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Indian Health Service The Federal Health Program for American Indians and Alaska Natives

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Stage 2 Overview

Summary

On September 4, 2012, CMS published a final rule Exit Disclaimer: You Are Leaving www.ihs.gov that specifies the Stage 2 criteria that EPs and EHs must achieve in order to continue participating in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. Changes range from higher thresholds and new performance measures to increased reporting for CQMs. See below for more details.

All providers must demonstrate Stage 1 MU before moving to Stage 2 MU. However, because new certified EHR technology is required for 2014, all participants, regardless of their stage, will only have a three-month reporting period in FY/CY 2014. Check out these tips to help you prepare for Stage 2.

EPs must:

  • Meet 17 core performance measures.
  • Meet 3 of 6 menu objectives. (RPMS users will only have five menu set items from which to choose.)
  • Report on 9 clinical quality measures (CQMs) from 3 of 6 National Quality Strategy Domains (CQMs have no performance targets). Note that, beginning in 2014, EPs beyond their first year of MU must report Medicare CQMs electronically to CMS. Reporting options for Medicaid CQMs vary by state.

EHs must:

  • Meet 16 core performance measures.
  • Meet 3 of 6 menu objectives. (RPMS users will only have five menu set items from which to choose.)
  • Report on 16 clinical quality measures (CQMs) from 3 of 6 National Quality Strategy Domains (CQMs have no performance targets). Note that, beginning in 2014, EHs beyond their first year of MU must report Medicare CQMs electronically to CMS. Reporting options for Medicaid CQMs vary by state.

Learn more about the Stage 2 core and menu set measures.

Security Risk Analysis

Per 45 CFR 164.308(a) (1), a Risk Analysis is required to meet MU. This Security Risk Analysis must be completed during each participation year prior to the end of the MU EHR reporting period.

Tribal and Urban sites may use the IHS External Risk Analysis. Please contact OITSecurity@ihs.gov with any questions.

IHS External Risk Analysis [DOC - 361 KB]