements for Stage 3 set the bar for success too high,” states Kim Allan Williams, Sr., MD, FACC, FAHA, FASNC, President of the American College of Cardiology, in a comment letter obtained by

“The Meaningful Use criteria should encourage the appropriate, purposeful and accurate use of health IT solutions, rather than mandate completion of tasks based on a particular timeline. Currently, there is too much emphasis on achieving specific objective metrics when the focus should be placed on the exchange of health information, increased usability of EHRs, and the appropriate realignment of clinical workflows to leverage health IT most effectively resulting in improved patient care.

READ MORE: EHR, Biobank Data Uncovers Genetics of Personalized Medicine

“The metrics do little to acknowledge that often times diagnostic and treatment strategies are dependent upon observations, findings, results, discussion with colleagues and study, rather than navigating a rigid clinical decision-making tree only to post findings to the portal as soon as possible – a process that is not so subtly enforced.”

The ACC also suggests that first-time Stage 3 attesters should be allowed a 90-day reporting period to test the impact of the new guidelines on provider productivity and patient care.  Williams notes that the time involved in meeting the stringent guidelines will severely impact workflows, and may be much more onerous than CMS envisions.

“While CMS estimates that participation in Stage 3 will require 6 hours and 52 minutes per physician participant (down from Stage 2’s proposed 10 hours and 33 minutes despite increasing thresholds), we strongly disagree,” he writes. “In fact, we estimate that the operational burden to both physicians and hospitals will dramatically increased amounting to multiple minutes per patient. CMS grossly underestimates the actual amount of work required.”

A 90-day reporting period would be a positive step, but the College of Health Information Management Executives (CHIME) goes quite a bit further with its plan to reinvent Stage 3 meaningful use.  Not only should first-time attesters be allowed to choose an initial 90-day reporting cycle, but providers should be allowed to shorten their attestation period any time they feel it is necessary to cope with EHR implementations or upgrades to other technologies that may significantly impact their workflow.

While CHIME agrees with its peers’ recommendations for removing the pass/fail requirements and fine-tuning existing data collection and reporting requirements, the organization suggests that none of these changes should take place until well after CMS has planned.

Currently, Stage 3 meaningful use is scheduled to start in 2017, and become mandatory the following year.  CHIME urges CMS to reconsider this timeline, stating that Stage 3 should begin no earlier than 2019 – and only if at least 75 percent of eligible providers have successfully attested to Stage 2.

“CHIME is concerned that 2018 does not represent a reasonable start date for the vast majority of providers,” the organization says. “The timeframe would only give providers and their vendor partners two years under Stage 2 before having to try and meet Stage 3 requirements, a timeframe which we know from the past is inadequate. Beginning Stage 3 in 2019 offers providers more time to focus on many of the beneficial changes CMS recently made under Stage 2.”

CHIME’s plan would remove the transitional 2017 year, and would push back the 2015 Edition Certified EHR Technology mandate until 2018.  This would prevent vendors from being caught in a certification bottleneck, as they experienced during the rocky transition from Stage 1 to Stage 2.

“Under current rules, vendors will need adequate time to develop software that can be tested and safely deployed,” CHIME points out. “To date, many vendors have been unable to deliver updated certified products to the market due to late and shifting federal policies. We worry about their ability to deliver 2015 Edition certified EHRs by 2017 given these previous challenges.”

CMS has not yet responded to any requests made during the open comment period, but stakeholders are becoming increasingly convinced that something will have to change if Stage 3 is to see any amount of success.  CMS has issued significant modifications to previous stages of the program in response to industry feedback, and may do so again if the pressure continues to build.

“The reality is that most new programs encounter difficulties in the beginning, and adjustments will need to be made for these challenges,” says Williams. “As physicians adopt EHRs, we should expect this to be the case and allow for some modifications in Stage 3 to address these difficulties.”


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