Stage 3 Program Requirements for Eligible Hospitals, CAHs and Dual-Eligible Hospitals Attesting to CMS
Guidance for Stage 3 program requirements for Eligible Hospitals, CAHs and Dual-Eligible Hospitals attesting to CMS.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: April 25, 2018
CMS is renaming the EHR Incentive Programs to the Promoting Interoperability (PI) Programs to continue the agency’s focus on improving patients’ access to health information and reducing the time and cost required of providers to comply with the programs’ requirements. CMS is also in the process of finalizing updates to the programs through rulemaking. For more information, visit the landing page where CMS will publish updates and additional resources as soon as they are available.
On November 14, 2016, CMS published a final rule with comment period that included changes responsive to stakeholder feedback and will result in continued advancement of certified EHR technology. The finalized changes will also utilize and result in a program result in more focused on supporting interoperability and data sharing for all participants under the Medicare and Medicaid EHR Incentive Programs.
NOTE: All providers who have not successfully demonstrated meaningful use in a prior year and are seeking to demonstrate meaningful use for the first time in 2017 to avoid the 2018 payment adjustment must attest to Modified Stage 2 objectives and measures.
Returning hospitals must successfully attest to avoid the Medicare payment adjustment.
Objectives and Measures
- All providers are required to attest to a single set of objectives and measures.
- For eligible hospital and CAHs (including Dual-Eligible hospitals) attesting to CMS, there are 6 objectives.
- View the Stage 3 Specification Sheets for Eligible Hospitals, CAHs and Dual-Eligible hospitals (PDF)attesting to CMS.
- To meet Stage 3 requirements, all providers must attest to objectives and measures using EHR technology certified to the 2015 Edition. A provider who has technology certified to a combination of the 2015 Edition and 2014 Edition may potentially attest to the Stage 3 requirements, if the mix of certified technologies would not prohibit them from meeting the Stage 3 measures. However, a provider who has technology certified to the 2014 Edition only may not attest to Stage 3.
- Please note there are no alternate exclusions or specifications available.
Changes to Specific Objectives and Measures
- Removal of the Clinical Decision Support (CDS) and Computerized Provider Order Entry (CPOE) objectives and measures.
- Reduction of the threshold for Provide Patient Access under the Patient Electronic Access to Health Information objective to more than 50 percent.
- Reduction of the threshold for Patient-Specific Education under the Patient Electronic Access to Health Information objective to more than 10 percent.
- Reduction of the threshold for View, Download or Transmit (VDT) under the Coordination of Care through Patient Engagement objective to at least one unique patient (or their authorized representatives).
- Reduction of the threshold for Secure Messaging under Coordination of Care through Patient Engagement objective to more than 5 percent.
- Reduction of the threshold for Send a Summary of Care under the Health Information Exchange objective to more than 10 percent.
- Reduction of the threshold for Request/Accept Summary of Care under the Health Information Exchange objective to more than 10 percent.
- Reduction of the threshold for Clinical Information Reconciliation under the Health Information Exchange objective to more than 50 percent.
- Reduction of the Public Health Reporting and Clinical Data Registry objective reporting requirements for eligible hospitals, CAHs and Dual-Eligible hospitals attesting to CMS to any combination of three measures.
- Addition of new naming conventions for measures (PDF).
- Changes to measure calculations policy, which specifies that actions included the numerator must occur within the EHR reporting period if that period is a full calendar year, or if it is less than a full calendar year, within the calendar year in which the EHR reporting period occurs. Specific measures affected are identified in the Additional Information section of the specification sheets.
EHR Reporting Period
- For 2017, the EHR reporting period for all returning participants and all new participants is a minimum of any continuous 90-days between January 1 and December 31, 2017.
- For 2018, the EHR reporting period for all participants is a minimum of any continuous 90 days between January 1 and December 31, 2018.
Requirements for EHR Incentive Programs in 2017 Resources
- Overview of the OPPS/ASC Final Rule Major Changes (PDF)
- Health Information Exchange Fact Sheet (PDF)
- Security Risk Analysis (PDF)
- Eligible Hospitals: Public Health Reporting (PDF)
- Patient Electronic Access to Health Information Tip Sheet (PDF)
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DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.