Updates on Stage 3 Meaningful Use for EHR

What do you need to know to be compliant?

Updates on Stage 3 Meaningful Use for EHR

What do you need to know to be compliant?


In 2009, the American Recovery and Reinvestment Act included the creation of the Centers for Medicare and Medicaid Services Meaningful Use (MU) program to facilitate the adoption of electronic health records, which many theorized would lead to higher quality and more efficient care than older paper records.1

The MU program allows for incentive payments for successfully implementing EHR and for attesting to MU criteria, in an attempt to increase the adoption of EHR technology.

The maximum Medicare incentive is $44,000 for those who successfully implemented in 2011 or 2012. The last year to implement EHR and receive an incentive payment was 2014, during which the maximum incentive decreased to $24,000.2

As of October 2013, 85% of eligible hospitals and more than 60% of eligible professionals had received some incentive payment through these programs.1 The MU programs have paid $28 billion in incentive payments as of December 2014.3


However, if Medicare eligible professionals (EPs) do not adopt and successfully demonstrate MU of a certified EHR technology by 2014, the EP’s Medicare physician fee schedule amount for covered professional services will be adjusted down by 1% beginning in 2015, increasing each year to a maximum of 5% by 2019.4

When coupled with other penalties, such as electronic Rx (eRx) adjustments of 1% and physician quality reporting system (PQRS) penalties of 1.5% for 2015, the total penalty amounts to 3.5% reductions in the Medicare physician fee schedule.

Ankoor R. Shah, MD, is a second-year vitreoretinal fellow at Associated Retinal Consultants in Royal Oak, MI. Jeremy D. Wolfe, MD, is assistant professor of ophthalmology at the William Beaumont School of Medicine in Royal Oak. Neither author reports financial interests in any products mentioned in this article. Dr. Wolfe can be reached via e-mail at

Not participating in PQRS will lead to additional penalties in the future through the value-based modifier program. Not participating in PQRS will lead to an additional -2.0% penalty through this modifier for groups of less than 10 people and -4.0% for groups of 10 or more beginning in 2017.5

It is important to note that, although the penalty is applied in 2017, it is based on 2015 reporting. Even if larger groups are able to meet PQRS criteria, a “high cost” and “low quality” practice will still be assessed the 4% penalty.5 The discussion of what determines “cost” and “quality” also raises numerous questions but is beyond the scope of this article.

Thus, the total possible penalties for groups of 10 or more EPs grows to 9% (5% for EHR, 4% for the PQRS value-based modifier while eRx is phased out) for physicians who fail to comply by 2019.6 A 9% cut to the top line of eligible professionals’ Medicare revenues may have an even more magnified effect on the bottom line, especially in specialties weighted toward Medicare patients.


Avoiding these penalties requires meeting the MU requirements of EHR. MU is divided into multiple stages with the goal of each subsequent stage building on the preceding one.

Stage 1 was focused on data capture and patient access; stage 2 worked toward achieving information exchange and care coordination; and stage 3 is targeted toward improving patient outcomes utilizing EHR. Eligible providers that have met stage 2 criteria will be eligible for the new stage 3 objectives. The timeline and reporting window to meet stage 2 objectives has changed, and implementation of stage 3 criteria has been delayed until January 2017.7

Despite the fluid nature of these recommendations, we review here a preliminary set of stage 3 guidelines submitted by the Health Information Technology Policy Committee’s (HITPC) Meaningful Use Workgroup.8

Based on these guidelines, most changes are expansions of existing objectives (12, of which two are unique to hospitals), some are new (eight), and a few have remained unchanged (six).


Below we highlight some of the changes most impactful on a retinal physician’s practice.

    1. For eligible professionals a new menu objective will be recording whether patients older than 65 years have an advanced directive. The tentative threshold will be 50% of eligible patients to achieve credit. Given typical retinal practice demographics, meeting this measure will require documentation for a large number of patients.

    2. A new menu objective for EHR will require provision of outcomes and results of specialty consultations to referring physicians. Writing a follow-up letter to a referring physician is common practice in the specialty setting, and many EHRs already have built-in functionality to write such letters. The burden of this criterion will largely be technical and will likely be less onerous than others.

    3. A novel menu objective for stage 3 will require the FDA unique device identifier (UDI) for implants to be recorded. For retinal practices, this will most typically require additional electronic documentation when using scleral buckles and secondary IOLs. There is no clear indication whether this field must be searchable; thus, scanning in documentation on the UDI may be sufficient to meet this criterion.

    4. One of the most challenging core criteria from stage 2 was that an online portal be made available within four days of a visit and that 5% of patients log on to use and access these data. In a practice population that is elderly and visually impaired, this target is particularly challenging to achieve. Changes in stage 3 will require health information to be available within 24 hours (four days for lab results) but will drop the requirement that patients view their data online.

    5. A new menu objective, which may pose significant challenges, requires electronic notifications to be sent to a patient’s primary care physician if a significant event (ie, arrival at the emergency department [ED], admission to the hospital, discharge from the hospital/ED, or death) occurs. Some scenarios that would affect retinal specialists would be referrals to the ED for stroke workup in arterial occlusions, admissions for endogenous endophthalmitis, and any hospital stays postvitrectomy for unstable patients. Although not common occurrences, the burden on both physicians and IT may be significant.

    6. A change in the use of imaging will require that the results of imaging, including both the image itself and the interpretation of the image, be included within the EHR. For retinal practices, this requirement will apply to the use of fundus photography, fluorescein angiography, and most commonly, OCT. While many physicians currently use the software provided by their image capture devices, this software will need to be synchronized with the practice EHR, which might not affect physician time significantly but will require additional IT investments.

Of these changes, some affect core (required) objectives, while others affect menu (must meet a certain number out of the total available) objectives, but the weight of these objectives will not be fully known until the final ruling is made.

The Office of the National Coordinator for Health Information Technology made its recommendations on stage 3 objectives in March,9 with a final ruling expected in the first half of 2015.


Additional challenges are expected to arise with the implementation of stage 3 objectives for MU of EHR. While these challenges will all be faced by eligible professionals’ practices, the distribution of the emphasis is varied among IT departments, technicians, and physicians.

What will be included and modified in the final ruling on stage 3 remains to be seen. The one thing that can be guaranteed, based on prior stages of MU, is that the stage 3 preliminary guidelines will see significant changes. RP


1. Wolfe JD. Meaningful use of EHR. Retin Today. 2012;2:20-21.

2. EHR incentive programs. Centers for Medicare & Medicaid Services Web site. Available at: Accessed March 1, 2015.

3. December 2014 EHR incentive program. Centers for Medicare & Medicaid Services Web site. Available at: Accessed March 1, 2015.

4. Payment adjustments & hardship exceptions tipsheet for eligible professionals. Centers for Medicare & Medicaid Services Web site. Available at: Accessed March 1, 2015.

5. American College of Radiology. 2015-2017 value-based payment modifier. American College of Radiology Web site. Available at: Accessed March 5, 2015.

6. Flam S. Hundreds of thousands of dollars lost in penalties — is that motivation enough? HealthFusion MediTouch Web site. Available at: Accessed March 1, 2015.

7. Tagalicod R, Reider J. Progress on adoption of electronic health records.” Centers for Medicare & Medicaid Services Web site. Available at: Accessed March 1, 2015.

8. Work product of the HITPC Meaningful Use Workgroup – Meaningful Use stage 3 recommendations. Web site. Available at: Accessed March 1, 2015.

9. Terry K. Proposed stage 3 Meaningful Use rule released. Medscape Medical News. Available at: Accessed April 21, 2015.