Meaningful Use Final Rule – What Will It Take to Qualify for EHR Incentives?

There are many comments about the EHR Incentive Program final rule (released on Tuesday) now being posted on the internet.  Here’s a couple of summaries from HealthcareIT News, Wall Street Journal Health Blog, the AMA statement, and, in full disclosure, ACP’s statement.   The Centers for Medicare & Medicaid Services has an “official site” for the EHR Incentive Program with its own new logo.  I’d encourage readers to review the Fact Sheet posted by CMS. The Department of Health & Human Services also has a well-organized site worth reviewing.

Most of the comments I’ve heard reflect the perception that the final rule for the EHR incentive program addresses several of the concerns raised during the comment period.  For example, the final rule reduces the number of measures required for “eligible professionals” (EPs) to qualify for the EHR incentive payments and introduces some flexibility to the selection of measures.  CMS created two categories of objectives and measures: 1) Core Set and 2) Menu Set. All of the calculations implied by the measures (see below) are part of the certification requirements for EHRs certified under the final rule released by the Office of the National Coordinator for Health Information Technology (ONC) on July 13th.  This will hopefully eliminate some of the paper processes that would have been necessary given some of the measures described in the proposed rule.  In addition, the rule includes reasonable exclusion criteria recognizing that not all of the measures apply to all EPs.

The Core Set has 15 measures all of which must be satisfied and the Menu Set has 10 measures of which 5 have to be met (with at least 1 of the measures being a test of reporting to an immunization registry or to a public health agency for syndromic surveillance).  If an EP meets the exclusion criteria for one of the Menu Set measures, the requirement is reduced from needing to meet 5 of 10 measures to achieving 4 of the remaining 9.

What’s in these sets?  From a primary care physician’s perspective, the measures seem to reflect good use of EHRs in medical practice  (which, of course, is the intent of the incentive program) and many of the requirements relate to each other.  For example, if a primary care EP and his/her practice use the functionality of the EHR to do the following 6 things, then it would be reasonable to expect that 8 Core and 3 Menu Set measures (listed below) could be achieved:

  • Enters problems in a structured format to populate a problem list
  • Enters allergies
  • Uses e-prescribing
  • Keeps track of vaccinations and preventive care needs (e.g., colon cancer screening, breast cancer screening, well-child checks)
  • Trains front office staff collect basic demographic data (date of birth, gender, race, ethnicity, and preferred language)
  • Requires clinical staff to check height, weight and blood pressure

Core Set: 1) Computerized Physician Order Entry; 2) Drug-drug/Drug-allergy interactions; 3) Maintain up-to-date problem list; 4) E-prescribing; 5) Active medication list; 6) Active allergy list; 7) Recording of demographics; 8) Record/chart vital signs.

Menu Set: 1) Drug-formulary check (at least 1): 3) Generate list of patient with a specific condition; 4) Send reminders for preventive/follow-up care.

So, what’s left to do?  In the Core Set, these are 7 remaining measures which would likely take a bit of additional work beyond what I’ve described above:

9) Record smoking status for patients 13 years old or older (more than 50% of all unique patients seen)

10) Report ambulatory clinical measures to CMS (this will be from a set of measures already specified for the PQRI program to be submitted electronically; certified EHR technology will need to have this capability);

11) Implement one clinical decision support rule;

12) Provide patient with an electronic copy of their health information upon request (more than 50% of all patients who request an electronic copy are provided it within 3 business days);

13) Provide clinical summaries for each office visit (more than 50% of all office visits within 3 business days);

14) Capacity to exchange key clinical information among providers of care and patient authorized entities electronically (at least one test of clinical information exchange);

15) Protect electronic health information through the implementation of appropriate technical capabilities (conduct or review a security risk analysis in accordance with established requirements and implement security updates as necessary and correct deficiencies).

Of these remaining Core Set measures, #9 should be relatively routine practice (note, the frequency of the smoking assessment is not specified); #10 would expected given the emphasis on PQRI – and hopefully EHRs will make reporting easier as long as the information is entered by the clinical team in the appropriate places in the record; #11 could be a bit of a challenge, but most EHRs now have the capability of providing decision support and will hopefully be able to track compliance as specified; #12 & #13 can be incorporated into the daily work flow of the office staff as long as the EHR can track requests as well as the delivery of the requested records; #14 will depend on the ability and availability of another entity to receive/exchange information; and #15 is good practice given the emphasis on privacy/security and the penalties for breach of privacy under HIPAA.

Turning to the Menu Set, the remaining options include:

2) Incorporate clinical lab test results into EHR as structured data (more than 40% of labs ordered which are represented in numerical or positive/negative format);

5) Provide patients with timely electronic access to their health information within 4 business days of the information available to the EP (at least 10% of all unique patients are provided this access with EP discretion allowed regarding release of certain information);

6) Identify patient-specific education resources and provide them if appropriate (more than 10% of unique patients seen are provided such information;

7) Medication reconciliation when receiving a patient from another setting of care or provider (more than 50% of transitions in care);

8) When sending a patient to another provider or setting of care, provide a summary care record for each transition (more than 50% of transitions or referrals are provided a summary of care).

The last two, one of which is must be addressed (#9 relates to immunization registries and #10 submission of syndromic surveillance data to public health agencies) require one test of the capability during the reporting period.

Of these, here’s my assessment recognizing that this scenario (per my description above) assumes that the practice is already set up to achieve 3 of the required 10 Menu options and therefore only needs to do either #9 or #10 and one other of the remaining five for 2011:

#2 – If a practice has established lab-EHR interfaces for ordering/receiving test results, then this should be relatively straightforward to meet

#5 – As described, this would likely require a connected personal health record or other portal to allow patients this access.  Therefore, if the functionality is available, it then becomes a question of cost and work flow implications.

#6 – Most EHRs now have educational resources accessible from within the program.  If this functionality is available and the EHR can track when such material is provided, then meeting this objective should be relatively easy and clinically relevant.

#7 & #8 relate to good transitions in care and high risk activities (medication safety issues; information exchange). To meet the intent of these measures might require some work flow changes and training of personnel. With regard to immediate clinical quality improvement, these may be worth the extra effort.

The final rule has many other important elements which will be the subject of future blog posts – but this is what most health care professionals are probably focusing on right now – as well as the EHR vendors.  If you are in the midst of evaluating EHRs, think about how each product on your short list could help you satisfy the meaningful use requirements.

What do you think about the Core Set and Menu Set introduced by the final rule? Is this achievable by most EHR-enabled practices? Will the measures help practices improve the quality of care delivered?

Note (9/14/10):  Post edited to correct an inadvertent omission.  E-prescribing was not included in the original list of activities for EPs and staff to accomplish.  There are 6 things for a primary care EP & his/her staff to do in order to get to the level of performance described (not 5).

This post is the personal opinion of the author and does not necessarily reflect the official policy or position of the American College of Physicians (ACP). ACP does not endorse a specific EHR brand or product and ACP makes no representations, warranties, or assurances as to the accuracy or completeness of the information provided herein.


3 responses to "Meaningful Use Final Rule – What Will It Take to Qualify for EHR Incentives?"
  • July 17, 2010
    Dr. Alan Brookstone (Cientis)

    Michael, do you think that the core requirement for CPOE (Computerized Physician Order Entry) may be challenging for practices to achieve? Are there specific functionalities that physicians should look for that can ease meeting this requirement? For example having an EHR with bi-directional interfaces with labs and the ability to order lab tests. Are there any other functionalities that could allow practices to meet the CPOE requirement that they should look for in terms of EHR functionality?

  • The specific wording in the final rule regarding computerized provider order entry (CPOE) is as follows:
    (1)(i) Objective. Use computerized provider order entry (CPOE) for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines.
    (ii) Measure. Subject to paragraph (c) of this section, more than 30 percent of all unique patients with at least one medication in their medication list seen by the EP have at least one medication order entered using CPOE.
    (iii) Exclusion in accordance with paragraph (a)(2) of this section Any EP who writes fewer than 100 prescriptions during the EHR reporting period.
    CMS was careful to limit CPOE to electronic prescribing for Stage 1 because of the challenges many practices would have had if the metric also included laboratory & test ordering. The other key point is that the 30% goal is based on a denominator which only includes those patients for whom a medication has been added to their medication list – not the entire patient population served by the eligible professional.
    However, the final rule already states that Stage 2 will raise the threshold from 30% to 60%. We can probably expect future Stages to also include objectives for laboratory and other test ordering. Therefore, practices should definitely inquire about the capability of EHR systems being considered to connect with the laboratories, radiology centers, and hospitals in their community through standardized interfaces.
    [This post is the personal opinion of the author and does not necessarily reflect the official policy or position of the American College of Physicians (ACP). ACP does not endorse a specific EHR brand or product and ACP makes no representations, warranties, or assurances as to the accuracy or completeness of the information provided herein.]

  • July 21, 2010
    Peter Basch, MD, FACP

    Great summary Michael – thanks. As a veteran EHR user, I think the final rule (while obviously not perfect – what reg is?) allows for veteran EHR users to easily meet Stage 1 of MU (which is what one would expect), and more importantly, that new users could see Stage 1 as attainable with some work by the end of 2012 (which still allows for the maximum $44K per physician via Medicare incentives).
    The final rule for Stage 1 is set – and I think it would be a waste of energy to argue on what is now history (remember, there are more people who see the final rule for Stage 1 as being too lenient for docs – so even if this could be reopened, that might not be a good thing). Rather, I think the time is right for those of our colleagues who are not yet using an EHR in their practices to begin the looking process – utilizing the advice from our partner site “”
    While an EHR is not for everyone – I think that most internists will find that a good one not only improves quality and safety of care – it helps to prepare us for success in any of the new internist-friendly payment models that are on the new term horizon (such as the Patient-Centered Medical Home).

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