1. Vermont Information Technology Leaders, Inc. Meaningful Use Stage 2 For Eligible Professionals Carol Kulczyk October 10, 2012 ckulczyk@vitl.net 802-839-1957

2. Vermont Information Technology Leaders (VITL) Non-profit organization funded by the Federal Office of the National Coordinator for Health Information Technology within HHS to provide direct assistance to primary care providers in Vermont Manages the Vermont Health Information Exchange with funding from the State of Vermont Offices in Montpelier and Burlington 2

3. Stage 2 Final Rule Defines Stage 2 and Changes to Stage 1 Clarification on timing of Stages New Clinical Quality Measures and reporting mechanism Medicaid program changes Payment adjustments and hardship exemptions Hints for Stage 3 Patient engagement focus 3

4. Summary of Stage 2 Retains Core/Menu Measures structure Most stage 1 Menu Measures become Stage 2 Core Measures Some Stage 1 Measures eliminated/combined Most patient thresholds raised New Measures: Core (1), Menu (6) List of Clinical Quality Measures expanded New method for electronic submission of patient information 4

5. Stage 2 Measures MeasureEPs Core17 of 17 Menu3 of 6 CQMs9 of 64 5

6. Clinical Quality Measures as of 2014 Clinical Quality Measures (“CQMs”) –No longer tied to a specific stage –Whether a first-time Stage 1 meaningful user or a Stage 2 meaningful user, EPs must complete 9 of 64 available CQMs –EP/EH will need to upgrade to a 2014 CEHRT –90 day reporting period whether EP is in Stage 1 or 2 (Calendar year 2014 only) 6

7. Timing for Medicare EP 1st Year of MU Stage of Meaningful Use 201120122013201420152016 2011111223 2012 11223 2013 1122 2014 112 2015 11 2016 1 For 2014 only, 90 day reporting period to allow for upgrade to 2014 CEHRT. EPs must report MU in consecutive years. 7

8. Timing for Medicaid EP 1st Year of MU Stage of Meaningful Use 20112012201320142015201620172018201920202021 20111112233 2012 112233 2013 112233 2014 112233 2015 112233 2016 112233 2017 11223 For 2014 only, 90 day reporting period to allow for upgrade to 2014 CEHRT. EPs are allowed to skip multiple years. 8

9. For 2014 Only Eligible Professionals (EPs) required to demonstrate MU for 3 month period (allows for time to upgrade to 2014 CEHRT) –Medicare: reporting period aligned to calendar year quarters (Jan.- Mar., Apr.- Jun., Jul.- Sept., Oct.- Dec.) –Medicaid: any consecutive 90 day reporting period 9

10. Clinical Quality Measures CQMs aligned with National Quality Strategy (NQS) policy domains 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 CQM list to be posted in future 10

11. CQM Changes ProviderStarting 2014 for Stage 1 and Stage 2 EP Complete 9 of 64 Choose at least 1 measure in 3 National Quality Strategy (NQS) domains EH Complete 16 of 29 Choose at least 1 measure in 3 National Quality Strategy (NQS) domains 11

12. Transformed Measures Stage 1 Test of exchange of key clinical information Stage 1 a.Provide patients with an e-copy of their health information b.Provide online access Stage 1 (in 2013) and Stage 2: Provide transition of care record to another setting of care Stage 2: Provide patients with timely online access to their health information 12

13. Stage 2: Transitions of Care Provider must send summary of care for > 50% of transitions of care and referrals to another setting of care –More than 10% must be electronic, using CEHRT –At least 1 summary of care document sent electronically to recipient with either different EHR vendor or CMS test EHR Exclusion: less than 100 transitions/referrals during EHR reporting period 13

14. Stage 2: Patient Access Provide 50% of unique patients seen by EP with timely online access to their health information –within 4 business days after data available to EP EP’s discretion to withhold information For > 5% of unique patients seen by EP –must view online, download or transmit to 3 rd party their health information Patient portal acceptable if certified by ONC 14

15. Stage 2: Patient Communication More than 5% of unique patients seen by EP must send secure messages to their EP using CEHRT –Email –Personal Health Record function –Online portal Exclusion - based on lack of 3Mbps broadband availability in county (determined by FCC) 15

16. CQMs Aligned with Other Programs Starting 2014, CMS will align –Hospital Inpatient Quality Reporting (IQR) Program –Physician Quality Reporting System (PQRS) –Children's Health Insurance Program Reauthorization Act (CHIRPA) –Accountable Care Organizations (ACO) –Meaningful Use CQMs Alignment includes: –Choosing same measures for different programs –Identifying ways to minimize multiple submissions 16

17. 2014 - Reporting Mechanism for CQMs EPs submit group CQM data using one file for all participating EPs File will be uploaded to CMS system 17

18. Medicaid EP Eligibility Determination Encounter defined as “any service rendered on any one day to an individual enrolled in a Medicaid program…” –the encounter counts even if Medicaid did not pay for the service –excludes stand-alone Title 21 patients 18

19. Payment Adjustments 19 Timeline to avoid payment adjustments for EPs who must demonstrate meaningful use for a full year in 2013 Full Year EHR Reporting Period 20132014*20152016 Avoid Adjustment for Payment Year 2015201620172018 * CMS only requiring 90 days of MU in 2014. For full description of payment adjustments, see CMS Payment Adjustments & Hardship Exceptions Tip Sheet for EPs

20. Payment Adjustments 20 Timeline to avoid payment adjustments for EPs who demonstrate meaningful use for a 90-day reporting period in 2013 90 day EHR Reporting Period 20132014* Full Year EHR Reporting Period 20152016 Avoid Adjustment for Payment Year 2015201620172018 * EPs must attest to meaningful use for 90 days no later than Oct. 1, 2014

21. Payment Adjustment Hardship Exceptions Lack of Infrastructure New Eligible Professional Unforeseen Circumstances Scope of Practice (ex. - anesthesiology, radiology, pathology) –Lack of interactions with patients –Lack of follow-up needed with patients –EP in multiple locations: lack of control over availability of CEHRT at practice location 21

22. Stage 1 Changes Most voluntary in 2013 but required in 2014 CPOE denominator: alternative measure Vital Signs: exclusion/age requirement revised Removed test exchange key clinical information Added view, download, and transmit patient data E-prescribing exclusion added (no pharmacy accepting e-Rx within 10 miles) 22

23. Stage 1 Changes Enter at least (1) electronic progress note, edited, and signed by EP for >30 % of unique patients Electronic progress notes must be text-searchable –Non-searchable notes do not qualify, but not all content has to be character text I’m sorry, I don’t understand this –Drawings and other content can be included with searchable text notes –Menu set exclusion limited (2014) 23

24. Stage 3 CMS will finalize criteria early 2014 to start in 2016 and will focus on: –Promoting improvements in quality, safety and efficiency leading to improved health outcomes –Decision support for national high priority conditions –Patient access to self-management tools –Access to comprehensive patient data through robust, secure, patient-centered HIE –Improving population health 24

25. Next set of slides has detailed information –Clarification about non-hospital based EP –Patient information required online –Stage 2 Core Measures –Stage 2 Menu Measures –Additional resources and contacts 25

26. Requirements for EPs seeking to reverse a hospital-based determination Beginning in payment year 2013, EP who meets the definition of hospital-based EP but who can demonstrate to CMS that EP funds the acquisition, implementation, and maintenance of CEHRT, including supporting hardware and interfaces needed for meaningful use without reimbursement from an eligible hospital or CAH, and uses such CEHRT in the inpatient or emergency department of a hospital (instead of the hospital’s Certified EHR Technology), may be determined by CMS to be a non-hospital-based EP. 26

27. Process for determining a non-hospital-based EP When an EP registers for a given payment year they should receive a determination of whether they have been determined "hospital-based." An EP determined "hospital-based," but who wishes to be determined non-hospital-based, may use an administrative process to provide documentation and seek a non-hospital-based determination. Such administrative process will be available throughout the incentive payment year and including the 2 months following the incentive payment year in which the EP may attest to being a meaningful EHR user. 27

28. Online Access Information Required Patient name, provider’s name, and office contact information Current and past problem list Procedures and laboratory test results Current medication list and medication history Current medication allergy list and medication allergy history Vital signs (height, weight, blood pressure, BMI, growth charts) Smoking status Demographics (language, sex, race, ethnicity, date of birth) Care plan field(s), including goals and instructions Any known care team members including the Primary Care Provider 28

29. Stage 2 Core EP Measure Stage 1 Stage 2 1. CPOE>30%>60% medication >30% labs >30% radiology orders 2. eRx>40%>50% prescriptions queried for drug formulary and transmitted electronically 3. Demographics*>50%>80% of all unique patients 4. Vital Signs*>50% Age =>2 >80% of all unique patients a. all ages record height/weight b. age =>3 record blood pressure 29 * Must be recorded as structured data

30. Stage 2 Core EP MeasureStage 1Stage 2 5. Smoking Status* >50% Age =>13 >80% of all unique patients (13 or older remains) 6. Clinical Decision Support Implement one CDS rule Implement 5 CDS interventions related to 4 or more CQMs and enable drug- drug and drug-allergy checks 7. Lab Results*40% Menu 55% of all clinical lab test results ordered are incorporated as structured data 8. List of Patients MenuList patients with 1 or more specific conditions 9. Reminders20% MenuSend to >10% of unique patients with 2 or more visits within 24 months prior to reporting period 30 * Must be recorded as structured data

31. Stage 2 Core EP MeasureStage 1Stage 2 10. Patient Access e-Copy and e-Access measures eliminated 1.More than 50% of all unique patients seen by the EP provided timely (within 4 business days after the information is available to the EP) online access to their health information subject to the EP's discretion to withhold certain information 2.More than 5% of all unique patients seen by the EP during the reporting period view, download, and transmit to a 3rd party their health information 31

32. Stage 2 Core EP MeasureStage 1Stage 2 11. Visit Summaries for Patients >50% of office visits within 3 business days Provide clinical summary to patients for >50% of office visits within one business day 12. Patient Education MenuPatient specific education resources identified by CEHRT provided to > 10% of unique patients 13. Medication Reconciliation MenuMedication reconciliation for > 50% of transitions of care received by EP 32

33. Stage 2 Core EP CoreStage 1Stage 2 14. Transition of Care Test of exchange of key clinical information eliminated 1. Provide summary of care for > 50% of transitions and referrals 2. Electronically transmit summary of care record for > 10% of transitions and referrals a.using CEHRT to a recipient b.through an NwHIN Exchange participant or ONC validated exchange (push or pull transaction) 3. Conduct one or more successful exchanges a.with recipient using different vendor EHR or b.with CMS designated test EHR 33

34. Stage 2 Core EP MeasureStage 1Stage 2 15. Immunizations Perform at least 1 test Successful ongoing transmission of immunization data from EHR to immunization registry or immunization reporting system 16. Security Analysis No encryption required Conduct or review security analysis including addressing encryption/security of data at rest and implement security updates as necessary and correct identified security deficiencies as part of risk management process 17. Secure Messaging New for Stage 2 > 5% of unique patients send secure electronic message to EP using CEHRT 34

35. Stage 2 EP Menu Objectives New Menu Objectives 1. Imaging results accessible through CEHRT 4. identify and report cancer cases to a public health central cancer registry 2. Record patient family health history as structured data 5. Identify and report specific cases to specialized registry other than cancer 3. Submit electronic syndromic surveillance data to public health agencies 6. Record electronic notes (searchable text required) 35

36. Resources and Contacts 36 CMS resources for stage 2 http://www.cms.gov/Regulations-and- Guidance/Legislation/EHRIncentivePrograms/Stage_2.html VITL resources at http://www.vitl.net/resources http://www.vitl.net/resources Contacts at VITL –If you would like to use VITL services, please contact Larry Gilbert lgilbert@vitl.net802-839-1943lgilbert@vitl.net –If you are already a VITL customer, please contact Carol Kulczykckulczyk@vitl.net 802-839-1957ckulczyk@vitl.net

37. 37 Discussion ……. Questions?