The Centers for Medicare & Medicaid Services (CMS) has released a proposed rule describing the stage 2 criteria that eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) must meet in order to qualify for Medicare and Medicaid electronic health record (EHR) incentive payments. The rule also proposes payment adjustments under Medicare for covered professional and hospital services provided by providers failing to demonstrate meaningful use of certified EHR technology, and introduces changes to the program timeline. Additionally, the rule would also revise certain Stage 1 criteria, as well as criteria that apply regardless of stage, as finalized in the EHR Program final rule. CMS notes that it currently anticipates updating the Stage 3 criteria with another proposed rule by early 2014. For Stage 3, CMS intends to propose higher standards for meeting meaningful use. The stages represent an initial graduated approach to arriving at the ultimate goal of patient-centered, evidence-based, prevention-oriented, efficient, and equitable health care. If there will be a Stage 4 of meaningful use, CMS says that it will provide information about this in the rulemaking for Stage 3.


Under the Health Information Technology for Economic and Clinical Health Act, part of American Recovery and Reinvestment Act of 2009, EPs, eligible hospitals, and CAHs can qualify for Medicare and Medicaid incentive payments when they adopt certified EHR technology and use it to demonstrate "meaningful use" of that technology by achieving objectives set by CMS. In the July 28, 2010, Federal Register, CMS published a final rule that specified:

  • The Stage 1 criteria EPs, eligible hospitals, and CAHs must meet in order to qualify for an incentive payment
  • Calculation of the incentive payment amounts
  • Other program participation requirements

In that final rule, CMS also explained that the Medicare and Medicaid EHR incentive programs would consist of 3 different stages of meaningful use requirements, with each stage requiring increasing use of EHRs and electronic information exchange.

In the July 28, 2010 rule, CMS outlined Stage 1 criteria, and finalized a separate set of core and menu objectives for both EP and eligible hospitals, and CAHs. Specifically, EPs and hospitals must meet or qualify for an exclusion to all of the core objectives and 5 out of the 10 menu measures in order to qualify for an EHR incentive payment. Though some functionalities were optional in Stage 1, all of the functionalities are considered crucial to maximize the value to the healthcare system provided by certified EHR technology. The proposed Stage 2 criteria were substantially adopted from the recommendations of the Health IT Policy Committee, a federal advisory committee that obtains industry and provider input regarding the Medicare and Medicaid EHR Incentive Programs, as well as through consideration of current program data for the Medicare and Medicaid EHR Incentive Programs.

Stage 1 Meaningful Use Criteria  

The Stage 1 meaningful use criteria, consistent with other provisions of Medicare and Medicaid law, focused on:

  • Electronically capturing health information in a structured format
  • Using that information to track key clinical conditions and communicating that information for care coordination purposes (whether that information is structured or unstructured, but in structured format whenever feasible)
  • Implementing clinical decision support tools to facilitate disease and medication management
  • Using EHRs to engage patients and families
  • Reporting clinical quality measures and public health information

Stage 1 focused heavily on establishing the functionalities in certified EHR technology that will allow for continuous quality improvement and ease of information exchange. By having these functionalities in certified EHR technology at the onset of the program and requiring that the EPs, eligible hospitals, or CAHs become familiar with them through the varying levels of engagement required by Stage 1, CMS believes that it has created a strong foundation to build on in later years.

Stage 2 Meaningful Use Objectives and Measures 

CMS's Stage 2 goals, consistent with other provisions of Medicare and Medicaid law, expand upon the Stage 1 criteria with a focus on ensuring that the meaningful use of EHRs supports the aims and priorities of the National Quality Strategy. Specifically, Stage 2 meaningful use criteria encourage the use of health IT for continuous quality improvement at the point of care and the exchange of information in the most structured format possible. The Stage 2 requirements include rigorous expectations for health information exchange including:

  • More demanding requirements for e-prescribing
  • Incorporating structured laboratory results
  • The expectation that providers will electronically transmit patient care summaries to support transitions in care across unaffiliated providers, settings, and EHR systems

Increasingly robust expectations for health information exchange in Stage 2 and Stage 3 will support the goal that information follows the patient. In addition, as forecasted in the Stage 1 final rule, CMS considers nearly every objective that was optional for Stage 1 a requirement in Stage 2. It also reevaluated the thresholds and exclusions of all the measures.

CMS proposes to maintain the same core-menu structure for the program for Stage 2. EPs would have to meet or qualify for an exclusion to 17 core objectives and 3 of 5 menu objectives. CMS proposes a total of 16 core objectives and 4 menu objectives for eligible hospitals and CAHs. An eligible hospital or CAH must meet the criteria or an exclusion for all of the core objectives and the criteria for 2 of the 4 menu objectives. CMS notes that nearly all of the Stage 1 core and menu objectives would be retained for Stage 2. The "exchange of key clinical information" core objective from Stage 1 would be re-evaluated in favor of a more robust "transitions of care" core objective in Stage 2, and the "provide patients with an electronic copy of their health information" objective would be removed and replaced by an "electronic/online access" core objective. There are also multiple Stage 1 objectives that would be combined into more unified

Stage 2 objectives, with a subsequent rise in the measure threshold that providers must achieve for each objective that has been retained from Stage 1. CMS provides a summary of stage 2 objectives and measures that it proposes to adopt in Table 4 of the rule.

To view this table, see Appendix 1 (Please note, this table has 8 parts).

Changes to Stage 1 Criteria for Meaningful Use 

CMS proposes the following changes to the objectives and associated measures for

Stage 1, most of which would be optional for Stage 1 in 2013, and would be required for Stage 1 beginning in 2014 (calendar year for EPs, fiscal year for eligible hospitals/CAHs). An overview of these proposed changes include:

  • Computerized Provider Order Entry (CPOE) Objective Measure Denominator: The current denominator for the CPOE objective measure for Stage 1 is the number of unique patients with at least one medication in their medication list seen by an EP or admitted to an eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period. Beginning in 2013, providers in Stage 1 would be permitted to use the alternative denominator of the number of medication orders created by the EP or in the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period. Starting with the EHR reporting periods in 2014, the proposed "alternative denominator" would be required for all providers in Stage 1 and Stage 2.
  • Age Limitations on Vital Signs: CMS proposes identical changes to the age limitations on vital signs for Stage 1, starting in 2013. These changes to the exclusion and age limitations would be an alternative in 2013 to the current Stage 1 requirements and would be required for Stage 1 beginning in 2014.
  • Elimination of the "Exchange of Key Clinical Information": CMS has found the objective of "capability to exchange key clinical information" to be surprisingly difficult for providers to understand, which has made the objective considerably more difficult to achieve than envisioned in the Stage 1 final rule. As the measure for this objective is simply a test with no associated requirement for follow-up submission, CMS is concerned the value of this objective is not sufficient to justify the burden of compliance. CMS proposes to remove this objective and measure from the Stage 1 core set beginning in 2013. In Stage 2, CMS proposes to move to actual use cases of electronic exchange of health information, which would require significant testing in the years of Stage 1.
  •  Replacing "Provide Patients with an Electronic Copy of their Health Information": For Stage 2, CMS is not proposing the Stage 1 meaningful use objectives for EPs and hospitals to provide patients with an electronic copy of their health information and discharge instructions upon request. CMS is replacing these Stage 1 objectives with proposed objectives and measures for Stage 2 that would enable patients to view online and download their health and hospital admission information. CMS believes that continued online access to such information is more useful and provides greater accessibility over time and in different healthcare environments than a single electronic transmission or a one-time provision of an electronic copy, especially when that access is coupled with the ability to download a comprehensive point in time record.

  •  Reporting on Clinical Quality Measures (CQMs): EPs, eligible hospitals, and CAHs are required to report on specified clinical quality measures in order to qualify for incentive payments under the Medicare and Medicaid EHR Incentive Programs. For EPs, CMS proposes a set of clinical quality measures beginning in 2014 that align with existing quality programs such as measures used for the Physician Quality Reporting System, CMS Shared Savings Program, and National Council for Quality Assurance for medical home accreditation, as well as those proposed under the Children's Health Insurance Program Reauthorization Act, and under ACA Section 2701. For eligible hospitals and CAHs, the set of CQMs CMS proposes beginning in 2014 would align with the Hospital Inpatient Quality Reporting and the Joint Commission's hospital quality measures. This proposed rule also outlines a process by which EPs, eligible hospitals, and CAHs would submit CQM data electronically, reducing the associated burden of reporting on quality measures for providers. CMS is soliciting public feedback on several mechanisms for electronic CQM reporting, including aggregate-level electronic group reporting options, and through existing quality reporting systems. Within these mechanisms of reporting, CMS outlines different approaches to CQM reporting that would require EPs to report 12 CQMs and eligible hospitals and CAHs to report 24 CQMs in total.

CMS is also proposing a revised definition of a meaningful EHR user which would incorporate the requirement to submit clinical quality measures. It is thus removing the objective to submit clinical quality measures beginning in 2013 and the associated regulation text under 45 CFR 495.6 for Stage 1 to conform with this change in the definition. Under the rule, CMS would move to electronic reporting of clinical quality measure information. Because the core and menu objectives under §495.6 are reported through attestation, CMS believes it makes more sense to separate the reporting of CQMs from the other meaningful use objectives and measures for Stage 2. CMS provides the changes to Stage 1 objectives in Table 3 of the proposed rule. 

View Table 3: Changes to Stage 1 

Payment Adjustments and Exceptions 

Medicare payment adjustments are required by statute to take effect in 2015. CMS proposes a process by which payment adjustment would be determined by a prior reporting period. Therefore, any successful meaningful user in 2013 would avoid payment adjustment in 2015. Also, any Medicare provider that first meets meaningful use in 2014 would avoid the penalty if they are able to demonstrate meaningful use at least 3 months prior to the end of the calendar or fiscal year (respectively) and meet the registration and attestation requirement by July 1, 2014, (eligible hospitals) or October 1, 2014 (EPs). However, CMS also outlines the following three categories of exceptions to these payment adjustments based on:

  • The lack of availability of internet access or barriers to obtaining IT infrastructure
  • A time-limited exception for newly practicing EPs or new hospitals that would not otherwise be able to avoid payment adjustments
  • Unforeseen circumstances such as natural disasters that would be handled on a case-by- case basis

CMS also solicits comments on a fourth category of exception due to a combination of clinical features limiting a provider's interaction with patients and lack of control over the availability of certified EHR technology at their practice locations.

However, it is important to note that the receipt of Medicaid EHR Incentive Program payments for having adopted, implemented, or upgraded to certified EHR technology is not the same as meeting the meaningful use criteria. Therefore, those providers may be subject to Medicare payment adjustments if they do not otherwise demonstrate meaningful use.

Modifications to Medicaid EHR Incentive Program 

CMS proposes to expand the definition of what constitutes a Medicaid patient encounter, which is a required eligibility threshold for the Medicaid EHR Incentive Programs. Encounters for individuals enrolled in a Medicaid program, including Title XXI-funded Medicaid expansion encounters (but not separate CHIP programs) would be included. CMS also proposes flexibility in the look-back period for patient volume to be over the 12 months preceding attestation, not tied to the prior calendar year. CMS also propose to make eligible approximately 12 additional children's hospitals that have not been able to participate to date, despite meeting all other eligibility criteria, because they do not bill Medicare and do not have a CMS certification number. 

Stage 2 Timeline Delay 

CMS proposes a minor delay of the implementation of the onset of Stage 2 criteria. In the Stage 1 final rule, CMS established that any provider who first attested to Stage 1 criteria for Medicare in 2011 would begin using Stage 2 criteria in 2013. The proposed rule delays the onset of those Stage 2 criteria until 2014, which CMS believe provides the needed time for vendors to develop certified EHR technology.

For More Information 

Read the proposed rule, published in the March 7, 2012, Federal Register.


 Appendix 1: Table 4(This table contains 8 parts)

Table 4 - Part 1

Table 4 - Part 2

Table 4 - Part 3

Table 4 - Part 4

Table 4 - Part 5

Table 4 - Part 6

Table 4 - Part 7

Table 4 - Part 8


Publication Date: Thursday, March 08, 2012

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