Vol. 79 Thursday, 

No. 171 September 4, 2014 

Part III 

Department of Health and Human Services 

Centers for Medicare & Medicaid Services 

42 CFR Part 495 

45 CFR Part 170 

Medicare and Medicaid Programs; Modifications to the Medicare and 

Medicaid Electronic Health Record (EHR) Incentive Program for 2014 and 

Other Changes to the EHR Incentive Program; and Health Information 

Technology: Revisions to the Certified EHR Technology Definition and EHR 

Certification Changes Related to Standards; Final Rule 


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52910 Federal Register / Vol. 79, No. 171 / Thursday, September 4, 2014 / Rules and Regulations 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

42 CFR Part 495 

[CMS–0046–F and CMS–0052–F] 

RINs 0938–AR71 and 0938–AS30 

Office of the Secretary 

45 CFR Part 170 

RINs 0991–AB89 and 0991–AB97 

Medicare and Medicaid Programs; 

Modifications to the Medicare and 

Medicaid Electronic Health Record 

(EHR) Incentive Program for 2014 and 

Other Changes to the EHR Incentive 

Program; and Health Information 

Technology: Revisions to the Certified 

EHR Technology Definition and EHR 

Certification Changes Related to 

Standards 

ACTION: Final rule. 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), and Office of 

the National Coordinator for Health 

Information Technology (ONC), HHS. 

SUMMARY: This final rule changes the 

meaningful use stage timeline and the 

definition of certified electronic health 

record technology (CEHRT) to allow 

options in the use of CEHRT for the EHR 

reporting period in 2014. It also sets the 

requirements for reporting on 

meaningful use objectives and measures 

as well as clinical quality measure 

(CQM) reporting in 2014 for providers 

who use one of the CEHRT options 

finalized in this rule for their EHR 

reporting period in 2014. In addition, it 

finalizes revisions to the Medicare and 

Medicaid EHR Incentive Programs to 

adopt an alternate measure for the Stage 

2 meaningful use objective for hospitals 

to provide structured electronic 

laboratory results to ambulatory 

providers; to correct the regulation text 

for the measures associated with the 

objective for hospitals to provide 

patients the ability to view online, 

download, and transmit information 

about a hospital admission; and to set a 

case number threshold exemption for 

CQM reporting applicable for eligible 

hospitals and critical access hospitals 

(CAHs) beginning with FY 2013. 

Finally, this rule finalizes the 

provisionally adopted replacement of 

the Data Element Catalog (DEC) and the 

Quality Reporting Document 

Architecture (QRDA) Category III 

standards with updated versions of 

these standards. 

DATES: These regulations are effective 

on October 1, 2014. 

FOR FURTHER INFORMATION CONTACT: 

Elizabeth Holland, (410) 786–1309. 

Elisabeth Myers, (410) 786–4751. 

Elise Sweeney Anthony, (202) 475– 

2485. 

SUPPLEMENTARY INFORMATION: 

I. Background 

A. Statutory Basis 

1. Standards, Implementation 

Specifications, and Certification Criteria 

The Health Information Technology 

for Economic and Clinical Health 

(HITECH) Act, Title XIII of Division A 

and Title IV of Division B of the 

American Recovery and Reinvestment 

Act of 2009 (ARRA) (Pub. L. 111–5) was 

enacted on February 17, 2009. The 

HITECH Act amended the Public Health 

Service Act (PHSA) and created ‘‘Title 

XXX—Health Information Technology 

and Quality’’ to improve health care 

quality, safety, and efficiency through 

the promotion of health IT and 

electronic health information exchange. 

Section 3004(b)(3) of the PHSA titled 

‘‘Subsequent Standards Activity’’ 

provides that the ‘‘Secretary shall adopt 

additional standards, implementation 

specifications, and certification criteria 

as necessary and consistent’’ with the 

schedule published by the HIT 

Standards Committee. We consider this 

provision in the broader context of the 

HITECH Act to grant the Secretary the 

authority and discretion to adopt 

standards, implementation 

specifications, and certification criteria 

that have been recommended by the HIT 

Standards Committee and endorsed by 

the National Coordinator, as well as 

other appropriate and necessary health 

IT standards, implementation 

specifications, and certification criteria. 

In the September 4, 2012 Federal 

Register (77 FR 54163), the Secretary 

issued a final rule (the ‘‘2014 Edition 

EHR certification criteria final rule’’) 

that adopted the 2014 Edition EHR 

certification criteria and a revised 

Certified EHR Technology (CEHRT) 

definition. The standards, 

implementation specifications, and 

certification criteria adopted by the 

Secretary in the final rule established 

the capabilities that CEHRT must 

include in order to, at a minimum, 

support the achievement of meaningful 

use by eligible professionals (EPs), 

eligible hospitals, and CAHs under the 

Medicare and Medicaid EHR Incentive 

Programs beginning with the EHR 

reporting periods in FY/CY 2014. 

2. Health IT Certification Programs 

Section 3001(c)(5) of the PHSA 

provides the National Coordinator with 

the authority to establish a certification 

program or programs for the voluntary 

certification of health IT. Specifically, 

section 3001(c)(5)(A) specifies that the 

‘‘National Coordinator, in consultation 

with the Director of the National 

Institute of Standards and Technology, 

shall keep or recognize a program or 

programs for the voluntary certification 

of health information technology as 

being in compliance with applicable 

certification criteria adopted under this 

subtitle’’ (that is, certification criteria 

adopted by the Secretary under section 

3004 of the PHSA). The certification 

program(s) must also ‘‘include, as 

appropriate, testing of the technology in 

accordance with section 13201(b) of the 

[HITECH] Act.’’ 

Section 13201(b) of the HITECH Act 

requires that with respect to the 

development of standards and 

implementation specifications, the 

Director of the National Institute of 

Standards and Technology (NIST), in 

coordination with the HIT Standards 

Committee, ‘‘shall support the 

establishment of a conformance testing 

infrastructure, including the 

development of technical test beds.’’ 

The HITECH Act also indicates that 

‘‘[t]he development of this conformance 

testing infrastructure may include a 

program to accredit independent, nonFederal laboratories to perform testing.’’ 

ONC has established the ONC HIT 

Certification Program for the purpose of 

testing and certifying health information 

technology, related to the compliance of 

health IT with adopted standards, 

implementation, and certification 

criteria. (see 76 FR 1262 and 77 FR 

54268). EHR technology capabilities 

certified through the ONC HIT 

Certification Program are required for 

use with the EHR Incentive Programs 

(see 76 FR 1262). 

3. Medicare and Medicaid EHR 

Incentive Programs 

The American Recovery and 

Reinvestment Act of 2009 (ARRA) (Pub. 

L. 111–5) amended Titles XVIII and XIX 

of the Social Security Act (the Act) to 

authorize incentive payments to EPs, 

eligible hospitals, CAHs, and Medicare 

Advantage (MA) organizations to 

promote the adoption and meaningful 

use of certified electronic health record 

(EHR) technology. Sections 1848(o), 

1853(l) and (m), 1886(n), and 1814(l) of 

the Act provide the statutory basis for 

the Medicare incentive payments made 

to meaningful EHR users. These 

statutory provisions govern EPs, MA 


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organizations (for certain qualifying EPs 

and hospitals that meaningfully use 

CEHRT, subsection (d) hospitals, and 

CAHs, respectively. Sections 1848(a)(7), 

1853(l) and (m), 1886(b)(3)(B), and 

1814(l) of the Act also establish 

downward payment adjustments, 

beginning with calendar or fiscal year 

2015, for EPs, MA organizations, 

subsection (d) hospitals, and CAHs that 

are not meaningful users of CEHRT for 

certain associated reporting periods. 

Sections 1903(a)(3)(F) and 1903(t) of the 

Act provide the statutory basis for 

Medicaid incentive payments. 

II. Provisions of the December 7, 2012 

Interim Final Rule With Comment 

Period and Analysis of and Responses 

to Public Comments 

In the December 7, 2012 Federal 

Register (77 FR 72985), CMS and ONC 

jointly published an interim final rule 

with comment period (IFC) titled 

‘‘Health Information Technology: 

Revisions to the 2014 Edition Electronic 

Health Record Certification Criteria; and 

Medicare and Medicaid Programs; 

Revisions to the Electronic Health 

Record Incentive Program’’ (the 

‘‘December 7, 2012 IFC’’). The 

Department of Health and Human 

Services (HHS) issued the December 7, 

2012 IFC to replace the Data Element 

Catalog (DEC) standard and the Quality 

Reporting Document Architecture 

(QRDA) Category III standard adopted in 

the final rule published on September 4, 

2012 in the Federal Register with 

updated versions of those standards. 

The December 7, 2012 IFC also revised 

the Medicare and Medicaid EHR 

Incentive Programs by: adding an 

alternative measure for the Stage 2 

meaningful use objective for hospitals to 

provide structured electronic laboratory 

results to ambulatory providers; 

correcting the regulation text for the 

measures associated with the objective 

for hospitals to provide patients the 

ability to view online, download, and 

transmit information about a hospital 

admission; and making the case number 

threshold exemption for CQM reporting 

applicable for eligible hospitals and 

CAHs beginning with FY 2013. This 

December 7, 2012 IFC also provided 

notice of CMS’s intention to issue 

technical corrections to the electronic 

specifications for CQMs released on 

October 25, 2012. 

In this final rule, we discuss the 

provisions of the December 7, 2012 IFC 

and describe our final policy. No 

comments within the scope of the IFC 

were timely received. However, we 

received some comments outside the 

scope of the December 7, 2012 IFC 

which provided recommendations for 

potential standards and policies to 

adopt in rulemaking for future stages of 

meaningful use. We are not addressing 

these comments in this rule. However, 

we will retain these comments for 

consideration in future rulemaking for 

the EHR Incentive Programs. 

A. Adoption and Incorporation by 

Reference of Newer Versions of the DEC 

and QRDA III Standards 

In the 2014 Edition EHR certification 

criteria final rule (77 FR 54163), we 

adopted the Data Element Catalog 

(DEC), August 2012 version, standard at 

45 CFR 170.204(c) and incorporated the 

standard by reference at 45 CFR 

170.299(m)(5). The DEC is included in 

the certification criterion at 45 CFR 

170.314(c)(1), which requires EHR 

technology presented for certification to 

be able to electronically record all of the 

data identified in the DEC that would be 

necessary to calculate each CQM. 

Prior to the December 7, 2012 IFC (77 

FR 72987), we performed a gap analysis 

to determine whether the August 2012 

version of DEC (now referred to as ‘‘DEC 

version 1.0’’) still appropriately 

specified all of the data that EHR 

technology would need to capture to 

support the final 2014 CQM especifications. Based on that analysis, 

we determined that the version of the 

DEC we adopted in the final rule needed 

to be updated in order to correctly align 

with data capture expectations 

expressed by numerous 2014 CQM especifications. Therefore, we 

provisionally adopted replacing Version 

1.0 of the DEC incorporated by reference 

at 45 CFR 170.299(m)(5) with the 

updated version (DEC, Version 1.1 

(October 2012)) as the standard 

referenced by the 2014 Edition EHR 

certification criterion at 45 CFR 

170.314(c)(1). 

We also replaced the version of the 

Quality Reporting Document 

Architecture (QRDA) Category III 

(QRDA III) standard incorporated by 

reference at 45 CFR 170.299(f)(14) with 

the November 2012 balloted version of 

QRDA III as the standard referenced by 

the 2014 Edition EHR certification 

criterion at 45 CFR 170.314(c)(3). The 

November 2012 balloted version of 

QRDA III clarifies ambiguities in the 

August version we had previously 

adopted in the 2014 Edition EHR 

certification criteria final rule (77 FR 

54232); specifically, certain data that 

would need to be included in any 

QRDA III file submitted to CMS, such as 

a provider’s National Provider Identifier 

(NPI) or Taxpayer Identification Number 

(TIN) in order for the electronic 

submission to be properly processed. 

Additionally, some of the required 

components have been changed to 

optional in the November 2012 balloted 

version of the standard, which may 

reduce the burden for EHR technology 

developers. 

While ONC is not required by statute 

to publish a final rule based on the 

previous publication of an interim final 

rule, we are using this joint rulemaking 

as an opportunity to respond to 

comments received on the December 7, 

2012 IFC provisions concerning 45 CFR 

170.299. 

We received no comments on the 

provisions concerning the DEC and 

QRDA III standards. For the reasons 

stated in the December 7, 2012 IFC, we 

are finalizing these provisions without 

modification. 

B. Revisions to the Medicare and 

Medicaid EHR Incentive Programs 

1. Meaningful Use Criteria 

a. Stage 2 Hospital Objective for 

Providing Electronic Lab Results to 

Ambulatory Providers 

In the Stage2 final rule (77 FR 54041 

through 54043), we included an 

objective and measure in the Stage 2 

menu set for eligible hospitals and 

CAHs at 42 CFR 495.6(m)(6)(i) and (ii) 

to provide structured electronic lab 

results to ambulatory providers for more 

than 20 percent of electronic lab orders 

received. 

In the December 7, 2012 IFC we 

added an alternative measure allowing a 

method for calculating the denominator 

using all lab orders received rather than 

only those received electronically. This 

change was provisionally adopted to 

accommodate cases where hospitals 

send a large number of lab results 

electronically in response to orders they 

receive through non-electronic means or 

where a hospital receives a very small 

percentage of its total lab orders 

electronically and therefore could have 

difficulty meeting the measure 

threshold regardless of the number of 

lab results it sends electronically to 

ordering providers. 

We received no comments on this 

provision and are finalizing this 

provision without modification for the 

reasons previously stated. 

b. Stages 1 and 2 Hospital Objective for 

View, Download, and Transmit 

In the Stage 2 final rule (77 FR 54041 

through 54043), we included the 

following objective in the Stage 2 core 

set for eligible hospitals and CAHs at 42 

CFR 495.6(l)(8)(i) and (ii). We also 

included the objective in the Stage 1 

core set for eligible hospitals and CAHs 

at 42 CFR 495.6(f)(12)(i)(B) and (ii)(B). 


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Objective: Provide patients the ability 

to view online, download, and transmit 

information about a hospital admission. 

In the Stage 2 final rule (77 FR 53968), 

we inadvertently omitted the word 

‘‘unique’’ from the regulation text for 

the denominators of the measures 

associated with this objective. 

In the December 7, 2012 IFC we made 

corrections to § 495.6(f)(12)(ii)(B), 

(l)(8)(ii)(A), and (l)(8)(ii)(B) to clarify 

that the measures for that objective for 

eligible hospitals and CAHs are based 

on the number of unique patients 

discharged from a hospital’s inpatient or 

emergency department during the EHR 

reporting period. 

We received no comments on this 

provision and are finalizing this 

provision without modification for the 

reasons previously stated. 

2. Case Number Threshold Exemption 

for CQM Reporting for Hospitals 

In the Stage 2 proposed rule, we 

solicited comments on whether a case 

number threshold would be appropriate 

for hospital CQM reporting, given the 

apparent burden on hospitals that very 

seldom have the types of cases 

addressed by certain measures. As we 

stated in the Stage 2 final rule (77 FR 

54080), many commenters noted that 

the implementation of a case number 

threshold for hospital CQM reporting 

would help reduce the burden placed 

on hospitals that very seldom have cases 

that would be counted in the 

denominator of certain CQMs. 

In the December 7, 2012 IFC we 

provisionally adopted a case threshold 

exemption applicable for eligible 

hospitals and CAHs in all stages of 

meaningful use beginning with FY 2013. 

Eligible hospitals and CAHs that 

demonstrate meaningful use for the first 

time and submit their CQMs using 

attestation would be able to qualify for 

the exemption. Eligible hospitals and 

CAHs with 5 or fewer discharges during 

the relevant EHR reporting period (if 

attesting to a 90-day EHR reporting 

period), or 20 or fewer discharges 

during the year (if attesting to a full year 

EHR reporting period) as defined by the 

CQM’s denominator population could 

claim an exemption for that CQM. 

To be eligible for the exemption, 

Medicare-eligible hospitals and CAHs 

must use the same process outlined in 

the Stage 2 final rule (see 77 FR 54080). 

This process includes submitting 

aggregate population and sample size 

counts for Medicare and non-Medicare 

discharges as defined by the CQM’s 

denominator population for the EHR 

reporting period no later than November 

30 after the end of the fiscal year 

containing the EHR reporting period (for 

example, November 30, 2013 for the 

hospital’s EHR reporting period that 

occurs in FY 2013). Medicaid-only 

hospitals, including children’s 

hospitals, must report this same 

information to the state to which they 

attest, in a manner specified by that 

state. 

We received no comments on this 

provision and we are finalizing this 

provision without modification for the 

reasons previously stated. 

3. Technical Corrections to CQM 

Electronic Specifications 

In the interim final rule with 

comment period, we announced our 

intent to issue technical corrections to 

the electronic specifications for the 2014 

CQMs on or around December 21, 2012. 

We received no comments on this 

provision and we are finalizing this 

provision without modification for the 

reasons previously stated. 

III. Provisions of the May 23, 2014 

Proposed Rule and Analysis of and 

Responses to Public Comments 

In the May 23, 2014 Federal Register 

(79 FR 29732), we published a proposed 

rule titled ‘‘Medicare and Medicaid 

Programs; Modifications to the Medicare 

and Medicaid Electronic Health Record 

Incentive Programs for 2014; and Health 

Information Technology: Revisions to 

the Certified EHR Technology 

Definition.’’ In this final rule, we 

discuss the provisions of that proposed 

rule, summarize and respond to the 

public comments timely received, and 

describe our final policy. 

In sections 1848(o)(2)(A) and 

1886(n)(3)(A) of the Act, the Congress 

identified the broad goal of expanding 

the use of EHRs through the concept of 

meaningful use. Section 1903(t)(6)(C) of 

the Act also requires Medicaid 

providers adopt, implement, upgrade, or 

meaningfully use CEHRT if they are to 

receive incentives under Title XIX of the 

Act. CEHRT used in a meaningful way 

is one piece of the broader health 

information technology infrastructure 

needed to reform the health care system 

and improve health care quality, 

efficiency, and patient safety. This 

vision of reforming the health care 

system and improving health care 

quality, efficiency, and patient safety 

should inform the definition of 

meaningful use. 

Certified EHR technology is defined 

for the Medicare and Medicaid EHR 

Incentive Programs at 42 CFR 495.4, 

which references the Office of the 

National Coordinator for Health 

Information Technology’s (ONC) 

definition of CEHRT under 45 CFR 

170.102. For Stages 1 and 2 of 

meaningful use, CMS and ONC worked 

closely to ensure that the definition of 

meaningful use of CEHRT and the 

standards and certification criteria for 

CEHRT were coordinated. The 

definition of CEHRT under 45 CFR 

170.102 requires, beginning with 

Federal fiscal year (FY) and calendar 

year (CY) 2014, EHR technology 

certified to the 2014 Edition EHR 

certification criteria. Therefore, all EPs, 

eligible hospitals, and CAHs must use 

2014 Edition CEHRT to meet 

meaningful use under the Medicare and 

Medicaid EHR Incentive Programs 

beginning with FY 2014 and CY 2014. 

On September 4, 2012, we published 

in the Federal Register (77 FR 53968 

through 54162) a final rule titled 

‘‘Medicare and Medicaid Programs; 

Electronic Health Record Incentive 

Program—Stage 2,’’ that established, 

among other final policies, the timeline 

for the stages of meaningful use through 

2021 and the EHR reporting periods in 

2014, as shown in Table 1 (77 FR 53973 

through 53975). 

TABLE 1—STAGE OF MEANINGFUL USE CRITERIA BY FIRST PAYMENT YEAR

First 

payment 

year 

Stage of meaningful use 

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 

2011 ..... 1 1 1 * 2 2 3 3 TBD TBD TBD TBD 

2012 ..... ................ 1 1 * 2 2 3 3 TBD TBD TBD TBD 

2013 ..... ................ ................ 1 * 1 2 2 3 3 TBD TBD TBD 

2014 ..... ................ ................ ................ * 1 1 2 2 3 3 TBD TBD 

2015 ..... ................ ................ ................ ................ 1 1 2 2 3 3 TBD 

2016 ..... ................ ................ ................ ................ ................ 1 1 2 2 3 3 


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TABLE 1—STAGE OF MEANINGFUL USE CRITERIA BY FIRST PAYMENT YEAR—Continued 

First 

payment 

year 

Stage of meaningful use 

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 

2017 ..... ................ ................ ................ ................ ................ ................ 1 1 2 2 3 

* 3-Month quarter EHR reporting period for Medicare and continuous 90-day EHR reporting period (or 3 months at state option) for Medicaid 

EPs. All providers in their first year in 2014 use any continuous 90-day EHR reporting period. 

EPs, eligible hospitals, and CAHs that 

attest to meaningful use for an EHR 

reporting period in 2014 for their first 

year of Stage 2 or their second year of 

Stage 1 have a 3-month quarter EHR 

reporting period in CY 2014 (EPs) or FY 

2014 (eligible hospitals and CAHs). For 

the Medicaid incentive payments for 

meaningful use, EPs have an EHR 

reporting period of any continuous 90- 

day period in CY 2014 as defined by the 

state Medicaid program, or, if the state 

so chooses, any 3-month CY quarter in 

2014. EPs, eligible hospitals, and CAHs 

that demonstrate meaningful use for the 

first time in 2014 have an EHR reporting 

period of any continuous 90-day period 

in CY 2014 or FY 2014, respectively. 

A. Proposed Changes to Meaningful Use 

Stage Timeline and the Use of CEHRT 

1. Reporting in 2014 

We are revisiting some of the 

requirements for the Medicare and 

Medicaid EHR Incentive Programs for 

2014. Many EHR vendors have 

indicated, through letters to CMS, 

public forums, listening sessions, survey 

data, and information related to the 

certification and testing process, that the 

amount of time available after the 

publication of the Stage 2 final rule was 

too short to make the required coding 

changes to enable their EHR products to 

be certified to the 2014 Edition of EHR 

certification criteria. We understand, 

based on information gained from EHR 

technology developers and ONCAuthorized Certification Bodies on 

timing, backlogs, and the certification 

case load, that many EHR products were 

certified later than anticipated. These 

late certifications impacted the 

corresponding time available to 

providers to effectively deploy 2014 

Edition CEHRT and to make the 

necessary patient safety, staff training, 

system testing and workflow revisions 

in order to be prepared to demonstrate 

meaningful use in 2014. The availability 

of 2014 Edition CEHRT is further 

limited by the large number of providers 

needing to upgrade to 2014 Edition 

CEHRT. By the end of February 2014, 

over 350,000 providers received an EHR 

incentive payment for adopting, 

implementing, upgrading, or 

successfully demonstrating meaningful 

use with 2011 Edition CEHRT. In 2014, 

in order for providers to successfully 

demonstrate meaningful use for Stages 1 

or 2, all eligible providers needed to 

adopt, implement, or upgrade to 2014 

Edition CEHRT. However, through 

letters to CMS, public forums, listening 

sessions, and public comment at CMS 

meetings, many provider associations 

expressed concern that, although 2014 

Edition CEHRT may be available for 

adoption, a several month backlog exists 

for the updated version to be installed 

and implemented so providers can 

successfully demonstrate meaningful 

use for an EHR reporting period in 2014. 

We also understand that the delay in 

availability may limit a provider’s 

ability to fully implement 2014 Edition 

CEHRT across the facility. For example, 

a hospital may have different systems in 

multiple settings, which all require an 

update and integration. Alternatively, a 

provider may have certain 2014 Edition 

CEHRT functionality that, once 

implemented in a live setting, requires 

software patches or workflow changes. 

Accordingly, in an effort to grant more 

flexibility to providers who experienced 

2014 Edition CEHRT product 

availability issues that impact the ability 

to fully implement 2014 Edition CEHRT 

to meet meaningful use, we proposed 

some changes for the Medicare and 

Medicaid EHR Incentive Programs for 

2014. We proposed to allow EPs, 

eligible hospitals, and CAHs that could 

not fully implement 2014 Edition 

CEHRT for an EHR reporting period in 

2014 due to delays in 2014 Edition 

CEHRT availability to continue to use 

2011 Edition CEHRT or a combination 

of 2011 Edition and 2014 Edition 

CEHRT for the EHR reporting periods in 

CY 2014 and FY 2014, respectively. 

These proposed alternatives are 

available only for those providers that 

could not fully implement 2014 Edition 

CEHRT to meet meaningful use for an 

EHR reporting period in 2014 due to 

delays in 2014 Edition CEHRT 

availability. 

We proposed these options for the use 

of CEHRT to meet meaningful use for an 

EHR reporting period in 2014 only. We 

will maintain the existing policy that all 

providers must use 2014 Edition CEHRT 

for the EHR reporting periods in CY 

2015, FY 2015, and in subsequent years, 

or until new certification requirements 

are adopted in subsequent rulemaking. 

Furthermore, in order to avoid 

inadvertently incentivizing the purchase 

of an outdated product that cannot be 

used to demonstrate meaningful use in 

a subsequent year, we proposed that to 

qualify for an incentive payment under 

Medicaid for 2014 for adopting, 

implementing, or upgrading CEHRT, a 

provider must adopt, implement, or 

upgrade to 2014 Edition CEHRT only. A 

provider would not be able to qualify for 

a Medicaid incentive payment for 2014 

for adopting, implementing, or 

upgrading to 2011 Edition CEHRT or a 

combination of 2011 and 2014 Edition 

CEHRT. We proposed to revise the 

definition of ‘‘Adopt, Implement or 

Upgrade’’ under 42 CFR 495.302 to 

reflect this proposal. 

The edition of certified EHR 

technology available to a provider 

dictates the stage and version of the 

meaningful use objectives and measures 

the provider will be able to meet. For 

example, 2011 Edition CEHRT alone 

does not have the necessary 

functionality required to meet the Stage 

2 objectives and measures. In addition, 

the edition of CEHRT determines which 

CQMs a provider calculates and reports 

because calculations are part of the 

software programming within the 

CEHRT system. 

The 3 options for the use of CEHRT 

editions and the available Stage of 

meaningful use objectives and measures 

associated with each option are as 

follows: 

a. Using 2011 Edition CEHRT Only 

We proposed that all EPs, eligible 

hospitals, and CAHs that use only 2011 

Edition CEHRT for their EHR reporting 

period in 2014 must meet the 

meaningful use objectives and 

associated measures for Stage 1 under 

42 CFR 495.6 that applied for the 2013 

payment year, regardless of their current 

stage of meaningful use. We note that in 

the Stage 2 final rule (77 FR 53975 

through 53979), we finalized certain 

changes to the Stage 1 objectives and 

associated measures, with some changes 

applying beginning with 2013, while 

other changes applying beginning with 


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2014. For ease of reference, we refer to 

the Stage 1 objectives and associated 

measures under 42 CFR 495.6 

applicable for 2013 as the ‘‘2013 Stage 

1 objectives and measures,’’ and refer to 

the Stage 1 objectives and associated 

measures under 42 CFR 495.6 

applicable for 2014 as the ‘‘2014 Stage 

1 objectives and measures.’’ Providers 

who choose this option must attest that 

they are unable to fully implement 2014 

Edition CEHRT because of issues related 

to 2014 Edition CEHRT availability 

delays when they attest to the 

meaningful use objectives and 

measures. 

b. Using a Combination of 2011 and 

2014 Edition CEHRT 

We proposed that all EPs, eligible 

hospitals, and CAHs using a 

combination of 2011 Edition CEHRT 

and 2014 Edition CEHRT for their EHR 

reporting period in 2014 may choose to 

meet the 2013 Stage 1 objectives and 

measures or the 2014 Stage 1 objectives 

and measures, or if they are scheduled 

to begin Stage 2 in 2014 under the 

timeline shown in Table 1, they may 

choose to meet the Stage 2 objectives 

and associated measures under 42 CFR 

495.6. Providers who choose this option 

must attest that they are unable to fully 

implement 2014 Edition CEHRT 

because of issues related to 2014 Edition 

CEHRT availability delays when they 

attest to the meaningful use objectives 

and measures. 

c. Using 2014 Edition CEHRT for 2014 

Stage 1 Objectives and Measures in 2014 

for Providers Scheduled to Begin Stage 

2 

A provider’s ability to fully 

implement all of the functionality of 

2014 Edition CEHRT may be limited by 

the availability and timing of product 

installation, deployment of new 

processes and workflows, and employee 

training. This effect is compounded for 

providers in Stage 2 as some providers 

may not be able to fully implement all 

of the functions included in 2014 

Edition CEHRT necessary to meet the 

Stage 2 objectives and measures in time 

to complete the EHR reporting period in 

2014. Therefore, under our proposal, 

providers scheduled to begin Stage 2 for 

the EHR reporting period in 2014 who 

cannot fully implement all the functions 

of their 2014 Edition CEHRT required 

for Stage 2 objectives and measures due 

to issues related to 2014 Edition CEHRT 

availability delays could use 2014 

Edition CEHRT to attest to the 2014 

Stage 1 objectives and measures for the 

EHR reporting period in 2014. Providers 

scheduled to begin Stage 2 in 2014 who 

choose this option must attest that they 

are unable to fully implement 2014 

Edition CEHRT because of issues related 

to 2014 Edition CEHRT availability 

delays when they attest to the 

meaningful use objectives and 

measures. 

The EHR reporting periods in 2014 

already have been established, and we 

did not propose any changes. Under the 

current timeline shown in Table 1, 

providers that first demonstrated 

meaningful use Stage 1 in 2011 or 2012 

must begin Stage 2 in 2014. We 

proposed that the options regarding use 

of the various editions of CEHRT 

outlined earlier applies only to the EHR 

reporting periods in 2014 for the EHR 

Incentive Program. Providers scheduled 

to begin Stage 2 in 2014 that instead 

meet the Stage 1 criteria in 2014 must 

begin Stage 2 in 2015 as noted in Table 

3. In 2015, all providers, except those in 

their first year of demonstrating 

meaningful use, must report based on a 

full year EHR reporting period. In 

addition, in 2015, all providers must 

have 2014 Edition CEHRT in order to 

successfully demonstrate meaningful 

use. 

TABLE 2—PROPOSED CEHRT SYSTEMS AVAILABLE FOR USE IN 2014 

If you were scheduled to 

demonstrate: 

You would be able to attest for Meaningful Use: 

Using 2011 Edition CEHRT 

to do: Using 2011 & 2014 Edition CEHRT to do: Using 2014 Edition CEHRT to do: 

Stage 1 in 2014 .................. 2013 Stage 1 objectives 

and measures*.

2013 Stage 1 objectives and measures* ......................

—OR— 

2014 Stage 1 objectives and measures* 

2014 Stage 1 objectives 

and measures. 

Stage 2 in 2014 .................. 2013 Stage 1 objectives 

and measures*.

2013 Stage 1 objectives and measures* ......................

—OR— 

2014 Stage 1 objectives and measures* 

—OR— 

Stage 2 objectives and measures* 

2014 Stage 1 objectives 

and measures* 

—OR— 

Stage 2 objectives and 

measures. 

* Only providers that could not fully implement 2014 Edition CEHRT for the EHR reporting period in 2014 due to delays in 2014 Edition CEHRT 

availability. 

The following are example scenarios 

under our proposal. 

Example A: An EP initiated participation 

in the Medicare EHR Incentive Program in 

2011. The EP successfully demonstrated 

meaningful use and received incentive 

payments for 2011, 2012, and 2013. Based on 

the timeline in the Stage 2 final rule, the EP 

is required to use 2014 Edition CEHRT and 

demonstrate Stage 2 of meaningful use in 

2014. Under our proposal, this EP who is 

scheduled to begin Stage 2 in 2014 would 

have the following options: 

• Attest to the Stage 2 objectives and 

measures of meaningful use using 2014 

Edition CEHRT in 2014 as scheduled. 

• Attest to the Stage 2 objectives and 

measures of meaningful use using a 

combination of 2011 and 2014 Edition 

CEHRT in 2014 if they are unable to fully 

implement 2014 Edition CEHRT due to 

delays in 2014 Edition CEHRT availability. 

• Attest to the 2014 Stage 1 objectives and 

measures using 2014 Edition CEHRT or a 

combination of 2011 and 2014 Edition 

CEHRT in 2014 if they are unable to fully 

implement 2014 Edition CEHRT due to 

issues related to 2014 Edition CEHRT 

availability delays. 

• Attest to the 2013 Stage 1 objectives and 

measures using 2011 Edition CEHRT or a 

combination of 2011 and 2014 Edition 

CEHRT in 2014 if they are unable to fully 

implement 2014 Edition CEHRT due to 

issues related to 2014 Edition CEHRT 

availability delays. Clinical quality measures 

must be submitted through attestation if 

attesting to the 2013 Stage 1 objectives and 

measures as discussed in section III.B. of this 

final rule. 

Example B: An EP initiated participation in 

the Medicare EHR Incentive Program in 2013. 

The EP successfully demonstrated 

meaningful use and received an incentive 

payment for 2013. Based on the timeline in 

the Stage 2 final rule, the EP is required to 

use 2014 Edition CEHRT and demonstrate 

Stage 1 of meaningful use in 2014. Under our 

proposal, this EP would have 1 of the 

following options: 

• Attest using 2014 Edition CEHRT to the 

2014 Stage 1 objectives and measures of 

meaningful use in 2014 as scheduled. 

• Attest using a combination of 2011 and 

2014 Edition CEHRT and meet the 2014 Stage 

1 objectives and measures of meaningful use 

in 2014 if they are unable to fully implement 


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2014 Edition CEHRT due to delays in 2014 

Edition CEHRT availability. 

• Attest using 2011 Edition CEHRT or a 

combination of 2011 and 2014 Edition 

CEHRT and meet the 2013 Stage 1 objectives 

and measures of meaningful use in 2014 if 

they are unable to fully implement 2014 

Edition CEHRT due to delays in 2014 Edition 

CEHRT availability. Clinical quality 

measures must be submitted through 

attestation if attesting to the 2013 Stage 1 

objectives and measures as discussed in 

section II.B. of this rule. 

Comment: The majority of 

commenters supported the proposals 

presented. Commenters explained that a 

wide range of EHR vendor and 

developer issues impeded successful 

implementation of 2014 Edition CEHRT. 

These issues include software 

installation difficulties, testing delays, 

repeated updates, and software issues 

that required costly and time-consuming 

manual corrections. Commenters also 

raised patient safety concerns about the 

potential for errors stemming from 

software glitches and crashes associated 

with 2014 Edition CEHRT. Some 

commenters explained that these 

software installation and 

implementation problems had a 

negative effect on productivity, record 

accuracy, and overall EHR operations 

because essential functions were not 

ready on time. Commenters stated that 

these EHR software delays and other 

problems have rendered it impossible 

for providers to adequately implement 

2014 Edition CEHRT, train their staff, 

and test all the required functions in 

time to demonstrate meaningful use for 

an EHR reporting period in 2014. Other 

commenters, many with several years of 

Stage 1 experience, further point out 

their EHR vendors do not even have 

2014 Edition CEHRT available for them 

to install so they have been unable to 

upgrade their CEHRT edition. 

Many commenters added that waiting 

until 2015 to require the use of 2014 

Edition CEHRT for an EHR reporting 

period will give everyone enough time 

to get their EHRs stabilized. This 

stabilization would allow providers to 

implement additional features, 

products, and workflows to successfully 

meet the objectives and measures of 

meaningful use. Accordingly, the 

overwhelming majority of commenters 

welcome the changes proposed. 

Response: We appreciate the 

commenters and all stakeholders for the 

suggestions provided on the EHR 

Incentive Program. The large number of 

public comments received is a testament 

to the continued commitment among 

the health care and health IT industry 

to improving access to quality care for 

patients. We understand the changes 

required to move the EHR Incentive 

Program forward take time; and we have 

heard your concerns over the challenges 

of successfully implementing 2014 

Edition CEHRT in time for an EHR 

reporting period in 2014. It is for this 

reason we proposed to offer providers 

options for the use of certified EHR 

technology in 2014. As confirmed by the 

overwhelming number of comments 

received in support of these proposals, 

we believe the changes proposed give 

providers the flexibility and time 

needed to adequately upgrade and fully 

implement 2014 Edition CEHRT. We 

look forward to working further with 

stakeholders as the next stages of the 

EHR Incentive Programs evolve, 

cognizant that stakeholder involvement 

remains critical to the continued 

success of this program. 

We also note that throughout this 

final rule, as in the proposed rule, we 

use the term ‘‘vendor.’’ We have added 

the term developer to this reference as 

some commenters used this term, and 

we note that in some cases, the 

developer and the vendor may be 

different entities. In other cases, 

products may be developed by the 

provider which means that the products 

were not purchased from an external 

vendor. For purposes of this final rule, 

we clarify that the term ‘‘vendor’’ shall 

include developers who create or 

develop health IT. 

Comment: Some commenters opposed 

the options for the use of CEHRT 

outlined in the proposed rule. These 

commenters explained that they 

successfully tested, upgraded, and 

implemented 2014 Edition CEHRT and 

characterized the proposals as unfair to 

those providers and EHR vendors who 

worked hard to ensure all Stage 2 

requirements and software were ready 

on time. Some categorized these 

proposals as unfair to early adopters of 

EHR technology. These commenters 

believed the changes as proposed may 

provide a free pass to those who waited 

until the last minute to implement 2014 

Edition CEHRT, and provide no benefit 

to those who are ready to move forward. 

Some commenters requested that we do 

not finalize this rule in any form, stating 

that although they acknowledge the 

EHR Incentive Programs presents some 

challenges, they believe some 

difficulties stem from stakeholders 

being simply unwilling to put in any 

effort. 

Other commenters stated that we 

should not finalize the proposals 

because they believe the EHR Incentive 

Programs are already too complicated 

given the different stages and 

requirements. These commenters 

believed adding more changes only 

further complicates a program already 

in need of simplification. 

Other commenters explained that the 

proposed rule should not be finalized 

because it does not support the effort to 

move the health care system forward, 

which is a clear goal of the EHR 

Incentive Programs and the meaningful 

use objectives and measures. These 

commenters expressed concern that the 

proposed changes might hinder the 

expansion of health information 

exchange; limit patients’ access to their 

health care information; or delay the 

momentum of the EHR Incentive 

Program. These commenters stated that 

the changes supported by meaningful 

use, like providing beneficiaries with 

online access to their health 

information, represent a monumental 

achievement in health IT; and they 

expressed concern that the options for 

the use of CEHRT in 2014 may result in 

delays in this effort. Similarly, 

commenters were concerned that this 

would delay forward progress in 

interoperability, which would be 

contrary to Congress’ intent in passing 

the HITECH Act and would limit the 

exchange of health care data between 

providers which supports the 

coordination of care. 

Response: We appreciate those 

stakeholders who fully implemented 

2014 Edition CEHRT and are able to 

meet the objectives and measures of 

meaningful use for an EHR reporting 

period in 2014. We understand the 

challenges faced in accomplishing that 

goal and wish to recognize the 

tremendous amount of work from 

providers and EHR vendors in meeting 

these objectives and helping to move 

health IT forward. 

However, we disagree with these 

commenters to the extent the changes 

proposed somehow give providers that 

waited until the last minute a ‘‘free 

pass’’, or punish those providers who 

were early adopters. We received 

numerous comments, and verified 

through internal research on 

implementation and readiness, that EHR 

development and implementation 

delays caused many providers to be 

unable to fully implement 2014 Edition 

CEHRT. Our analysis further showed no 

identifiable correlation between a 

provider’s efforts to prepare to 

demonstrate meaningful use—including 

successful past participation—and the 

ability to obtain and implement CEHRT 

in a practice setting. Many providers 

had no control over their position in 

their vendor’s queue for CEHRT 

installation, no influence on a product’s 

development timeline, and no 

participation in the product’s movement 

through the certification process. All of 


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which may have also contributed to the 

overall delay in 2014 Edition CEHRT 

availability. It is for these reasons we 

proposed these changes. Our intent in 

proposing these options was not to 

further complicate the program, to 

provide a benefit to certain providers, or 

to penalize other providers. Rather, we 

sought to be responsive to stakeholder 

concerns by proposing options for 

providers who were unable to fully 

implement 2014 Edition CEHRT for an 

EHR reporting period in 2014 because of 

issues related to 2014 Edition CEHRT 

availability delays. 

We note that several commenters 

raised concerns about the potential 

impact of these proposals on health IT 

interoperability. However, we believe 

that the proposed options for the use of 

CEHRT in the short term will support 

moving interoperability forward over 

the long term. Allowing providers 

additional time to fully implement the 

2014 Edition CEHRT required for health 

information exchange will support 

efforts to expand the use of this 

technology on the whole and continue 

providers’ efforts to incorporate 

electronic health information exchange 

and care coordination into their 

practices. 

We also recognize the concerns 

expressed by commenters about how 

our proposals may affect patients and 

their families if progress on patient 

engagement initiatives is slowed. We 

understand that patients’ electronic 

access to health information, supported 

by the meaningful use of EHR 

technology, comprises an integral part 

of improving patient-provider 

engagement and patient health literacy. 

Again, we believe that the short-term 

delay will allow for more providers to 

continue forward progress and begin 

providing essential health information 

to their patients through certified EHR 

technology. 

In addition, we cannot ignore the 

overwhelming concern from providers, 

or the supporting data showing that 

many providers cannot successfully 

meet meaningful use for an EHR 

reporting period in 2014 using 2014 

Edition CEHRT because of issues related 

to 2014 Edition CEHRT availability 

delays. We believe that giving 

additional time to providers who have 

not otherwise been able to fully 

implement 2014 Edition CEHRT in their 

practice will help them continue to 

make progress toward more advanced 

use of EHRs including the health 

information exchange and patient 

engagement objectives. 

In addition, requiring providers to 

rush implementation despite significant 

obstacles does not improve health care 

outcomes or best serve patient safety as 

a whole. Rather, we believe that the 

options proposed will allow providers 

and EHR vendors sufficient time to 

upgrade and safely and effectively 

implement the 2014 Edition CEHRT, 

which, in turn, will result in better 

health outcomes for patients. 

Finally, the actions involved in 

meeting the objectives and measures of 

meaningful use are not simply part of a 

reporting program, they are also based 

on changing behaviors and setting 

standards that drive toward improved 

clinical process and better outcomes for 

patients. For providers who could not 

otherwise participate because of a lack 

of 2014 Edition CEHRT, the allowance 

of flexibility in the use of CEHRT 

Editions means they may continue to be 

actively engaged in the processes and 

actions required by the program. For the 

2013 Stage 1 objectives and measures, 

this includes providing important 

information to patients about their care, 

implementing patient safety measures 

like automated drug interaction and 

drug allergy checks, and reporting on 

public health data. These objectives 

help to move the EHR Incentive 

Programs forward and to support 

delivery system transformation efforts 

through health IT. 

Comment: While most commenters 

support the proposal to provide options 

for providers using CEHRT to meet 

meaningful use in 2014, some 

commenters expressed concern about 

the cost and time required to modify 

state Medicaid EHR attestation systems 

to accommodate the program changes 

specified in the proposed rule. Some 

commenters requested that CMS allow 

states the flexibility to decline the 

changes proposed, or to make additional 

changes within state Medicaid EHR 

Incentive Programs beyond those 

proposed by CMS. 

Response: We recognize the potential 

burden that these changes may have on 

state system development and 

enhancement activity, and are aware 

that the changes specified in the 

proposed rule may have implications for 

cost, timing, and system changes. In 

order to accommodate these changes, 

we are committed to working with 

individual states to update contracts 

and funding requests in 

Implementation-Advance Planning 

Documents (I–APDs) to enact the 

systems changes needed to support 

these policy changes. We remind states 

that enhanced Federal financial 

participation is available for EHR 

Incentive Program administration costs. 

We do not believe these concerns 

outweigh the benefits of the proposed 

options for the use of CEHRT, which we 

believe would enable providers who 

would otherwise be unable to meet 

meaningful use, to be able to do so in 

2014. 

Comment: Several commenters 

reported that the proposed rule would 

increase the complexity of an already 

difficult transition from Stage 1 to Stage 

2 for many Medicaid EPs, and requested 

that we provide guidance to clarify any 

changes to the program that result from 

this final rule. Commenters requested 

clarification on whether this change is 

limited to the use of CEHRT for an EHR 

reporting period in 2014 for Medicaid 

given that state Medicaid programs must 

make administrative, system, and 

operational changes in response to the 

changes proposed, which may take 

significant time to complete. 

Response: We recognize the 

additional complexity introduced under 

these proposals for providers 

participating in the Medicaid EHR 

Incentive Program, but we believe that 

the benefits of giving providers option 

for using CEHRT in 2014 to meet 

meaningful use will outweigh any 

additional confusion that may occur. 

We will provide ongoing technical 

assistance and appropriate materials to 

state staff and providers to help them 

understand how the changes in this rule 

affect participation in the Medicaid EHR 

Incentive Program. We stress that the 

changes regarding the options for using 

CEHRT are limited to the EHR reporting 

period in 2014 for both Medicare and 

Medicaid. For 2015 and subsequent 

years, we proposed no changes 

regarding the use of CEHRT or the stage 

of meaningful use a provider must attest 

to, except for the change in the Stage 3 

start date. 

Comment: Several commenters 

encouraged CMS to not adopt any 

changes or exclusions which affect the 

ability of providers serving patients 

residing in correctional facilities to meet 

the requirements of meaningful use. 

Response: We appreciate the 

commenters’ feedback. However, we did 

not propose any changes that would 

uniquely affect providers serving 

patients in correctional facilities. 

Comment: We received numerous 

comments during this public comment 

period that were either unrelated to the 

EHR Incentive Program or outside the 

scope of the proposed rule. These 

comments included changes to Stage 2, 

requests for revisions to EHR reporting 

periods in years other than 2014, and 

suggestions for implementation of Stage 

3. 

Response: We thank all the 

commenters for their suggestions and 

feedback on the EHR Incentive 

Programs. However, comments 


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unrelated to the proposals fall outside 

the scope of the proposed rule and are 

not be addressed in this final rule. 

Instead, we urge readers, especially 

those who provided comments 

pertaining to Stage 3, to wait until the 

release of the Stage 3 proposed rule to 

provide comments on this particular 

area. 

Comment: We received multiple 

comments from providers on the delays 

in service and a perceived lack of 

communication from EHR vendors. 

Commenters stated that some vendors 

are still unable to provide them with 

2014 Edition CEHRT, or that products 

they have in place have not yet been 

certified. Another provider requested 

that CMS compel EHR vendors to better 

communicate with their clients, 

especially in cases where they are not 

actively pursuing certification. These 

commenters stressed the need to be able 

to rely on EHR vendors, and the 

perceived lack of communication often 

inhibits trust in a business relationship. 

However, another commenter believed 

the proposed rule forced providers to 

blame vendors and system developers, 

in order to take advantage of the options 

for using CEHRT. This commenter 

added that such behavior did not foster 

a cooperative relationship between 

vendor and provider. 

Response: We recognize the concern 

and need for effective and timely 

communication with EHR vendors 

during the EHR certification process. 

We are committed to working with our 

federal partners at the ONC and 

industry stakeholder groups 

representing EHR vendors to create and 

disseminate meaningful use related 

resources for use in supporting 

providers. 

We stress that in this proposed rule, 

we did not intend to attribute fault to 

any stakeholder, including EHR 

vendors, always recognizing the success 

of this program hinges upon the 

cooperation of all stakeholders. Rather, 

the options we proposed recognize the 

overall difficulties and delays in the 

industry as a whole in getting 2014 

Edition CEHRT fully certified and 

implemented in time for providers to 

use for an EHR reporting period in 2014. 

Comment: Several commenters 

requested that we finalize this rule as 

quickly as possible and questioned the 

public comment period. A commenter 

stated that we did not specify the end 

of the comment period in the proposed 

rule. Other commenters requested that 

CMS either shorten or eliminate the 

public comment period entirely, or 

provide a definitive date for final rule 

implementation. In general, these 

commenters expressed concern that the 

comment period ending on July 21, 

2014 would delay the implementation 

of the rule and effectively limit 

providers to using the 4th quarter as 

their EHR reporting period. These 

commenters expressed concern that this 

timeframe is not feasible for eligible 

hospitals because the fourth quarter of 

FY 2014 began on July 1, 2014, prior to 

the end of the comment period. 

Response: We thank the commenters 

for their suggestions but respectfully 

disagree with the concerns raised. First, 

we disagree with the commenter that 

stated that we did not specify the end 

of the public comment period. The 

proposed rule, as pointed out by other 

commenters, specified that the comment 

period ended on July 21, 2014. The 

comment period allows us to receive 

invaluable feedback on the proposals 

and gain a better understanding of the 

impact they may have on providers and 

the health care industry. 

Second, we acknowledge a perceived 

concern that the timing of this final rule 

effectively limits a provider’s EHR 

reporting period in 2014 to the fourth 

quarter. However, we believe this 

concern stems largely from a 

misunderstanding of the EHR reporting 

periods and the time allowed for 

attestation. There are two related actions 

required to report on the objectives and 

measures to demonstrate meaningful 

use. The first is to capture data for an 

EHR reporting period, the second is to 

attest to that data in the EHR Incentive 

Programs Registration and Attestation 

System. First, providers may capture 

data for any EHR reporting period of a 

three-month quarter within 2014 (CY for 

EPs, FY for eligible hospitals and CAHs) 

using the options in this final rule. For 

example, a provider may meet the 

meaningful use objectives and measures 

using the options in this final rule 

during the first quarter EHR reporting 

period in 2014 (October 2013 through 

December 2013 for eligible hospitals 

and CAHs, January 2014 through March 

2014 for EPs). Second, a provider may 

submit their data and attest to 

meaningful use at any point from the 

end of the selected EHR reporting 

period through the end of the attestation 

period. The attestation period does not 

open and close after each reporting 

period. The attestation period opens at 

the end of the first reporting period of 

the year and is open the remainder of 

the year and finally closes 2 months 

after the end of the year (CY for EPs, FY 

for eligible hospitals and CAHs), not at 

the end of any given EHR reporting 

period. 

Therefore if an eligible hospital were 

unable to fully implement 2014 Edition 

CEHRT for an EHR reporting period in 

2014 because of issues related to 2014 

Edition CEHRT availability delays, the 

options provided in this rule would 

allow that eligible hospital to use 2011 

Edition CEHRT, or a combination of 

2011 and 2014 Edition CEHRT to meet 

meaningful use during any 3-month 

quarter EHR reporting period in FY 

2014. That eligible hospital could select 

the first, second, third, or fourth quarter 

of FY 2014 as its EHR reporting period 

and attest to meeting the meaningful use 

objectives and measures at the end of 

the year. Therefore, the last quarter of 

the year is not the only available quarter 

which a provider may use for their EHR 

reporting period in 2014. 

Comment: Some commenters wanted 

us to extend the options for the use of 

CEHRT we proposed for 2014 into 2015. 

These commenters stated the additional 

flexibility would allow time for 

providers and EHR vendors to 

adequately implement the technology. 

Another commenter suggested 

extending the options for using CEHRT 

into 2015 in order to align the program 

with the upcoming ICD–10 transition. 

Response: The options detailed in the 

proposed rule apply to the use of 

CEHRT for the EHR reporting period in 

2014 and do not extend to 2015 or 

subsequent years. We believe the 

options proposed for 2014 allow 

providers to continue moving forward 

with the meaningful use of certified 

EHR technology. However, to extend the 

proposed options for using CEHRT 

beyond the EHR reporting period in 

2014 puts ongoing program goals at risk. 

We set the new standards for 2014 

Edition CEHRT to achieve more 

advanced functionalities and drive 

toward enhanced information exchange 

and interoperability. We acknowledged 

in previous comment and response 

discussion that even these proposed 

options for the use of CEHRT represent 

some delay to forward progress. 

However, we believe our proposals 

would mitigate that delay by enabling 

more providers to participate in the 

program in 2014 while maintaining the 

requirement to use 2014 Edition CEHRT 

in 2015. But, allowing any further 

extension compounds the potential risk 

to health information exchange 

infrastructure and may detrimentally 

affect the alignment with related CMS 

programs such as PQRS and IQR. For 

these reasons, we did not propose 

extending the options for the use of 

CEHRT beyond 2014. 

Comment: A few commenters 

questioned whether providers ready to 

move forward with attestations should 

still do so. These commenters 

questioned whether providers who have 

adopted and are live with 2014 Edition 


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CEHRT should use one of the CEHRT 

options proposed for the EHR reporting 

period in 2014. Some commenters 

further questioned if they should delay 

active installation of their 2014 Edition 

CEHRT to accommodate these changes. 

Response: Providers who have fully 

implemented 2014 Edition CEHRT must 

attest to the objectives and measures for 

their stage of meaningful use for an EHR 

reporting period in 2014. The proposed 

options for using CEHRT are available 

only to those providers who are unable 

to fully implement 2014 Edition CEHRT 

for an EHR reporting period in 2014 

because of issues related to 2014 Edition 

CEHRT availability delays. 

We stated in the proposed rule that 

we strongly recommend EPs, eligible 

hospitals, and CAHs that have not yet 

purchased EHR technology to obtain 

2014 Edition CEHRT as these providers 

will still need to use 2014 Edition 

CEHRT for their EHR reporting period 

in 2015. This also applies for providers 

in the process of installing or 

implementing 2014 Edition CEHRT. 

These providers should continue the 

implementation process as 2014 Edition 

CEHRT will be required for use for an 

EHR reporting period in 2015. 

In addition, we proposed that a 

Medicaid provider must adopt, 

implement, or upgrade to only 2014 

Edition CEHRT if they wish to qualify 

for the adopt, implement, or upgrade 

incentive payment under Medicaid for 

their first participation year. This was 

proposed in order to avoid inadvertently 

incentivizing the purchase of an 

outdated product that cannot be used to 

demonstrate meaningful use in a 

subsequent year. 

Comment: A commenter requested 

clarification of what we meant by 

requiring Medicaid EPs to adopt, 

implement, or upgrade 2014 Edition 

CEHRT. The commenter questioned 

whether documentation of a plan to 

upgrade from older technology is 

sufficient. 

Response: We proposed that to 

receive an incentive payment for 

‘‘adopt, implement, upgrade’’ under 

Medicaid, EPs will need to adopt, 

implement, or upgrade (AIU) to 2014 

Edition CEHRT only. As mentioned in 

the proposed rule, this requirement 

discourages the purchase of an outdated 

product that could not be used to meet 

meaningful use in subsequent years. We 

do not consider a plan to upgrade from 

older technology sufficient. We further 

note that Medicaid EPs who qualify for 

a first year incentive payment for AIU 

may be subject to the Medicare payment 

adjustment under section 1848(a)(7) of 

the Act if they do not demonstrate 

meaningful use for an applicable EHR 

reporting period. 

Comment: We received multiple 

comments on the proposed options for 

the use of CEHRT. Generally, the 

majority of commenters supported the 

proposed options, and several 

commenters requested clarification on 

one or more of the options. A few 

commenters generally objected to one or 

more of the options, finding the options 

for the use of CEHRT time consuming, 

complicated, confusing, or 

inconvenient. 

Some commenters requested that 

CMS clarify how the edition of CEHRT 

would dictate the stage of Meaningful 

Use under the CEHRT options. 

Specifically, commenters requested 

clarification on how the proposed 

options for the use of CEHRT would 

work with objectives, associated 

measures, and CQMs. Commenters 

questioned whether the options for the 

use of CEHRT extended to allowing 

options for measure selection. A few 

commenters suggested that we allow 

additional options for the use of CEHRT 

regardless of the Edition of CEHRT the 

provider has implemented. These 

options included: allowing providers to 

attest to Stage 2 with exclusion of one 

or more core objectives; allowing 

providers to report on either Stage 1 or 

2, using either the 2011 or 2014 Edition 

CEHRT; allowing providers to choose 

between 2014 Stage 1 objectives and 

measures and the 2013 Stage 1 

objectives and measures; and allowing 

providers to report on any version of 

CQMs. 

Many commenters wanted additional 

explanation of what we meant by a 

combination of 2011 and 2014 Edition 

CEHRT. These commenters requested 

that we clarify if the combination 

referred to set amounts of time, or 

whether a specific ratio between CEHRT 

editions was required, or whether a 

specific CEHRT edition needed to be 

used for each objective or measure. 

These commenters were also concerned 

that the coding differences between the 

software editions would make it 

difficult to use a combination of the two 

as proposed in the options for the use 

of CEHRT. Other commenters requested 

clarification if the combined 2011/2014 

option for the use of CEHRT could be 

used for providers practicing in 

multiple locations equipped with 

different editions of CEHRT. 

In addition, many commenters 

requested that guidance on the 

documentation requirements for the 

related reporting requirements be 

provided to program auditors for each 

potential option. 

Response: We appreciate the 

supportive comments regarding the 

options for the use of CEHRT proposed 

for meeting meaningful use for an EHR 

reporting period in 2014. Our priority is 

to promote the meaningful use of 

certified EHR technology and support 

the successful implementation of 2014 

Edition CEHRT including the 

functionalities required to support 

enhanced patient engagement, 

interoperability, and health information 

exchange. We recognize clinical 

workflows, business procedures, and 

maintaining documentation may require 

modifications upon implementation of 

2014 Edition CEHRT. In addition, we 

recognize that affected providers will 

need to consider multiple factors in 

determining the option for which they 

may be eligible. However, we believe 

the proposals outlined for the use of 

CEHRT in 2014 will allow affected 

providers the flexibility to choose the 

option which applies to their particular 

circumstances. Upon attestation, 

providers may select one of the options 

proposed and the EHR Incentive 

Program Registration and Attestation 

System will prompt the provider to 

attest to meeting the applicable 

objectives, measures, and CQMs based 

on their Edition of CEHRT. 

Furthermore, we note, as suggested by 

some commenters, that auditors will be 

provided guidance related to reviewing 

attestations associated with the options 

for using CEHRT. 

While we understand it may be 

cumbersome for providers to use a 

combination of 2011 and 2014 Edition 

CEHRT to meet meaningful use in 2014, 

we expect the benefit of ultimately 

demonstrating meaningful use 

outweighs the complexity of using two 

CEHRT editions. We do not specify 

whether a provider must use 2011 

Edition CEHRT or 2014 Edition CEHRT 

for a certain amount of time during the 

EHR reporting period, whether a certain 

amount of modules in one CEHRT 

edition or another is required, or 

whether a certain number of provider 

settings must have one CEHRT edition 

over another. This is because we expect 

there will be significant variation among 

practices based on the type of software 

used, the complexity of a provider’s 

total systems, and the overall 

implementation timeline for 2014 

Edition CEHRT installation. 

Providers who use a combination of 

2011 Edition and 2014 Edition CEHRT 

will enter a certification number into 

the Registration and Attestation System, 

and they will be presented with a choice 

of 2013 Stage 1 objectives and measures, 

or 2014 Stage 1 objectives and measures 

(and Stage 2 objectives and measures if 


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they were previously scheduled to begin 

Stage 2). Providers using a combination 

of 2011 Edition and 2014 Edition 

CEHRT who choose to attest to the 2013 

Stage 1 meaningful use objectives and 

measures will report on only those 

objectives and measures and attest to 

the CQMs that were applicable for 2013. 

Providers using a combination of 2011 

and 2014 Edition CEHRT who choose to 

attest to the 2014 Stage 1 meaningful 

use objectives and measures will report 

on only those objectives and measures 

and submit the 2014 CQMs through 

attestation or electronic reporting. 

Providers using a combination of 2011 

Edition and 2014 Edition CEHRT who 

choose to attest to Stage 2 objectives and 

measures will attest to only the Stage 2 

objectives and measures and submit the 

2014 CQMs through attestation or 

electronic reporting. 

Comment: We received numerous 

comments on the EHR reporting periods 

for both 2014 and 2015. For 2014, some 

commenters wanted us to allow 

providers to skip attestation entirely. 

Some commenters requested 

clarification regarding the EHR 

reporting period for providers 

employing the options outlined in the 

rule. Another commenter questioned 

whether it was possible to attest based 

on a 3rd quarter (April through June) 

instead of 4th quarter (July through 

September) EHR reporting period in FY 

2014 using the CEHRT options 

proposed. Some commenters suggested 

that eligible hospitals should attest 

using any one quarter of the fiscal year, 

while others disagreed with using a 3- 

month period by quarter. 

Another commenter suggested that 

CMS should generally allow a 90-day 

reporting period for Stage 2, year 1, in 

order to allow ample time to test and 

meet the measures in Stage 2. 

However, the majority of commenters, 

focused on the 2015 reporting period 

and made suggestions regarding the 

length of the EHR reporting period. 

Several commenters requested that CMS 

consider 2015 a transition period with 

the use of 2014 Edition CEHRT. Many 

of these commenters suggested a 90-day 

attestation period for 2015, citing that 

providers and EHR vendors do not have 

enough time in 2014 to fully integrate 

2014 Edition CEHRT. The majority of 

these commenters then requested a 

flexible 90-day period, explaining that 

the rule will not be finalized prior to the 

beginning of the last EHR reporting 

period. Commenters added reporting for 

a full year in 2015 is impossible if 

providers had to switch systems on the 

first of the year. 

Other commenters explained that a 

90-day reporting period is needed for 

2015 because the proposed extension is 

not enough given the time needed to 

adopt, implement, and operationalize a 

2014 Edition CEHRT and all of the 

changes that accompany it. These 

commenters noted such a short 

extension does not adequately serve the 

purpose of the proposed rule. Finally, 

some commenters wanted a 90-day 

reporting period because of the delay in 

ICD–10 implementation, or because they 

believed Stage 2 measures fell outside 

their control. Many commenters 

requested clarification regarding the 

ramifications of not being able to 

implement 2014 Edition CEHRT by 

January 1, 2015. 

Response: The special 3-month 

quarter EHR reporting period in 2014 

was established in the Stage 2 final rule 

and does not apply to 2015 or 

subsequent years. In the proposed rule, 

we did not propose to change the EHR 

reporting periods that were established 

in the Stage 2 final rule for 2014 or any 

subsequent year with regard to the 

incentive payments or payment 

adjustments. The purpose of the 

proposed rule was to provide options 

for the use of CEHRT to allow providers 

to meet meaningful use within the 

existing EHR reporting periods using the 

technology available to them. We are 

not considering changes to the EHR 

reporting periods for 2015 or subsequent 

years in this final rule for the same 

reasons we are not considering changing 

the edition of CEHRT required for 2015 

or subsequent years. Changes to the EHR 

reporting period would put the forward 

progress of the program at risk, and 

cause further delay in implementing 

effective health IT infrastructure. In 

addition, further changes to the 

reporting period would create further 

misalignment with the CMS quality 

reporting programs like PQRS and IQR, 

which would increase the reporting 

burden on providers and negatively 

impact quality reporting data integrity. 

However, as stated previously in this 

final rule, providers may attest based on 

an EHR reporting period of any quarter 

in 2014 using the options specified in 

this final rule. We believe the options 

for using CEHRT proposed, as well as 

the ability for a provider to attest based 

on any quarter in 2014, strike a balance 

between being responsive to those 

providers unable to fully implement 

2014 Edition CEHRT because of issues 

related to 2014 Edition CEHRT 

availability delay and continuing to 

move the EHR Incentive Program 

forward. 

Comment: Commenters questioned 

how states will verify that eligible 

providers are ‘‘unable to fully 

implement 2014 Edition CEHRT 

because of issues related to 2014 Edition 

CEHRT availability delays’’ when they 

attest to meaningful use objectives and 

measures for the Medicaid EHR 

Incentive Program. Commenters stated 

that without having detailed guidance 

on how states should capture and verify 

this new attestation requirement that 

states would be at a greater risk of 

making improper payments to 

providers. 

Response: We recognize the potential 

difficulties in adding this requirement 

for both providers and state Medicaid 

agencies, but still believe that it is 

necessary to ensure that this final rule 

is tailored to those providers who were 

unable to fully implement 2014 Edition 

CEHRT. 

Comment: Several commenters sought 

clarification on the circumstances under 

which providers could use the proposed 

options for the use of CEHRT outlined 

in the proposed rule. Commenters 

requested that CMS clarify or further 

define the terms ‘‘unable to fully 

implement’’ and ‘‘2014 Edition CEHRT 

availability delays.’’ 

The comments pertaining to this 

particular area fell into several 

categories. The largest commenter group 

wanted precise definitions because they 

believed the proposed rule was not 

sufficiently clear. Several commenters 

remarked that we provided limited 

examples in the proposed rule. These 

commenters explained these terms, so 

critical to determining available options 

for using CEHRT, could encompass an 

endless number of scenarios. Other 

commenters wanted to know if 

providers retained the discretion to 

determine what these terms meant, and 

if not, who would ultimately decide 

what they meant. Some commenters 

suggested that the use of the proposed 

options should be based on a provider’s 

determination that it could not 

effectively deploy 2014 Edition CEHRT. 

Other commenters wanted the options 

for using CEHRT expanded to more than 

just issues with 2014 CEHRT 

availability delays. 

Some commenters expressed concern 

that the language we used was too 

broad; while others stated that the 

language was too restrictive. Several 

commenters wanted us to either 

substitute or add to ‘‘fully implement’’ 

with a host of other terms, including 

deployment, operationalize, work, 

establish, institute, initiate, place, or 

execute. Several commenters expressed 

confusion about whether they could use 

the options for CEHRT when they have 

2014 Edition CEHRT available, but 

could not train new personnel or 

establish new workflows because of late 

software installations. 


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Many commenters requested 

timeframes or deadlines for when these 

terms would be applicable. For 

example, a commenter questioned what 

would be considered an adequate 

amount of time to complete all of the 

transitional processes (training, 

workflow, validation of reporting) post 

2014 Edition CEHRT deployment. 

Other commenters suggested 

expanding the circumstances where an 

inability to fully implement or 2014 

Edition CEHRT availability delays could 

be used. Specifically, many commenters 

remarked delays with implementation 

of 2014 Edition CEHRT consisted of 

more than just vendor related 

availability issues and added that we 

should clarify that many issues could be 

involved. A commenter noted that the 

time period to be considered for the 

option to report on Stage 1 should 

consist of not only the time for the 

vendor to obtain 2014 edition 

certification, but also should extend to 

all subsequent vendor and health care 

provider tasks required to fully 

operationalize Stage 2. Other 

commenters wanted us to consider an 

inability to fully test 2014 Edition 

CEHRT an appropriate circumstance 

under which to use the CEHRT options. 

Other commenters noted a lack of 

training on the new technology changes 

and requested that this be considered a 

valid reason for using the CEHRT 

options. 

Commenters explained that EHR 

vendors did not train providers in time, 

thereby resulting in an inability to attest 

to meaningful use. Other commenters 

stated that cost and staff turnover and 

changes caused their inability to fully 

implement 2014 Edition CEHRT, and 

wanted clarification on whether that 

qualified them to use the CEHRT 

options. Another commenter suggested 

we consider a financial hardship as a 

reason to be unable to fully implement 

2014 Edition CEHRT because of issues 

related to 2014 Edition CEHRT 

availability delays. 

Some commenters stated problems 

associated with the 2014 Stage 1 

objectives and measures or the Stage 2 

objectives and measures themselves 

should be considered as a suitable 

reason for using the CEHRT options. A 

commenter remarked that his vendor 

only released the capability for the lab 

result measure in June, and he still is 

waiting for the upgrade to be able to 

report on the measure. 

Many commenters expressed concern 

over attesting to Stage 2 because of a 

lack of 2014 Edition CEHRT availability 

associated with the Stage 2 transitions 

of care measure requiring transmission 

of an electronic summary of care 

document using 2014 Edition CEHRT. 

This measure requires providers to send 

an electronic summary of care 

document for more than 10 percent of 

transitions or referrals. EPs especially 

expressed this concern because their 

2014 implementation timeline may be 3 

months behind eligible hospitals and 

CAHs given fiscal and calendar year 

differences. Commenters explained that 

even those EPs who did fully implement 

their own 2014 Edition CEHRT systems 

may still be unable to meet Stage 2 

requirements due to other EPs and 

community hospitals lacking 2014 

Edition CEHRT. Since Stage 2 requires 

electronic summary of care records for 

more than 10 percent of transitions of 

care to be electronically transmitted by 

the referring or transitioning EP using 

2014 Edition CEHRT or facilitated by an 

eHealth Exchange participant, 

commenters indicated that the EP 

cannot guarantee receipt if the recipient 

or intermediary does not have the 2014 

Edition CEHRT functionality required to 

receive the electronic document. These 

commenters suggested we allow an EP 

under these circumstances to attest to 

the Stage 1 objectives when insufficient 

opportunities exist to send summary of 

care records electronically because 

recipients did not fully implement 2014 

Edition CEHRT. 

Other commenters raised concerns 

over other measures under the EHR 

Incentive Program, some requiring the 

specific use of 2014 Edition CEHRT. 

Many commenters wanted to know 

whether issues with direct messaging, 

portal non-use by patients, mapping 

problems, or other similar measure 

issues could be considered an inability 

to fully implement 2014 Edition CEHRT 

because of issues related to a 2014 

CEHRT availability delay. A commenter 

explained that Stage 2’s focus on 

cooperation among providers makes 

implementation difficult when not all 

providers are at the same capability 

level. Commenters maintained these 

issues fell outside the provider’s control 

and should be considered suitable 

reasons to use the CEHRT options. Some 

commenters added that providers 

should be allowed to meet less than the 

required thresholds and still be 

considered to meet meaningful use for 

the EHR reporting period in 2014. 

Other commenters remarked that 

although they had no issues with 2014 

Edition CEHRT availability, providers 

could not meet several measure 

requirements because of late code 

releases on a short time frame. 

Therefore, these commenters suggested 

that all providers be allowed to use the 

CEHRT options. Similarly, many 

commenters wanted all restrictions for 

using the CEHRT options eliminated 

completely, and instead, allow all 

providers to use the options for CEHRT 

regardless of the reason. 

Response: We agree that some 

clarification is necessary regarding what 

we meant by ‘‘not able to fully 

implement’’ and ‘‘delays in 2014 

Edition CEHRT availability’’ in the 

proposed rule. We begin by addressing 

those commenters who pointed out that 

we did not provide examples which 

fully encompass every scenario where 

an inability to fully implement or a 2014 

Edition CEHRT availability delay was 

possible, as well as those commenters 

who stated the terminology generally 

was vague and unclear. We did not 

provide an exhaustive list of every 

possible scenario in the proposed rule 

in recognition of the many different 

scenarios where a provider may not be 

able to fully implement 2014 Edition 

CEHRT for an EHR reporting period in 

2014 due to delays in 2014 Edition 

CEHRT availability. We also did not 

propose alternate terminology for 

‘‘implement’’, such as operationalize, 

institute, or initiate, as suggested by 

commenters because we wanted to use 

consistent terminology in the proposed 

rule. 

Next, we clarify what we meant by a 

delay in 2014 Edition CEHRT 

availability. As stated previously, we 

proposed the options for using CEHRT 

due to the overwhelming number of 

providers who informed us they could 

not meet the objectives and measures of 

meaningful use with 2014 Edition 

CEHRT because, for example, they did 

not have the product installed, or were 

waiting for EHR vendor certification or 

for necessary software updates from the 

EHR vendor. Such delays then gave the 

provider little to no time to get the 

necessary training, system testing and 

workflow revisions in place to fully 

implement their 2014 Edition CEHRT in 

time for an EHR reporting period in 

2014. Thus, the delay in the 2014 

Edition CEHRT availability resulted 

from one or more delays related to the 

development, certification, testing, and 

release of an EHR product by the EHR 

vendor which then results in the 

inability for a provider to fully 

implement 2014 Edition CEHRT for an 

EHR reporting period in 2014. In stating 

that the delays are attributable to the 

development, certification, testing, and 

release of an EHR product by the EHR 

vendor, we do not intend to infer that 

the EHR vendor is culpable. We 

recognize that vendors themselves may 

have experienced unexpected delays 

during the development process because 

of the compressed timeline between 

receipt of final requirements to the 


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deadline for implementation. This could 

include delays within the certification 

process as well. For example, if a 

vendor’s actions were timely but the 

ONC Authorized Certification Body 

experienced a backlog due to a high 

volume of certification requests, a delay 

in the testing and certification of a 

product may have occurred. Further, as 

reflected in the special shortened EHR 

reporting period in 2014 established in 

the Stage 2 final rule, we anticipated 

potential delays from the volume of 

providers requiring a simultaneous 

software upgrade. Rather, we proposed 

the options for the use of CEHRT to 

alleviate provider and vendor burden in 

light of our research and analysis 

demonstrating that the scale of the 

problem was greater than anticipated 

when the Stage 2 final rule was 

published. Accordingly, a provider’s 

ability to use these flexible options for 

CEHRT is based on the provider’s 

inability to fully implement 2014 

Edition CEHRT based on these types of 

issues related to software development, 

certification and release of the product 

by the EHR vendor which affected 2014 

CEHRT availability. 

We did not intend, as suggested by 

some commenters, to allow reasons 

such as a provider waiting too long to 

purchase the software or, as explained 

later in this section, a lack of staff or 

resources to constitute a ‘‘delay’’ for 

purposes of using one of the proposed 

CEHRT options. Therefore, we stress the 

delay in 2014 Edition CEHRT 

availability must be attributable to the 

issues related to software development, 

certification, implementation, testing, or 

release of the product by the EHR 

vendor which affected 2014 CEHRT 

availability, which then results in the 

inability for a provider to fully 

implement 2014 Edition CEHRT. 

Next, we clarify what we meant by an 

inability to fully implement 2014 

Edition CEHRT. It is in this area where 

we intended to provide the broadest 

application. We start with examples of 

what does not constitute an inability to 

fully implement 2014 Edition CEHRT. 

We believe that beginning with what is 

not permissible, rather than what is, 

represents a far smaller set of 

circumstances that will both quell 

providers’ concerns about audits and 

provide additional parameters on the 

use of the CEHRT options generally. 

Accordingly, we clarify that the 

following situations would not be 

permissible reasons to use the options 

for CEHRT because they do not 

constitute an inability to fully 

implement 2014 Edition CEHRT. First, 

providers that did not fully implement 

2014 Edition CEHRT due to financial 

issues, such as the costs associated with 

implementing, upgrading, installing, 

testing, or other similar financial issues, 

would not be able to use the options for 

CEHRT for the EHR reporting period in 

2014. Although we understand cost is a 

factor for health care providers, as it is 

with any other business, we proposed 

the options for CEHRT to address delays 

in the availability of 2014 Edition 

CEHRT, and not the costs associated 

with it. Therefore, we do not find cost 

to be a permissible reason for using one 

of the options for CEHRT. Rather, we 

point out that providers facing 

significant cost concerns relating to 

such things as insufficient internet 

access and insurmountable barriers to 

obtaining infrastructure (broadband 

access) have the option to file an 

application for a hardship exception. 

Second, with limited exception 

discussed later in this section, issues 

related to the meaningful use objectives 

and measures do not constitute an 

inability to fully implement 2014 

Edition CEHRT. Several commenters 

mentioned that although 2014 Edition 

CEHRT was available, fully functioning, 

and implemented, they wanted to attest 

with one of the CEHRT options because 

of issues relating to one or more Stage 

2 objectives and measures, such as the 

inability to meet certain measure 

thresholds which increased from Stage 

1 to Stage 2, an overall objection to 

Stage 2 measures generally, or concerns 

with measures believed to be outside a 

provider’s control—such as an inability 

to obtain a beneficiary’s email address. 

Again, we proposed alternate options 

only for those providers who could not 

fully implement 2014 Edition CEHRT 

for a full EHR reporting period in 2014 

because of issues related to 2014 Edition 

CEHRT availability delays. We did not 

propose these options in order for 

providers to be exempted from meeting 

Stage 2 measure requirements. We do 

not find that an inability to meet one or 

more measures, as in the examples cited 

previously, fits within the rationale we 

proposed for using one of the CEHRT 

options. Rather, overall concerns and 

comments requesting changes or 

exemptions to one or more of the Stage 

2 measures and objectives fall outside 

the scope of this rule, and will not be 

discussed with any further detail here. 

Accordingly, for the reasons stated 

previously, those providers who have 

fully implemented 2014 Edition CEHRT 

and cannot meet one or more measures 

for reasons unrelated to the inability to 

fully implement 2014 Edition CEHRT 

due to delays in the product availability 

cannot use the options for the use of 

CEHRT and must attest to their stage of 

meaningful use using 2014 Edition 

CEHRT as originally intended. 

However, we recognize the concern 

raised by commenters, stated 

previously, that in the Stage 2 

meaningful use objective for provision 

of a summary of care document during 

for more than 10 percent of transitions 

of care, the second measure requires 

electronic transmission using CEHRT, 

which implies that the recipient or 

intermediary is able to receive the 

summary of care document in the 

standard required for transmission. As 

mentioned by commenters, the sending 

provider may experience significant 

difficulty meeting the 10 percent 

threshold, despite the referring 

provider’s ability to send the electronic 

document, if the intermediary or the 

recipient of the transition or referral is 

experiencing delays in the ability to 

fully implement 2014 Edition CEHRT. 

We acknowledge referring providers 

may not be able to meet the summary 

of care measure in 2014, if receiving 

providers they frequently work with 

have not upgraded to 2014 Edition 

CEHRT. We therefore believe a limited 

exception is warranted for providers 

who could not meet the threshold for 

the Stage 2 summary of care measure 

requiring the transmission of an 

electronic summary of care document 

for more than 10 percent of transitions 

or referrals because the recipients of the 

transitions or referrals were impacted by 

issues related to 2014 Edition CEHRT 

availability delays and therefore could 

not implement the functionality 

required to receive the electronic 

summary of care document. Therefore, 

we consider the inability to fully 

implement to extend to those providers 

for the summary of care document 

measure at 42 CFR 495.6 (d)(14)(ii)(B) 

for EPs and (l)(11)(ii)(B) for eligible 

hospitals and CAHs. A referring 

provider under this circumstance may 

attest to the 2014 Stage 1 objectives and 

measures for the EHR reporting period 

in 2014. However, the referring provider 

must retain documentation clearly 

demonstrating that they were unable to 

meet the 10 percent threshold for the 

measure to provide an electronic 

summary of care document for a 

transition or referral for the reasons 

previously stated. 

We stress that other issues related to 

objectives and measures, such as a 

failure to meet a measure threshold, or 

failure to conduct the activities required 

to meet a measure, will not be 

considered a suitable basis to use the 

CEHRT options outlined in this final 

rule. 

Next, we find staff changes and 

turnover to be an insufficient rationale 


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for a provider to use the CEHRT options. 

Some commenters explained that 

circumstances such as the termination 

or attrition of staff rendered them 

unable to train new staff in time to 

implement 2014 Edition CEHRT. 

However, we did not intend such 

rationale to be permissible. Rather, 

references we made in the proposed rule 

regarding the inadequate amount of time 

to train staff stemmed, again, from the 

fact that EHR vendors were delayed in 

installing 2014 Edition CEHRT, which, 

in turn, gave providers little to no time 

to train their staff on the new software. 

We consider staff turnover and changes, 

as well as any other similar situations, 

to be issues frequently encountered in 

the normal course of business and 

therefore insufficient grounds for a 

provider to use the CEHRT options. 

Finally, we do not find situations 

stemming from a provider’s inaction or 

delay in implementing 2014 Edition 

CEHRT sufficient to use one of the 

CEHRT options. These situations 

include providers waiting too long to 

engage a vendor or a provider’s inability 

or refusal to purchase the requisite 

software update. Such circumstances 

would not be permissible reasons to use 

the CEHRT options because they did not 

stem from a 2014 Edition CEHRT 

availability delay. 

We again stress that the proposed rule 

was intended to allow options for 

providers that were unable to fully 

implement 2014 Edition CEHRT for an 

EHR reporting period in 2014 due to 

issues relating to 2014 Edition CEHRT 

availability delays. Therefore, we will 

not remove the requirement that a 

provider’s inability to fully implement 

2014 Edition CEHRT was based on 

issues related to 2014 Edition CEHRT 

availability delays, because this 

requirement comprises the primary 

reason for the proposed rule. 

In deciding whether a provider can 

use a CEHRT option, we stress that the 

installation of 2014 Edition CEHRT 

alone is not the sole factor. Obviously, 

those providers still waiting for 

installation of 2014 Edition CEHRT 

represent the most concrete example of 

those able to use the CEHRT options 

because it represents the clearest 

illustration of both a 2014 Edition 

CEHRT availability delay and lack of 

full implementation. However, those 

providers with 2014 Edition CEHRT 

installed may also be able to use the 

options for the use of CEHRT. Again, we 

stress that an availability delay is not 

based solely on whether the software is 

certified and then installed or not, as 

many commenters questioned. Rather, 

providers with 2014 Edition CEHRT 

installed may nonetheless face a 2014 

CEHRT availability delay because they 

are waiting for vendor software updates, 

or the software itself is presenting 

problems with functionality, or when 

the software does not yet contain all 

required components. This also may 

include situations where a problem with 

the software presents a safety issue, 

such as when a drug allergy or drug 

interaction clinical decision support 

does not function properly, or cases 

where the vendor identified a 

functionality problem and sends out 

patches to fix the problem, requiring the 

provider to wait until the issue is 

resolved to use the software. We 

recognize these issues take time to 

resolve, and the overall delay in 2014 

Edition CEHRT availability may have 

constrained that time for many 

providers. So, although we cannot list 

every possible scenario, installed 2014 

Edition CEHRT with delayed or missing 

software updates, or cases where the 

software itself renders a provider unable 

to reliably use the software would be 

permissible reasons to use the CEHRT 

options because such issues are 

considered to be a 2014 Edition CEHRT 

availability delay. We stress that this 

does not include, as explained earlier, 

circumstances where the software 

functions properly but the provider 

cannot meet one or more requirements 

of the measure or the increased 

thresholds on measures common to both 

stages. The basis for using one of the 

CEHRT options stems from a problem 

with first getting the software installed 

because of EHR vendor delays, and then 

fully implementing (including training, 

workflows, and related activities) 2014 

Edition CEHRT in time for a full EHR 

reporting period in 2014. We note that 

being able to implement 2014 Edition 

CEHRT for a part of the reporting period 

is not considered full implementation of 

2014 Edition CHERT. Providers who are 

only able to implement 2014 Edition 

CEHRT for part of a reporting period 

would be permitted to use the CEHRT 

options in this rule. 

Along this vein, we received requests 

to define what is allowable for staff 

training, system testing and workflow 

revision under the proposed options for 

providers who are unable to fully 

implement 2014 Edition CEHRT. An 

inability to train staff, test the updated 

system, or put new workflows in place 

because of delays associated with the 

installation of 2014 Edition CEHRT 

constitutes a failure to fully implement, 

and provides sufficient rationale to use 

the options for the use of CEHRT. We 

note several commenters wanted us to 

specify cutoff dates for training or 

workflows where we would find it 

suitable to allow using the CEHRT 

options. However, such limits would be 

impossible for us to adequately capture. 

Because the number and types of 

providers involved with the EHR 

Incentive Program vary greatly, we 

cannot simply state a hard date or exact 

time because a large hospital chain 

would possess different time and 

workflow requirements, for example, 

than a single EP. However, we can 

clarify that in order to use one of the 

options for the use of CEHRT, the 

provider must not have had enough 

time to fully implement 2014 Edition 

CEHRT, including training of staff, 

perform system testing, and establishing 

revised workflows in order to report for 

a full EHR reporting period. If a large 

hospital, for example, had their CEHRT 

installed in August, we expect that this 

hospital would not have enough time to 

be able to report for an EHR reporting 

period in 2014 because the hospital 

would not be able to train staff or 

establish the necessary changes in 

workflow. However, if a hospital had 

2014 Edition CEHRT installed in 

January 2014 and decided to wait until 

August 2014 to begin training, testing 

and workflow activities, for example, 

then this rationale would not be 

sufficient to establish that the provider 

could not fully implement 2014 Edition 

CEHRT due to a delay in 2014 Edition 

CEHRT availability, because the delay 

was on the part of the hospital. 

Again, we note that we cannot capture 

every scenario where a provider can use 

an option for the use of CEHRT and 

understand a number of providers will 

likely choose to attest under one of the 

options proposed in this final rule. 

Given the number of stakeholders who 

raised problems with getting 2014 

Edition CEHRT fully implemented and 

running, we expected a fairly wide use 

of the options for the use of CEHRT, 

which is why we proposed these 

provisions. However, as explained 

earlier, we also proposed the 

requirement that a provider must attest 

to an inability to fully implement 2014 

Edition CEHRT due to issues relating to 

2014 Edition CEHRT availability delays 

in order to use the CEHRT options. 

Although we understand the broad 

application that will likely ensue, we 

believe the parameters set forth earlier 

will provide further guidance to 

stakeholders in determining whether to 

use the options, while at the same time, 

continue to move the program forward 

toward the overall goal of the 

meaningful use of certified EHR 

technology. 

Comment: A number of commenters 

raised fairness concerns around those 

providers who met all requirements and 


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can report using 2014 Edition CEHRT in 

2014. These commenters explained that 

such providers and EHR vendors were 

not being provided with any benefit 

from the options outlined in the 

proposed rule, or with meeting 

requirements as originally created. 

Some even suggested that we provide 

additional incentives to those providers 

who can report as scheduled, as an 

award for meeting all requirements in 

2014. Other commenters requested that 

all providers be allowed to use the 

options for the use of CEHRT regardless 

of the reason. 

Response: We appreciate the 

commenters’ feedback. However, the 

proposed rule was not intended to 

unfairly favor any stakeholder. Rather, 

we proposed this rule to provide relief 

to those providers who could not meet 

meaningful use for an EHR reporting 

period in 2014 using 2014 Edition 

CEHRT because of vendor delays with 

software implementation. These 

providers were caught in situations 

where their vendors did not have 2014 

Edition CEHRT ready, and therefore 

would be unable to meet meaningful use 

for an EHR reporting period in 2014. 

These providers would otherwise not be 

participating in the program which 

would weaken the overall momentum 

and diminish essential program goals 

such as continuing to build health 

information exchange infrastructure, 

increasing participation in essential 

public health reporting programs, and 

capturing and reporting data on clinical 

standards and quality. 

We applaud those providers and EHR 

vendors who met all requirements and 

upgraded in time for the EHR reporting 

period in 2014. We understand the time 

and effort that such a task entailed and 

continue to appreciate the work these 

pioneers accomplish in moving the EHR 

Incentive Program forward. But, 

allowing all providers, including those 

who have fully implemented 2014 

Edition CEHRT, to use an alternate 

edition of CEHRT would simply be 

counterintuitive. If we allowed such a 

step, we expect many providers would 

choose the alternate options and 

continue to report on Stage 1, which 

would thereby leave us, as also noted by 

some commenters, with little to no data 

to review on Stage 2. Such 

circumstances, we fear, would later 

prove problematic in implementing 

Stage 3 and would go against our 

rationale to review Stage 2 data in order 

to mold Stage 3. The entire overarching 

purpose of the EHR Incentive Program 

is to move providers towards advanced 

use of health IT to support reductions in 

cost, increased access, and improved 

outcomes for patients. However, 

allowing all providers—including those 

who can meet meaningful use using 

2014 Edition CEHRT—to delay their 

forward progress would put these goals 

at significant risk. Therefore, providers 

must be able to show an inability to 

fully implement 2014 Edition CEHRT 

because of delays in 2014 Edition 

CEHRT availability in order to use one 

of the options for the use of CEHRT. 

In addition, although we again 

applaud those providers who can meet 

meaningful use for an EHR reporting 

period in 2014 using 2014 Edition 

CEHRT as originally intended, we do 

not believe that an extra incentive for 

these providers is warranted. The dollar 

amounts of the incentive payments are 

established by statute, and we do not 

have authority to award additional 

amounts. 

Comment: Many commenters raised 

objections to the Stage 2 objectives and 

measures. Some commenters stated the 

measure requirements for meeting 

meaningful use in 2014 are 

unreasonable. Other commenters 

suggested that the resources and costs 

required to meet the Stage 2 objectives 

and measures are substantial. 

A commenter stated that although 

EHR vendors do not have 2014 Edition 

CEHRT ready, CMS and ONC continue 

to set requirements ahead of the pace of 

the market. Some commenters stated 

that the rush results in hurried check 

box measures, which vendors cannot 

have ready on time and which simply 

do not work. Other commenters cited 

general issues with 2014 Edition CEHRT 

measures including lab interfaces, 

patient portals, and direct messaging 

functions. 

Many commenters took objections to 

the Stage 2 measures themselves. Some 

commenters stated it was unrealistic to 

expect the Medicare beneficiary 

population to be computer savvy or use 

email. Other commenters objected that 

labs, prescriptions, and radiology orders 

must be initiated electronically by a 

licensed clinician. These commenters 

stated that the lack of hand writing for 

such orders requires a great deal of 

changes in workflows for most practices 

and affects the staffing choices 

providers make in their practices. 

Many commenters objected to the 

data that needed to be entered for one 

or more of the Stage 2 measures 

themselves, finding them time 

consuming, intrusive, costly, and 

difficult to implement. 

Response: We appreciate the 

thoughtful input commenters provided 

regarding the Stage 2 meaningful use 

objectives and measures, including 

challenges in meeting certain measures 

and the number of objectives to report. 

The flexibility in this final rule 

recognizes the difficulties in meeting 

measures and objectives specifically due 

to the inability to fully implement 2014 

Edition CEHRT based on delays in 

availability. However, modifications to 

the Stage 2 meaningful use objectives 

and measures were not included in the 

scope of the proposed rule and will not 

be considered in this final rule. We urge 

readers to wait until the release of the 

Stage 3 proposed rule to provide 

comments on ways to improve the 

meaningful use requirements. 

Comment: Some commenters 

requested clarity on how this will affect 

public health reporting with respect to 

HL7 version 2.3.1 and version 2.5.1, and 

the effect on how providers will meet 

the measures or claim exclusions. 

Response: We proposed no changes to 

specific measures or to the exclusions 

related to the measures where 

exclusions apply. We expect providers 

will continue the process of enrolling 

with and reporting to public health 

agencies as per the requirements of the 

meaningful use objectives related to 

public health reporting. In addition, if a 

provider sent a test message to a public 

health agency in a previous EHR 

reporting period and chooses to report 

to 2013 Stage 1 objective and measures 

or 2014 Stage 1 objectives and measures 

for the 2014 reporting period with one 

of the alternate options for the use of 

CEHRT, the provider is not required to 

send another test message to meet the 

public health measure for the 2014 

reporting period. 

Comment: Some commenters 

requested that CMS clarify how the 

flexible CEHRT options would be 

applicable for a provider who practices 

in multiple locations. These 

commenters questioned how an EP 

should attest to meaningful use if 2014 

Edition CEHRT is fully implemented in 

one location, but not in other locations. 

These providers seek clarification as to 

whether they can attest to meaningful 

use using patient data from only the 

location with the most encounters 

during an EHR reporting period, and 

exclude patient data from other 

locations. 

Response: EPs who practice in 

multiple locations which have been 

unable to fully implement 2014 Edition 

CEHRT for an EHR reporting period in 

2014 due to CEHRT availability delays 

may attest using the options outlined in 

this final rule. If an EP uses different 

editions of CEHRT at multiple locations, 

he or she may choose to use the 

alternate CEHRT option that is best 

applied for his or her patient encounters 

across all locations during the EHR 

reporting period. However, these EPs 


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should then use the data from all patient 

encounters which occur at a location 

equipped with any edition of certified 

EHR technology, just as the EP would 

use the patient data from all locations 

equipped with CEHRT to meet 

meaningful use in any other year. 

However, if over 50 percent of the 

EP’s patient encounters during the EHR 

reporting period occur at locations 

equipped with 2014 Edition CEHRT 

which has been fully implemented, the 

EP would not be eligible to use the 

flexibility options in this final rule and 

should therefore limit their 

denominators to only those patient 

encounters in locations equipped with 

fully implemented 2014 Edition CEHRT. 

Comment: Several commenters noted 

that it is unreasonable to expect first 

time providers to attest by October 1, 

2014. These commenters suggested that 

providers who are attesting for the first 

time in 2014 should be allowed to do so 

through the end of the calendar year. 

Response: It should be noted that new 

participants in the EHR Incentive 

Programs may choose any 90 days up to 

the end of the year to complete and EHR 

reporting period, and they have until 

the close of the attestation period 

(February 28, 2015 for EPs and 

November 30, 2014 for CAHS and 

eligible hospitals) to attest to 

meaningful use and receive an incentive 

payment for the EHR reporting period in 

2014. Successfully demonstrating 

meaningful use for any reporting period 

in 2014 would allow these providers to 

avoid the 2016 payment adjustment. 

The October 1, 2014 deadline is the date 

by which EPs who have not 

demonstrated meaningful use in a prior 

year must attest in order to also avoid 

the 2015 payment adjustment. First time 

participants would otherwise be subject 

to the 2015 payment adjustment because 

they did not meet meaningful use in 

2013. This does not apply to brand new 

providers who have an automatic 2 year 

exemption from the payment 

adjustments. 

However, we reiterate all new 

participants in 2014 may earn an 

incentive payment for 2014 and avoid 

the 2016 payment adjustment by 

successfully demonstrating meaningful 

use for an EHR reporting period of any 

continuous 90 days in 2014. Even if 

these providers do not meet the early 

attestation deadline and therefore 

receive a payment adjustment in 2015, 

they may still earn an incentive 

payment for meeting meaningful use for 

an EHR reporting period in 2014. 

Comment: Several commenters 

questioned whether they could attest for 

2014 using a prior quarter in 2014 using 

2011 Edition CEHRT and 2013 Stage 1 

objectives and measures, or whether 

they can only use the fourth quarter for 

an EHR reporting period. Other 

commenters stated generally whether 

any earlier reporting period could be 

used and requested clarification on the 

attestation deadlines for each quarterly 

reporting period. 

Response: Given commenter feedback, 

we recognize that some confusion exists 

in this area. We wish to reiterate the 

attestation deadline to attest for an EHR 

reporting period is not 60 days after the 

end of any given reporting period (3- 

month quarter or 90 days for new 

participants). The deadline is 2 months 

after the end of the federal fiscal year 

(for hospitals) or the calendar year (for 

EPs).). 

Therefore, we are clarifying that 

providers may attest to any 3-month 

quarter EHR reporting period in 2014 

from the date of completion of that 

reporting period, through the end of the 

open attestation period for the year. For 

EPs, this means any point after the close 

of their chosen reporting period through 

to 2 months after the end of the calendar 

year (February 28, 2015). For eligible 

hospitals and CAHs this means any 

point after the close of their chosen 

reporting period through to 2 months 

after the end of the fiscal year 

(November 30, 2014). 

Comment: Several commenters 

requested clarification regarding the 

attestation process. Commenters 

rrequested that CMS clarify what 

documentation that would be required 

to show an inability to fully implement 

2014 Edition CEHRT. A commenter 

recommended that CMS provide an 

attestation statement for providers to 

certify they could not fully implement 

the 2014 Edition CEHRT due to delays 

in availability. Another commenter 

suggested that CMS specify when the 

attestation system will be updated with 

the new requirements promulgated in 

the final rule. 

Response: For providers attesting for 

the EHR reporting period in 2014, the 

system determines the CEHRT edition 

entered by the provider when the EHR 

certification number is entered. 

Providers utilizing the options proposed 

would be required to attest that they 

were unable to fully implement 2014 

Edition CEHRT for a full EHR reporting 

period in 2014 due to delays in 2014 

Edition CEHRT availability. We did not 

propose requiring additional 

documentation from providers at the 

time of attestation beyond the data 

required to be entered into the 

Registration and Attestation System. We 

present further clarification of the full 

attestation process in section IV of this 

final rule. 

Comment: Several commenters 

questioned how the audit process would 

work given the flexible options for using 

certified EHR technology. These 

commenters sought clarification on 

what types of documentation would be 

required in cases of an audit. Some 

commenters request that CMS not 

require any documentation, in order to 

alleviate provider burden. However, 

other commenters, mainly those 

responsible for attestation, wanted us to 

require some level of documentation, in 

order to provide protection in cases of 

an audit. Commenters were generally 

concerned with auditors retroactively 

applying different standards than what 

is outlined in this rule. 

A few commenters wanted the 

provider’s decision to use flexible 

attestation outside the auditor’s purview 

completely. Other commenters were 

concerned with the auditor’s focus 

given these flexible requirements. These 

commenters explained with such a 

small pool of Stage 2 attesters likely, 

auditors may not focus their efforts 

evenly across both Stages, thereby 

unfairly punishing the smaller Stage 2 

attester group, who succeeded in 

implementing and reporting using the 

2014 Edition CEHRT. These 

commenters suggested ensuring that 

audits were fairly conducted across both 

Stages, given the likelihood for a higher 

number of Stage 1 attesters. 

Response: We appreciate the 

commenters’ feedback and would like to 

clarify some aspects of the audit process 

in response to the comments. Audits 

under the EHR Incentive Program do not 

occur based solely upon provider type, 

location, stage of meaningful use, or 

year of participation. Rather, we follow 

standard guidelines for programs 

conducting audits including auditing 

providers based on a random selection 

process, as well as selection based on 

key identifiers such as prior audit 

failure or known incidence of fraud. 

Therefore, although we acknowledge 

that the flexible options for CEHRT we 

proposed may modify a provider’s 

timeline for implementation of 

meaningful use, we stress that a 

provider attesting to Stage 2 using the 

2014 Edition CEHRT is no more likely 

to be subject to an audit than any other 

provider attesting in 2014. 

We also acknowledge providers’ 

concerns about required documentation 

in cases of an audit. To alleviate those 

concerns, we wish to clarify that we will 

provide guidance to auditors relating to 

this final rule and the attestation 

process. This instruction should include 

requiring auditors to work closely with 

providers on the supporting 

documentation needed applicable to the 


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provider’s individual case. We further 

stress that audit determinations are 

finalized on a case by case basis, which 

allows us to give individual 

consideration to each provider. We 

believe that such case-by-case review 

will allow us to adequately account for 

the varied circumstances that may result 

in a provider selecting a different 

CEHRT option. 

Comment: Some commenters 

suggested that these changes would lead 

to many Medicaid EPs not submitting 

their 2014 attestations until after 

January 1, 2015; and if they are also 

Medicare providers they may be subject 

to the Medicare penalty if they did not 

submit a hardship exemption by the 

deadline. Many commenters are 

concerned that if states extend the 

attestation period in order to 

accommodate these changes, it will only 

result in slowing 2015 work flows. They 

believe that providers who are already 

struggling with navigating the 

requirements must add another layer of 

decisions in the process. 

Response: We do anticipate that if 

states require additional time to 

implement system changes to allow 

providers to attest to meaningful use 

under these proposed options, a 

contingent of Medicaid EPs may not be 

able to submit 2014 attestations until 

after January 1, 2015. However, if a 

provider meets meaningful use for an 

EHR reporting period for 2014 in the 

Medicaid program, they will not be 

subject to a Medicare payment 

adjustment in 2016 even if they attest 

after January 1, 2015. 

It is true that Medicaid providers who 

do not meet meaningful use for an EHR 

reporting period in 2014, who are also 

Medicare providers, may be subject to 

the Medicare penalty if they did not 

submit a hardship exception application 

by the deadline. However, we note that 

the application deadline for providers 

who do not demonstrate meaningful use 

in 2014 is April 1, 2015 for eligible 

hospitals and July 1, 2015 for EPs. 

Therefore, there is time for these EPs to 

apply for an exception if they find they 

are unable to meet meaningful use in 

the Medicaid program. Further 

clarification of hardship exceptions may 

be found in later in this section of this 

final rule. Regarding the deadline for 

attestations, states that have extended 

this deadline (and in many cases, on an 

annual basis) in the past, have had a 

significant number of EPs and eligible 

hospitals attest during that period. 

These states have not reported work 

flow delays as a result. It is important 

for states, with CMS support, to educate 

the provider community with the latest 

information related to meeting the 

requirements of meaningful use and to 

raise awareness on CEHRT requirements 

so providers can make informed 

decisions and successfully participate in 

the program. 

Comment: Some commenters 

expressed a variety of concerns around 

hardship exceptions for the Medicare 

payment adjustments. Some wanted 

clarification on the requirements for a 

hardship exception application for 

providers who were unable to 

implement 2014 Edition CEHRT due to 

delays in 2014 Edition CEHRT 

availability. A few commenters 

requested clarification that this final 

rule did not affect the ability for a 

provider to receive an incentive 

payment. Another commenter expressed 

frustration with losing his incentive 

payment should he choose to file a 

hardship exception application. Other 

commenters stated that their vendors 

refused to provide letters on their behalf 

to include with their hardship exception 

application. A commenter specifically 

questioned whether the 2014 Edition 

CEHRT hardship would remain in effect 

for payment year 2015. Several 

commenters suggested that we should 

allow hardship exceptions for those 

providers near retiring, as the cost to 

implement and upgrade EHR systems 

are far too costly for those with one or 

few more years of practice. Many 

commenters stated that the deadline to 

file a hardship application should be 

extended given the timing of this rule. 

Other commenters wanted us to 

consider a blanket hardship exemption 

allowing all EPs to skip attestations in 

2014 without penalty. These 

commenters noted establishing this 

alternative would push back penalties to 

2016, allowing Medicare EPs to skip 

2014 without affecting their Medicare 

reimbursement rates. 

Response: We thank the commenters 

for their input and we recognize that 

further clarification is required around 

the subject of hardship exceptions 

related to the 2014 Edition CEHRT 

availability delays. To clarify the basic 

deadlines, a provider who is unable to 

demonstrate meaningful use in 2014 

may apply to qualify for a hardship 

exception for the 2016 payment 

adjustment at any point before April 1, 

2015 for eligible hospitals and CAHS, 

and July 1, 2015 for EPs. 

The only providers for whom the 

hardship exception application deadline 

has already passed are providers seeking 

an exception from the 2015 payment 

adjustment because they did not 

successfully demonstrate meaningful 

use in 2013. This may include providers 

that are participating in the program for 

the first time in 2014 and seek to 

demonstrate meaningful use by the 

deadline established for new 

participants to avoid the 2015 payment 

adjustment. A new participant who 

applied for a hardship by the July 1 

deadline, and then later is able to meet 

meaningful use, may attest to their 

meaningful use data for 2014 without 

needing to withdraw the hardship 

application and without any other 

penalty. 

The proposals allow providers 

flexible options to meet meaningful use 

in order to qualify for an incentive 

payment for 2014, and to meet 

meaningful use to avoid the 2016 

payment adjustment. These options are 

based on a provider’s inability to fully 

implement 2014 Edition CEHRT caused 

by a delay in 2014 Edition CEHRT 

availability. 

Again, it is not necessary to extend 

the hardship exception application 

deadline for providers who are unable 

to meet meaningful use in 2014 and 

therefore wish to apply for an exception 

to the 2016 payment adjustment. We 

reiterate that the deadline for eligible 

hospitals to apply for a hardship 

exception for the 2016 payment 

adjustment is April 1, 2015. The 

deadline for EPs to apply for a hardship 

exception for the 2016 payment 

adjustment is July 1, 2015. Comments 

requesting that we consider other types 

of hardship exceptions fall outside the 

scope of this rule and will not be 

addressed. 

Comment: Many commenters 

questioned whether the proposed 

changes would affect the payment 

incentives and payment adjustments for 

2014 and subsequent years. Some 

commenters requested clarification on 

the progression through the Stage of 

meaningful use and on the participation 

schedule if providers use one of the 

CEHRT options to meet meaningful use 

for an EHR reporting period in 2014. 

These comments included suggestions 

such as extending incentive payments 

indefinitely and suggestions to provide 

additional payment incentives for 

providers who meet meaningful use 

using 2014 Edition CEHRT in 2014 as 

scheduled. On payment adjustments, 

commenters requested that we delay all 

payments adjustments for multiple 

years or eliminate payment adjustments 

entirely. 

Response: First, the schedule of 

participation for a provider in the 

Medicare EHR Incentive Program for 

2015 and subsequent years is not altered 

under this rule. For example, if a 

provider in the Medicare program first 

demonstrates meaningful use in 2012 

that is Stage 1 Year 1 for that provider. 

Subsequently, the stages and years 


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progress consecutively for the Medicare 

EHR Incentive Program whether or not 

the provider meets meaningful use; or 

whether or not the provider uses a 

different CEHRT option in 2014. So a 

Medicare provider who does Stage 1 

Year 1 in 2012 would be in Stage 2 Year 

2 in 2015 regardless of their 

participation in the intervening years. 

One of the reasons we proposed this 

rule was because we recognized that 

2014 is the last year to begin earning 

incentive payments under the Medicare 

EHR Incentive Program. This rule will 

allow providers to meet meaningful use 

and earn and incentive payment using 

the flexible CEHRT options for an EHR 

reporting period in 2014 if they were 

unable to fully implement 2014 Edition 

CEHRT due to 2014 Edition CEHRT 

availability delays. If a provider meets 

meaningful use in 2014, that provider 

may go on to earn incentive payments 

for successful participation in 2015 and 

2016 in the Medicare EHR Incentive 

Program. 

However, both the incentive payment 

amounts and timing, and the payment 

adjustment amounts and timing, are set 

by the HITECH Act. The dollar amounts 

and timing of the incentive payments 

under Medicare and Medicaid are 

established by statute (see, for example, 

section 1848(o)(1)(B) of the Act), and 

CMS does not have authority to extend 

or provide additional incentive 

payments. Similarly, the statute requires 

downward adjustments to Medicare 

payments beginning in 2015 (see, for 

example, section 1848(a)(7)(A) of the 

Act) if a provider is not a meaningful 

EHR user for an EHR reporting period 

for the payment adjustment year, and 

we do not have authority to delay or 

eliminate these adjustments. 

Comment: Several commenters 

suggested that we consider whether the 

regulation text under 42 CFR Part 495 

should be further revised to reflect the 

proposed options for using CEHRT in 

2014 and the corresponding objectives 

and measures of Stages 1 and 2 of 

meaningful use to which a provider 

would attest. In particular, the 

commenters noted that the regulation 

text for the Stage 1 criteria of 

meaningful use for EPs, eligible 

hospitals, and CAHs under § 495.6 

includes references to changes in the 

criteria applicable beginning in 2014. 

Response: We thank the commenters 

for their suggestions and agree that 

further changes to the regulation text 

will help to offer clarity for providers 

seeking to demonstrate meaningful use 

for 2014 under these options. 

Accordingly, we revised § 495.6 to 

specify the flexible options for using 

CEHRT in 2014 and the objectives and 

associated measures of meaningful use 

to which providers using these options 

would attest. Specifically, these 

revisions indicate that for an EHR 

reporting period in 2014, if a provider 

could not fully implement 2014 Edition 

CEHRT due to delays in 2014 Edition 

CEHRT availability, the following apply. 

An EP, eligible hospital, or CAH that 

uses only 2011 Edition CEHRT must 

satisfy the objectives and measures for 

Stage 1 applicable for an EHR reporting 

period in 2013. An EP, eligible hospital, 

or CAH that uses a combination of 2011 

Edition CEHRT and 2014 Edition 

CEHRT may choose to satisfy the 

objectives and measures for Stage 1 that 

were applicable for 2013 or the 

objectives and measures for Stage 1 that 

are applicable beginning with 2014, or 

if they are scheduled to begin Stage 2 in 

2014, they may choose to satisfy the 

objectives and measures for Stage 2. An 

EP, eligible hospital, or CAH that is 

scheduled to begin Stage 2 in 2014, but 

is unable to fully implement all the 

functions of their 2014 Edition CEHRT 

required for the Stage 2 objectives and 

measures due to delays in 2014 Edition 

CEHRT availability, may choose to 

satisfy the objectives and measures for 

Stage 1 that are applicable beginning 

with 2014 using 2014 Edition CEHRT. 

As noted earlier, we proposed that 

EPs, eligible hospitals, and CAHs that 

use these options must attest that they 

are unable to fully implement 2014 

Edition CEHRT because of issues related 

to 2014 Edition CEHRT availability 

delays when they attest to the 

meaningful use objectives and 

measures. In this final rule, we revised 

§ 495.8 to reflect this attestation 

requirement for providers that use the 

options for CEHRT in 2014 described in 

the preceding paragraph. 

After reviewing the public comments, 

and for the reasons stated previously, 

we are finalizing the proposals 

discussed in section III.A.1. of this final 

rule without modification as well as the 

revisions to the regulation text under 

§§ 495.6, 495.8, and 495.302. 

2. Extension of Stage 2 

In the proposed rule, we noted that 

under the current timeline shown in 

Table 1, an EP, eligible hospital or CAH 

that first became a meaningful user in 

2011 or 2012 would be required to begin 

Stage 3 on January 1, 2016 (the first day 

of CY 2016 for EPs) or October 1, 2015 

(the first day of FY 2016 for eligible 

hospitals or CAHs), respectively. 

However, because we intend to analyze 

the meaningful use Stage 2 data to 

inform our development of the criteria 

for Stage 3 of meaningful use, we 

proposed a 1-year extension of Stage 2 

for those providers as is reflected in 

Table 3. We proposed that Stage 3 

would begin in CY 2017 for EPs and FY 

2017 for eligible hospitals and CAHs 

that first became meaningful users in 

2011 or 2012. The goal of this proposed 

change is two-fold: first, to allow CMS 

and ONC to focus efforts on the 

successful implementation of the 

enhanced patient engagement, 

interoperability, and health information 

exchange requirements in Stage 2; and 

second, to use data from Stage 2 

participation to inform policy decisions 

for Stage 3. 

This proposed change would allow 

EPs, eligible hospitals, and CAHs that 

first became meaningful users in 2011 or 

2012 to begin Stage 3 on January 1, 2017 

(EPs) and October 1, 2016 (eligible 

hospitals and CAHs). We will maintain 

the existing timeline for providers that 

first became meaningful users in 2013 

and for those that begin in 2014 and 

subsequent years or until new 

certification requirements are adopted 

in subsequent rulemaking, as shown in 

Table 3. 

TABLE 3—PROPOSED STAGE OF MEANINGFUL USE CRITERIA BY FIRST PAYMENT YEAR

First 

payment 

year 

Stage of meaningful use 

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 

2011 ....... 1 1 1 1 or 2* 2 2 3 3 TBD TBD TBD 

2012 ....... ................ 1 1 1or 2* 2 2 3 3 TBD TBD TBD 

2013 ....... ................ ................ 1 1* 2 2 3 3 TBD TBD TBD 

2014 ....... ................ ................ ................ 1* 1 2 2 3 3 TBD TBD 

2015 ....... ................ ................ ................ 1 1 2 2 3 3 TBD 

2016 ....... ................ ................ ................ ................ 1 1 2 2 3 3 


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TABLE 3—PROPOSED STAGE OF MEANINGFUL USE CRITERIA BY FIRST PAYMENT YEAR—Continued 

First 

payment 

year 

Stage of meaningful use 

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 

2017 ....... ................ ................ ................ ................ ................ 1 1 2 2 3 

* 3-month quarter EHR reporting period for Medicare and continuous 90-day EHR reporting period (or 3 months at State option) for Medicaid 

EPs. All providers in their first year in 2014 use any continuous 90-day EHR reporting period. 

Comment: Many commenters 

supported what they considered to be a 

delay of Stage 2. Some commenters 

requested that we delay the start of 

Stage 2 into 2015 for private practices 

given the significant changes to the EHR 

systems, which challenge small 

independent private practices to become 

knowledgeable about new features and 

allow enough time to train staff. 

Response: As confirmed by the 

overwhelming number of comments 

received in support of these proposals, 

we believe the changes proposed give 

providers the flexibility and time 

needed to adequately upgrade and 

implement 2014 Edition CEHRT. 

However, we do wish to clarify that the 

proposals do not delay the start of Stage 

2, as characterized by several 

commenters. Rather, the proposals do 

two things: provide options to those 

providers who could not fully 

implement 2014 Edition CEHRT for an 

EHR reporting period in 2014 due to 

delays in the availability of 2014 Edition 

CEHRT, and extend Stage 2 through 

2016 so that providers who would have 

started Stage 3 in that year will not do 

so until 2017. Moreover, although we 

welcome comments and suggestion on 

the EHR Incentive Program, we did not 

propose to delay the start of Stage 2 to 

2015. The proposed rule was not 

intended to delay the forward progress 

from Stage 1 to Stage 2, but to provide 

relief for providers in any stage of 

meaningful use who were unable to 

fully implement 2014 Edition CEHRT as 

required for any stage or year of 

participation in the program. We believe 

the requirements of Stage 2 build on the 

foundation of Stage 1, and are essential 

to moving toward advanced use of 

EHRs, enhanced interoperability and 

health information exchange, and 

ultimately will support efforts to 

improve patient care. For these reasons, 

we did not propose to change the 

schedule to begin Stage 2, the reporting 

requirements, or the objectives and 

measures of Stage 2 of meaningful use. 

Comment: Commenters generally 

agree with extending Stage 2 through 

2016 for providers who would have 

begun Stage 3; however, many 

commenters further suggested delaying 

Stage 3 indefinitely or at least for one 

or more additional years. Some 

commenters believe that starting Stage 3 

in 2017 is premature. Some commenters 

requested that Stage 3 remain optional 

or not even start until at least 2018. 

Other commenters requested that CMS 

not finalize Stage 3 yet or at all and 

continue with Stages 1 and 2 until we 

change the requirement in future 

rulemaking. Another commenter 

suggested we stay on Stage 1 for the 

next few years and then implement 

Stages 2 and 3 as optional pilot 

programs. 

Response: Although we always 

welcome suggestions on ways to 

improve the EHR Incentive Program, 

other changes to Stage 3 of meaningful 

use are not under consideration in this 

rule. We urge readers to wait until the 

release of the Stage 3 proposed rule to 

provide comments on this particular 

area including potential timing for 

implementation. 

Comment: Commenters generally 

supported delaying Stage 3 to allow 

time to evaluate prior performance so 

that we can incorporate lessons learned 

from Stage 2 into Stage 3, although some 

questioned whether the timing for Stage 

3 would allow adequate reflection on 

performance in Stage 2. Some 

commenters stated that merely delaying 

Stage 3, as proposed, is not enough. A 

commenter specifically requested detail 

on how the data we obtain in Stage 2 

would be analyzed and used in Stage 3. 

Another requested that we conduct 

surveys of providers as part of Stage 3, 

to increase the quality of our 

educational guidance. 

Response: We appreciate the 

commenters’ input and reiterate that we 

intend to use the data received on 

performance at Stages 1 and 2 of 

meaningful use to inform policy 

decisions in consideration for Stage 3. 

We also are engaged with our partners 

at ONC in conducting ongoing analysis 

into meaningful use participation 

among providers including both 

readiness for advanced use of EHRs and 

provider reflections on the functions of 

CEHRT including the objectives and 

measures which represent the greatest 

potential benefit for providers and 

patients. We will use this information to 

inform decision making for the 

provisions included in Stage 3 of 

meaningful use. 

After consideration of the public 

comments received, and for the reasons 

stated previously, we are finalizing the 

proposal to extend Stage 2 through CY 

2016 for EPs and FY 2016 for eligible 

hospitals and CAHs that first became 

meaningful EHR users in CY/FY 2011 or 

2012. These providers will begin Stage 

3 in CY or FY 2017, respectively. Stage 

3 objectives and measures and reporting 

criteria will be defined in future 

rulemaking. 

B. Clinical Quality Measure Submission 

in 2014 

In the proposed rule, we described 

how beginning in 2014, as part of the 

definition of ‘‘meaningful EHR user’’ 

under 42 CFR 495.4, all eligible 

providers are required to select and 

report on CQMs from the relevant sets 

adopted in the Stage 2 final rule (77 FR 

54069 through 54075, and 77 FR 54081 

through 54089) and further specified as 

noted in the December 7, 2012 interim 

final rule with comment period (77 FR 

72985) and published on the CMS 

eCQM Library [http://cms.gov/ 

Regulations-and-Guidance/Legislation/ 

EHRIncentivePrograms/ 

eCQM_Library.html], regardless of their 

stage of meaningful use or year of 

participation in the EHR Incentive 

Program. We proposed the following 

changes for reporting on clinical quality 

measures in 2014 for EPs, eligible 

hospitals, and CAHs for the Medicare 

and Medicaid EHR Incentive Programs. 

The method of CQM submission under 

this proposal would depend on the 

edition of CEHRT a provider uses to 

record, calculate, and report its CQMs 

for the EHR reporting period in 2014. 

Due to limitations in the Registration 

and Attestation System for the EHR 

Incentive Program and other CMS data 

systems, the reporting options and 

methods for CQMs for 2014 would 

depend upon the edition of CEHRT that 

a provider uses for the EHR reporting 

period in 2014. If a provider elects to 

use only 2011 Edition CEHRT for the 

EHR reporting period in 2014, the 

provider would be required to report 

CQMs by attestation as follows: 


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• EPs would report from the set of 44 

measures and according to the reporting 

criteria finalized in the Stage 1 final rule 

(75 FR 44386 through 44411)— 

++ Three core/alternate core; 

++ Three additional measures; and 

++ The reporting period would be 

any continuous 90 days within CY 2014 

for EPs that are demonstrating 

meaningful use for the first time or a 3- 

month CY quarter for EPs that have 

previously demonstrated meaningful 

use. 

• Eligible hospitals and CAHs would 

report all 15 measures finalized in the 

Stage 1 final rule (75 FR 44411 through 

44422). 

• The reporting period would be any 

continuous 90 days within FY 2014 for 

hospitals that are demonstrating 

meaningful use for the first time or a 3- 

month FY quarter for hospitals that have 

previously demonstrated meaningful 

use. 

If a provider elects to use a 

combination of 2011 Edition and 2014 

Edition CEHRT and chooses to attest to 

the 2013 Stage 1 objectives and 

measures for its EHR reporting period in 

2014, the provider would be required to 

report CQMs by attestation using the 

same measure sets and reporting criteria 

outlined earlier for providers who elect 

to use only 2011 Edition CEHRT for the 

EHR reporting period in 2014. Because 

of the differences in how CQMs are 

calculated and tested between the 2011 

and the 2014 Editions of CEHRT, we 

further proposed that a provider may 

attest to data for the CQMs derived 

exclusively from the 2011 Edition 

CEHRT for the portion of the reporting 

period in which 2011 Edition CEHRT 

was in place. 

If a provider elects to use a 

combination of 2011 Edition and 2014 

Edition CEHRT and chooses to attest to 

the 2014 Stage 1 objectives and 

measures or the Stage 2 objectives and 

measures, the provider would be 

required to submit CQMs in accordance 

with the requirements and policies 

established for clinical quality measure 

reporting for 2014 in the Stage 2 final 

rule and subsequent rulemakings. For 

further explanation, we refer readers to 

the following: For EPs—77 FR 54049 

through 54089, 77 FR 72985 through 

72991, 78 FR 74753 through 74757; and 

for eligible hospitals and CAHs—77 FR 

54049 through 54089, 77 FR 72985 

through 72991, 78 FR 50903 through 

50906. We also proposed that a provider 

must submit CQMs in accordance with 

the requirements and policies 

established for 2014 in those 

rulemakings if the provider elects to use 

only 2014 Edition CEHRT for the entire 

duration of its EHR reporting period in 

2014, regardless of the stage of 

meaningful use that the provider 

chooses to meet. For the Medicaid EHR 

Incentive Program, the method of 

reporting CQMs for EPs and eligible 

hospitals will continue to be at the 

state’s discretion subject to our prior 

approval, as established in the Stage 2 

final rule (77 FR 54075 through 54078, 

and 54087 through 54089). 

Comment: We received a number of 

comments on a variety of issues relating 

to the CQMs under the EHR Incentive 

Program. These comments included 

multiple suggestions falling outside the 

scope of the proposals outlined in the 

proposed rule. These suggestions 

included changing or excluding one or 

more measures from the program, 

general objections to the measures or 

measure calculations, or suggestions for 

new measures for inclusion in the 

program. Other commenters suggested 

hospitals were simply not ready to 

report quality measures through 

electronic health data rather than chart 

abstraction. These commenters 

requested that we allow hospitals more 

time to move into the electronic world. 

Other commenters expressed concern 

over the difficulty specialists may 

encounter in reporting on the current 

CQMs as some CQMs are not relevant to 

their practice specialty or their patient 

population. 

Those comments falling within the 

scope of the proposed rule mainly 

sought clarification on CQM reporting 

given the flexible options proposed for 

the use of CEHRT. Some commenters 

questioned if a provider, using 2014 

Edition CEHRT, could choose to attest 

to either Stage 1 or Stage 2 objectives 

and measures, and whether the provider 

would need to submit CQMs in 

accordance with the requirements 

established for clinical quality measure 

reporting for 2014 in prior final rules. 

Other commenters sought clarification 

on the proper CQM version to use for 

attestation. Specifically, commenters 

sought confirmation that a provider 

must report on the versions of the CQMs 

in use before 2014 if they attest to the 

2013 Stage 1 objectives and measures; 

and that a provider must report on the 

2014 CQMs if they attest to the 2014 

Stage 1 objectives and measures or Stage 

2 objectives and measures. A few 

commenters added that under these 

types of situations, making vendors 

support older versions of CQMs 

represents an obstacle and burden to 

participating using an alternate CEHRT 

option. A commenter added that most 

vendors who upgraded to 2014 will not 

be able to support requirements for the 

prior version of CQMs. 

Other commenters requested 

clarification regarding quality measure 

reporting and alignment across 

programs such as how the proposals 

affect requirements for the EHR 

Incentive Program and PQRS. Some 

commenters encouraged CMS to allow 

physician participation in PQRS in 2014 

to satisfy the quality measure portion of 

the EHR Incentive Program for 2014. 

These commenters pointed out that the 

use of an older edition may not support 

electronic quality measure reporting, 

thereby resulting in duplicative 

reporting in PQRS and the EHR 

Incentive Programs. The commenters 

believe such duplicative reporting will 

be confusing and burdensome to many 

providers, and requested that CMS 

consider reporting in PQRS sufficient to 

cover both programs. 

Response: As detailed in previous 

parts of this final rule, we proposed a 

limited number of changes for the EHR 

Incentive Programs in 2014. These 

changes did not include alterations or 

exclusions to the CQMs themselves. 

We appreciate commenter’s concern 

regarding the limited number of 

measures applicable to certain 

specialties and wish to provide some 

clarification in this area. For these 

providers, we encourage them to 

evaluate the entire list of CQMs and 

choose those CQMs most applicable to 

their practice, including the more 

broadly applicable preventive care 

CQMs. We understand cases may exist 

where an EP may not find a full set of 

CQMs where they have data for both the 

numerator and denominator. We remind 

providers that they may submit a zero 

as the denominator for a CQM if that is 

the resulting calculation displayed by 

their EHR, and as long as their EHR is 

certified to report the CQM for providers 

who are using 2014 Edition CEHRT. 

Next, we wish to address those 

comments raised in relation to CQM 

reporting for the purposes of meeting 

meaningful use for an EHR reporting 

period in 2014. We remind providers 

that for any of the options for the use 

of CEHRT, a provider may report CQMs 

on a 3 month quarter, or any 90 days if 

demonstrating meaningful use for the 

first time. A provider may also report a 

full year of CQM data if they so choose. 

We confirm that a provider who 

chooses to attest to the 2013 Stage 1 

objectives and measures must also 

report the CQMs that were applicable 

for 2013 through the registration and 

attestation system in the manner that 

was required for 2013 for the purposes 

of meeting meaningful use. Although we 

acknowledge that this requirement may 

cause some difficulty with maintaining 

older measure versions that cannot be 


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electronically reported, we believe for 

many providers it outweighs the risk of 

failing to meet meaningful use due to 

the inability to fully implement 2014 

Edition CEHRT for an EHR reporting 

period in 2014. 

We further clarify that a provider who 

chooses to attest to the 2014 Stage 1 

objectives and measures or the Stage 2 

objectives and measures must also 

report the 2014 CQMs in the manner 

that was required for 2014 for the 

purposes of meeting meaningful use. 

This includes attestation or electronic 

reporting of CQM data through the 

established reporting methods. 

Finally, while we understand and 

share the commenter’s commitment to 

quality measurement alignment, we 

cannot accept submission of CQMs 

unless they are submitted using the 

previously established reporting 

methods for the EHR Incentive Program 

in 2014 using 2014 Edition CEHRT. In 

addition, we cannot accept CQM 

submissions for providers using only 

2011 Edition CEHRT unless they are 

submitted through the attestation 

process. We seek to align quality 

reporting programs where appropriate 

and reduce provider burden wherever 

possible, as shown by our previous 

efforts to align some of the reporting and 

submission requirements for the CQM 

portion of meaningful use with the EHR 

reporting option for PQRS. Moving 

forward, we will continue to evaluate 

ways to align these programs to reduce 

provider burden. 

Comment: Some commenters wanted 

clarification of the CQM submission in 

2014 and alignment of the GPRO Web 

interface program with Meaningful Use 

in 2014 as a GPRO submitter. These 

commenters questioned if the option to 

submit quality measures via the GPRO 

web interface to report the 2014 CQMs 

and meet the meaningful use 

requirement for CQM reporting would 

still be available in 2014 if they are 

attesting to the 2014 edition of CEHRT 

for Meaningful Use for either stage 1 or 

2. 

Response: We appreciate the 

commenter for these questions and 

provide confirmation that this 

understanding is correct. Group 

practices that successfully complete the 

PQRS GPRO Web Interface in 2014 will 

also satisfy the CQM component of 

meaningful use for the Medicare EHR 

Incentive Program as long as they use an 

EHR technology product certified to the 

2014 edition certification criteria. 

However, we note that EPs within the 

group will still be required to separately 

attest to their meaningful use objectives 

through the Medicare EHR Incentive 

Programs Registration and Attestation 

System. 

Comment: Several commenters 

wanted the option of mixing and 

matching between 2013 and 2014 Stage 

1 objectives and measures and the 

related CQMs. These commenters 

wanted the ability to pick some 2013 

stage 1 functional objectives and 

measures and then some 2014 stage 1 

functional objectives and measures and 

different versions of the CQMs in order 

to demonstrate meaningful use. Other 

commenters, along similar lines, wanted 

to mix and match between the 2013 

Stage 1 functional objectives and the 

2014 CQMs, or vice versa. Several 

commenters believe providers should 

have more flexibility in the CQMs they 

choose to report, regardless of the 

specific stage of meaningful use they 

meet. 

Response: We appreciate the 

commenters’ suggestions. However, we 

did not propose the ability to mix and 

match between the meaningful use 

objectives and measures and the CQMs 

for different years for a number of 

reasons. First, the flexibility proposed 

leverages the existing definitions of 

meaningful use which are tied to the use 

of specific editions of CEHRT. These 

CEHRT Editions are required to support 

specific meaningful use objectives and 

measures as well as the clinical quality 

measures required for the program. 

Second, the complexity of the systems 

required to support attestation and CQM 

submission would mean we would be 

unable to operationalize that flexibility 

in time to allow providers to attest for 

an EHR reporting period in 2014 if we 

allowed for additional flexibility in this 

manner. Therefore, providers must 

attest to the required set of objectives 

and measures applicable for the CEHRT 

option they choose, as well as the CQMs 

that relate to that option. If a provider 

chooses the 2013 Stage 1 objectives and 

measures they must attest to the CQMs 

using the reporting requirements 

specified for 2013. Providers selecting 

this option for the use of CEHRT have 

the ability to electronically report the 

2014 CQMs to quality programs such as 

PQRS and IQR separately for 

participation in those programs should 

they so choose. 

Comment: Some commenters 

expressed concern about the potential 

difficulty with reporting CQMs for the 

EHR reporting period in 2014 under the 

options outlined in the proposed rule. 

These concerns included issues around 

the backward compatibility of 2014 

Edition CEHRT to 2011 CQMs, as well 

as the overall changes to the CQMs 

available for providers to report in 2014 

which may not include CQMs they 

reported on in previous years. In 

addition, some commenters mentioned 

that their EHR modules for reporting 

CQMs might be entirely separate from 

the rest of their CEHRT and therefore 

updated at a different point in time. 

Providers also mentioned that this could 

impact the integrity of the data for 

CQMs which are derived from 2011 

Edition CEHRT or a combination of 

CEHRT editions. A commenter 

questioned whether an EP using 2011 

Edition CEHRT for 60 days of a 90-day 

reporting period (and 2014 Edition 

CEHRT for 30 days of the EHR reporting 

period), would only have to report on 

CQMs for that 60-day period if they 

chose to attest to the 2013 Stage 1 

meaningful use objectives and 

measures. 

Response: We appreciate the 

commenters for their insight on how 

CQM reporting may be a challenge 

under the proposed options, especially 

given the nuances of how the CQMs are 

collected within the CEHRT. As 

discussed previously, we are not 

considering an option to decouple the 

CQMs applicable for use in 2013 from 

the 2013 Stage 1 objectives and 

measures, nor are we considering 

separating the 2014 CQMs from the 

2014 Stage 1 objectives and measures or 

the Stage 2 objectives and measures. 

However, providers are already 

permitted under the EHR Incentive 

Programs to use a different reporting 

period for the CQMs for 2014 than for 

the objectives and measures of 

meaningful use under § 495.6. We 

believe this existing provision will help 

to mitigate the potential of a provider 

having a different timeline for 

implementation of a 2014 Edition 

CEHRT module for CQMs than for the 

rest of their 2014 Edition CEHRT. This 

means that providers could use an 

earlier quarter of data derived from their 

2011 Edition CEHRT to report CQMs if 

they use the option allowing for 

attestation to the 2013 Stage 1 objectives 

and measures using 2011 Edition 

CEHRT or a combination of 2011 and 

2014 Edition CEHRT. In addition, we 

confirm the commenter’s query that if a 

provider chooses to use a combination 

of 2011 Edition and 2014 Edition 

CEHRT and attests to the 2013 Stage 1 

meaningful use objectives and 

measures, that provider may use the 

2011 Edition CEHRT for 60 days of a 90- 

day reporting period (and 2014 Edition 

CEHRT for 30 days of the reporting 

period), and only report on CQMs for 

that 60-day period. We proposed 

allowing providers to use a subset of 

data for the CQMs in use for 2013 for 

any period of time in which the 2011 

Edition CEHRT was in place if they are 


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attesting to the 2013 Stage 1 objectives 

and measures using a combination of 

2011 Edition and 2014 Edition CEHRT. 

We believe this will help mitigate 

problems for providers that are seeking 

to use a combination of 2011 Edition 

and 2014 Edition CEHRT that may no 

longer have the same CQMs available in 

their 2014 Edition CEHRT. Finally, we 

will be clearly categorizing the data 

received from each reporting option in 

order to preserve the ability to 

effectively analyze the data received for 

the purposes of meaningful use. 

After reviewing the public comments, 

and for the reasons stated previously, 

we are finalizing the proposals 

discussed in this section (III.B) without 

modification. 

C. Revision to the CEHRT Definition for 

Flexibility in 2014 

In the May 23, 2014 proposed rule, 

ONC proposed making a minor, but 

necessary, corresponding revision to the 

CEHRT definition at 45 CFR 170.102 to 

support the CMS proposals to provide 

additional flexibility in the use of 

CEHRT for the Medicare and Medicaid 

EHR Incentive Programs during 2014. 

This proposal was intended to remove 

the cutoff date for the use of 2011 

Edition CEHRT in order to allow for its 

continued use by providers to meet 

meaningful use for an EHR reporting 

period in 2014. 

ONC proposed revising the CEHRT 

definition to change certain Federal 

fiscal year (FY)/calendar year (CY) 

cutoffs in paragraphs (1) and (2) of the 

CEHRT definition under 45 CFR 

170.102. These FY/CY cutoffs were 

finalized in ONC’s 2014 Edition final 

rule (77 FR 54257 through 54260). The 

policy in paragraph (1) of the definition 

applies to any fiscal year/calendar year 

up to and including 2013. The policy in 

paragraph (2) of the definition applies to 

FY 2014/CY 2014 and all subsequent 

years. 

Paragraph 1 sets forth policy that 

permitted the use of 2011 Edition 

certified Complete EHRs and EHR 

Modules, a combination of 2011 and 

2014 Edition certified Complete EHRs 

and EHR Modules, and 2014 Edition 

certified Complete EHRs and EHR 

Modules to be used to meet the CEHRT 

definition through the end of FY 2013/ 

CY 2013. In addition, paragraph 2 

establishes that, starting with FY 2014/ 

CY 2014, only the use of 2014 Edition 

certified Complete EHRs and EHR 

Modules could be used to meet the 

CEHRT definition. 

Therefore, we proposed the following 

specific revisions to the CEHRT 

definition, which are necessary to 

support the added flexibility in the use 

of CEHRT for providers to meet 

meaningful use for an EHR reporting 

period in 2014. The effect of these 

revisions would be to allow EPs, eligible 

hospitals, and CAHs to use either 2011 

Edition or a combination of 2011 

Edition and 2014 Edition CEHRT, 

including certified Complete EHRs and 

EHR Modules, to meet the CEHRT 

definition required to meet meaningful 

use for an EHR reporting period in 2014. 

Specifically, ONC proposed 

modifying the CEHRT definition at 45 

CFR 170.102 to replace the following: 

• ‘‘2013’’ with ‘‘2014’’ in the first 

sentence of paragraph (1). 

• ‘‘FY and CY 2014’’ with ‘‘FY and 

CY 2015’’ in paragraph (1)(i) and (1)(iii). 

• ‘‘2014’’ with ‘‘2015’’ in the first 

sentence of paragraph (2). 

Overall, this proposed revision would 

make the first day of FY 2015 (for 

eligible hospitals and CAHs) and CY 

2015 (for EPs) the new required start 

date for exclusive use of 2014 Edition 

certified Complete EHRs and EHR 

Modules to meet the CEHRT definition. 

As discussed in sections III.A. and 

III.B. of this final rule, we received 

numerous comments about the options 

available for the use of CEHRT; however 

we received no comments specific to 

this proposal to change the definition of 

CEHRT at 45 CFR 170.102. We note that 

this change does not limit the ability of 

providers to use 2014 Edition CEHRT 

for an EHR reporting period in 2014 as 

scheduled. For the reasons stated 

previously, we are finalizing this 

provision as proposed with no further 

revisions. 

IV. Attestation and the Options in This 

Final Rule 

We offer several points of clarification 

around attestation and the options 

finalized in this rule, as follows: 

• The options outlined in this final 

rule may be used only by providers who 

are unable to fully implement 2014 

Edition CEHRT for an EHR reporting 

period in 2014 due to delays in the 

availability of 2014 Edition CEHRT. 

• Providers will be required to attest 

to their inability to fully implement 

2014 Edition CEHRT as part of the 

attestation process should they select 

one of the options outlined in this final 

rule. 

• Providers may attest based on an 

EHR reporting period of any 3-month 

quarter (or any continuous 90 days for 

new participants) in 2014 (CY for EPs; 

FY for eligible hospitals and CAHs) up 

until the close of the 2014 attestation 

period 2 months following the end of 

the fiscal or calendar year. 

• Providers must attest to the 

objectives and measures supported by 

their CEHRT for the 2013 Stage 1 

objectives and measures, the 2014 Stage 

1 objectives and measures, or the Stage 

2 objectives and measures, as well as the 

related CQMs specified, for each of the 

options. There are no options to attest 

to a mixed set of objectives or split the 

CQM reporting from the option selected. 

• For providers attesting to 2014 

Stage 1 objectives and measures or Stage 

2 objectives and measures, the CQM 

reporting methods for the 2014 CQMs 

are available including attestation and 

electronic reporting options as outlined 

in section III.B of this regulation. 

Upon the effective date of this final 

rule, we generally expect the attestation 

process for the EHR reporting periods in 

2014 to be as follows, although we 

recognize that operational or systems 

issues may require procedural changes: 

• A provider will first select from the 

ONC’s Certified Health IT Product List 

(CHPL) the certified Complete EHR(s) or 

certified EHR Module(s) they used for 

the EHR reporting period in 2014. Upon 

selecting the certified products used 

during the EHR reporting period, the 

provider will need to generate a ‘‘CMS 

EHR Certification ID’’ number for their 

attestation. 

• If the provider selects from the 

CHPL only EHR technology certified to 

2011 Edition certification criteria (to 

meet the CEHRT definition), the CHPL 

will create a ‘‘CMS EHR Certification 

ID’’ number that reflects only 2011 

Edition EHR technology was selected. 

When this number is entered in the EHR 

Registration and Attestation System, it 

will interpret the number to mean that— 

++ The provider is attesting to 2013 

Stage 1 performance for 2014; 

++ Reporting on the 2013 Stage 1 

Objectives and Measures; and 

++ Attesting to the CQMs that were 

applicable for 2013 (2011 Edition). 

• If the provider selects from the 

CHPL only EHR technology certified to 

2014 Edition certification criteria (to 

meet the CEHRT definition), the CHPL 

will create a ‘‘CMS EHR Certification 

ID’’ number that reflects only 2014 

Edition EHR technology was selected. 

When this number is entered in the EHR 

Registration and Attestation System, it 

will interpret the number and will then 

trigger the system to determine the 

provider’s scheduled Stage of 

meaningful use participation. 

If the provider is scheduled to be in 

Stage 1 for 2014 the system identifies 

that— 

++ The provider remains in Stage 1 for 

2014 and is attesting to 2014 Stage 1 

performance; 

++ Reporting on the 2014 Stage 1 

Objectives and Measures; and 


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++ Reporting on the 2014 CQMs via 

attestation or electronic reporting. 

• If the provider is scheduled to be in 

Stage 2 for 2014 the system will offer 

them a choice to select Stage 1 or Stage 

2. 

If the provider selects Stage 1, the 

system then records that— 

++ The provider is attesting to 2014 

Stage 1 performance instead of their 

previously required Stage 2 performance 

level for 2014; 

++ Reporting on the 2014 Stage 1 

Objectives and Measures; and 

++ Reporting on the 2014 CQMs via 

attestation or electronic reporting; 

or 

If the provider selects Stage 2, the 

system then records that— 

++ The provider is attesting to Stage 2 

performance as scheduled for 2014; 

++ Reporting on the Stage 2 Objectives 

and Measures; and 

++ Reporting on the 2014 CQMs via 

attestation or electronic reporting 

• If the provider selects from the 

CHPL a combination of EHR technology 

certified to the 2011 Edition and 2014 

Edition certification criteria (to meet the 

CEHRT definition), the CHPL will create 

a specific ‘‘CMS EHR Certification ID’’ 

number that reflects the combination of 

2011 Edition and 2014 Edition EHR 

technology was selected. When this 

number is entered in the EHR 

Registration and Attestation System, it 

will interpret the number and then ask 

the provider to select whether they 

intend to attest to the 2013 Stage 1 

objectives and measures or whether they 

intend to attest to the 2014 Stage 1 

objectives and measures or the Stage 2 

objectives and measures. 

++ If the provider selects 2013 

objectives and measures, the provider 

remains in Stage 1 for 2014 and reports 

on the 2013 Stage 1 objectives and 

measures and attests to the clinical 

quality measures as outline previously 

for 2011 Edition CEHRT. 

++ If the provider selects 2014 

objectives and measures, the system 

determines the provider’s scheduled 

Stage of meaningful use and then 

provides the options as outlined 

previously for 2014 Edition CEHRT. 

Providers who use a 2011 Edition 

CEHRT number, or who make any 

selection which differs from their 

scheduled participation timeline, will 

be required to attest that they are unable 

to fully implement 2014 Edition CEHRT 

for the EHR reporting period in 2014 

because of issues related to 2014 Edition 

CEHRT availability delays. 

Providers must retain all relevant 

supporting documentation (in either 

paper or electronic format) used in the 

completion of the EHR Registration and 

Attestation System responses. 

Documentation to support attestation 

data for meaningful use objectives and 

CQMs must be retained for 6 years postattestation. Documentation to support 

payment calculations (such as cost 

report data) should continue to follow 

the current documentation retention 

processes. 

In the attestation disclaimer, 

providers agree to keep such records as 

necessary to demonstrate meeting 

Medicare EHR Incentive Program 

requirements and to furnish those 

records to the Medicaid state agency, 

Department of Health and Human 

Services, or contractor acting on their 

behalf. 

V. Collection of Information 

Requirements 

This document does not impose any 

new information collection 

requirements, that is, reporting, 

recordkeeping or third-party disclosure 

requirements, as defined under the 

Paperwork Reduction Act of 1995 (5 

CFR 1320). However, it does make 

reference to the currently approved 

information collection request 

associated with the Electronic Health 

Record Incentive Program. The 

information collection requirements for 

the program are currently approved 

under OMB control number 0938–1158 

with an expiration date of April 30, 

2015. 

VII. Regulatory Impact Statement 

We have examined the impact of this 

rule as required by Executive Order 

12866 on Regulatory Planning and 

Review (September 30, 1993), Executive 

Order 13563 on Improving Regulation 

and Regulatory Review (January 18, 

2011), the Regulatory Flexibility Act 

(RFA) (September 19, 1980, Pub. L. 96– 

354), section 1102(b) of the Social 

Security Act, section 202 of the 

Unfunded Mandates Reform Act of 1995 

(March 22, 1995; Pub. L. 104–4), 

Executive Order 13132 on Federalism 

(August 4, 1999) and the Congressional 

Review Act (5 U.S.C. 804(2). 

Executive Orders 12866 and 13563 

direct agencies to assess all costs and 

benefits of available regulatory 

alternatives and, if regulation is 

necessary, to select regulatory 

approaches that maximize net benefits 

(including potential economic, 

environmental, public health and safety 

effects, distributive impacts, and 

equity). Section 3(f) of Executive Order 

12866 defines a ‘‘significant regulatory 

action’’ as an action that is likely to 

result in a rule: (1) (Having an annual 

effect on the economy of $100 million 

or more in any 1 year, or adversely and 

materially affecting a sector of the 

economy, productivity, competition, 

jobs, the environment, public health or 

safety, or state, local or tribal 

governments or communities (also 

referred to as ‘‘economically 

significant’’); (2) creating a serious 

inconsistency or otherwise interfering 

with an action taken or planned by 

another agency; (3) materially altering 

the budgetary impacts of entitlement 

grants, user fees, or loan programs or the 

rights and obligations of recipients 

thereof; or (4) raising novel legal or 

policy issues arising out of legal 

mandates, the President’s priorities, or 

the principles set forth in the Executive 

Order. A regulatory impact analysis 

(RIA) must be prepared for major rules 

with economically significant effects 

($100 million or more in any 1 year). 

This rule does not include provisions 

which incur significant additional cost 

beyond the expenditures previously 

estimated for incentive payments and 

operations costs for the EHR Incentive 

Programs in 2014. Therefore, this rule 

does not reach the economic threshold 

and thus is not considered a major rule. 

The RFA requires agencies to analyze 

options for regulatory relief of small 

entities. For purposes of the RFA, small 

entities include small businesses, 

nonprofit organizations, and small 

governmental jurisdictions. Most 

hospitals and most other providers and 

suppliers are small entities, either by 

nonprofit status or by having revenues 

of less than $7.0 million to $35.5 

million in any 1 year. Individuals and 

states are not included in the definition 

of a small entity. We are not preparing 

an analysis for the RFA because we have 

determined, and the Secretary certifies, 

that this final rule would not have a 

significant economic impact on a 

substantial number of small entities. 

The reporting burden for small entities 

does not significantly change as a result 

of this rule therefore the impact on 

small entities would be negligible. 

In addition, section 1102(b) of the Act 

requires us to prepare a regulatory 

impact analysis if a rule may have a 

significant impact on the operations of 

a substantial number of small rural 

hospitals. This analysis must conform to 

the provisions of section 604 of the 

RFA. For purposes of section 1102(b) of 

the Act, we define a small rural hospital 

as a hospital that is located outside of 

a Metropolitan Statistical Area for 

Medicare payment regulations and has 

fewer than 100 beds. We are not 

preparing an analysis for section 1102(b) 

of the Act because we have determined, 

and the Secretary certifies, that this final 

rule would not have a significant impact 


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52932 Federal Register / Vol. 79, No. 171 / Thursday, September 4, 2014 / Rules and Regulations 

on the operations of a substantial 

number of small rural hospitals. 

Section 202 of the Unfunded 

Mandates Reform Act of 1995 also 

requires that agencies assess anticipated 

costs and benefits before issuing any 

rule whose mandates require spending 

in any 1 year of $100 million in 1995 

dollars, updated annually for inflation. 

In 2014, that threshold is approximately 

$141 million. This final rule will have 

no consequential effect on state, local, 

or tribal governments or on the private 

sector. 

Executive Order 13132 establishes 

certain requirements that an agency 

must meet when it promulgates a 

proposed rule (and subsequent final 

rule) that imposes substantial direct 

requirement costs on state and local 

governments, preempts state law, or 

otherwise has Federalism implications. 

Because the programs allow that states 

may receive federal assistance for 

administrative costs incurred to support 

the Medicaid EHR Incentive Programs, 

this rule does not impose substantial 

costs on state or local governments, the 

requirements of Executive Order 13132 

are not applicable. 

We proposed, for 2014 only, that EPs, 

eligible hospitals, and CAHs would be 

able to use either 2011 Edition, 2014 

Edition or a combination of 2011 and 

2014 Edition certified Complete EHRs 

and EHR Modules to meet the CEHRT 

definition and to demonstrate 

meaningful use during 2014. 

To support the policy to provide 

added flexibility in the Medicare and 

Medicaid EHR Incentive Programs 

during 2014, ONC made a minor, but 

necessary, corresponding revision to the 

CEHRT definition specified at 45 CFR 

170.102, to change certain FY/CY 

cutoffs in paragraphs (1) and (2) of the 

CEHRT definition. These FY/CY cutoffs 

were finalized in ONC’s 2014 Edition 

final rule (77 FR 54257 through 54260). 

This final rule will allow the 

flexibility to use 2011 Edition Certified 

EHR Technology, a combination of 2011 

Edition and 2014 Edition Certified EHR 

Technology, or solely 2014 Edition 

Certified EHR Technology in 2014, we 

do not believe that this will have a 

significant impact as it merely gives 

providers the flexibility to choose to 

retain and use their 2011 Edition 

CEHRT, a combination of 2011 and 2014 

Edition CEHRT, or 2014 Edition CEHRT 

in 2014. We finalized this policy in 

response to concerns that the 

availability of 2014 Edition CEHRT is 

quite limited. We refer readers to the 

impact analyses included in the final 

rule titled ‘‘Medicare and Medicaid 

Programs; Electronic Health Record 

Incentive Program—Stage 2’’ (77 FR 

53698 through 54162). Similarly, ONC 

finalized the revised CEHRT definition 

to provide additional flexibility in 

support of our proposal and ONC does 

not believe that it will have a significant 

impact (see ‘‘Health Information 

Technology: Standards, Implementation 

Specifications, and Certification Criteria 

for Electronic Health Record 

Technology, 2014 Edition; Revisions to 

the Permanent Certification Program for 

Health Information Technology’’ (77 FR 

54163 through 54292)). 

In accordance with the provisions of 

Executive Order 12866, this rule was 

reviewed by the Office of Management 

and Budget. 

List of Subjects 

42 CFR Part 495 

Administrative practice and 

procedure, Health facilities, Health 

maintenance, organizations (HMO), 

Medicare, Penalties, Privacy, Reporting 

and recordkeeping requirements. 

45 CFR Part 170 

Computer technology, Electronic 

health record, Electronic information 

system, Electronic transactions, Health, 

Health care, Health information 

technology, Health insurance, Health 

records, Hospitals, Incorporation by 

reference, Laboratories, Medicaid, 

Medicare, Privacy, Reporting and 

recordkeeping requirements, Public 

health, Security. 

For the reasons stated in the preamble 

of this final rule, the Centers for 

Medicare & Medicaid Services and the 

Department of Health and Human 

Services confirms as final without 

changes the interim rule published on 

December 7, 2012 at 77 FR 72985 and 

further amend 42 CFR Part 495 and 45 

CFR subtitle A, subchapter D, part 170 

as set forth below: 

Title 42—Public Health 

PART 495—STANDARDS FOR THE 

ELECTRONIC HEALTH RECORD 

TECHNOLOGY INCENTIVE PROGRAM 

■ 1. The authority citation for part 495 

continues to read as follows: 

Authority: Secs. 1102 and 1871 of the 

Social Security Act (42 U.S.C. 1302 and 

1395hh). 

■ 2. Section 495.6 is amended by adding 

paragraphs (a)(4), (b)(4), (h)(3), and (i)(3) 

to read as follows: 

§ 495.6 Meaningful use objectives and 

measures for EPs, eligible hospitals, and 

CAHs. 

(a) * * * 

(4) Flexible options for using certified 

EHR technology in 2014. For an EHR 

reporting period in 2014, if an EP could 

not fully implement 2014 Edition 

certified EHR technology due to delays 

in availability and uses— 

(i) Only 2011 Edition certified EHR 

technology, the EP must satisfy the 

objectives and associated measures of 

the Stage 1 criteria that were applicable 

for 2013; or 

(ii) A combination of 2011 Edition 

certified EHR technology and 2014 

Edition certified EHR technology, the EP 

may choose to satisfy one of the 

following sets of objectives and 

associated measures: 

(A) The Stage 1 criteria that were 

applicable for 2013. 

(B) The Stage 1 criteria that are 

applicable beginning 2014. 

(C) If the EP is scheduled to begin 

Stage 2 in 2014, the Stage 2 criteria. 

(b) * * * 

(4) Flexible options for using certified 

EHR technology in 2014. For an EHR 

reporting period in 2014, if an eligible 

hospital or CAH could not fully 

implement 2014 Edition certified EHR 

technology due to delays in availability 

and uses— 

(i) Only 2011 Edition certified EHR 

technology, the eligible hospital or CAH 

must satisfy the objectives and 

associated measures of the Stage 1 

criteria that were applicable for 2013; 

(ii) A combination of 2011 Edition 

certified EHR technology and 2014 

Edition certified EHR technology, the 

eligible hospital or CAH may choose to 

satisfy one of the following sets of 

objectives and associated measures: 

(A) The Stage 1 criteria that were 

applicable for 2013. 

(B) The Stage 1 criteria that are 

applicable beginning 2014. 

(C) If the eligible hospital or CAH is 

scheduled to begin Stage 2 in 2014, the 

Stage 2 criteria. 

* * * * * 

(h) * * * 

(3) Flexible options for using certified 

EHR technology in 2014. For an EHR 

reporting period in 2014, if an EP is 

scheduled to begin Stage 2 in 2014, but 

is unable to fully implement all the 

functions of 2014 Edition certified EHR 

technology required for the objectives 

and associated measures of the Stage 2 

criteria due to delays in availability, the 

EP may choose to satisfy the objectives 

and associated measures of the Stage 1 

criteria that are applicable beginning 

2014 using 2014 Edition certified EHR 

technology. 

(i) * * * 

(3) Flexible options for using certified 

EHR technology in 2014. For an EHR 

reporting period in 2014, if an eligible 

hospital or CAH is scheduled to begin 


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Federal Register / Vol. 79, No. 171 / Thursday, September 4, 2014 / Rules and Regulations 52933 

Stage 2 in 2014, but is unable to fully 

implement all the functions of 2014 

Edition certified EHR technology 

required for the objectives and 

associated measures of the Stage 2 

criteria due to delays in availability, the 

eligible hospital or CAH may choose to 

satisfy the objectives and associated 

measures of the Stage 1 criteria that are 

applicable beginning 2014 using 2014 

Edition certified EHR technology. 

* * * * * 

■ 3. Section 495.8 is amended by adding 

paragraphs (a)(2)(i)(D) and (b)(2)(i)(D). 

§ 495.8 Demonstration of meaningful use 

criteria. 

(a) * * * 

(2) * * * 

(i) * * * 

(D) For 2014 only, if the EP uses one 

of the options specified under 

§ 495.6(a)(4) or (h)(3), the EP must attest 

that he or she is unable to fully 

implement 2014 Edition certified EHR 

technology for an EHR reporting period 

in 2014 due to delays in 2014 Edition 

certified EHR technology availability. 

* * * * * 

(b) * * * 

(2) * * * 

(i) * * * 

(D) For 2014 only, if the eligible 

hospital or CAH uses one of the options 

specified under § 495.6(b)(4) or (i)(3), it 

must attest that it is unable to fully 

implement 2014 Edition certified EHR 

technology for an EHR reporting period 

in 2014 due to delays in 2014 Edition 

certified EHR technology availability. 

* * * * * 

■ 4. Section 495.302 is amended by 

adding paragraph (4) to the definition of 

‘‘Adopt, implement or upgrade’’ to read 

as follows: 

§ 495.302 Definitions. 

* * * * * 

Adopt, implement or upgrade * * * 

(4) For payment year 2014, the 

references to ‘‘certified EHR 

technology’’ in paragraphs (1) through 

(3) of this definition are deemed to be 

references to paragraph (2) of the 

definition of ‘‘Certified EHR 

Technology’’ under 45 CFR 170.102 

(that is, the definition of ‘‘Certified EHR 

Technology’’ for FY and CY 2015 and 

subsequent years). 

* * * * * 

Title 45—Public Welfare 

PART 170—HEALTH INFORMATION 

TECHNOLOGY STANDARDS, 

IMPLEMENTATION SPECIFICATIONS, 

AND CERTIFICATION CRITERIA AND 

CERTIFICATION PROGRAMS FOR 

HEALTH INFORMATION 

TECHNOLOGY 

■ 5. The authority citation for part 170 

continues to read as follows: 

Authority: 42 U.S.C. 300jj–11; 42 U.S.C. 

300jj–14; 5 U.S.C. 552. 

§ 170.102 [Amended] 

■ 6. In § 170.102, the definition of 

‘‘Certified EHR Technology’’ is amended 

as follows: 

■ A. In paragraph (1) introductory text, 

by removing the year ‘‘2013’’ and 

adding in its place the year 

‘‘2014’’. 

■ B. In paragraph (1)(i), by removing 

‘‘; or’’ and adding in its place ‘‘;’’. 

■ C. In paragraph (1)(iii), by removing 

the phrase ‘‘FY and CY 2014’’ and 

adding in its place the phrase ‘‘FY and 

CY 2015’’ and by removing the crossreference ‘‘paragraph (2);’’ and adding in 

its place the cross-reference ‘‘paragraph 

(2) of this definition’’. 

■ D. In paragraph (2) introductory text, 

by removing the phrase ‘‘FY and CY 

2014’’ and adding in its place the phrase 

‘‘FY and CY 2015’’. 

Dated: August 19, 2014. 

Marilyn Tavenner, 

Administrator, Centers for Medicare & 

Medicaid Services. 

Approved: August 27, 2014. 

Sylvia M. Burwell, 

Secretary, Department of Health and Human 

Services. 

[FR Doc. 2014–21021 Filed 8–29–14; 4:15 pm] 

BILLING CODE 4120–01–P 


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