Meaningful use was created by the 2009 American Recovery and Reinvestment Act (ARRA), which allocated almost $800 billion to create jobs in the United States. The original purpose of ARRA was not focused on physician efficiency or patient service, but on helping the economy recover. To that end, over $35 billion was set aside to pay "eligible professionals" for "demonstrating use of a qualified electronic health record in a meaningful manner." The $35-billion incentive was expected to jump-start the use of technology in healthcare and create thousands of healthcare information technology jobs.

The meaningful use payments were based on separate programs for Medicare and Medicaid. Significant differences between the programs include the amount of incentive money, first payment qualifications, and the effective dates of the program. For example, Medicare requires eligible clinicians to attain meaningful use before any payments are made, whereas the Medicaid program makes the initial payment when the eligible clinician has started to implement an EHR.

The regulatory apparatus of the government then defined who an eligible provider was, what a qualified electronic health record was, and how one attains meaningful use.

 What Is Meaningful Use?

The meaningful use program was open to eligible providers. In the Medicare version of meaningful use, "eligible providers" were defined as doctors; the Medicaid version added nurse midwives, nurse practitioners, and some physician assistants. Starting in 2017, Medicare is replacing "meaningful use" as "advancing care information" and changing the term "eligible provider" to "eligible clinicians." Eligible clinicians include physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists.

The US Department of Health and Human Services established three stages to measure use of EHRs in a "meaningful manner":

Stage 1 of meaningful use focused on acquiring a baseline of information on patients. This stage included measures that dealt with collecting information on allergies, problems, and prescriptions, as well as presenting a patient with a clinical summary for an office visit. Stage 1 also included some initial information-sharing through electronic prescriptions (which were already well established) and an option to convey referral information from the EHR. 2011 was the first year that a clinician could qualify for stage 1 incentives.

Stage 2 capitalized on stage 1 requirements to support advanced clinical processes. It increased the performance requirement for several stage 1 measures. For example, eligible providers had to enter 30% of medication orders under stage 1, which increased to 60% of medication orders for stages 2 and 3. Stage 2 added a measure to provide patients with electronic access to their medical information, which is supported by a patient portal for most EHRs. The first year that clinicians could attain stage 2 was 2014.

Stage 3 of meaningful use had been renamed "advancing care information" (PI), under the new Medicare Merit-Based Incentive Payment System (MIPS). In 2018, CMS renamed the program again, changing it to “promoting interoperability” (PI) to further emphasize the need for sharing patient data. PI focuses on providing electronic access to patient information (using a patient portal for most EHRs), exchanging information with patients, and exchanging information with other healthcare providers through a health information exchange. Note that the stage 2 requirements, such as a clinical summary, physician order entry, and vital signs are no longer separately measured under PI, but are required to meet the PI items in most cases. PI is not required until 2018, but eligible clinicians can move to PI in 2017.

PI includes completely new requirements and terms that will require additional thought and planning. For example, a new PI measure requires that the eligible provider capture patient information from a nonclinical setting, such as an electronic scale or blood pressure device in the patient's home.

Each meaningful use stage and PI consists of approximately 20 measures and a quality reporting requirement. Results are reported to CMS at the end of the reporting period to qualify for the incentive payments or avoid the Medicare penalty. For 2016, eligible providers who are newly working with stage 1 or 2 can use a reporting period of any 90 days, whereas all other eligible providers will report for the full year. For 2017, Medicare eligible clinicians who are starting PI (formerly stage 3 of meaningful use) can use a 90-day reporting period, whereas all other Medicare eligible providers have to report for the entire year. Starting in 2018, all eligible providers must use a full-year reporting period under PI.

Under meaningful use, each measure has a performance threshold that must be met, and each eligible provider is separately responsible for meeting each measure. If the eligible provider meets all relevant measures, he or she qualifies as a meaningful user. If only one measure is missed, the eligible provider will not get the incentive or will have a negative Medicare payment adjustment of -2% in 2016 and -3% in 2017.

PI has two separate scoring components: base and performance scores. The base score is determined by meeting each PI requirement, whereas the performance score is calculated from the ability of the practice to meet the measures for as many patients as possible. For example, providing electronic access to all patients will result in a higher PI score than providing electronic access to 5% of the practice's patients.

Since the start of meaningful use in 2011, many modifications were made to the program to account for the fact that EHRs were not ready to support stage 1 or stage 2, as well as for serious challenges faced by eligible providers in meeting the meaningful use measures. For example, stage 2 included a new measure that required 5% of an eligible provider's patients to submit a secure message on a clinical matter to the clinician. This measure was difficult, and success depended on patients sending a message rather than the clinician's activities.

At the end of 2015, the stage 2 secure message requirement was minimized to having the capability available, and the measure was changed to the clinician sending messages to patients starting with PI. CMS has also delayed the effective date of aspects of the meaningful use programs because so many EHR vendors were not ready to support the meaningful use requirements.

What Is the Connection Between Meaningful Use (and PI) and EHRs?

Meaningful use and PI require use of an EHR that has been certified (in place of "qualified," in the language of ARRA) to support the meaningful use or PI requirements. The evolution of a certified EHR is interesting, because the original concept required an EHR to meet a best practices and features model developed by an industry group. However, owing to political issues, the certified EHR standard was stripped down to meet a less rigorous requirement: support the meaningful use measures through 2016 and PI measures starting in 2017.

For example, certified EHRs keep score for all of the meaningful use measures to allow clinicians to track their status and progress. The EHR-based scores substantiate the performance of eligible providers when reporting their results for the incentive payments or to avoid penalties. Starting in 2019, the scores will be used to calculate the PI component of the Medicare MIPS.

EHR products are separately certified for each meaningful use or PI stage, and clinicians must use an EHR that is certified for the stage that they are attesting to. Hundreds of products have been certified to meet the meaningful use standards. However, the certification process does not necessarily guarantee an elegant or user-friendly solution to the requirement. More important, the certified EHR process does not ensure that the product does anything more than support meaningful use or PI. For example, certified EHRs are not required to have features or checklists to support any particular area of medicine.

Should Physicians Bother With Meaningful Use?

By the end of 2015, 56% of office-based physicians were participating in the meaningful use program. Many physicians who have not yet attained meaningful use never plan to. The failure to meet meaningful use will have several financial and strategic implications.

From a financial perspective, Medicare clinicians who do not meet meaningful use will be subjected to Medicare payment penalties of 2% for 2016 and 3% in 2017. The 2018 penalty may be 3% or 4%, depending on the number of clinicians who meet meaningful use in 2017. 2018 is the last year of the meaningful use penalty.

Starting in 2019, meaningful use becomes PI, a part of the Medicare MIPS. PI represents 15%-25% of a physician's MIPS score, which will affect their Medicare payments. Clinicians with the lowest MIPS scores will have Medicare payments adjusted by up to -4% for 2019, escalating to -9% in 2022.

The best MIPS-performing physicians can receive a 10% increase in their Medicare payments. Forgoing the substantial PI component of the MIPS score may prevent clinicians from attaining a positive adjustment to MIPS-based Medicare payments and will certainly preclude such eligible clinicians from achieving the best-performing category. Just as important, EHRs are needed to support the other MIPS components and are required to qualify for the 5% alternative payment model incentive starting in 2019. A clinician's MIPS scores will be publically available to patients and clinicians through a CMS website.

From a strategic perspective, physicians who do not meet the meaningful use or PI requirements may encounter issues with other clinicians in their healthcare network. For example, PI requires the use of electronic transitions of care (such as referrals). Physicians who can't receive electronic transitions of care may not be viewed as desirable to referral sources, because the quality initiatives being developed by CMS measure care coordination and the outcome of care coordination. This may be a double-edged sword for physicians who are avoiding EHRs, because they may not be able to efficiently coordinate care with referring clinicians who want or need to meet quality metrics for care coordination.

From a clinical care perspective, physicians who do not meet meaningful use or PI may be at a disadvantage in working with patients. Meaningful use and PI include various patient engagement and service issues that require an EHR. For example, drug/drug interactions, patient treatment plan management, and the ability of patients to send secure messages are all aspects of meaningful use that may differentiate physicians among patients who are becoming more savvy about what is possible with technology. Physicians may also be at a disadvantage in managing patient adherence and patient service. For example, clinicians who are compliant with PI will have a variety of tools to interact with and serve patients out of the office.

When all of these factors are taken into consideration, physicians who do not attain meaningful use or PI may find it difficult, or even impossible, to transition to the quality and outcomes focus of the evolving Medicare MIPS-based environment. From the communication and patient service aspects to the quality measures that monitor the effects of clinical efforts, patients and clinicians in your care network will not want to forgo the benefits of meaningful use or PI that improve communication with other practices and patients.

Indeed, your patients and treatment relationships may come to expect PI (or meaningful use) in the same manner that physicians assume that you comply with HIPAA privacy rules. More important, meaningful use participation may become an indication of performance or quality that reflects positively (or negatively) on a physician or a practice.