CMS-0052-P 

DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Centers for Medicare & Medicaid Services 

42 CFR Part 495 

CMS-0052-P 

RIN 0938-AS30 

Office of the Secretary 

45 CFR Part 170 

RIN 0991-AB97 

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 

AGENCY: Centers for Medicare & Medicaid Services (CMS), and Office of the 

National Coordinator for Health Information Technology (ONC), HHS. 

ACTION: Proposed rule. 

SUMMARY: This proposed rule would change the meaningful use stage timeline and 

the definition of certified electronic health record technology (CEHRT). It would also 

change the requirements for the reporting of clinical quality measures for 2014.

DATES: To be assured consideration, comments must be received at one of the 

addresses provided below, no later than 5 p.m. on [OFR insert date 60 days after the date 

of filing for public inspection at OFR.] 

ADDRESSES: In commenting, please refer to file code CMS-0052-P. Because of staff 

and resource limitations, we cannot accept comments by facsimile (FAX) transmission. 
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 You may submit comments in one of four ways (please choose only one of the 

ways listed): 

1. Electronically. You may submit electronic comments on this regulation to 

http://www.regulations.gov. Follow the "Submit a comment" instructions. 

 2. By regular mail. You may mail written comments to the following address 

ONLY: 

 Centers for Medicare & Medicaid Services, 

Department of Health and Human Services, 

Attention: CMS-0052-P, 

P.O. Box 8013, 

Baltimore, MD 21244-1850. 

Please allow sufficient time for mailed comments to be received before the close 

of the comment period. 

3. By express or overnight mail. You may send written comments to the 

following address ONLY: 

 Centers for Medicare & Medicaid Services, 

 Department of Health and Human Services, 

 Attention: CMS-0052-P, 

 Mail Stop C4-26-05, 

 7500 Security Boulevard, 

Baltimore, MD 21244-1850.
CMS-0052-P 

4. By hand or courier. Alternatively, you may deliver (by hand or courier) 

your written comments ONLY to the following addresses prior to the close of the 

comment period: 

a. For delivery in Washington, DC-- 

 Centers for Medicare & Medicaid Services, 

Department of Health and Human Services, 

Room 445-G, Hubert H. Humphrey Building, 

 200 Independence Avenue, SW., 

 Washington, DC 20201 

(Because access to the interior of the Hubert H. Humphrey Building is not readily 

available to persons without Federal government identification, commenters are 

encouraged to leave their comments in the CMS drop slots located in the main lobby of 

the building. A stamp-in clock is available for persons wishing to retain a proof of filing 

by stamping in and retaining an extra copy of the comments being filed.) 

b. For delivery in Baltimore, MD-- 

 Centers for Medicare & Medicaid Services, 

Department of Health and Human Services, 

7500 Security Boulevard, 

Baltimore, MD 21244-1850. 

If you intend to deliver your comments to the Baltimore address, call telephone 

number (410) 786-7195 in advance to schedule your arrival with one of our staff 

members. 
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 Comments erroneously mailed to the addresses indicated as appropriate for hand 

or courier delivery may be delayed and received after the comment period. 

For information on viewing public comments, see the beginning of the 

"SUPPLEMENTARY INFORMATION" section. 

FOR FURTHER INFORMATION CONTACT: 

Elizabeth Holland, (410) 786-1309. 

Elisabeth Myers, (410) 786-4751. 

Steven Posnack, (202) 690-7151. 

SUPPLEMENTARY INFORMATION: 

Inspection of Public Comments: All comments received before the close of the comment 

period are available for viewing by the public, including any personally identifiable or 

confidential business information that is included in a comment. We post all comments 

received before the close of the comment period on the following Web site as soon as 

possible after they have been received: http://www.regulations.gov. Follow the search 

instructions on that Web site to view public comments. 

 Comments received timely will also be available for public inspection as they are 

received, generally beginning approximately 3 weeks after publication of a document, at 

the headquarters of the Centers for Medicare & Medicaid Services, 7500 Security 

Boulevard, Baltimore, Maryland 21244, Monday through Friday of each week from 

8:30 a.m. to 4 p.m. To schedule an appointment to view public comments, phone 1-800-

743-3951. 
CMS-0052-P 

I. Background 

A. Statutory Basis for the 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 eligible professionals (EPs), eligible hospitals, critical access 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 organizations (for certain qualifying EPs and hospitals that 

meaningfully use certified EHR technology (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. 

B. Considerations in Defining Meaningful Use and CEHRT 

 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 that Medicaid providers adopt, implement, 

upgrade, or meaningfully use CEHRT if they are to receive incentives under Title XIX of 
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the Act. CEHRT used in a meaningful way is one piece of the broader health information 

technology (HIT) 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). 
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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

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 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. 

II. Provisions of the Proposed Regulations 

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 and listening sessions, survey data, and information related to the 
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certification and testing process, that the amount of time available after the publication of 

the Stage 2 final rule in which to make the required coding changes to enable their EHR 

products to be certified to the 2014 Edition of EHR certification criteria was much too 

short. We understand, based on information gained from EHR technology developers 

and ONC-Authorized Certification Bodies on timing, backlogs, and the certification case 

load, many EHR products were certified later than anticipated, which has impacted the 

corresponding time available to providers—especially hospitals—to effectively deploy 

2014 Edition CEHRT and to make the necessary patient safety, staff training, and 

workflow investments 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 had received an EHR incentive payment for adopting, 

implementing, or upgrading, or for successfully demonstrating meaningful use using 

2011 Edition CEHRT. All providers need 2014 Edition CEHRT to adopt, implement, or 

upgrade, or to successfully demonstrate meaningful use for Stage 1 or Stage 2 in 2014. 

Through letters to CMS, public forums, listening sessions, and public comment at CMS 

meetings, many provider associations have expressed concern that, although 2014 Edition 

CEHRT may be available for adoption, there is a backlog of many months for the 

updated version to be installed and implemented so that providers can successfully attest 

for 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, (1) a hospital 

may have different systems in multiple settings, which all require an update and 
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integration or (2) a provider may have certain 2014 Edition CEHRT functionality that, 

once implemented in a live setting, requires software patches or workflow changes. 

 In an effort to grant more flexibility to providers who have experienced 2014 

Edition CEHRT product availability issues that impact the ability to fully implement 

2014 Edition CEHRT to attest to meaningful use using 2014 Edition CEHRT, we are 

proposing the following changes for the Medicare and Medicaid EHR Incentive 

Programs for 2014 for providers that are not able to fully implement 2014 Edition 

CEHRT for a full EHR reporting period in 2014. We are proposing to allow these EPs, 

eligible hospitals, and CAHs that could not fully implement 2014 Edition CEHRT for the 

2014 reporting year 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 for providers that could not fully implement 2014 Edition CEHRT to 

meet meaningful use for the duration of an EHR reporting period in 2014 due to delays in 

2014 Edition CEHRT availability. 

 We are proposing this change for 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. 

We strongly recommend eligible professionals, eligible hospitals, and CAHs that 

have not yet purchased EHR technology to obtain 2014 Edition CEHRT as these 
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providers will still need to use 2014 Edition CEHRT for their EHR reporting period in 

2015 as stated earlier. 

 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 are 

proposing 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 are proposing to revise 

the definition of "Adopt, Implement or Upgrade" under 42 CFR 495.302 to reflect this 

proposal. 

 The edition of certified EHR technology which is available to a provider dictates 

the stage and version of the meaningful use objectives and measures to which the 

provider will be able to attest. 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 clinical quality measures a provider 

can calculate and report because the calculations are part of the software programming 

within the CEHRT system. 

 The three 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 
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 We are proposing 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 were applicable 

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, and some of those changes were 

applicable beginning with 2013 while other changes were applicable beginning with 

2014. For ease of reference, we will refer to the Stage 1 objectives and associated 

measures under 42 CFR 495.6 that were applicable for 2013 as the "2013 Stage 1 

objectives and measures," and we will refer to the Stage 1 objectives and associated 

measures under 42 CFR 495.6 that are 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 are proposing 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 
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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 that are necessary to meet the Stage 2 

objectives and measures in time to complete their EHR reporting period in 2014. 

Therefore, under our proposal, providers who are scheduled to begin Stage 2 for the 2014 

EHR reporting period but are unable to fully implement all the functions of their 2014 

Edition CEHRT required for Stage 2 objectives and measures due to delays in 2014 

Edition CEHRT availability would have the option of using 2014 Edition CEHRT to 

attest to the 2014 Stage 1 objectives and measures for the 2014 EHR reporting period. 

Providers who are 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 are not 

proposing any changes. Under the current timeline shown in Table 1, providers that first 
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demonstrated meaningful use Stage 1 in 2011 or 2012 are required to begin Stage 2 in 

2014. We are proposing that the flexibility regarding use of the various editions of 

CEHRT as outlined earlier would apply only to the EHR reporting periods in 2014 for the 

EHR Incentive Program. Providers that were scheduled to begin Stage 2 in 2014 that 

instead meet the Stage 1 criteria in 2014 will be required to begin Stage 2 in 2015 as 

noted in Table 3. In 2015, all providers, except those in their first year of demonstrating 

meaningful use, are required to have a full year EHR reporting period. In addition, in 

2015, all providers are required to 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* 

-OR2014 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* 

-OR2014 Stage 1 objectives 

and measures* 

-ORStage 2 objectives and 

measures* 

2014 Stage 1 

objectives and 

measures* 

-ORStage 2 objectives 

and measures 

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

2014 due to delays in 2014 Edition CEHRT availability. 

The following are example scenarios under our proposal. 
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 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 delays in 2014 Edition CEHRT availability. 

● 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 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 below in section B of this proposal. 

 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 
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required to use 2014 Edition CEHRT and demonstrate Stage 1 of meaningful use in 2014. 

Under our proposal, this EP would have one 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 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 

proposed rule. 

2. Extension of Stage 2 

 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 are proposing a 1-year extension of Stage 2 for those 

providers as is reflected in Table 3. We are proposing that Stage 3 would begin in 

CY 2017 for EPs and FY 2017 for eligible hospitals and CAHs that first became 
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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 utilize 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 

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. 

 We invite public comment on our proposals. 

B. Clinical Quality Measure Submission in 2014 

 In 2014, as part of the definition of "meaningful EHR user" under 42 CFR 495.4, 

all providers are required to select and report on clinical quality measures (CQMs) from 
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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-andGuidance/Legislation/EHRIncentivePrograms/eCQM_Library.html], regardless of their 

stage of meaningful use or year of participation in the EHR Incentive Program. We are 

proposing 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 clinical quality 

measures for the selected 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 its 

EHR reporting period in 2014. If a provider elects to use only 2011 Edition CEHRT for 

its EHR reporting period in 2014, the provider would be required to report CQMs by 

attestation as follows: 

• 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 
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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 their EHR reporting periods in 2014. Because of 

the differences in how CQMs are calculated and tested between the 2011 and the 2014 

Editions of CEHRT, we are further proposing 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 
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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 

are also proposing 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). 

 We invite public comment on our proposal. 

C. Revision to the CEHRT Definition for Additional Flexibility in 2014 

 To support the CMS proposals to provide additional flexibility in the Medicare 

and Medicaid EHR Incentive Programs during 2014, ONC is proposing to make a minor, 

but necessary, corresponding revision to the CEHRT definition at 45 CFR 170.102. 

 ONC is proposing to revise 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. 
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 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 FY2013/CY 2013. 

However, paragraph (2) establishes policy that, starting with FY2014/CY 2014, only the 

use of 2014 Edition certified Complete EHRs and EHR Modules could be used to meet 

the CEHRT definition. 

 The following specific proposed revisions to the CEHRT definition are necessary 

to support the added flexibility we proposed for 2014. The effect of these proposed 

revisions would be to allow EPs, eligible hospitals, and CAHs to use either 2011 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 Stage 1 for 2014. 

 Specifically, ONC is proposing to modify 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 eligible professionals) the new required start date 

for exclusive use of 2014 Edition certified Complete EHRs and EHR Modules to meet 

the CEHRT definition. 

 We invite public comment on our proposals. 
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III. 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. 

IV. Response to Comments 

Because of the large number of public comments we normally receive on Federal 

Register documents, we are not able to acknowledge or respond to them individually. 

We will consider all comments we receive by the date and time specified in the "DATES" 

section of this preamble, and, when we proceed with a subsequent document, we will 

respond to the comments in the preamble to that document.

V. 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). 
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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). 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 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 proposed rule would 

not have a significant economic impact on a substantial number of small entities. 

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 603 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 
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proposed rule would not have a significant impact 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 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. Since this rule does not impose any costs on State or local 

governments, the requirements of Executive Order 13132 are not applicable. 

CMS is proposing, 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 CMS proposals to provide added flexibility in the Medicare and 

Medicaid EHR Incentive Programs during 2014, ONC is proposing to make 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). 
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 With respect to our proposal to 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 proposal 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 are making this 

proposal 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, the ONC proposal to revise the CEHRT 

definition merely provides additional flexibility in support of the CMS proposals 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. 
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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 proposed rule, the Centers for 

Medicare & Medicaid Services is proposing to amend 42 CFR Part 495 and the 

Department is proposing to amend 45 CFR 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 495.302 is amended by adding paragraph (4) to the definition of 

"Adopt, implement or upgrade" to read as follows: 
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§ 495.302 Definitions. 

* * * * * 

 Adopt, implement or upgrade means-- 

* * * * * 

 (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 Health 

PART 170—HEALTH INFORMATION TECHNOLOGY STANDARDS, 

IMPLEMENTATION SPECIFICATIONS, AND CERTIFICATION CRITERIA 

AND CERTIFICATION PROGRAMS FOR HEALTH INFORMATION 

TECHNOLOGY 

 3. 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] 

 4. 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 ";". 
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 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 cross-reference 

"paragraph (2);" and adding in its place the cross-reference "paragraph (2) of this 

definition". 

D. In paragraph (2), by removing the phrase "FY and CY 2014" and adding in its 

place the phrase "FY and CY 2015". 

Dated: May 12, 2014 

 _______________________________ 

Marilyn Tavenner, 

Administrator, 

 Centers for Medicare & Medicaid Services. 

Approved: May 13, 2014 

 __________________________________ 

Kathleen Sebelius, 

Secretary, 

Department of Health and Human Services. 

BILLING CODE 4120-01-P 
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[FR Doc. 2014-11944 Filed 05/20/2014 at 4:15 pm; Publication Date: 05/23/2014]