Stage 2 Meaningful Use What the Future Holds…

Lindsey Wiley, MHA HIT Manager

Oklahoma Foundation for Medical Quality

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Mission of OFMQ-HIT

To advance the implementation and use of vital health information technology to improve healthcare

quality, efficiency and safety by assisting physician practices and hospitals in achieving meaningful use of

electronic health records.

OFMQ-HIT Service Lines

• Security & Privacy Analysis • Security & Privacy Validation • Meaningful Use Gap Analysis • Meaningful Use Gap Audit • Meaningful Use Attestation • HIPAA Security Preparedness • HIPAA Privacy Preparedness • Staff IT Security Training

Lindsey Wiley, MHA Lindsey works with healthcare providers and hospitals to advance the use of electronic health records (EHR) to improve patient care and health outcomes. She consults with physician practices and hospitals to successfully implement and meaningfully use EHRs, including assistance associated with vendor products, hardware, software and system configuration and troubleshooting, staffing considerations, workflow analysis, EHR utilization, security and privacy, and quality data reporting from EHR systems.

OFMQ • Oklahoma Foundation for Medical Quality • Independent, non-profit, community-based

organization (founded in 1972) • Our Mission Statement:

“Leading efforts to improve healthcare and improve lives.”

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OFMQ-HIT • OFMQ Health Info. Technology Regional Extension Center • American Recovery & Reinvestment Act (ARRA) – 2-17-09

“Stimulus Package” • HITECH Act:

– Office of the National Coordinator for Health Information Technology (ONC)

– Incentive payments for providers and hospitals to adopt Electronic Health Records

– Achieve “Meaningful Use”

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Mission of OFMQ-HIT

To advance the implementation and use of vital health information technology to improve healthcare

quality, efficiency and safety by assisting physician practices and hospitals in achieving meaningful use of

electronic health records.

Medicare EHR Incentive Program

Run by CMS Maximum incentive amount is $44,000

Payments over 5 consecutive years Payment adjustments will begin in 2015 for providers who are eligible but decide not to participate

Providers must demonstrate meaningful use every year to receive incentive payments.

Medicare EHR Incentive Program

Medicare Incentive Table

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MEDICARE Medicare Profession Qualifies for first payment in Year:

2011 2012 2013 2014 2015 2016

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 $ -

2016 $ - $ 2,000 $ 4,000 $ 4,000 $ - $ -

TOTAL: $ 44,000 $ 44,000 $ 39,000 $ 24,000 $ - $ -

HPSA: $ 48,400 $ 48,400 $ 42,900 $ 26,400 $ - $ -

“The longer you wait the steeper and more difficult the climb.”

Medicaid Incentive Table

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“ARRA Eligible Providers” (EP) Medicare Medicaid ($44,000) ($63,750)

Doctor of Medicine x x Doctor of Osteopathy x x

Doctor of Dental Surgery x x Doctor of Dental Medicine x x

Doctor of Podiatric Medicine x Doctor of Optometry x

Chiropractor x Certified Nurse-Midwife x

Nurse Practitioner x Physician Assistant

(Practicing in FQHC or RHC that is led by a PA) x

ARRA Eligible Providers

Timelines • Everyone gets 2 years of Stage 1 • Calendar Year • First Year: ANY 90 consecutive days • Second Year: 365 consecutive days • 2014: Regardless of stage everyone does 90 days,

must select 1 of 4 quarters

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Providers that are attesting to Meaningful Use for the first time in calendar year (CY) 2014, the following applies. • To avoid the 2015 penalty, providers need to attest in

the first 9 months of their respective fiscal year (FY) for EHs or CY 2014 for EPs.

• If providers wait until Q4 to attest, they will: – Get penalized in 2015 for failing to attest in first 9 months. – Still get a 2014 incentive because they did attest to MU for

90 days during CY 2014. – Avoid the 2016 penalty because 2014 is the basis for

2016's penalty and they did MU in 2014, just not in time to avoid the 2015 penalty.

Timelines

Notice of Proposed Rulemaking (NPRM)

CMS rule to help providers make use of Certified EHR Technology Rule also proposes to extend Stage 2 of the EHR Incentive Programs through 2016 • Provide eligible professionals (EP) and eligible hospitals (EH) more flexibility in how

they use certified EHR technology to meet meaningful use • Providers would be allowed to use the 2011 Edition CEHRT or a combination of 2011

and 2014 Edition CEHRT for the EHR reporting period in 2014 • Beginning in 2015 all EP’s and EH’s would still be required to report using 2014

Edition CEHRT • Includes provision that would extend Stage 2 through 2016 and begin Stage 3 in 2017

Proposed Changes to Meaningful Use Timeline

Proposed Changes to Meaningful Use Timeline

The comment period for the NPRM on “Medicare and Medicaid Programs: Modifications, Revisions: Medicare and Medicaid Electronic Health Record Incentive Programs for 2014: Health Information Technology” is now OPEN http://www.regulations.gov/#!documentDetail;D=CMS-2014-0064-0002

Payment Adjustments American Recovery and Reinvestment Act of 2009 (ARRA) mandates that payment adjustments should be applied to Medicare EP’s and EH’s who are not meaningful users of CEHRT under the Medicare EHR Program. • Providers must participate in either the Medicare or Medicaid EHR

Incentive program to avoid payment adjustments • Payment adjustments will be applied beginning on October 1 2014 for

hospitals and January 1, 2015 for Medicare

Payment Adjustments for Medicare EP’s

• The payment adjustment is 1% per year and is cumulative for every year that an EP is not a meaningful user.

• Depending on the total number of Medicare EP’s who are meaningful users after 2018, the max cumulative payment adjustment can reach as high as 5%.

The following tables illustrate the potential application of payment adjustments to covered professional services for Medicare EP who is not a meaningful user beginning in 2014

Hardship Exception Eligible professionals may apply for hardship exceptions to avoid the payment adjustments previously described. Hardship exceptions will be granted only under specific circumstances and only if CMS determines that providers have demonstrated that those circumstances pose a significant barrier to their achieving meaningful use.

Hardship Exception Categories 1. Infrastructure: Eligible professionals must demonstrate that

they are in an area without sufficient internet access or face insurmountable barriers to obtaining infrastructure (e.g., lack of broadband).

2. New Eligible Professionals: Newly practicing eligible professionals who would not have had time to become meaningful users can apply for a 2-year limited exception to payment adjustments. Thus eligible professionals who begin practice in calendar year 2015 would receive an exception to the penalties in 2015 and 2016, but would have to begin demonstrating meaningful use in calendar year 2016 to avoid payment adjustments in 2017.

3. Unforeseen Circumstances: Examples may include a natural disaster or other unforeseeable barrier.

Hardship Exception Categories

4. Patient Interaction: • Lack of face-to-face or telemedicine interaction with patient • Lack of follow-up need with patients

5. Practice at Multiple Locations: Lack of control over availability of CEHRT for more than 50% of patient encounters

6. 2014 EHR Vendor Issues: The eligible professional’s EHR vendor was unable to obtain 2014 certification or the eligible professional was unable to implement meaningful use due to 2014 EHR certification delays.

Hardship Exception • Applications are due by midnight EDT on July 1, 2014. • Submitting the form doesn't guarantee a waiver from

the payment penalties set to begin Jan.1, 2015. • Eligible professionals who do not achieve Meaningful

Use by Oct. 31, 2014 and who do not apply for the Hardship Exception will be subject to penalties beginning in 2015

Meaningful Use Stage 1 – Focuses on Functional & Interoperability Measures

– Health Outcomes Policy Priorities: • Improve quality, safety, efficiency and reduce

disparities • Engage patients and families in their healthcare • Improve care coordination • Improve population and public health

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Meaningful Use Stage 2 Meaningful Use released August 23rd 2012

– The Focus: • Increase health information exchange between

providers • Promote patient engagement by giving patients

secure online access to their health information

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Clinical Quality Measures (CQM)

o Change from Stage 1 to Stage 2: CQMs are no longer a Meaningful Use core objective- 2013

o CQMs have been incorporated into the definition of being a “Meaningful User” of certified EHR technology-2013

o CQMs must be reported electronically to CMS-2014

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CQMs for Eligible Professional

• Required in 2014 • EPs will submit 9 CQMs from at least 3 of the

National Quality Strategy domains – Potential list of 29 CQMs across 6 domains

• Data must be sent electronically via a CMS-designated transmission method

• EPs participating in PQRS – One submission will give you credit for both PQRS

and the Medicare EHR Incentive Program

Stage 1 vs. Stage 2 Eligible Providers, EP

Stage 1 25 Objectives – EPs

• 15 Core (CQM included)

• 10 Menu (Choose 5)

• 20 Total

Stage 2 23 Objectives – EPs

• 17 Core (CQM not included)

• 6 Menu (Choose 3) • CQM • 20 Total

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Core Objectives

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Stage 2 EP Core Objectives • CPOE (Computerized Physician

Order Entry) • eRx • Record demographics • Record vital signs • Record smoking status • Implement 5 Clinical Decision

Support (CDS) rules • Structured lab results • Generate lists of patients by

condition • Reminders for

preventative/follow-up care

• Provide online access to health info

• Provide clinical visit summaries • Provide patient education

resources • Secure messaging with patients • Medication reconciliation • Provide summary of care

document • Submit electronic data to

immunization registry • Conduct security risk analysis

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Core Objectives o CPOE:

• Medication, laboratory & radiology orders • Threshold – 60% for meds; 30% for lab & radiology • Exclusion-

• EP who writes fewer than 100 medication, radiology, or laboratory orders during reporting period

o eRx: • Threshold – 50% of all permissible Rx • Implement at least 1 drug formulary • Exclusion-

• EP who writes fewer than 100 prescriptions during reporting period

• EP who does not have a pharmacy within 10 that accepts electronic prescriptions

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Core Objectives

o Demographics: • Preferred language, Sex, Race, Ethnicity, DOB • Threshold – 80% of all unique patients • No exclusion

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Core Objectives o Record and chart changes in vital signs:

• Height/length, Weight, BP (age 3+), Calculate and display BMI, Plot and display growth charts for patients 0-20 years

• Threshold – 80% of unique patients • Exclusion-

• EP sees no patients 3 and over • EP believes ht. & wt. are not relevant • EP believes BP is not relevant • EP believes all 3 vitals are not relevant • 2013 Only (Optional); 2014 – Onward (Required)

o Record smoking status: • Threshold – 80% of unique patients 13 years old + • Exclusion-

• EP that sees no patients 13 years or older

o Use clinical decision support: • Implement 5 CDS interventions related to 4 or more

CQMs • Enabled drug-drug & drug-allergy interactions • Exclusion-

• Only for drug-drug, if EP writes fewer than 100 medications during reporting period

Core Objectives

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Core Objectives o Provide patients the ability to view online,

download, and transmit their health info within 4 business days of the info being available to the EP:

• More than 50% of all unique patients have timely electronic access

• More than 5% of unique patients view, download, or transmit to a 3rd party their health info

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Core Objectives o Provide clinical summaries for each office visit:

• Clinical summary provided within 1 business day for more than 50% of office visits

• Summary must include: • Patient name, Provider’s name and contact info, Date and location of

visit, Reason for office visit, Current problem list and any updates, Current medication list and any updates, Current medication allergy list and any updates, Procedures preformed during the visit, Immunizations or medications administered during the visit, Vital signs and any updates, Laboratory test results, List of diagnostic tests pending, Clinical instructions, Future appointments, Referrals to other providers, Future scheduled tests, Demographics maintained by EP, Smoking status, Care plan field including goals and instructions, Recommended patient decision aids

• Exclusion- • Any EP who has no office visits during the reporting period

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Core Objectives o Lab test results:

• Threshold – 55% of all tests ordered are recorded as structured data

• Exclusion- • Any EP who orders no lab tests where results

are either in a positive/negative affirmation or numeric format during reporting period

o Generate list of patients by specific condition: • Generate at least 1 report • No exclusion

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Core Objectives o Reminders for preventative/follow-up care:

• More than 10% of all unique patients who have had an office visit in the past 24 months prior to the beginning of the reporting period were sent a reminder, per patient preference

• Exclusion- • Any EP who has had no office visits in the 24 months before the

reporting period

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Core Objectives o Patient-Specific education resources:

• Use certified EHR to identify patient-specific education resources and provide to the patient

• Threshold – 10% of unique patients • Exclusion-

• Any EP who has had no office visits during the reporting period

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Core Objectives o Medication reconciliation:

• Perform med reconciliation when receiving a patient from another setting of care

• Threshold – 50% of transitions of care, where patient was transitioned into the care of the EP

• Exclusion- • Any EP who was not the recipient of any transitions of

care during the reporting period

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Core Objectives o Summary of care record:

• Provide summary of care for more than 50% of transitions of care and referrals

• Provide summary of care for more than 10% of such transitions and referrals either

A) electronically transmitted using CEHRT to a recipient B) via exchange through NwHIN Exchange participant or in a manner consistent with ONC governance mechanism

• Must satisfy one of the two following criteria: A) Exchange of summary with a recipient who uses a different EHR vendor B) Conduct one or more successful tests with the CMS designated test EHR

• Exclusion- • Any EP who transfers a patient to another setting or refers a patient to another

provider less than 100 times during reporting period is excluded from all three measures

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Core Objectives

o Public Health Objective – Immunization Data: • Successful ongoing submission of electronic immunization

data to an immunization registry • Exclusion-

• The EP does not administer any of the immunizations to any of the populations for which data is collected by their jurisdiction’s immunization registry during the reporting period

• The EP operates in a jurisdiction for which no immunization registry is capable of accepting the specific standards required

• The EP operates in a jurisdiction where no immunization registry provides information timely on capability to receive immunization data

Oklahoma providers can register here: OSDH – Meaningful Use Immunization Message Submission

o Use secure electronic messaging to communicate with patients on relevant health information: • Send a secure message using electronic messaging function

of certified EHR technology to more than 5% of unique patients

• Exclusion- • Any EP who has no office visits during reporting period, or who conducts 50

percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 3 Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period

Core Objectives

Core Objectives o Implement Systems to Protect Privacy & Security of

Patient Data: 45 CFR 164.308 (a)(1)

• Conduct or review a security risk analysis • Implement security updates as necessary • Address encryption/security of data at rest • No Exclusion

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Why Security & Privacy Risk Analysis? • Required for Meaningful Use • Primary tenet for HIPAA (1996) and HITECH (2009) • Used to determine which safeguards and technologies

will best protect the confidentiality, integrity, and availability of e-PHI- Electronic Protected Health Information

• Risk analysis is the first step in an organization’s Security Rule compliance efforts

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Why Security & Privacy Risk Analysis?

• Because patients trust you with their health information

• Your Organization, NOT your EHR vendor, is responsible for taking the steps necessary to protect the confidentiality, integrity, and availability of health information in your EHR and comply with HIPAA Rules and CMS Meaningful Use requirements

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Specifics for Meaningful Use • Provider is responsible for obtaining a compliant risk

analysis for each reporting period • Results of the Risk Analysis must be kept as part of

the Meaningful Use Attestation • Provider is responsible for any identified deficiencies,

inventory, as well as ongoing mitigation • Have to address your findings (risks) with proper

documentation

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Risk Assessment

Security Risk Analysis Process

Review Existing Security of PHI

Identify Threats and

Vulnerabilities

Assess Risks for Likelihood and

Impact

Mitigate Security Risks

Monitor Results

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4 3

2 5

Menu Objectives

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Stage 2 EP Menu Objectives

• Imaging results accessible through EHR • Record family health history • Record electronic notes in patient records • Submit electronic syndromic surveillance data to

public health agencies • Identify and report cancer cases to cancer registry • Identify and report specific cases to a specialized

registry (other than cancer)

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Menu Objectives

o Record electronic notes in patient records: • Enter at least one electronic progress note

created, edited, and signed by an EP • Threshold: 30% • Electronic notes must be text searchable (i.e. No

scanned progress notes) • No Exclusion

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Menu Objectives o Imaging results and information:

• More than 10% of all tests are accessible through the EHR

• Exclusion- • Any EP who orders less than 100 tests whose result is an

image during the reporting period

o Record patient family health history: • More than 20% of all unique patients have a

structured data entry for one or more first-degree relatives

• Exclusion- • Any EP who has no office visits during the reporting

period

Menu Objectives

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Menu Objectives

o Electronic Syndromic Surveillance Data: • Capability to submit public health agencies • Exclusion-

• Any EP who is not in a category of providers that collect ambulatory syndromic surveillance information on their patients

• Any EP who operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data

o Identify and Report Cancer Cases: • Capability to report to public health central cancer

registry • Exclusion-

• The EP does not diagnose or directly treat cancer • The EP operates in a jurisdiction for which no public

health agency is capable of receiving electronic cancer case information

Menu Objectives

o Specialized Registry: • Capability to identify and report specific cases to a

specialized registry (other than a cancer registry) • Exclusion-

• The EP does not diagnose or directly treat any disease associated with a specialized registry sponsored by a national specialty society for which the EP is eligible

• The EP operates in a jurisdiction for which no specialized registry sponsored by a public health agency or by a national society for which the EP is eligible is capable of receiving electronic specific case information

Menu Objectives

Questions?

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Upcoming Events

Our Next WebEx Seminar Wed, Sept 17 | 12:15pm (Central Time)

“Meaningful Use Audits for Medicare & Medicaid”

Register at www.ofmq.com/event-month

Thank You! Lindsey Wiley, MHA, CHTS-IM, CHTS-TS

lwiley@ofmq.com