The U.S. Department of Health and Human Services (HHS) has come out with the final rule for the second stage of the Medicare and Medicaid electronic health record (EHR) incentive program. 

Congress included the EHR incentive program in the American Recovery and Reinvestment Act of 2009 in an effort to reward doctors and hospitals for making “meaningful use” of EHR systems.

The program affects only providers who participate in Medicare and Medicaid, but, because so many providers participate in those programs, health policy experts are hoping the program also will help commercial health insurers, by dramatically increasing the percentage of payer-provider communications that can be handled with automated systems rather than with paper forms and envelopes, traditional mail and data entry and analysis processes that rely heavily on live humans.

Officials also are hoping that providers, insurers and others eventually will use EHR databases to improve efforts to identify and do something about gaps in patients’ care.

Budget analysts estimate HHS will spend about $5.1 billion to encourage providers to move beyond manila folders in fiscal year 2014, which will start Oct. 1, 2013.

Stage 1 of the program started in 2011. Stage 1 rewards physicians and hospitals for taking relatively simple steps toward use of EHR systems, such as capturing data electronically and giving patients electronic copies of health information. HHS officials say that about half of eligible hospitals and about 20% of eligible health care professionals are participating in the EHR Stage 1 incentive payment program.

Stage 2 — the next stage to start — is supposed to encourage providers to exchange patient health information with one another and to give patients online access to health information through Web portals. HHS now has posted a preliminary version of the Stage 2 regulations, and the Federal Register expects to publish the final version of the final rule Sept. 4.

Stage 3 will encourage providers to use EHR systems to improve the quality of care.

Providers have until 2017 to start participating in the incentive program.

HHS and the HHS arm responsible for the incentive program, the Centers for Medicare & Medicaid Services (CMS), received about 6,100 comments on a draft of the Stage 2 program regulations that was published March 7, officials say.

The final rule states that no providers will have to follow the Stage 2 requirements before 2014 and that providers will have to encrypt electronic personally identifiable health information.

HHS also has updated the criteria for certifying whether EHR technology meets incentive program standards, and it has assured providers that they can continue to use “2011 Edition Certified EHR Technology” until 2014.  

To qualify for EHR bonuses, physicians will have to meet 20 of 23 EHR goals and report on 9 quality measures chosen from a list of 64 measures. Hospitals will have to meet 19 of 22 EHR goals and report on 16 quality measures chosen from a list of 29 measures.

One issue that came up in a discussion of the comments was the cost of complying with the Stage 2 online portal requirements. Some commenters said physicians would have to hire more workers and change their workflow to accommodate online messages from patients. Some suggested that the government should lighten the burden or pay providers more for setting up and updating the portals.

HHS officials are dismissing the idea that implementing online access for patients imposes a significant burden on providers.

“While we note that in some scenarios it may be possible for an EP [eligible provider] to receive reimbursement from private insurance payers for online messaging, we acknowledge that EPs are generally not reimbursed for time spent responding to electronic messaging,” officials say in a preamble to the regulations. “However, it is also true that EPs are generally not reimbursed for other widely used methods of communication with patients (for example, telephone).”

HHS officials believe that increased use of online messaging systems has reduced the time many physicians spend on using the phone and on answering questions, officials say.

When physicians set up the Web portals, “we expect the same will be true for online access to health information by reducing continuous requests for health records, test results, and other pertinent patient information,” officials say.

Moreover, the Stage 2 rule is setting the standards for the information going into the patient portal, and increased EHR standardization should help providers feed information into other providers’ EHR systems, officials say.

Some commenters suggested that, instead of requiring physicians to provide online portal access, HHS should let physicians encourage patients to use any access method that suits them. 

“These commenters noted that engagement offline reduces both the need and value for engagement online,” officials say. “We agree that patient engagement can occur effectively through a variety of media, and we also believe that electronic access to health information can be an important component of patient engagement. We do not believe that offline engagement reduces the need for online access, as patients may opt to access information in a variety of ways.”