An Overview of Meaningful Use Proposed Rules in 2015 Jeffery Smith, M.P.P. Sr. Policy Advisor, CHIME

Agenda at a Glance Overview of Stage 3 Proposed Rule Program Design & Content Overview of “Modifications” Proposed Rule Alignment Issues Comments, Concerns and Irresponsible Predictions (a.k.a. the Q&A)

Meaningful Use Stage 3 Program Design Begins 2018 Single Definition Optional in 2017 Single Definition Regardless of historic participation Final Stage of MU Last, but not least Ongoing requirements EHs / CAHs move to Calendar Year in 2017 CMS adds that multiple technological and clinical care standard changes associated with EHR technology may warrant changes to the objectives and measures of meaningful use under the EHR Incentive Programs, and these would be addressed in future rulemaking. 11/27/2018

Proposed Stage 3 Timeline Year Proposed Policy: Stages of Meaningful Use 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 1 2 2 or 3 3 1, 2 or 3 The proposed policy revisions announced by CMS and ONC in late 2013 would give providers that began in 2011 and 2012 an additional year at Stage 2 before being required to start Stage 3. The proposed revisions will also build on the “Edition construct” that will allow more iterative improvements to CEHRT without being compulsory. This means that providers will not be forced by government regulations to use 2015 or 2016 Edition CEHRT, that they will be allowed to use 2014 Edition in 2015 or 2016 if they so choose. However, it is expected that the 2017 Edition will be required of all providers, in order to meet new objectives and measures for the beginning of Stage 3. = 2014 Edition CEHRT = 2015 Edition CEHRT (optional in 2016/17, required beginning 2018)

Objectives & Measures Protect ePHI – 1 Measure e-prescribing – 1 Measure CDS – 2 Measures CPOE – 3 Measure Patient Electronic Access to Health Information – 2 Measures Coordination of Care through Patient Engagement – Report on 3; Must meet 2 Health Information Exchange (HIE) – Report on 3; Must meet 2 Public Health and Clinical Data Registry Reporting – 6 Measures (EPs must report on 3 of 5 and EHs / CAHs must report on 4 of 6) Clinical Quality Measures (CQMs) requirements will be determined through PFS and IPPS 11/27/2018

Patient Electronic Access Measures 1: More than (>) 80% of patients are provided access to view, download or transmit health info within 24 hours of availability to the provider OR > 80% of patients are provided access to an ONC-certified API Measure 2: The EP or hospital must use clinically relevant information from CEHRT to identify patient-specific educational resources and provide electronic access to those materials to > 35% 11/27/2018

Alternatives for Measure 1 Alternate A Require both view, download, and transmit and API functions to be available instead of allowing the provider to choose between the two. Alternate B Require the provider to choose to have either both functions or just an API function. Alternate C Require the provider to only have the API function; use of a separate view, download, and transmit function would be entirely at the provider’s discretion. 11/27/2018

Coordination of Care through Patient Engagement Measure 1 More than (>) 25% of patients view, download or transmit health info or > 25% use an ONC-certified API to access information Measure 2 > 35% of patients send a secure message Measure 3 Patient-generated health data or data from a “non-clinical setting” is incorporated into the CEHRT for > 15% 11/27/2018

Health Information Exchange Measure 1: For > 50% of transitions of care and referrals, the EP or hospital that transitions or refers (1) creates a summary of care record using CEHRT; and (2) electronically exchanges the summary of care record. Measure 2: For > 40% of transitions or referrals received and patient encounters in which the provider has never before encountered the patient, the EP or hospital incorporates into the patient’s EHR an electronic summary of care document from a source other than the provider’s EHR system. Measure 3: For > 80 % of transitions or referrals received and patient encounters in which the provider has never before encountered the patient, the EP or hospital performs a clinical information reconciliation. Providers must attest to all three of the following measures, and must successfully meet the threshold for two of these three measures: 11/27/2018

Public Health & Clinical Data Registry Reporting Measure 1: Immunization Registry Reporting Measure 2: Syndromic Surveillance Reporting Measure 3: Case Reporting Measure 4: Public Health Registry Reporting Measure 5: Clinical Data Registry Reporting Measure 6: Electronic Reportable Laboratory Result Reporting (EPs must report on 3 of the first 5; EHs / CAHs must report on 4 of the 6) 11/27/2018

“Modifications” Rule 2015 Program Design Begins in 2015, effective through 2017 Modifies Stage 2 objectives & measures Exclusions available for Stage 1 providers & some Stage 2 providers in 2015 ONLY “Continuous” 90-day reporting period for all in 2015 In 2016, 1st time participants would have an EHR reporting period of any continuous 90-days; all returning providers have full-year In 2017, 1st time participants would have a full-year reporting period, as do all returning providers 11/27/2018

Stage of Meaningful Use MU 2015 - 2017 First Year of Participation Stage of Meaningful Use   2015 2016 2017 2018 2011 Modified Stage 2 Modified Stage 2 or Stage 3 Stage 3 2012 2013 2014 Modified Stage 2* N/A Modified Stage 2* = limited exclusions and alternative measures available to providers scheduled to demonstrate Stage 1 in 2015.

Proposed Objectives & Measures CPOE – 3 measures eRx – 1 measure Clinical Decision Support – 2 measures Patient Electronic Access – 2 measures Protect ePHI – 1 measure Patient Specific Education – 1 measure Medication Reconciliation – 1 measure Summary of Care – 2 measures Secure Messaging – 1 measure (EPs only) Public Health – 2 measures (EPs); 3 measures (EHs) Measures based on Stage 2 as finalized in 2012, with alternate exclusions and specifications for certain providers in 2015

Measure Exclusion Example - eRx Eligible Hospital/CAH Measure: More than 10 percent of hospital discharge medication orders for permissible prescriptions are queried for a drug formulary and transmitted electronically using Certified EHR Technology. The EH / CAH may claim an exclusion for the eRx objective and measure if they were either: Scheduled to demonstrate Stage 1 in 2015, which does not have an equivalent measure, or If they are scheduled to demonstrate Stage 2 in 2015, but did not intend to select the Stage 2 eRx menu objective for an EHR reporting period in 2015.

Patient Access, Summary of Care Additional Objective / Measure Modifications Patient Electronic Access 5% threshold for VDT dropped to < 1 patient Secure Messaging 5% threshold changed to “During the EHR reporting period, the capability for patients to send and receive a secure electronic message with the provider was fully enabled.” Summary of Care Now reads: The EP, eligible hospital or CAH that transitions or refers their patient to another setting of care or provider of care (1) uses CEHRT to create a summary of care record; and (2) electronically transmits such summary to a receiving provider for more than 10 percent of transitions of care and referrals.

Alignment Issues 2015 proposal may be too difficult for many providers to achieve…especially in 2015 Shift to calendar year reporting helps, but concerns remain Public health requirements / exclusions Stage 3 proposal also very difficult, concerns over its reliance on technology solutions

Glass Half Full A new progression for providers to meet MU All providers attest to a single set of objectives and measures beginning in 2015 These measures are “equivalent to a reduced version of Stage 3” The delta between delivery and payment reform is shrinking Adoption on the rise, MU participation in 2014 at all-time high for EHs and EPs HHS targets for alternative payment models Medicare Access and CHIP Reauthorization Act of 2015

Glass Half Empty A new progression for providers to meet MU Has the MU escalator turned into a mine shaft? Adoption on the rise, but just under half of EPs have NEVER participated in MU 2014 changes made participation possible, but 2015 is unknown Regulatory churn and year-to-year flux MU fatigue EHR developer bandwidth More than 75% of providers and one-third of all hospitals scheduled to move to Stage 2 in 2014 either applied for a hardship exemption from the program, used the CMS's “flex rule” to stay in Stage 1 or didn't attest to meeting the program's requirements.

Q&A Jeffery Smith, M.P.P. Sr. Policy Advisor CHIME jsmith@chimecentral.org