Prepared by: Health Technology Services Regional Extension Center A division of Mountain-Pacific Quality Health

 MU Overview  MU Stage 2 Final Rule ◦ Core/Menu Objectives ◦ Clinical Quality Measures ◦ Payment Adjustments 2

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 CMS Rule: 2mipkysrh))/OFRUpload/OFRData/ _PI.pdf 2mipkysrh))/OFRUpload/OFRData/ _PI.pdf  ONC Rule: 2mipkysrh))/OFRUpload/OFRData/ _PI.pdf 2mipkysrh))/OFRUpload/OFRData/ _PI.pdf 4

 Vision Enable significant and measurable improvements in population health through a transformed health care delivery system  Goals: ◦ Improving quality, safety, efficiency, and reducing health disparities ◦ Engage patients and families in their health care. ◦ Improve care coordination ◦ Improve population and public health ◦ Ensure adequate privacy and security protections for personal health information 5 Goals Adapted from National Priorities Partnership. National Priorities and Goals: Aligning Our Efforts to Transform America’s Healthcare. Washington, DC: National Quality Forum; 2008.

Congress established three fundamental criteria: 1. Use of a certified Electronic Health Record (EHR) that meets guidelines 2. Electronic Exchange of health information 3. Reporting on Clinical Quality and other Measures 6

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8 June ‘11 HITPC Recommendations on Stage 2 Feb ‘12 Stage 2 Proposed Rule May ‘12 NPRM Comment Period Ends Aug ‘12 Stage 2 Final rule Oct ‘13/Jan ‘14 Stage 2 Start Dates

9 1 st Year Stage of Meaningful Use TBD TBD TBD TBD TBD

Eligible Professionals -15 core objectives -5 of 10 menu objectives -20 total objectives Eligible Professionals -15 core objectives -5 of 10 menu objectives -20 total objectives 10 Eligible Professionals -17 core objectives -3 of 6 menu objectives -20 total objectives Eligible Professionals -17 core objectives -3 of 6 menu objectives -20 total objectives Eligible Hospitals -14 core objectives -5 of 10 menu objectives -19 total objectives Eligible Hospitals -14 core objectives -5 of 10 menu objectives -19 total objectives Eligible Hospitals -16 core objectives -3 of 6 menu objectives -19 total objectives Eligible Hospitals -16 core objectives -3 of 6 menu objectives -19 total objectives

Changed  Exclusions no longer count to meeting one of the menu objectives Not Changed  No change in 50% of EP outpatient encounters must occur at locations equipped with certified EHR technology  Measure compliance = objective compliance  PAs still ineligible, unless lead at RHC/FQHC  Denominators based on outpatient locations equipped with CEHRT and include all such encounters or only those for patients whose records are in CEHRT depending on the measure. 11

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13 Core ObjectiveMeasureStage 2 Change 1. CPOE Use CPOE for more than 60% of medication, 30% of laboratory, and 30% of radiology Up from 30% of just medication orders 2. E-RxE-Rx for more than 50% Up from 40% Drug/formulary checks folded into this measure from Stage 1 menu item 3. Demographics Record demographics for more than 80% Up from 50% 4. Vital SignsRecord vital signs for more than 80% Up from 50% 5. Smoking StatusRecord smoking status for more than 80% Up from 50% EPs must meet all 17 core objectives: Challenges! Core #2 requires the availability of pharmacies in your area to accept eRx. Core #2 requires the availability of pharmacies in your area to accept eRx.

14 Core ObjectiveMeasureStage 2 Change 6. Interventions Implement 5 clinical decision support interventions + drug/drug and drug/allergy Up from one CDSI rule Must be linked to at least 4 Clinical Quality Measures (CQMs) Drug/drug and drug/allergy folded into this measure 7. Labs Incorporate lab results for more than 55% Up from 40% and no longer a menu item 8. Patient ListGenerate patient list by specific condition No longer a menu item EPs must meet all 17 core objectives: Challenges! Core #6 CDSI rules must be useful to the provider at the point of care. Core #6 CDSI rules must be useful to the provider at the point of care.

15 Core Objective MeasureStage 2 Change 9. Preventive Reminders Use 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 No longer a menu item, but down from 20% 10. Patient Access Provide online access to health information for more than 50% with more than 5% actually accessing No longer a menu item and up from 10% on part #1. Replaces electronic access and electronic copy of medical record. Part #2 is new and requires patient action to meet the measure and additional software. Exclusion for providers in areas with limited Internet access. EPs must meet all 17 core objectives: Challenges! Core #10 requires patient engagement to meet MU.

16 Core ObjectiveMeasureStage 2 Change 11. Visit Summaries Provide office visit summaries for more than 50% of office visits within 1 business day Down from three business days, percent is the same (50%) 12. Education Resources Use EHR to identify and provide education resources more than 10% No longer a menu item 13. Secure Messages More than 5% of patients send secure messages to their EP New for Stage 2 Requires patient action to meet the measure 14. Rx Reconciliation Medication reconciliation at more than 50% of transitions of care No longer a menu item EPs must meet all 17 core objectives: Core #11 has been one of the most challenging measures for EPs. Core #12 education materials is often limited in the EHR. Challenges! Core #13 requires patient engagement to meet MU.

17 Core ObjectiveMeasureStage 2 Change 15. 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 No longer a menu item 10% sent electronically is a new requirement 16. Immunizations Successful ongoing transmission of immunization data No longer a menu item Requires more than just a test to meet this measure 17. Security Analysis Conduct or review security analysis and incorporate in risk management process EPs must meet all 17 core objectives: Challenges! Core #15 requires a method to send summary information out side of your own vendor networks. Core #15 requires a method to send summary information out side of your own vendor networks.

18 Menu ObjectiveMeasureStage 2 Change 1. Imaging Results More than 20% of imaging results are accessible through Certified EHR Technology New for Stage 2 2. Family History Record family health history for more than 20% New for Stage 2 3. Syndromic Surveillance Successful ongoing transmission of syndromic surveillance data Requires more than just a test to meet this measure EPs must select 3 out of 6 menu objectives:

19 Menu ObjectiveMeasureStage 2 Change 4. Cancer Successful ongoing transmission of cancer case information New for Stage 2 Requires more than just a test to meet this measure 5. Specialized Registry Successful ongoing transmission of data to a specialized registry New for Stage 2 Requires more than just a test to meet this measure 6. Progress NotesEnter an electronic progress note for more than 30% of unique patients New for Stage 2 EPs must select 3 out of 6 menu objectives:

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21 Core ObjectiveMeasureStage 2 Change 1. CPOE Use CPOE for more than 60% of medication, 30% of laboratory, and 30% of radiology Up from 30% of just medication orders 2. Demographics Record demographics for more than 80% Up from 50% 3. Vital Signs Record vital signs for more than 80% Up from 50% 4. Smoking StatusRecord smoking status for more than 80% Up from 50% Hospitals must meet all 16 core objectives:

22 Core ObjectiveMeasureStage 2 Change 5. Interventions Implement 5 clinical decision support interventions + drug/drug and drug/allergy Up from one CDSI rule Must be linked to 4 Clinical Quality Measures (CQMs) Drug/drug and drug/allergy folded into this measure 6. Labs Incorporate lab results for more than 55% Up from 40% No longer a Menu objective 7. Patient List Generate patient list by specific condition No longer a Menu objective 8. eMAReMAR is implemented and used for more than 10% of medication orders New for Stage 2 Hospitals EPs must meet all 16 core objectives: Challenges! Core #5 CDSI rules must be useful to the provider at the point of care. Core #5 CDSI rules must be useful to the provider at the point of care.

23 Core ObjectiveMeasureStage 2 Change 9. Patient Access Provide online access to health information for more than 50% with more than 5% actually accessing No longer a menu item and up from 10% on part #1 Replaces electronic access and electronic copy of medical record Part #2 is new and requires patient action to meet the measure and additional software 10. Education Resources Use EHR to identify and provide education resources more than 10% No Longer a Menu objective Hospitals must meet all 16 core objectives: Challenges! Core #9 requires patient engagement to meet MU.

24 Core ObjectiveMeasureStage 2 Change 11. Rx Reconciliation Medication reconciliation at more than 50% of transitions of care No Longer a Menu objective 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 No longer a menu item 10% sent electronically is a new requirement Hospitals must meet all 16 core objectives: Challenges! Core #12 requires a method to send summary information out side of your own vendor networks. Core #12 requires a method to send summary information out side of your own vendor networks.

25 Core ObjectiveMeasureStage 2 Change 13. Immunizations Successful ongoing transmission of immunization data No longer a menu item Requires more than just a test to meet this measure 14. Labs Successful ongoing submission of reportable laboratory results No longer a menu item Requires more than just a test to meet this measure 15. Syndromic Surveillance Successful ongoing submission of electronic syndromic surveillance data No longer a menu item Requires more than just a test to meet this measure 16. Security Analysis Conduct or review security analysis and incorporate in risk management process Hospitals must meet all 16 core objectives:

26 Menu ObjectiveMeasureStage 2 Change 1. Progress Notes Enter an electronic progress note for more than 30% of unique patients New for Stage 2 2. E-Rx More than 10% electronic prescribing (eRx) of discharge medication orders New for Stage 2 3. Imaging ResultsMore than 20% of imaging results are accessible through Certified EHR Technology New for Stage 2 Hospitals must select 3 out of 6 menu objectives:

27 Menu ObjectiveMeasureStage 2 Change 4. Family History Record family health history for more than 20% New for Stage 2 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% New for Stage 2 Hospitals must select 3 out of 6 menu objectives:

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Denominator: Unique Patient with at least one medication in their med list 29 Denominator: Number of Orders during the EHR Reporting Period Age Limits: Age 2 for Blood Pressure & Height/Weight Age Limits: Age 3 for Blood Pressure, No age limit for Height/Weight CPOE - Optional in 2013 and beyond Vital Signs - Optional in 2013 Required in 2014+

Exclusion: All three elements not relevant to scope of practice 30 Exclusion: Allows BP to be separated from height/weight One test of electronic transmission of key clinical information Requirement removed effective 2013 Vital Signs - Optional in 2013 Required in Test of HIE– Effective 2013

Objective: Provide patients with e-copy of health information upon request Objective: Provide electronic access to health information 31 Replacement Objective: Provide patients the ability to view online, download and transmit their health information Immunizations Reportable Labs Syndromic Surveillance Addition of “except where prohibited” to all three E-Copy and Online Access - Required in Public Health Objectives – Effective 2013

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 CQMs are no longer a meaningful use core objective, but reporting CQMs is still a requirement for meaningful use. 33

All providers must select CQMs from at least 3 of the 6 HHS National Quality Strategy domains:  Patient and Family Engagement  Patient Safety  Care Coordination  Population and Public Health  Efficient Use of Healthcare Resources  Clinical Processes/Effectiveness 34

35 ProviderPrior to and Beyond Regardless of Stage EPs Complete 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 CAHs Complete 15 out of 15Complete 16 out of 29 Choose at least 1 measure in 3 NQS domains

CMS selected the CQMs for the proposed core set based on analysis of several factors:  Conditions that contribute to the morbidity and mortality of the most Medicare and Medicaid beneficiaries  Conditions that represent national public/ population health priorities  Conditions that are common to health disparities 36

 Conditions that disproportionately drive healthcare costs and could improve with better quality measurement  Measures that would enable CMS, States, and the provider community to measure quality of care in new dimensions, with a stronger focus on parsimonious measurement  Measures that include patient and/or caregiver engagement 37

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 The HITECH Act stipulates that for Medicare EPs a payment adjustment applies if they are not a meaningful EHR user.  An EP/Hospital becomes a meaningful EHR user when they successfully attest to meaningful use under either the Medicare or Medicaid EHR incentive program  Adopt, implement and upgrade (AIU) does not constitute meaningful use. A provider receiving a Medicaid incentive for AIU would still be subject to the Medicare payment adjustment. 39

% Adjustment Assuming less than 75% of EPs are meaningful EHR users for CY 2018 and subsequent years EP is not subject to e-Rx penalty in %98%97%96%95% EP is subject to e-Rx penalty in % 97%96%95% % Adjustment Assuming more than 75% of EPs are meaningful EHR users for CY 2018 and subsequent years EP is not subject to e-Rx penalty in %98%97% EP is subject to e-Rx penalty in % 97%

EP who has demonstrated meaningful use in 2011 or Payment Adjustment Year Full Year EHR Reporting Period EP who demonstrates meaningful use in 2013 for the first time Payment Adjustment Year day EHR Reporting Period 2013 Full Year EHR Reporting Period

EP who demonstrates meaningful use in 2014 for the first time 42 Payment Adjustment Year day EHR Reporting Period 2014 Full Year EHR Reporting Period

 In order to avoid the 2015 payment adjustment the EP must attest no later than Oct 1, 2014 which means they must begin their 90 day EHR reporting period no later than July 1,  To Avoid Payment Adjustments: EPs must continue to demonstrate meaningful use every year to avoid payment adjustments in subsequent years. 43

% Decrease in the Percentage Increase to the IPPS Payment Rate that the hospital would otherwise receive for that year: % Decrease25%50%75%

For a hospital that has demonstrated meaningful use in 2011 or 2012 (fiscal years): 45 Payment Adjustment Year Full Year EHR Reporting Period For a hospital that demonstrates meaningful use in 2013 for the first time: Payment Adjustment Year day EHR Reporting Period 2013 Full Year EHR Reporting Period

For a hospital that demonstrates meaningful use in 2014 for the first time: 46 Payment Adjustment Year day EHR Reporting Period 2014 Full Year EHR Reporting Period

 In order to avoid the 2015 payment adjustment the hospital must attest no later than July 1, 2014 which means they must begin their 90 day EHR reporting period no later than April 1, 2014  To Avoid Payment Adjustments: Hospitals must continue to demonstrate meaningful use every year to avoid payment adjustments in subsequent years. 47

Applicable % of reasonable costs reimbursement which absent payment adjustments is 101%: : % of reasonable costs %100.33%100%

For a CAH who has demonstrated meaningful use prior to 2015 (fiscal years): 49 Payment Adjustment Year Full Year EHR Reporting Period For a CAH who demonstrates meaningful use in 2015 for the first time: Payment Adjustment Year day EHR Reporting Period 2015 Full Year EHR Reporting Period

 To Avoid Payment Adjustments: CAHs must continue to demonstrate meaningful use every year to avoid payment adjustments in subsequent years. 50

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Rick Yearry Health Technology Services | Regional Extension Center