Overview of the Meaningful Use NPRM

posted by Kevin Heubusch

Jan 20, 2010 08:42 pm

AHIMA Meaningful Use White Paper Series

Paper no. 1

On January 13, 2010, the Centers for Medicare and Medicaid Services (CMS) published a notice of proposed rulemaking on the “meaningful use” EHR incentive program. On the same day, the Office of the National Coordinator for Health Information Technology (ONC) published a companion interim final rule describing the certification criteria for EHRs that qualify for the meaningful use program. Together, these two documents make up the basis for the incentive program called for under the American Recovery and Reinvestment Act of 2009.

This is the first paper in a series in which AHIMA will take a closer look at the incentive program and its impact on the health information management profession and on healthcare providers that choose to participate. These brief white papers will focus on the meaningful use proposal, with references to the certification criteria.

This paper offers an introduction and general overview to the meaningful use rule. The next paper provides greater detail on the NPRM’s requirements. (The entire schedule appears at the end of this paper.)

Key Descriptions and Dates

Item Notice of proposed rulemaking on the “meaningful use” incentive program Interim final rule on EHR certification criteria related to the meaningful use program
Description Describes the criteria providers and hospitals must meet to receive incentive payments Outlines the initial standards, implementation specifications, and certification criteria for EHRs to achieve meaningful use
Author Centers for Medicare and Medicaid Services Office of the National Coordinator for Health Information Technology
Publication date January 13, 2010  (75FR1844) January 13, 2010  (75FR2014)
Effective date Not yet announced February 12, 2010
Comments due March 15, 2010 March 15, 2010

Background on “Meaningful Use”

CMS’s notice of proposed rulemaking, or NPRM, is titled “Medicare and Medicaid Programs Electronic Health Record Incentive Program.” A draft was released on December 30, 2009, and it was published officially on January 13, 2010 in the Federal Register. CMS’s intent in releasing an NPRM was to solicit comments, which it will accept for 60 days-until 5 p.m. EST on March 15, 2010.

The proposed rule results from provisions in the American Recovery and Reinvestment Act (ARRA). Section 2, Division B, Title IV (”Medicare and Medicaid Health Information Technology; Miscellaneous Medicare Provisions”) established Medicare and Medicaid incentive payments to hospitals and providers that become “meaningful users” of EHRs. ARRA established many of the program’s date-specific requirements, and CMS has in turn attempted to work its regulation requirements within the time frame dictated by Congress.

The NPRM also cites the HITECH Act within ARRA (Division A, Title XIII – “Health Information Technology” or Health Information Technology for Economic and Clinical Health Act”), because much of the technical support providers may need to gain the incentives for meaningful use is included here.

Since this is a proposed rule, an effective date has not been announced; however, it is assumed that CMS will work to have to rule in place by June 2010, because the goal of the ARRA legislation is to provide incentive payments by 2011.

The Certification Criteria

ARRA specifies that a condition of meaningful use is use of a certified EHR system. It charged the Department of Health and Services to determine the certification criteria, which the department is managing through ONC.

The interim final rule, or IFR, titled “Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology,” was also published in the Federal Register on January 13, 2010. This rule is more than a proposal-it takes effect 30 days after publication in order to meet the ARRA statute requirement. However, it is an “interim” rule, and the door is open for modifications before the rule is finalized.

The rule’s effective date is February 12, 2010; however, the ONC will accept comments until 5 p.m. EST on March 15, 2010. Comments related to other interim rules have been known to affect the final rule, so the status should not dissuade anyone from commenting.

Overview of the Meaningful Use NPRM

All NPRMs follow a standard format, thus the meaningful use NPRM begins with instructions for submitting comments (p.1844) and information on whom to contact with questions. It then offers a background that explains the origin of the regulation and identifies other regulations that might be affected-in this case, legislation and regulation that concern payments made under the federal Medicare and Medicaid programs (pp. 1846-47).

A section-by-section description of the provisions begins on page 1847. In it CMS describes the input it received regarding the ARRA legislation, including recommendations made by the Health IT Policy Committee and the Health IT Standards Committee, which were established under HITECH. Further, CMS describes its rational in formulating the proposal and highlights areas of the proposal where it especially desires comments.

Included in this description are definitions, reporting requirements for clinical quality measures (one of the goals Congress desired in the program), criteria and reporting for meaningful use, eligibility requirements for both hospitals and individual providers, and how CMS will oversee the disbursement of the incentive payments. Additionally, CMS describes how the Medicare program will reduce program entitlement payments to providers if they have not achieved meaningful use by the deadlines set by Congress.

Because Medicaid payments are made through the states, the proposed rule also describes how CMS will work with the states, the duties and obligations of the states, and the potential differences in how the state Medicaid program might work from that of CMS (while stressing a desire that the Medicaid programs not radically change the program from that which CMS is proposing). This potential difference in rules and process between Medicare and Medicaid comes about from the ARRA provisions.

The incentive program includes reporting and attestation requirements for healthcare providers and states, and the NPRM includes a separate section listing them (beginning p. 1848). These requirements normally would be proposed separately, but in this case they have been folded into the NPRM. In particular, the reporting and attestation requirements could change as a result of the comments CMS receives.

All NPRMs require a regulatory impact analysis (pp. 1972(91). However, CMS stresses the difficulty of determining the impact since the incentives are optional-no provider is forced to take the incentive payment or to begin it at a set time-and aspects of the NPRM itself could change based on comments. CMS also notes that the impact will be affected by the status of a particular provider’s readiness to obtain and implement an EHR, or upgrade an EHR, and other variations.

Finally, the NPRM lays out the proposed rule itself, beginning on page 1992.

For more detail on the proposed rule, see the second paper in the series.

In addition, AHIMA published a longer overview of the draft rule that was released on December 30, 2009.

Responding to the Rule

Both CMS and ONC encourage reader comments throughout their respective rules. There is also the opportunity to comment on what criteria should be added to or taken away from the proposals to best achieve the stated goals.

Readers of these proposed rules can consider them from three perspectives. First, they can consider if the rules have the capability of moving the healthcare industry toward the goals Congress set for interoperable electronic health records and electronic health information exchange.

Secondly, they can determine how these proposed rules will affect their organizations. Do the rules create opportunities or barriers to the organization’s adoption, implementation, and use of health IT within the given time frames? CMS’s proposal acknowledges that organizations are starting from varying starting lines.

A third set of questions derives from the first two: how will an organization approach its EHR adoption, implementation, upgrading, or management to maximize the incentive payments it may be eligible to receive? Conversely, how can an organization ensure it will avoid reduced payments when the program begins to penalize those who are not meaningful users?

Finally, readers may want to consider how their organizations will incorporate the final meaningful use requirements into their plans to achieve quality care and efficiency.

The provisions within the final rule will determine the direction of many healthcare initiatives and reset many priorities. This is a time to shape the future and plan for many long-term goals.

The White Paper Series

This white paper series will follow the schedule below, with one to two papers each week:

  • Paper 1: Overview of the NPRM
  • Paper 2: Meaningful Use-Provider Requirements
  • Paper 3: Meaningful Use-Incentive Payments and Program Requirements
  • Paper 4: Meaningful Use and Certification
  • Papers 5a/b: Measure Reporting: Health IT Functionality Measures for Eligible Providers/Hospitals
  • Papers 6a/b: Measure Reporting: Clinical Quality Measures for Eligible Providers/Hospitals
  • Paper 7: Process for Demonstrating Meaningful Use
  • Paper 8: AHIMA Comments on Meaningful Use (part 1)
  • Paper 9: AHIMA Comments on Meaningful Use (part 2)

All papers also will be posted as PDFs on the AHIMA ARRA Web page (see “AHIMA Analysis”).

AHIMA. "Overview of the Meaningful Use NPRM." (AHIMA report, January 20, 2010).