An Overview of Meaningful Use Stage 1

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Electronic health records (EHR) systems are now commonplace in medical offices all over the United States, but it wasn’t always that way. The transition from paper records to electronic ones began in the 2000s with a little push from the U.S. government—specifically, a set of standards collectively known as “meaningful use.” 

Meaningful use standards were run through the country’s Medicaid and Medicare health care programs, and established under the Health Information Technology for Economic and Clinical Health (HITECH Act) as a means to encourage health care providers to adopt EHRs, use them to protect and share patient information more easily, and improve the quality of patient care

Meaningful use stage 1 was the first phase of implementing these standards. Its primary objective: motivate health care professionals and institutions to adopt EHRs and begin to store and share health information electronically. 

Meaningful Use 

The idea behind meaningful use was simple: Get health care providers to start storing and sharing health data electronically, and they’ll be better able to improve clinical processes and, in turn, health outcomes for their patients. 

All of which could help modernize the U.S. health care system and work toward meeting key policy priorities, specifically: 

  • Improve the quality of patient care and reduce health disparities. 
  • Engage patients in their health and health care. 
  • Make it easier to coordinate care across providers. 
  • Improve the overall health of a given patient population or community. 
  • Secure and protect people’s personal health information.

Meaningful Use Stages 

Health officials knew all of this would take time. So they decided to roll out the program in three stages: 

  • Stage 1: Focused on getting health care providers to adopt EHRs and store clinical data electronically
  • Stage 2: Encouraged health care professionals and institutions to then use that data and technology to improve the quality of care for their patients and make it easier to exchange information within and between organizations. 
  • Stage 3: Centered on leveraging EHRs and clinical data to improve health outcomes, and eased reporting requirements to make them more in line with other government health programs. 

In 2018, the Centers for Medicare and Medicaid Services (CMS) renamed the Medicaid and Medicare incentive programs the “Promoting Interoperability Programs,” and established a new phase of EHR measurements. But many health care providers and institutions still often refer to the standards as simply “meaningful use.”  

Eligibility 

Not all health care professionals or medical offices were able to participate in meaningful use. Only providers and hospitals that met certain criteria were eligible to participate in either the Medicare version of the program or the Medicaid version. 

Medicare EHR Incentive Program Eligibility Requirements

Providers eligible to participate in the Medicare EHR incentive program included: 

  • Doctors of medicine (MD)
  • Doctors of osteopathy (DO)
  • Doctors of podiatry.
  • Doctors of optometry
  • Chiropractors.

In order for hospitals to qualify for the Medicare EHR incentive program, they had to be: 

  • Considered "subsection (d) hospitals" in states paid by the Inpatient Prospective Payment System (IPPS) 
  • Critical access hospitals
  • Affiliated with Medicare Advantage 

Medicaid EHR Incentive Program Eligibility Requirements

Requirements under the Medicaid version of the program were slightly different. Health care professionals eligible for the Medicaid EHR incentive program included: 

  • Physicians
  • Nurse practitioners
  • Certified nurse-midwives
  • Dentists
  • Physician assistants at a physician-led federally qualified health center or rural health clinic

They also had to show that at least 30% of their patient population participated in the state’s Medicaid program (or 20% if they were pediatricians), or that they worked in a federally qualified health center or rural health center where at least 30% of the patients they saw were considered economically disadvantaged. 

In order for a hospital to be eligible for the Medicaid EHR incentive program, they had to be:

  • Acute care hospitals, where at least 10% of their patients were on Medicaid 
  • Children’s hospitals

While health care professionals were only allowed to participate in one of the two programs, hospitals were allowed to participate in both.   

Incentives

In order to get health care providers and hospitals on board, the U.S. government offered financial incentives for those that met certain criteria and complied with specific standards. 

How much hospitals or health care professionals received in incentives varied based on a number of factors, such as:

  • Whether they were enrolled in the Medicare or Medicaid incentive program 
  • The number of years of participation
  • The number of patient discharges
  • The percent of total inpatient bed-days charges attributable to Medicaid 

These incentives were distributed through two programs: the Medicaid EHR Incentive Program and the Medicare EHR Incentive Program.

As the program progressed, CMS also added penalties—in addition to the incentives—to encourage providers and hospitals to participate.

Objectives and Requirements 

In order to take advantage of the incentives, eligible health care professionals and institutions had to show CMS that they were using a certified EHR and that they met certain objectives. Measures were broken down into three groups—core objectives, menu objectives, and clinical quality measures. 

Core Objectives

Core objectives were specific measures that had to be met in order to qualify for incentives through either the Medicaid or Medicare EHR incentive programs. Providers and hospitals had to show they were able to use their EHR to do some specific tasks: 

  • Order medications using computerized provider order entry (CPOE) for at least 30% of their patients with at least one medication on file .
  • Prescribe medications electronically, as opposed to on a hand-written prescription pad, at least 40 percent of the time.
  • Check for drug allergies or interactions.
  • Record demographics for at least 50 percent of patients in the EHR, such as preferred language, gender, race, ethnicity, or date of birth. 
  • Record vital signs for at least 50 percent of patients, including height, weight, or blood pressure.
  • Maintain an active “problem” list for at least 80% of patients, even if it’s simply noting in the EHR that there are no known problems. 
  • Maintain an active medication list for at least 80% of patients, including noting in the EHR when patients don’t have any active prescriptions.
  • Maintain a list of medication allergies for at least 80% of patients, or at minimum, noting in the EHR that there are no known medication allergies for the patient.
  • Implement one clinical decision support rule—that is, use the EHR to generate notifications or care suggestions automatically, based on elements in the patient’s chart (like blood pressure or lab test results).
  • Record smoking status for patients over 13 years old.
  • Conduct a security risk analysis to make sure health information is protected.
  • Report aggregate data on patients.
  • Give patients access to their health data, including the ability to see, download, or transmit their health information electronically within four business days of it being available.
  • Provide visit summaries for at least 50% of patients after visiting the office within three business days.
  • Exchange clinical information with a third party.

Menu Set Objectives 

In addition to core objectives, participants had to meet reporting meeting at least five menu set objectives. These measures focused on leveraging EHR technology to exchange data with other providers or public health agencies. 

Menu set objectives included the following measures: 

  • Implement drug-formulary checks by accessing at least one drug formulary (internal or external).
  • Incorporate clinical lab test results into a patient’s electronic record in a structured format.
  • Generate lists of patients with a specific condition, which could be used to identify and reduce health disparities in a given patient population.
  • Send reminders to patients to come into the clinic for preventive or follow-up care (ex. Missed or upcoming vaccine doses in kids under 5 years old). 
  • Give patients electronic access to their health information within a few business days. 
  • Identify relevant education resources based on the patient’s health information.  
  • Record advance directives for patients over 65. 
  • Perform medical reconciliation for patients coming from other providers or facilities—that is, verifying that the patient’s medication list is correct and up to date.  
  • Provide a summary-of-care record for patients being referred or transitioned to a different provider or facility.
  • Submit immunization data electronically to an immunization registry. 
  • Send reportable lab results to public health agencies. 

Clinical Quality Measures

Participating providers and hospitals were also asked to provide clinical quality measures (CQM) on their patient populations. Some examples of these measures included: 

  • Percent of adult patients with hypertension
  • Percent of adult patients who have been asked if they use tobacco in the past two years
  • Percent of patients aged 2 years with specific vaccine doses on record. 
  • Percent of patients over 50 years who got their flu shot between September and February. 
  • Percent of pregnant patients who were screened for HIV during the first or second prenatal visit. 
  • Perfect of women 21-64 years who’ve been screened for cervical cancer.  

From 2011-2013, eligible health care professionals were required to submit six of 44 possible measures and hospitals 15 of 15. Starting in 2014, however, CMS adjusted the CQM reporting to require that providers report nine of 64 possible measures. Hospitals were asked to report on 16 of 29 possible CQM. 

These measures also had to cover at least three of six National Quality Strategy domains: patient and family engagement, population/public health, patient safety, efficient use of health care resources, care coordination, and clinical process/effectiveness.

Reporting

When it was first initiated, providers and hospitals participating in meaningful use had to provide reports every year showing they met all of the core set objectives and at least five of the menu set measures. So long as they met certain thresholds, the participants would continue to get their incentives and avoid penalties. 

As the incentive program progressed, however, CMS has tweaked the reporting structure for providers and hospitals. Starting in 2019, reporting for the Medicare version of the program switched to a performance-based scoring system, where each measure is assigned a score, and hospitals had to achieve a score of 50 or more (out of 100) to stay in the program and avoid cuts to their Medicare payments. For the Medicaid program, however, each state can choose whether they want to adopt the new system for their participating providers.

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