1. Meaningful Use Stage 2 Annual Conference February 22, 2013 Kathy Church, BSN, PMP Director of Clinical Operations

2. Objectives  Gain understanding of the changes  Focus on Transitions in Care and Patient Engagement  Recognize the increasing HIE role

3. Who Are You? What is YOUR Need Today? A.Office staff B.Hospital staff C.Physicians or Midlevels D.Students E.Other guests

4. Better care for individuals, better health for populations, and lower per- capita costs. IHI-Triple Aim Initiative

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6. Not the Path We Want!

7. MU Stage 2 The final rule set for Meaningful Use Stage 2 was announced on August 23, 2012 and encompasses the following objectives:  New Criteria - Starting in 2014, providers participating in the EHR Incentive Programs who have met Stage 1 for two or three years will need to meet meaningful use Stage 2 criteria.  Improving Patient Care - Stage 2 includes new objectives to improve patient care through better clinical decision support, care coordination and patient engagement.  Saving Money, Time, Lives - With this next stage, EHRs will further save our health care system money, save time for doctors and hospitals, and save lives.

8. Good Points of Access

9. Changes from Stage 1  2 Stage 1Stage 2 Eligible Professionals 15 core objectives 5 of 10 menu objectives 20 total objectives Eligible Professionals 17 core objectives 3 of 6 menu objectives 20 total objectives Eligible Hospitals & CAHs 14 core objectives 5 of 10 menu objectives 19 total objectives Eligible Hospitals & CAHs 16 core objectives 3 of 6 menu objectives 19 total objectives Menu Objective Exclusion While you can continue to claim exclusions if applicable for menu objectives, starting in 2014 these exclusions will no longer count towards the number of menu objectives needed.

10. Where Will 2014 Find YOU? A.Stage 1 AIU B.Stage 1 90 days C.Stage 1 365 days— really only 90 in 2014 D.Stage 2 90 days E.Not started

11. 2014 Changes EHRs Meeting ONC 2014 Standards -  Starting in 2014, all EHR Incentive Programs participants will have to adopt certified EHR technology that meets ONC's Standards & Certification Criteria 2014 Final Rule. Reporting Period Reduced to Three Months -  To allow providers time to adopt 2014 certified EHR technology and prepare for Stage 2, all participants will have a three-month reporting period for 2014.

12. Medicaid Eligibility Changes  States have the option to allow providers to calculate Medicaid patient volume across 90-day period in last 12 months preceding a provider’s attestation.  This also applies to needy patient volume and patient panel methodology with at least one Medicaid encounter taking place in the 24 months prior to the 90-day period. 12

13. Negative Impact  All EPs not meeting MU by 2015 will be subject to a payment adjustment  EPs who first demonstrated meaningful use in 2011 or 2012 must demonstrate meaningful use for a full year in 2013 to avoid payment adjustments in 2015. They must continue to demonstrate meaningful use every year to avoid payment adjustments in subsequent years.

14. Exceptions to Payment Adjustments  Infrastructure(both)  Newly practicing physician/functioning hospital (both)  Unforeseen circumstances(both)  And also, three specialties: anesthesiology, radiology and pathology(EPs)

15. Stage 2 EP Core Core ObjectiveMeasure CPOEUse CPOE for more than 60% of medication, 30% of laboratory, and 30% of radiology orders created by the EP. E-RxE-Rx for more than 50%. DemographicsRecord demographics for more than 80%. Vital SignsRecord vital signs for more than 80%. Smoking StatusRecord smoking status for more than 80%. InterventionsImplement 5 clinical decision support interventions + drug/drug and drug/allergy. EPs must meet all 17 core objectives:

16. Page 2 LabsIncorporate lab results for more than 55%. Patient ListGenerate patient list by specific condition. Preventative RemindersUse EHR to identify and provide reminders for preventive/follow-up care for more than 10% of patients with two or more office visits in the last 2 years. Patient AccessProvide online access to health information for more than 50% with more than 5% actually accessing. Visit SummariesProvide office visit summaries for more than 50% of office visits. Education ResourcesUse EHR to identify and provide education resources more than 10%.

17. Page 3 Secure MessagesMore than 5% of patients send secure messages to their EP. Rx ReconciliationMedication reconciliation at more than 50% of transitions of care. Summary of CareProvide summary of care documents for more than 50% of transitions of care and referrals with 10% sent electronically and at least one sent to a recipient with a different EHR vendor or successfully testing with CMS test EHR. ImmunizationsSuccessful ongoing transmission of immunization data. Security AnalysisConduct or review security analysis and incorporate in risk management process.

18. Stage 2 EP Menu Objectives Menu ObjectiveMeasure Imaging ResultsMore than 20% of imaging results are accessible through Certificed EHR Technology. Family HistoryRecord family health history for more than 20%. Syndromic SurveillanceSuccessful ongoing transmission of syndromic surveillance data. CancerSuccessful ongoing transmission of cancer case information. Specialized RegistrySuccessful ongoing transmission of datat to a specialized registry. Progress NotesEnter an electronic progress note for more than 30% of unique patients. EPs must select 3 out of the 6:

19. Margaret comic

20. Stage 2 MU Hospital Core Core Objective Measure 1. CPOE Use CPOE for more than 60% of medication, 30% of laboratory, and 30% of radiology 2. DemographicsRecord demographics for more than 80% 3. Vital SignsRecord vital signs for more than 80% 4. Smoking StatusRecord smoking status for more than 80% 5. Interventions Implement 5 clinical decision support interventions +drug/drug and drug/allergy 6. LabsIncorporate lab results for more than 55% 7. Patient ListGenerate patient list by specific condition 8. eMAReMAR is implemented and used for more than 10% of medication orders

21. Page 2 Core ObjectiveMeasure 9. Patient Access Provide online access to health information for more than 50% with more than 5% actually accessing 10. Education ResourcesUse EHR to identify and provide education resources more than 10% 11. Rx ReconciliationMedication reconciliation at more than 50% of transitions of care 12. Summary of Care Provide summary of care document for more than 50% of transitions of care and referrals with 10% sent electronically and at least one sent to a recipient with a different EHR vendor or successfully testing with CMS test EHR 13. ImmunizationsSuccessful ongoing transmission of immunization data 14. LabsSuccessful ongoing submission of reportable laboratory results 15. Syndromic Surveillance Successful ongoing submission of electronic syndromic surveillance data 16. Security Analysis Conduct or review security analysis and incorporate in risk management process

22. Stage 2 MU Hospital Menu Menu ObjectiveMeasure 1. Progress Notes Enter an electronic progress note for more than 30% of unique patients 2. E-Rx More than 10% electronic prescribing (eRx) of discharge medication orders 3. Imaging Results More than 20% of imaging results are accessible through Certified EHR Technology 4. Family History Record family health history for more than 20% of unique patients 5. Advanced Directives Record advanced directives for more than 50% of patients 65 years or older 6. LabsProvide structured electronic lab results to EPs for more than 20%

23. Clinical Quality Measures Although reporting CQMs is no longer a core objective of the EHR Incentive Programs, all providers are required to report on CQMs in order to demonstrate meaningful use. In 2014 and beyond, reporting programs will be streamlined in order to reduce provider burden. 2014 represents CMS's commitment to aligning quality measurement and reporting among programs, including Hospital Inpatient Quality Reporting Program, PQRS, CHIPRA, and ACO Programs. ProviderPrior to 20142014 and Beyond EPsComplete 6 out of 44 3 core or 3 alt. core 3 menu Complete 9 out of 64 Choose at least 1 measure in 3 NQS domains Recommended core CQMs include:9 CQMs for the adult population 9 CQMs for the pediatric population Prioritize NQS domains Eligible Hospitals and CAHsComplete 15 out of 15Complete 16 out of 29 Choose at least 1 measure in 3 NQS domains

24. Alignment Among Programs 2014 represents CMS’s commitment to aligning quality measurement and reporting among programs, including Hospital Inpatient Quality Reporting Program, PQRS, CHIPRA, and ACO Programs. Hospital Inpatient Quality Reporting Program PQRSCHIPRAACO

25. NQS ACO MU Compare National Quality Strategy Priorities NQS Goals for each Priority MU Health Outcomes Policy Priorities ACO Domains and Intent Making care safer by reducing harm caused in the delivery of care. Eliminate preventable health care-acquired conditions Improving quality, safety, efficiency and reducing health disparities Domain Patient Safety Concepts Promote Evidence-Based Medicine Ensuring that each person and family are engaged as partners in their care. Create a delivery system that is less fragmented and more coordinated, where handoffs are clear, and patients and clinicians have the information they need to optimize the patient-clinician partnership Engage patients and families in their care Domain Patient/Care Giver Experience Concepts Promote Patient Engagement Promote Care Coordination Promoting effective communication and coordination of care. Build a system that has the capacity to capture and act on patient-reported information, including preferences, desired outcomes, and experiences with health care Improve care coordinationDomain Care Coordination Patient Experience Concepts Promote Patient Engagement Promote Care Coordination Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease. Prevent and reduce the harm caused by cardiovascular disease Improving quality, safety, efficiency and reducing health disparities Domain Patient Safety Preventive Health At Risk Population Concepts Promote Evidence-Based Medicine Working with communities to promote wide use of best practices to enable healthy living. Support every U.S. community as it pursues its local health priorities Improve population and public health Domain Preventive Health Concepts Promote Patient Engagement Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models. Identify and apply measures that can serve as effective indicators of progress in reducing costs Improving quality, safety, efficiency and reducing health disparities Domain Preventive Health Concepts Promote Evidence-Based Medicine

26. Comparative Quality Standards Patient-Centered Medical Home (NCQA) Six Standards Patient-Centered Medical Home Required Measure Meaningful Use Objective Enhance Access and ContinuityAccess During Office Hours Provide Electronic Access Identify and Manage Patient PopulationsUsing Data for Population Management Collect Demographic and Clinical Data for Population Management Plan and Manage CareManaged Care Reconciles Patient Medications at Visits and Post-Hospitalization E-Prescribing Provide Self-Care and Community Support Self-Care Process Work with Patient/Family to Develop a Self-Care Plan Provide Tools and Resources Track and Coordinate CareReferral Tracking and Follow-up Discharge Instructions Measure and Improve PerformanceImplements Continuous Quality Improvement Demonstrate Improved Performance

27. From Farzad Mostashari: "information follows the patient regardless of geographic, organizational, or vendor boundaries” From the MU2 document, "We continue to believe that making vendor-to-vendor standards-based exchange attainable for all meaningful EHR users is of paramount importance. In that regard, and as we look toward meaningful use Stage 3, we will monitor the ease with which EPs, eligible hospitals, and CAHs engage in electronic exchange, especially across different vendors EHRs," Dr. Mostashari read, "If we do not see sufficient progress or that continued impediments exist such that our policy goals for standards-based exchange are not being met, we will revisit these more specific measurement limitations and consider other policies to strengthen the interoperability requirements." He then said, "I want there to be no question about the seriousness of our intent on this issue. The bottom line is it's what's right for the patient and it's what we have to do as a country to get to better healthcare and lower costs.”

28. Use case  Two new activities key in Stage 2 Transitions in Care Patient Engagement

29. Electronic CCD Paper

30. Connecting is Key  Importance of cost effective interfaces  Order entry out of EMR to systems without huge costs—protecting our current hospital relationships  Outbound ease with a defined receiver  Inbound capability with discreet data  Referral patterns enhanced regardless of type of EMR used by each group.  Data out to registries, State agencies…

31. Sharing Data for Full Cardiovascular Care When IMA refers patient to CV surgeons, they forward CV testing results out of their EMR CV surgeons can request information from IMA electronically if CV testing is needed Urgent cardiovascular surgery is hastened by this. CeCe Cassidy Smith, NP Cardiovascular Surgery Team Member

32. Transitions in Care Sharing with next “provider of care”—peers Sharing with hospitals and other care sites Sharing via HIE to HIE; State ARRA funding; 5 HIEs just in Indiana Sharing with VA, SSA,…

33. Need versus Product  CCD/CCR has format with good data components  “snapshot in time” implies a CCD plus Last visit note Referral request Other key information individualizing the patient and his/her need

34. The Right Balance of Help?

35. Patient Engagement  Patient engagement is an important focus of Meaningful Use Stage 2. What this means is that a small percentage of patients will have to perform certain actions in order for the EP to meet certain objectives.  Requirements for Patient Action:  More than 5% of patients must send secure messages to their EP.  More than 5% of patients must access their health information online.  EXCLUSIONS: CMS is introducing exclusions based on broadband availability in the provider's county.

36. What’s Your Patients’ Access Tool? A.Tethered Portal B.Personal Health Record (PHR) C.Other D.Uncommitted

37. Serving the Patient  Sharing data with the patient –Patient Portal—tethered –Personal Health Record—not tethered

38. PHR—current pilot for us with an employer –Alerts to Care Managers of ED visits and Admissions using DIRECT email –Contacting patients/parents –Developing a Shared Care Plan Developed together with patient Shared with patient Shared with provider –Balance PHRs and EMRs for Documentation…Challenge ahead Engaging the Patient

39. Electronic Exchange  Stage 2 focuses on actual use cases of electronic information exchange:  Stage 2 requires that a provider send a summary of care record for more than 50% of transitions of care and referrals.  The rule also requires that a provider electronically transmit a summary of care for more than 10% of transitions of care and referrals.  At least on summary of care document send electronically to a recipient with different EHR vendor or to CMS test EHR.

40. HealthLINC, YES…We Are Different  Spending every day making patient care better.  The right data in the right place for the right care to the right patient in the hands of the right caregiver  Making technology work for quality A doctor A nurse Is PCMH/NCQA to be combined with Stage2?

41. Contact Info HealthLINC Team 877.331.5477 Meaningful Useext 1 Portal ext 2 Clinical Messagingext 3 Other ext 4 Kathy Church812.353.4026 kathychurch@healthlinc.org