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What's new for meaningful use stage 2?


The Centers for Medicare and Medicaid Services (CMS) electronic health record (EHR) incentive programs are well under way. Many primary care physicians (PCPs) already have attested to meaningful use (MU) stage 1 and will be upgrading their EHR systems to the new MU certification standards so they can progress to stage 2.

If you're already in the process of attesting to MU, keep in mind that stage 2 is similar in many ways to stage 1 but with some distinct differences. Two stand-out areas that differentiate stage 2 from stage 1 involve CMS' focus on health information exchange and online patient portals as core objectives of MU stage 2.


MU stage 2 features many of the same recording objectives as stage 1, although many of those objectives now have increased thresholds. This means that physicians must apply those same stage 1 objectives to an increased number of patients in stage 2.

In addition, CMS added new core objectives for stage 2 centered around promoting health information exchange between providers and making health information available to patients online.

"We focused on two areas that make stage 2 very different from stage 1," says Robert Anthony, a policy analyst with CMS' Office of E-Health Standards and Services.

Much of stage 2 will be familiar to people who already are working on the program and already have attested to stage 1. One of the optional menu objectives in stage 1, however, is now a required core objective in stage 2 that centers around transitions of care.

"Essentially, this objective requires physicians who are transitioning their patient to another care setting or another care provider to transmit a summary of care record to the next provider of care," Anthony says. "This is all about making sure that information is moving from different points of care and that it's available across different sites to increase care coordination and ultimately improve care for patients."

Three different measures for transition of care exist: For more than half of all the transitions of care or referrals, a care summary is sent to the next provider of care. The summary can be sent in any manner available to the physician, be it paper, fax, or digital (CD, DVD, jump drive, etc.).Of that 50%, more than 10% must be transmitted electronically to a recipient directly from the physician's certified EHR in either continuity of care document (CCD) or continuity of care record (CCR) format. CMS believes that this type of information exchange eventually will supplant all other forms of information exchange between physicians. "We think that most physicians will find it easiest to do this type of exchange rather than mailing or faxing the information," Anthony says. (Many organizations already have networks in place for transmitting health information in this way or through a certified third-party information exchange that complies with Office of the National Coordinator for Health Information Technology standards.)At least one electronic transmission of the electronic care record must be to a care setting or physician who is using a completely different EHR vendor than the transmitting physician. "Providers seem to be confused about the purpose of this measure most of all," Anthony says. "We wanted to ensure that information could travel across boundaries-that electronically it wouldn't be kept within the walled garden of a particular vendor or organizational network. We wanted to ensure that the certified EHR technology in the EHR incentive programs facilitated the exchange of information across any platform regardless of who was using what EHR technology. This measure ensures that capability."

Although, to attest to stage 2, each physician must demonstrate that his or her EHR system has the capacity to exchange data with another EHR system from a different vendor, CMS decided to require only one demonstration of this capability.

"We know that there are providers in 'high-penetration' areas where 90% of all physicians are on the same EHR products," Anthony says. "If you're in one of those areas, you could find it difficult to do an exchange outside of that network with somebody who's using a different EHR vendor. It might not come up all that often during your normal scope of practice."

CMS, therefore, is working on providing an EHR test site where physicians can go to exchange data with a different EHR system and fulfill that stage 2 core objective.


Anthony says that local and regional providers have begun to strategize how they plan to meet the stage 2 objectives. This course of action is desirable for at least two reasons: Attesting to stage 2 is inevitable. Everyone must go through it. So many physicians are attracted to finding out how others are doing.The infrastructure isn't always immediately available. So people are building solutions that will work at regional levels rather than waiting to see what might develop, he says.

"There are a number of exciting things starting to happen because of this requirement," Anthony says. "As we get more people onto stage 2, we're going to see a lot more robust information exchange."

In MU stage 1, most physicians opted to defer the information exchange menu objective, meaning they opted not to include this capability in their stage 1 attestation.

"Literally over 80% of [eligible professionals (EPs)] deferred the transition of care menu objective in stage 1," Anthony says.

That's because information exchange is quite challenging to implement into a hospital or primary care practice's workflow, he says. This difficulty explains why only 20% of practices opt to attest to health information exchange in stage 1. In stage 2, however, no option to defer exists; health information exchange is a required core objective. All Medicare and Medicaid providers must exchange information electronically for more than 50% of their patient referrals or transitions of care.

"We're talking about a significant step," Anthony says. Not all physicians, however, are happy about these requirements.

CMS receives a significant amount of feedback from Medicare and Medicaid providers who do not want to implement EHRs, who do not believe EHRs will help them provide better outcomes for their patients, or who simply do not have the funds necessary to comply with the government's mandates, Anthony says. He adds that CMS understands these views and offers physicians many types of support.

"We hear those concerns and anxieties all the time," Anthony says.

One way CMS is trying to help is by putting PCPs, doctors who practice in rural settings, and physicians in smaller practices in touch with other doctors who already have started implementing EHRs. 

"If you go to our Web site, you'll find links to testimonials from physicians who are in exactly these circumstances and who are extolling the virtues of what an EHR has done for their practice," Anthony says. "It's made them more efficient. It's helped them recover costs that they might not have been able to recover previously. It's helped them become better organized, and most importantly, it's helped them provide better care for their patients.

"We hear again and again how the management of chronic disease has fallen to PCPs," he continues. "Populations [such as patients with] diabetes, for example. To be able to utilize EHR technology to look at your patients, see who has HbA1C levels that are under control, see which patients are having problems, and then to be able to strategize for that population, and to investigate how to use an EHR to help all your patients-I think that makes all the difference for physicians.

"We can talk about incentives, we can talk about payment adjustments, but in the end, what motivates most physicians is the quality of care they can provide for their patients," Anthony says.

Some physicians, however, are not convinced. Physicians in smaller practices in particular, he says, are skeptical that an EHR will have any effect on their ability to treat their patients.

"It might be true that comparing your chronic disease patients to a group of patients in another state might not impact how you treat your patients," Anthony says. "But there are functionalities within an EHR you can use to look at your patient base in ways that can enable you to make significant differences in the care of your patients.

"Most medicine is practiced by PCPs in smaller practices," he continues. "We're determined to convince those folks that an EHR can work for them in just the same way that it can work for larger practices."


Stage 1 requirements contained core objectives that required EPs and critical access hospitals to provide an electronic copy of health information on request. In stage 2, that core objective has been refined and is no longer "upon request" but instead is required to be available online for patients to access 24/7, with the ability to view, download, and even transmit their information from the online portal directly to another provider who can automatically receive the information.

"When we talk about stage 2," Anthony says, "we're not just talking about increasing the availability of information in the form of information exchange between providers, but also about making the information available online, in the cloud, so that patients can access it from any location."

This particular requirement is retroactive to stage 1, so it will affect all providers by 2014, when more than 50% of all patients are required to have online access to their records. This information includes: recent problems lists,medications/allergies lists, anddiagnostic lab test results.


An additional requirement for stage 2 states that more than 5% of patients in a practice must actually access their information online. To fulfill this core objective, physicians must actively promote their online portals and track their usage.

"It's a small measurement, but we think that makes it achievable," Anthony says. "We felt that it was important to place patient usage requirements into stage 2, and we think that providers are in a unique position to encourage the use of health information technology by their patients for improving their own healthcare."

Just as providers collaborate with their patients in other ways, CMS hopes providers also will work with their patients to use health information technology to access their health information and use it across other settings of care as well.

To encourage this new collaboration, CMS transformed the stage 1 patient education menu measure into a core objective. In addition, stage 2 EHR certification requires that EHRs have the ability to tailor the educational tools it generates to a patient's specific healthcare needs and medical requirements.

"This is where we talk about the functionality of an EHR coming together for providers," Anthony says. "It's not just comparing your population to a remote population. It's using an EHR's resources to look at a patient's individual information, suggest resources for that patient, identify clinical decision support that will be useful for a patient not only in patient safety (for instance, drug/drug and drug/allergy alerts) but also looking at clinical decision alerts that can improve patient care as well."


The earliest that stage 2 can go into effect for hospitals is October 1, 2013. The earliest stage 2 can go into effect for EPs, such as PCPs, is January 1, 2014.

It's important to note, however, that because stage 2 is always going to be the second step toward MU, the timing of when you begin stage 2 always will be linked to when you began the MU program in the first place.

In other words, if you started the MU program in 2011 or 2012, then you'll begin stage 2 in 2014. If you started the program in later years, then stage 2 will correspondingly start in later years for you as well. In general, no matter when you start the program, you'll always do stage 1 for 2 years, and then stage 2 for 2 years.

To make matters even more confusing, however, CMS realized many practices that already have attested to stage 1 will be required to upgrade their existing EHR systems to stage 2 certification standards before they can move on to stage 2. Therefore, to give these practices enough time to upgrade their systems, in 2014 only, the reporting period for attestation will only be 90 days, regardless of the stage to which you are attesting at that time.

"That's a special period just for 2014," Anthony says. "If your stage 2 reporting period actually falls in 2015, then it would be for an entire year."


To help make the timing of stage 1 and stage 2 attestation clearer for doctors, CMS is developing a "timeline calculator" that will enable providers to generate a proper schedule for attestation. You simply will input the date you got started attesting to MU under Medicare or Medicaid, and the calculator will return for each successive year which stage you'll be at when and how long your reporting period will be.

At the time of this writing, CMS is still working on the calculator, but Anthony believes it will be ready for use by the first quarter of 2013, and possibly sooner. Check the CMS Web site (specifically,| for updates. 


"The most important thing physicians should be contemplating right now when it comes to stage 2 MU is the timing aspect of it all," Anthony says. "You need to think about getting your 2014-certified EHR, because everybody has to upgrade to new versions of certified EHR systems in 2014. That's how you'll complete either stage 1 or stage 2. Everyone is going to be on new certified software, because that software contains all of the new functionalities.

"You'll also want to have a plan for how you're going to work things like providing a summary of care record to the next provider, and putting patient information on your Web site, into your workflow," he adds. "That's going to happen somewhat automatically based on what you have in your EHR, but a lot of practices haven't thought about the timeline on which they actually get that information into their EHR, and there's a timeline requirement for most of this on the Web site. So you really want to think about integrating this into your clinical workflow to make it work the best for you."


Helpful resources

To help providers better understand the meaningful use stage 2 requirements, the Centers for Medicare and Medicaid Services has developed or is developing:

specification sheets that detail the stage 2 objectives and how to meet them, e-specifications of the clinical quality measures that go into effect in 2014, andtechnical specification sheets for vendors that are developing products for 2014.

Links to these and many more tools for providers and EHR developers are available on the CMS EHR Incentive Program Web site,|

Additionally, under the Stage 2 tab in the left column, you'll find a plethora of tip sheets and resources for Stage 2. Visit| .

Send your feedback to Also engage at| and| .


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Jennifer N. Lee, MD, FAAFP
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