The Centers for Medicare and Medicaid Services Thursday announced its long-awaited Notice of Proposed Rulemaking for Stage 2 requirements for the Medicare and Medicaid Electronic Health Record Incentive Programs.

Substantially adopted from the Health IT Policy Committee's recommendations, CMS' proposed Stage 2 criteria for meaningful use focus on increasing the electronic capturing of health information in a structured format, and increasing the exchange of clinically relevant information between providers of care at so-called "care transitions."

Physicians are specifically encouraged to communicate with patients online, with the new rules requiring that more than 10 percent of their patients be able to correspond with them via "secure messages" or an encrypted form of email. Furthermore, patients must receive timely electronic access to their health care information from their physicians.

Speaking with DOTmed News not even an hour after the rule was announced, Mark Segal, GE Healthcare IT's vice president of government and industry affairs and health care information technology, noted that he was not particularly surprised by anything in the 455-page document, after a quick scan.

"The rule seems to include more flexibility for specialists, but also more precision," said Segal."[CMS] is trying to eliminate ambiguity in wording that then requires clarifications to be written and then clarifications on the clarifications. So I think in general they have learned from what they did before."

In July 2010, CMS initiated a separate set of core objectives and menu objectives for eligible providers, eligible hospitals and critical access hospitals for Stage 1. All but one of the 10 elective objectives in Stage 1 will become mandatory, with many of them also being combined or unified for Stage 2.

Diagnostic imaging is involved in one of the new elective objectives for Stage 2, with the proposal stating that physicians can choose to demonstrate that more than 40 percent of all tests and scans resulting in an image are EHR-assessable. In cases where there are situations that make it impossible for an eligible provider or eligible hospital to meet the measure, an exclusion was defined.

A subsequent rise in the measure threshold that providers must achieve for each objective that has been retained from Stage 1 also eliminates unnecessary accounting and reporting stresses for providers by recognizing that, for providers who have been long-time Stage 1 meaningful users, recording these data in structured form has become routine in their delivery of care. Up from 40 percent, more than 65 percent of prescriptions must be e-prescribed by meaningful users, for example.

CMS also proposed several changes to existing Stage 1 criteria for meaningful use -- optional for use by providers in Stage 1, but essential for Stage 2. The proposal includes: Changes to the denominator of computerized provider order entry; changes to age limitations for vital signs; elimination of Stage 1's core objective "exchange of key clinical information" in favor of a "transitions of care" core objective, requiring electronic exchange of summary of care documents in Stage 2; and replacing the "provide patients with an electronic copy of their health information" objective with a "view online, download and transmit" core objective. The proposal's objectives have greater applicability to many specialty providers, recognizing the leadership role that many specialty providers have played in the meaningful use of health IT for quality improvement purposes, according to CMS.

For clinical quality reporting to become routine, CMS acknowledges that the administrative burden of reporting must be lessened. To do this, CMS has proposed a set of measures that align Stage 2 clinical quality measures with existing quality programs for EPs. Likewise, for eligible hospitals and CAHs, CMS is proposing to align Stage 2 CQMs with the Inpatient Quality Reporting and the Joint Commission's hospital quality measures. By submitting their CQM data electronically, EPs, eligible hospitals and CAHs may find it easier to report on quality measures for providers, noted the proposal.

CMS proposed that any Medicare EP or hospital that demonstrates meaningful use in 2013 would avoid 2015's payment adjustment. Exceptions to these payment adjustments were also proposed by CMS, including the availability of Internet access or barriers to obtaining IT infrastructure; a time-limited exception for newly practicing EPs who would not otherwise be able to avoid payment adjustments; and unforeseen circumstances such as natural disasters that would be handled on a case-by-case basis.

While big bucks are in store for physicians who meet Stage 1 requirements, earning them up to $64,000, those who fail will lose 1 percent in Medicare reimbursements in 2015, with the penalty increasing to 2 percent in 2016, 3 percent in 2017 and so on.

Finally, CMS is proposing an extension of Stage 1, so that providers have an additional year for implementation of Stage 2 criteria. This proposed rule delays the onset of those Stage 2 criteria for providers who first attested to Stage 1 criteria in 2011 until 2014, which CMS believes allows the needed time for vendors to develop Certified EHR Technology that can meet the Stage 2 requirements proposed here.

Referring to the Stage 1 extension, Segal said: "This was something we had pushed very hard for from an advocacy standpoint, because the reality is that the schedule they had before was entirely unworkable."

There is a 60-day comment period for the proposed Stage 2 meaningful-use rules. A final version of the regulations will be issued by CMS after taking public input into account. The companion set of regulations is expected to be released from the Office of the National Coordinator Friday.

"I have a fun weekend of reading ahead of me," Segal said, referring to CMS' document.