Meaningful Use: Moving from Stage 1 to Stage 2

Meaningful Use: Moving from Stage 1 to Stage 2

UnderStanding the

CMS ehr inCentive

prograMS

Adele Allison, National Director of Government Affairs

September 2012

White PaPer

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CertificationsSuccessEHS is a nationally acclaimed vendor providing Electronic Health Record (EHR) and Practice Management solutions with Integrated Medical Billing Services. SuccessEHS also provides Electronic Dental Record (EDR) and Dental Imaging solutions. Founded in 1995, SuccessEHS established itself as a leader in the emerging practice management applications market by delivering an innovative blend of clinical, operational and financial software paired with a suite of specialized integrated success services. SuccessEHS, entirely in-house developed and supported, has achieved multiple certifications from CCHIT.

SuccessEHS’s SuccessEHS 6.1 is a CCHIT Certified ® 2011 Ambulatory EHR additionally certified for Child Health, with a 5-star usability rating.

SuccessEHS 6.1 is also 2011/2012 compliant and was certified as a Complete EHR on September 30, 2010 by the Certification Commission for Health Information Technology (CCHIT®), an ONC-ATCB, in accordance with the applicable certification criteria for Eligible Providers adopted by the Secretary of Health and Human Services. The certification ID number is CC-1112-909422-1. The clinical quality measures certified include: NQF 0421, NQF 0013, NQF 0028, NQF 0041, NQF 0024, NQF 0038, NQF 0043, NQF 0031, and NQF 0034. The additional software used in testing includes Multum, SuccessEHS Patient Portal, ExitCare Patient Education, and Oracle. This certification neither represents an endorsement by the U.S. Department of Health and Human Services nor guarantees the receipt of incentive payments.

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Moving from Stage 1 to Stage 21

the hiteCh portion of the american recovery and reinvestment act of 2009 (arra) establishes the CMS Medicare and Medicaid ehr incentive programs.

• The program rewards and accelerates adoption of interoperable certified electronic health record technology

• Eligible Professionals can receive incentives for timely adoption; penalties under Medicare for non-adoption

• Each provider must meet the requirements contained herein individually and annually• Stage 1 Final Rule was released on July 14, 2010• Stage 2 Final Rule was released on Aug. 23, 2012 and includes changes to Stage 1

Contained in this White paper:• Medicare and Medicaid EHR Incentive Program Highlights including Program Penalties• Meaningful Use Stage 1 Changes• Meaningful Use Stage 2 Objectives, Measures, Exclusions, Thresholds and Health IT Needs• Clinical Quality Measures

Meaningful Use: Moving from Stage 1 to Stage 2

UnderStanding the CMS ehr inCentive prograMSAdele Allison, National Director of Government Affairs

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ehr incentive program highlightsOn Sept. 12, 2012, Dr. Farzad Mostashari, the National Coordinator for Health Information Technology within the Office of National Coordinator (ONC), addressed attendees at the HIMSS Policy Summit in Washington, D.C. “Technology is growing in leaps and bounds. Let’s bring that to health care,” he said. That is the essence of HITECH under the American Recovery and Reinvestment Act of 2009 (ARRA). HITECH is about rewarding and accelerating the adoption of interoperable certified electronic health record technology (CEHRT). The goal is to let CEHRT be a servant to clinicians working through efforts in improving quality and delivering care at a lower cost.

The rules governing “meaningful use” of CEHRT are bestowed to the public in stages. There are four marks to this transformative process:

• Adopt and use certified electronic health record technology (CEHRT)• Capture data in a structured format• Move data between disparate systems interoperably• Report data to the federal and state government

Stage 1 rules were released to the public on July 13, 2010 (Centers for Medicare & Medicaid Services [CMS], 2010). The final rules regulating Stage 2 were released on Aug. 23, 2012 (CMS, 2012c). As the market positions for the next wave of Meaningful Use that starts in 2014, there are some obvious trends resulting from this legislative trigger. Since the enacting of ARRA and the launch of Stage 1, health care in the U.S. has seen more progress in 20 months than in 20 years. According to the Harvard School of Public Health, 57 percent of U.S. physicians were using “any” EHR technology in 2011 (DesRoches, Painter, & Jha, 2012). More than one of every two (58 percent) office-based physicians was an ePrescriber in 2011, an increase from just 10 percent or one in 10 just three years ago (surescripts, 2012). Approximately 75 percent of U.S. hospitals have registered for meaningful use and around 50 percent have some portion of Stage 1 incentives totaling over $4.2 billion (CMS, 2012b). Likewise, nearly 50 percent of the eligible professionals in the U.S. have registered for either the Medicare or the Medicaid EHR Incentive Program and almost 25 percent have received some portion of Stage 1 incentives totaling almost $2.1 billion (CMS, 2012b).

The industry has realized gains in population health management with the launch of meaningful use. CEHRT is about arming a clinician to care about all of his/her patients, not just the ones that show up for an appointment. The adoption of clinical decision support has moved providers from simply accounting for patients to measured improvement in care. At Cleveland Clinic Florida, the pre-EHR rate of hypoglycemia subcutaneous insulin order sets was 9.6 percent and dropped to 3.8 percent after adoption (iHealthBeat, 2012). Additionally, the rates of euglycemia or normal blood sugar increased from 60 percent to 65 percent (iHealthBeat, 2012). Conclusion? CEHRT adoption is done so that patients can get better, faster.

Providers should be congratulated on the progress made. Stage 1 was about adoption and use; capturing data. Now as we look ahead to Stage 2, the infrastructure wave is at hand. Policy is gearing up for production health information exchange (HIE) and patient engagement, both of which must be bigger than the practice financial network to consider the community of providers. HIE as a verb, not HIE as a noun, is the imperative. The patient is the one with skin in the game, so providers are being asked to engage the patient as an active member of the care team – let them help. Success will be measured by the extent to which the patient and/or their caregiver can get their information from whatever stakeholder needed. This new era should be achievable within the next five years.


Before we get to the meat of Meaningful Use Stage 2 (MU2), let us cover some common questions.

1 What happens when the incentive money runs out?

The EHR Incentive Programs are not funded by Senate appropriations. It is an entitlement program, meaning eligible providers (EPs) are entitled to the incentives as a matter of law. The timelines under which the incentives can be received are statutorily defined under ARRA. Medicare EPs are ineligible for incentives if initiating after CY2014; Medicaid EPs must initiate by CY2016. (See Tables 1 and 2)

Table 1 - Medicare EHR Incentive Program Incentive Table

Calendar Year

First Calendar Year in which the EP Receives an Incentive Payment

2011 2012 2013 2014 2015 and subsequent years

2011 $18,000

2012 $12,000 $18,000

2013 $8,000 $12,000 $15,000

2014 $4,000 $8,000 $12,000 $12,000

2015 $2,000 $4,000 $8,000 $8,000 $0

2016 $2,000 $4,000 $4,000 $0

Total $44,000 $44,000 $39,000 $24,000 $0

Shortage Area Totals* $48,400 $48,400 $42,900 $26,400 $0

Table 2 - Medicaid EHR Incentive Program Incentive Table

Calendar YearFirst Calendar Year in which the EP Receives an Incentive Payment

2011 2012 2013 2014 2015 2016

2011 $21,250

2012 $8,500 $21,250

2013 $8,500 $8,500 $21,250

2014 $8,500 $8,500 $8,500 $21,250

2015 $8,500 $8,500 $8,500 $8,500 $21,250

2016 $8,500 $8,500 $8,500 $8,500 $8,500 $21,250

2017 $0 $8,500 $8,500 $8,500 $8,500 $8,500

2018 $0 $0 $8,500 $8,500 $8,500 $8,500

2019 $0 $0 $0 $8,500 $8,500 $8,500

2020 $0 $0 $0 $0 $8,500 $8,500

2021 $0 $0 $0 $0 $0 $8,500

Total $63,750 $63,750 $63,750 $63,750 $63,750 $63,750

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2 Must an EP be at Meaningful Use Stage 3 by CY2015 to avoid the Medicare payment adjustments?

No. The statute requires the Secretary to implement penalties starting in CY2015 for non-adoption. However, to whom these are applied are a matter of policymaking. Under the Final Rule for Stage 2, an EP who achieves any meaningful use in CY2013 will have no adjustments in 2015. EPs that register for the Medicare program and attest to Stage 1 (at a minimum) by Oct. 1, 2014, will experience no adjustment in 2015. Additionally, the Secretary offers hardship exceptions to the application of penalties, namely:

• Lack of availability of the Internet or IT infrastructure barriers• A time-limited exception of two years for newly practicing EPs• Unforeseen circumstances (e.g., natural disaster) on a case-by-case basis• Demonstration of lack of face-to-face or telemedicine interaction with patients and lack of a need to follow-

up with patients (e.g. anesthesiology)• A combination of clinical features limiting a provider’s patient interaction and lack of control over availability

of CEHRT at practice locations for 50 percent or more of their encounters.

However, Medicaid EPs should be advised – receiving a Medicaid incentive for adopt, implement or upgrade (AIU) is not meaningful use and the EP would still be subject to the Medicare payment adjustment. As of July 1st of the year preceding the payment adjustment year, EPs whose primary specialties are anesthesiology, radiology or pathology can receive a hardship exception based on the fourth bullet above.

3 Will providers who are part of a larger group be able to submit attestation as a group or must they continue to attest individually?

Stage 2 allows for batch or group reporting. Starting in 2014, groups will be permitted to submit attestation information for their entire individual EPs in a single file uploaded to the Attestation System as opposed to having each individual EP enter data.

4 Which measures in Stage 2 will require production HIE?

The Stage 2 final rule sets forth three actual use cases for electronic information exchange:

• Sending a summary of the care record for more than 50 percent of transitions of care and referrals, • Electronic transmission of a summary of care for more than 10 percent of transitions of care and referrals,

and• At least one summary of care document sent electronically to a recipient with a different EHR vendor or to

the CMS “test” EHR.

6 FOOTNOTE

Moving from Stage 1 to Stage 25www.successehs.com

5 Did the Secretary uphold the proposed delay in the launch of Stage 2 Meaningful Use?

Yes. The MU2 final rule confirms the delay of the Stage 2 onset until CY2014. Additionally, in CY2014, EPs performing the first year of Stage 2 or the second year of Stage 1 would have an EHR reporting period of 3 months, defined by quarter (Jan-Mar; Apr-Jun; Jul-Sep; Oct-Dec). (See Table 3)

However, latecomers of CEHRT initiating meaningful use after 2015 would be subject to a full year. The reason for the full year of reporting is for consideration of data integrity between the clinical quality submissions and efforts towards alignment with other federal programs initiated or strengthened under ACA, including the Physician Quality Reporting System (PQRS), Accountable Care Organizations and others.

Table 3 - Revised Meaningful Use Timeline (Red line of demarcation indicates the point of Medicare Payment Adjustments)

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

6 Has there been an expansion in the Medicaid patient volume calculation for eligibility?

Yes. The Final Rule for Stage 1 meaningful use sets the general threshold per provider at 30 percent. Pediatricians still qualify with a reduced threshold, as low as 20 percent, although the incentive will be reduced by one third. Pediatricians that meet the 30 percent volume threshold would be eligible for the full incentive. Additionally, providers performing more than 50 percent of their services at a Federally Qualified Health Center (FQHC) or a Rural Health Center (RHC) are afforded special considerations in the calculation. Under Stage 1, the EP would use a 90-day date range for the previous calendar year. Under the Stage 2 Rule, the look-back period to make this calculation has been changed to the 12 months preceding attestation and is no longer tied to a calendar year.

The definition of what counts as a Medicaid patient encounter has changed to include encounters for anyone enrolled in a Medicaid program, including Medicaid expansion encounters (except stand-alone Title 21), and those with a zero-pay claims. This delivers added flexibility in the look-back period for the overall patient volume calculation. The encounter can be counted in the numerator if the patient is a Medicaid-enrolled individual,

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Steps for EHR Incentive Program Registration

• Eligible Professional (EP) must register on the national website (www.cms.gov/EHRIncentive Programs/)

• Go to the Registration Tab and select “Register” under Action

• Select “Start Registration” (Note: The system will apply a check mark for completed topics. Once all topics are “complete,” the user can select “Begin submission.”)

• Answer the questions with a red * including the incentive program selected, type of EP, and whether they have a certified EHR. You will need the ONC Certification number for the EHR from the ONC Certified Health IT Product List website (http://onc-chpl.force.com/ehrcert).

• Follow the instructions on each page, selecting “Save and Continue” upon completion of the web page.

• Upon satisfactory completion of the initial pages, the site will display check marks in three areas: EHR Incentive Program, Personal Information, and Business Address and Phone.

• Upon conclusion, select “Begin Submission,” review/validate information, agree to terms and conditions and hit “Submit.”

• The EP will receive a confirmation and Registration ID tracking number – KEEP TRACK OF THIS NUMBER.

• FOR MEDICAID EPs: Because Medicaid is state run, the EP’s State Medicaid Agency will need to collect and verify additional eligibility information, such as patient volume and adoption, implementation, or upgraded certified EHR technology. Each state will have an “eligibility verification tool” and the CMS website provides a link to find the EP’s state (www.cms.gov/apps/files/medicaid-HIT-sites/).

• Medicaid EPs must participate with their state Medicaid Agency and meet a state volume threshold calculation of 30 percent Medicaid patient encounters; pediatricians can still qualify at 20 percent.

regardless of the payment liability and including CHIP encounters for patients in Title 19 and Title 21 expansion programs. However, this does not include separate stand-alone CHIP programs for encounters with patients in Title 21-funded Medicaid expansions.

Zero pay claims includes claims: 1 – denied due to the Medicaid patient having maxed-out the service limit; 2 – denied because of non-coverage under the State’s Medicaid program; 3 – paid at $0 because another payer’s payment exceeded the Medicaid payment; or, 4 – denied due to lack of timely submission.


Stage 1 program ChangesStage 1 Meaningful Use launched for EPs in CY2011. Adhering to the concept that one must crawl before they walk before they run, all providers must achieve meaningful use under the Stage 1 criteria before moving to Stage 2. However, CMS learned much from its first year of program administration, including the fact that some of the Stage 1 measures needed to be tweaked. As a result, the Stage 2 Final Rule incorporates some changes to the Stage 1 meaningful use objectives, measures and exclusions for EPs. Some changes go into effect as early as Jan. 1, 2013, for EPs while others will not take effect until the 2014 calendar year and will be optional to EPs in 2013.

CY2013 Core Measure CPOE

EPs who are Stage 1 meaningful users in 2013 will have an optional alternative measure for computerized provider order entry (CPOE). As of January 2013, an EP can select either of the following measures to satisfy this core objective:

• Original: The denominator is the number of unique patients with at least one medication seen by an EP during the EHR reporting period.

• Alternative: The denominator is the number of orders for medications during the EHR reporting period. Also, this will be the denominator for Stage 2 EPs.

CY2013 Core Measure ePrescribing

Stage 1 EPs will have an added exclusion clause for ePrescribing wherein the provider is not within a ten (10) mile radius of a pharmacy that accepts electronic prescriptions.

CY2013 Core Measure Height, Weight and BP and Patient Age

Currently, Stage 1 EP must record all three vital signs (height, weight, blood pressure) and can only exercise an exclusion if all three are not relevant to their scope of practice. Starting in 2013, EPs will have the option of an alternative measure that becomes core beginning in CY2014, as follows:

• Original: This measure can be excluded if height, weight and blood pressure are irrelevant to the scope of the EP’s practice.

• 2013 Alternative / 2014 Permanent Change: Vitals are separated into three exclusion options: 1 – all three vitals are not relevant; 2 – height and weight are not relevant, in which case the EP would record blood pressure; or, 3 – blood pressure is not relevant, in which case the EP would record height and weight.

Additionally, the current measure requires vital signs be recorded for more than 50 percent of all unique patients ages 2 and older. This requirement has been amended to make the age limit 3 and older on blood pressure, while height and weight would apply to all ages. Thus, the age exclusion clause on the measure has been amended as follows:

• Original: The EP sees no patients ages 2 years and older.• 2013 Alternative / 2014 Permanent Change: The EP sees no patients ages 3 years and older.

CY2013 Core Measure of Electronic Exchange of Key Clinical Information

As of 2013, Stage 1 EPs will no longer be required to meet the core measure of a test of exchanging key clinical information. Why? Simply because there was no value seen in this measure and the industry is moving toward more vigorous electronic exchange in Stage 2, making the measure somewhat obsolete.

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CY2013 Core Measure of Reporting Clinical Quality Measures

The EP’s reporting of clinical quality measures (CQMs) is no longer a separate measure/objective for meaningful use as of 2013. Reporting CQMs will become part of the definition of being a meaningful user. Removal of this objective as a standalone requirement was deemed redundant since providers would be expected to submit data electronically, and that submission will drive compliance with meaningful use in and of itself.

CY2013 Menu Measures Public Health Reporting

All of the Stage 1 public health objectives – immunization registry, syndromic surveillance, or reportable lab results – will require EPs to perform at least one test of their CEHRT’s ability to send data to public health agencies, unless prohibited. The intent is to encourage submission even if it is not required by state or local law. Additionally, if successful with the test, EPs should move into production with the entity with whom they have tested.

CY2014 Menu Measure Exclusion Clauses

First of all, CMS is closing the loophole on menu measure exclusions. Under Stage 1, EPs are required to select five of the 10 menu measures, including at least one public health measure. Many of these measures have exclusion clauses. As of January 2014, an EP pursuing Stage 1 meaningful use can no longer count an exclusion measure toward the five measure minimum if an alternative menu measure can be met. However, the EP will not be penalized if they select a menu measure and the exclusion is valid where they would also qualify for exclusions on all remaining menu objectives. In other words if there are five applicable menu measures available to the EP, he/she must go with the five that are available.

CY2014 Core Measure Electronic Copy and Menu Measure Electronic Access to Health Information

Starting in 2014, Stage 1 EPs will replace the two measures of providing patients with electronic copies of and access to their health information with the Stage 2 patient engagement measure of the ability to view, download and transmit health information. As of 2014, CEHRT must be capable of delivering this functionality and therefore with the advance of health IT, the Stage 1 measure will be upgraded, as well. Therefore, EPs who are at Stage 1 meaningful use starting in 2014 will replace the following two measures with the new Stage 2 patient engagement core measure:

• Stage 1 Core Measure, Obsolete CY2014: Provide patients with an electronic copy of their health information, including diagnostic test results, problem list, medication lists, medication allergies, discharge summary and/or procedures, upon request.

• Stage 1 Menu Measure, Obsolete CY2014: Provide patients with timely electronic access to their health information, including lab results, problem list, medication lists, and allergies within four business days of the information being available to the EP.

• Replacement Measure (Core) CY2014 for Stage 1: Patients can view online, download and transfer information within four days of the information being available to the EP, subject to the EP’s discretion to withhold certain information. More than 50 percent of all unique patients seen by the EP during the EHR reporting period are provided this timely online access to their health information.


Stage 2 objectives and MeasuresEach eligible professional (EP) seeking Meaningful Use Stage 2 incentives must meet a total of 20 of the 23 measures. The Final Rule issued by CMS on Aug. 23, 2012, and published in the Federal Register on Sept. 4, 2012, sets forth 17 Core Measures (tasks) and six Menu Measures. All 17 Core Objectives/Measures and three of five from the Menu Objectives/Measures group must be met. Below identifies all 26 measures and the corresponding thresholds and potential exclusions. The table includes considerations to evaluate health IT needs and potential gaps in CEHRT.

17 Core Objectives for EPs

No. Objective Measure ThresholdNew, Revised,

Expanded, Consolidated or Unchanged

Exclusion Clauses Health IT Needs

1Computerized

Physician Order Entry

(CPOE)

Use CPOE for medications, lab and radiology orders entered by any professional permitted by law

60% Rx (up from 40%); 30% labs; 30% radiology

ExpandedEP has < 100 Rx, lab, radiology orders collectively

• Orders Management

• Orders Audit Trails• Delinquency Alerts

2

Generate and Transmit Permissible

Prescriptions Electronically

Using a certified EHR technology and compared to at least 1 drug formulary (still excludes controlled substance [Sch. II-V] and OTC)

50% (up from 40%) Expanded

• EP writes <100 Rx; or,

• No pharmacy w/in 10 miles of the practice

• Rx Database• Interaction Alerting• eRx (e.g.,

Surescripts)• Formulary

Checking

3Record Patient

Demographics

Gender, race, ethnicity, DOB, and preferred language as structured data

80% (up from 50%) Expanded None

• Patient Administration

• Master Patient Index

4Record

Vital Signs and Chart Changes

Height & weight (all ages), blood pressure (ages 3+), BMI (all ages), and growth charts for children (0-20) as structured data

80% (up from 50%)

Revised/Expanded

• No pts. age 3+• Ht., Wt., BP

irrelevant• BP only

irrelevant

• Vitals Capture Tool• Detailed Entry• Normal Ranges

and Graphing• Automated BMI

and Growth Charts

5Record

Smoking Status

Patients age 13 and older as structured data

80% (up from 50%) Expanded EP does not see

pts. age 13+

• Smoking Status• Alerting to lack of

Documentation

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6

Implement Clinical Decision Support

and Track Compliance

Implement CDS to improve on high-priority condition:1. 5 CDS

interventions for 5 or more CQMs during entire reporting period; and

2. Enable drug-drug and drug-allergy checks for entire reporting period.

5 Rules and Rx alerting by

attestation

Expanded / Consolidated

2nd measure only – EP writes < 100 Rx

• Evidence-based guidelines

• Population Management Tool

• Point-of-Care Alerting for non-adherence

• Static and Customizable Interventions

7Incorporate Clinical Lab Test Results

into EHR

Incorporated as structured data – positive/negative or numerical format – within the EHR

55% (up from 40% and made

Core)Expanded

EP orders no lab tests during EHR reporting period

• Bidirectional Lab Interface for in-house and/or reference labs

8Generate Lists of Patients by

Condition

1 List with a Specific Condition for use in quality improvement, reduction of disparities, research or outreach

By attestation (Made Core) Unchanged None



• Action Tracking and Escalation

• Patient Portal Alerting

• Form letter merging• Phone Lists

9Send

Reminders to Patients

Preventive and follow-up care for all patients based on clinically relevant info for anyone with an OV in past 24 months

10% (down from 20%, all patients and made core)

ExpandedEP has no office visit in previous 24 months



• Action Tracking and Escalation

• Patient Portal Alerting

• Form letter merging• Phone Lists






10

Timely Electronic

Access to Health

Information

Patients can view online, download and transfer info within 4 days of being available to EP, subject to EPs discretion to withhold certain info

1. 50% of all pts., and

2. 5% of pts. access

New

• EP has no orders / creates info required

• >50% visit in county with >50% with 3Mbps broadband avail.

• Advanced Patient Portal

• Robust Portal Integration to CEHRT

• Access Tracking• Patient

Administration

11Provide Patients

with Clinical Summaries

For each office visit to patients within 1 business day, which includes up-to-date lists of problems, medications and Rx allergies (paper & electronic must be avail. to pt.)

50% (Unchanged) Expanded / Consolidated

EP has no office visit during EHR reporting period


• Robust integration of Portal to CEHRT

12

Use of Secured

Messaging with Patients

Send secured messages to patients seen during reporting period

5% NewEP has no office visit during EHR reporting period


• Messaging Capabilities

13

Use EHR for Patient-

Specific Education Resources

Provide patient-specific education resources to all patients

10% (Unchanged but made Core and “if appropriate” removed)

ExpandedEP has no office visit during EHR reporting period

• Integrated Patient Education Tools

• Static and Customizable forms

• Multi-language

14Perform

Medication Reconciliation

During transitions of care (TOC) into care of EP

50% (Made Core) Unchanged

EP not recipient of any TOC during EHR reporting period

• HIE (Direct or Exchange)

• Rx History

15Provide

Summary of Care Record

Patients referred or transitioned to another provider or setting and electronically transmit to a different system.

1. 50% of TOC or referrals (made core)

2. 10% electronically transmitted

Expanded; New

EP neither transfers nor refers patient during EHR reporting period <100 times

• CCDA• HIE (Direct or

Exchange)• HIE Tracking

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16

Submission of Electronic Immunization

Data to Registry/

Information Systems

Ongoing submission During Entire EHR Reporting Period (Made Core)

Expanded

• EP does not admin. immunizations,

• No electronic registry available*

• No timely provision of information on available registry

• No registry that accepts CEHRT standards available*

• Immunization Registry Interface or HIE submission to Immunization Registry

• CEHRT Immunization Guideline Adherence Tracking Tool

• Detailed Immunization Tool

17

Implement Systems to Protect

Privacy and Security of

Patient Data

Conduct/review a security risk analysis; implement security updates as necessary and correct security deficiencies; encrypt data at rest in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3)

During Reporting Period by attestation

Expanded None

• Thin-Client CEHRT Operations

• Encryption Technology

• (Optional) Data-hosting

• Internet Access

*Exclusion does not apply if the registry can accept data through a designated HIE.


3 of 6 Menu Objectives

No. Objective Measure Threshold

New, Revised,

Expanded, Consolidated

or Unchanged

Exclusions Health IT Needs

1 Imaging Results and Information

Are accessible through the CEHRT

10% New

• EP does not perform diagnostic interpret. of scans/test whose result is an image during reporting period, or

• EP orders imaging results < 100 times

• PACS Results Interface

• PACS Portal for image retrieval

2 Patient Family Health History

Structured data entry for one or more first-degree relatives

20% New EP has no office visits during reporting period

• Structured Knowledge Base for documentation

• Family Health History clinical concepts

3 Record Electronic Notes

At least 1 note created, edited and signed by EP for pts with at least 1 OV during EHR reporting period

30% New

• No office visits during reporting period, or

• >50% visit in county with >50% with 3Mbps broadband access

• Structured Knowledge Base for documentation,

• Voice Recognition, • Customizable

Forms, and/or• Ability to type note

4

Submission of Electronic Syndromic

Surveillance Data

Ongoing data submission to Public Health agencies (where agencies can accept electronic data)

During Entire EHR Reporting

Period

Expanded

• EP does not collect any data,

• No electronic registry available*


• No registry that accepts CEHRT standards available*

• Public Health Registry Interface or HIE submission to Public Health Registry

• CEHRT Surveillance tracking tools

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3 of 6 Menu Objectives

No. Objective Measure Threshold

New, Revised,

Expanded, Consolidated

or Unchanged

Exclusions Health IT Needs

5 Submission of Cancer Cases

Ongoing data submission to a state cancer registry


Period

New

• EP does not diagnose or directly treat CA

• No public health agency is capable of receiving data


• No registry that accepts CEHRT standards available

• State Cancer Registry Interface or HIE submission to State Cancer Registry

• CEHRT Cancer tracking tools

6Submission

of Specialized Cases

Ongoing data submission to a specialized registry


Period

New

• EP does not diagnose or directly treat CA

• No public health agency is capable of receiving data


• No registry that accepts CEHRT standards available

• Specialized Registry Interface or HIE submission to Specialized Registry

• CEHRT Specialized Case tracking tools

*Exclusion does not apply if the registry can accept data through a designated HIE.


Clinical Quality MeasuresThe fourth mark of meaningful use is reporting clinical data. All providers are required to report on Clinical Quality Measures (CQMs) as part of demonstrating meaningful use. It is no longer an individual measure because it is intrinsic with the EHR Incentive Programs and expected.

In the Stage 2 final rule as required under the Affordable Care Act (ACA), CMS is aligning clinical reporting under meaningful use with other reporting programs including PQRS and ePrescribing. The idea is to ease and streamline the reporting burden for providers. Along these lines, the CMS alignment includes:

• The ability to choose the same measure for different program measure sets,• Collaboration through public input into the design and coordination of measures, and• Minimizing multiple submission requirements and mechanisms through program association.

There will be no change in CQMs through 2013, although there are two reporting methods available for Stage 1 measures in 2012 and 2013: 1 – Standard manual calculation and attestation on the CMS website; or, 2 – eReporting pilot under the PQRS EHR Incentive Program Pilot.

Medicaid EPs will continue to submit CQMs through their state-based attestation submission. Each state Medicaid agency is responsible for sharing the ins and outs of this electronic process with its provider community. In addition to the process, the state can set forth the timeline, subject to CMS’ prior approval.

Providers are asked to select CQMs from at least three of six HHS National Quality Strategy domains, as follows:

1 Patient and Family Engagement

2 Patient Safety

3 Care Coordination

4 Population and Public Health

5 Efficient Use of Healthcare Resources

6 Clinical Processes/Effectiveness

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Manual calculation and simple attestation of CQM data will not be sufficient regardless of the meaningful use stage starting in CY2014. CMS is updating the electronic specifications for the CQMs for CEHRT. All providers, regardless of their meaningful use stage, will be required to electronically report their CQM data to CMS beginning in 2014 under the Medicare program. Likewise, Medicaid providers will be expected to electronically report CQMs to their state. Because CQM reporting is being removed as a formal measure, the stage of meaningful use becomes moot. Therefore, all EPs must report CQMs when pursuing Meaningful Use:

• Prior to 2014: Through manual attestation, six of a total 44 available CQMs that includes three core or alternative core and three menu.

• CY2014 and Beyond: Through electronic submission, nine out of a total 64 available CQMs that includes one measure in three National Quality Strategy domains, at a minimum. CMS recommends a core set of CQMs that include: nine CQMs for the adult population; nine CQMs for the pediatric population; and, prioritized National Quality Strategy domains.

Starting in 2014, Medicare EPs in the first year of meaningful use will submit an aggregation of data for all payers through attestation. After the Medicare EPs first year of demonstrating meaningful use, he/she will have the option to electronically report nine CQMs in aggregate for all payers; or, report an individual continuity of care document (CCD) on the individual Medicare patient only by satisfying the requirements of PQRS EHR Direct reporting using their CEHRT. EPs who are members of an Accountable Care Organization (ACO) will report under the group reporting option for the Medicare Shared Savings Program or Pioneer ACO. EPs can also report via the PQRS group reporting option to satisfy CQM reporting under meaningful use.

in ConclusionSince its launch in January 2011 through July 2012, approximately 117,000 eligible professionals and 3,600 hospitals have received incentive funds (CMS, 2012a). Looking at the Stage 1 in hindsight, this program triggered the simple adoption, use and data capture through CEHRT. Stage 2 begins to leverage CEHRT and the data contained therein to engage the patient, an essential shift in the paradigm that is vital to the mission of improving quality and lowering costs of health care in the U.S. Stage 2 also begins to breakdown the walls between providers through data sharing to bolster collaboration with undoubted returns in quality and costs. Finally, Stage 2 automated the process of clinical quality reporting. This reporting of data is foundational to efforts underway in payment reform.

Essentially, Stage 2 offers providers a three-legged stool – engage patients, share data and measure quality – at a time when the U.S. cannot sustain the status quo. Change is hard. The vision is set. Will it work? That depends on the community of providers.


Centers for Medicare & Medicaid Services. (2010). Medicare and Medicaid Programs: Electronic Health Record Incentive Program: Final rule. Retrieved Sept. 17, 2012, from http://www.gpo.gov/fdsys/pkg/FR-2010-07-28/pdf/2010-17207.pdf

Centers for Medicare & Medicaid Services. (2012a). EHR Incentive Program. Retrieved Sept. 17, 2012, from http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/July2012_MonthlyReports.pdf

Centers for Medicare & Medicaid Services. (2012b). EHR Incentive Programs: Data and program reports. Retrieved Sept. 17, 2012, from http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/DataAndReports.html

Centers for Medicare & Medicaid Services. (2012c). Medicare and Medicaid Programs: Electronic Health Record Incentive Program - Stage 2: Final rule. Retrieved Sept. 17, 2012, from http://www.ofr.gov/OFRUpload/OFRData/2012-21050_PI.pdf

DesRoches, C. M., Painter, M. W., & Jha, A. K. (2012). Health information technology: Driving toward delivery system change, 2012. Princeton, NJ: Robert Wood Johnson Foundation.

iHealthBeat. (2012). EHR tool helps improve blood sugar control for patients with diabetes. Retrieved Sept. 17, 2012, from http://www.ihealthbeat.org/articles/2012/5/31/ehr-tool-helps-improve-blood-sugar-control-for-patients-with-diabetes.aspx

surescripts. (2012). The national progress report on e-prescribing and interoperable healthcare: Year 2011. Retrieved Sept. 17, 2012, from http://www.surescripts.com/downloads/national-progress-report-executive-summary.pdf

references

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Meaningful Use: Moving from Stage 1 to Stage 2

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