NextGen HQM Meaningful Use Stage 2. User Guide

Transcription

1 NextGen HQM Meaningful Use Stage 2 User Guide

2 Introduction NextGen HQM Portal Reports Reporting Specifics Meaningful Use Stage 2: Eligible Professional Guidebook Contents Last Updated: 1/23/2015 Core Measures Requirement Source Core 1: CPOE For Orders >60% Medications, 30% Labs, 30% Radiology Orders NG HQM Report Core 2: eprescribing (erx) >50% of all permissible prescriptions NG HQM Report Core 3: Record Demographics >80% of unique patients NG HQM Report Core 4: Record Vital Signs >80% of unique patients NG HQM Report Core 5: Record Smoking Status >80% of unique patients 13+ years NG HQM Report Core 6: Clinical Decision Support Client Y/N Self Attestation Documentation Core 7: Patient Electronic Access >50% of unique patients provided enrollment token NG HQM Report >5% of patients download their PHR Core 8: Clinical Summaries >50% of all office visits NG HQM Report Core 9: Protect Electronic Health Information Y/N Self Attestation Client Documentation Core 10: Clinical Lab Test Results >55% of all clinical lab tests NG HQM Report Core 11: Generate Patient Lists Y/N Self Attestation Client Documentation Core 12: Preventative Care >10% of patients that had 2 office visits NG HQM Report Core 13: Patient Specific Education NG HQM Report Resources >10% of unique patients Core 14: Medication Reconciliation >50% of transitions into care NG HQM Report >50% of transitions of care, >10% to be submitted NG HQM Report Core 15: Summary of Care through CEHRT, > 1 electronic exchange to a recipient with different EHR technology Core 16: Immunization Registries: Data Submission Y/N- Self Attestation Client Documentation Core 17: Secure Electronic Messaging >5% of patients NG HQM Report Menu Measures Requirement (must choose 3 out of the 6) Menu 1: Syndromic Surveillance: Data Submission Y/N- Self Attestation Client Documentation Menu 2: Electronic Notes >30% of unique patients NG HQM Report Menu 3: Imaging Results >10% of all radiology tests NG HQM Report Menu 4: Family Health History >20% of unique patients NGHQM Report Menu 5: Reporting to Cancer Registries Menu 6: Reporting to Specialized Registries Appendices A. MU Check and CQM Check Templates B. Additional Measure Details Y/N- Self Attestation Y/N- Self Attestation Client Documentation Client Documentation

3 Guidebook Contents Last Updated: 1/23/2015 Introduction Meaningful Use HQM Reports The EHR Incentive Program objectives and measures are broken down into two key categories: Meaningful Use Objectives represent the overarching 23 objectives and their respective measures which determine provider utilization of the EHR system and patient engagement. As of January 1 st, 2014, NextGen EHR will no longer utilize the MU Crystal Reports to help report on the respective measures for the Meaningful Use objectives. In 2014, the collection of all Meaningful Use objective data will take place via the HQM Portal. Unlike the MU Crystal Reports, the HQM Portal reports update on a weekly basis not daily. Please keep this in mind as you monitor your provider s reports. Clinical Quality Measures. Starting in 2014, CMS has released a new list of clinical quality measures for providers to report on. Providers will be required to report on 9 clinical quality measures. NextGen EHR will utilize the HQM Module to assist in the reporting of Clinical Quality measures. Additional Reporting Details To be a meaningful EHR user, an EP must have 50% or more of their patient encounters during the EHR reporting period at a practice/location or practices/locations equipped with certified EHR technology. For certain measures, 80% of provider s patients must have records in the EHR. o At the EP s discretion, the numerators and denominators of certain measures may be calculated using only the patient records maintained in certified EHR technology. The EP may also elect to calculate the numerators and denominators of these measures using ALL patient records. EPs must indicate which method they used in their calculations. Notice of Disclosure: Failure to meet regulatory requirements or failure to implement and utilize the necessary technology will impact eligibility, may result in missed incentives and/or penalties. TSI Healthcare has attempted to provide guidance of current policy, CMS guidelines, and NextGen documentation, and does not present these findings as expert advice regarding the federal policies, their requirements, data collection methods, or reporting guidelines. Meaningful Use requirements and other incentives programs are defined by the various agencies and offices of the US Federal Government. Incentive programs are part of ARRA and are administered by such agencies outlined therein and are subject to change. TSI Healthcare does not administer incentive payments, guarantee eligibility, or guarantee the accuracy of analysis and any statements about the program. TSI Healthcare and the NextGen family of products and services can only provide the tools to achieve these requirements; however the responsibility remains on the provider to achieve, correctly collect data, and report on each measurement. Should the Client have any questions as to the interpretation of ARRA, the HITECH Act or other relevant rules, regulation or incentive programs, and/or their application to the specific practice, the Client should contact the appropriate government agency directly.

4 Core Objective 1 of 17 Last Updated: 6/23/2015 Objective Measure(s) Exclusion Change From Stage 1 CPOE for Medication, Laboratory, & Radiology Orders Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines. More than 60 percent of medication, 30 percent of laboratory, and 30 percent of radiology orders created by the EP during the EHR reporting period are recorded using CPOE. Any EP who writes fewer than 100 medication, radiology, or laboratory orders during the EHR reporting period. Change in focus from unique patients to medication orders Increased medication percentage from 30% to 60% Added laboratory orders Added radiology orders *It is in TSI Healthcare s opinion that the radiology measure has been misnamed as CMS definition of terms expands this measure beyond x-rays to include various other imaging related orders. Please note that this measure will impact various specialties including ophthalmology. CMS Definition of Terms Computerized Provider Order Entry (CPOE) A provider's use of computer assistance to directly enter medical orders (for example, medications, consultations with other providers, laboratory services, imaging studies, and other auxiliary services) from a computer or mobile device. Laboratory Order Order for any service provided by a laboratory that could not be provided by a non-laboratory. Laboratory A facility for the biological, microbiological, serological, chemical, immunohematological, hematological, biophysical, cytological, pathological, or other examination of from the human body for the purpose of providing information for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings. These examinations also include procedures to determine, measure, or otherwise describe the presence or absence of various substances or organisms in the body. Facilities only collecting or preparing specimens (or both) or only serving as a mailing service and not performing testing are not considered laboratories. Radiology Order Order for any imaging services that uses electronic product radiation. The EP can include orders for other types of imaging services that do not rely on electronic product radiation in this definition as long the policy is consistent across all patient and for the entire EHR reporting period. Electronic Product Radiation Any ionizing or nonionizing electromagnetic or particulate radiation, or any sonic, infrasonic, or ultrasonic wave that is emitted from an electronic product as the result of the operation of an electronic circuit in such product. Unique Patient If a patient is seen by an EP more than once during the EHR reporting period, then for purposes of measurement that patient is only counted once in the denominator for the measure. CMS Attestation Requirements Attestation Type: DENOMINATOR/NUMERATOR/THRESHOLD/EXCLUSION Objective 1 Measure 1: Medication Orders DENOMINATOR: Number of medication orders created by the EP during the EHR reporting period. NUMERATOR: The number of orders in the denominator recorded using CPOE. THRESHOLD: The resulting percentage must be more than 60 percent in order for an EP to meet this measure. EXCLUSION: Any EP who writes fewer than 100 medication orders during the EHR reporting period.

5 Core Objective 1 of 17 Last Updated: 6/23/2015 Objective 1 Measure 2: Radiology Orders DENOMINATOR: Number of radiology orders created by the EP during the EHR reporting period. NUMERATOR: The number of orders in the denominator recorded using CPOE. THRESHOLD: The resulting percentage must be more than 30 percent in order for an EP to meet this measure. EXCLUSION: Any EP who writes fewer than 100 radiology orders during the EHR reporting period. Objective 1 Measure 3: Laboratory Orders DENOMINATOR: Number of laboratory orders created by the EP during the EHR reporting period. NUMERATOR: The number of orders in the denominator recorded using CPOE. THRESHOLD: The resulting percentage must be more than 30 percent in order for an EP to meet this measure. EXCLUSION: Any EP who writes fewer than 100 laboratory orders during the EHR reporting period. CMS Additional Information The provider is permitted, but not required, to limit the measure of this objective to those patients whose records are maintained using certified EHR technology (CEHRT). The CPOE function must be used to create the first record of the order that becomes part of the patient's medical record and before any action can be taken on the order to count in the numerator. However, in some situations it may be impossible or inadvisable to wait to initiate an intervention until a record of the order has been created. For example, situations where an intervention is identified and immediately initiated by the provider, or initiated immediately after a verbal order by the ordering provider to a licensed healthcare professional under his/her direct supervision. Therefore in these situations, so long as the order is entered using CPOE by a licensed healthcare professional or certified medical assistant to create the first record of that order as it becomes part of the patient s medical record, these orders would count in the numerator of the CPOE measure. Any licensed healthcare professionals and credentialed medical assistants, can enter orders into the medical record for purposes of including the order in the numerator for the objective of CPOE if they can originate the order per state, local and professional guidelines. Credentialing for a medical assistant must come from an organization other than the organization employing the medical assistant. Electronic transmittal of the medication order is not a requirement for meeting the measure of this objective. CPOE is the entry of the order into the patient's EHR that uses a specific function of CEHRT. It is not how that order is filled or otherwise carried out. In order to meet this objective and measure, an EP must use the capabilities and standards of CEHRT at 45 CFR (a)(1).

6 Objective 1 Measure 1: Medication Orders Meaningful Use Stage 2: Eligible Professional Core Objective 1 of 17 Last Updated: 6/23/2015 NextGen Measure Report & Analysis DENOMINATOR: The number of medication orders that have been printed, faxed, or e-prescribed during the reporting period. This does not include Over the Counter (OTC) or Durable Medical Equipment (DME). NUMERATOR: The number of medication orders included in the denominator that have been entered by the rendering provider or by an externally credentialed staff member. THRESHOLD: The resulting percentage (Numerator Denominator) must be more than 60 percent in order for an EP to meet this measure. EXCLUSION: Any EP who writes fewer than 100 medication orders during the EHR reporting period. NextGen Data Entry Requirements & Suggested Workflow All prescriptions should be entered into the NextGen EHR Medications Module to be accurately counted. Handwritten prescriptions are not counted. User Workflow for Denominator: All prescriptions that are not DME and not OTC that are printed, faxed, or e- prescribed are in the denominator. An order is a medication order that has been printed, faxed, or e-prescribed. User Workflow for Numerator: All prescriptions from the denominator that are entered by the provider or by an externally credentialed staff member meet the numerator requirements. NextGen Recommended Setup Medication Module Set-Up: It is recommended that each user enable the Created By column from within the NextGen EHR Medications Module to display which users are entering new medications into the Medications Module. To enable the Created By column: 1. Click on Grid Preferences 2. Select the Set Columns to Display option

7 Core Objective 1 of 17 Last Updated: 6/23/ Highlight the Created By option 4. Select Add 5. Utilize the Move Up or Move Down buttons to rearrange the ordering of the columns in the Medications Module. Then click OK **Note: This is a user specific setting. Each user must set the specific columns they would like to display within the Medications Module under their own NextGen login. Special Considerations The HQM report queries the user that Accepts the order, which should be the rendering provider with a relationship set to self in NextGen System Administrator, or a user that has been setup as an externally credentialed staff member. If there are any staff members that you would like to set up as an externally credentialed staff please review and submit the following form to the TSI Helpdesk: For any questions related to a staff member meeting the definition of an externally credentialed staff member, contact the TSI helpdesk at

8 Core Objective 1 of 17 Last Updated: 6/23/2015 Objective 1 Measure 2: Radiology Orders NextGen Measure Report & Analysis DENOMINATOR: Number of all R type orders during the reporting period* NUMERATOR: The number of radiology orders included in the denominator that have been entered by the EP or by an externally credentialed staff member. THRESHOLD: The resulting percentage (Numerator Denominator) must be more than 30 percent in order for an EP to meet this measure. EXCLUSION: Any EP who writes fewer than 100 radiology orders during the EHR reporting period. *Radiology orders not setup in the NextGen HQM Portal will not be included in the denominator NextGen Data Entry Requirements & Suggested Workflow All radiology orders should be entered into the NextGen Ambulatory EHR Orders module with the exception of ophthalmology specialty. All other specialties should enter radiology orders into the orders module To be accurately counted. The hand-written radiology orders are not captured. User Workflow for Denominator: All radiology orders during the reporting period. All radiology orders can be in the Orders module or can be entered within NextGen KBM and then submitted to the Orders module. User Workflow for Numerator: All radiology orders from the denominator that are entered by the provider or by an externally credentialed staff member meets the numerator requirements. Orders placed within the NextGen KBM needs to be processed or submitted to the Orders module. A provider or externally credentialed staff member does not need to be the user that processes or submits the order. Use the Process and Submit Lab/Radiology Orders pop-up with NextGen KBM, Version 8.3.x and higher. The process pop-up can be launched from multiple places within the NextGen KBM including (but not limited to): o My Plan o Lab Master o Diagnostic Studies o Intake OPH (using My Plan link) o Intake (using My Plan Link) o Intake Allergy (using My Plan link) o Intake Dermatology (using My Plan link)

9 Core Objective 1 of 17 Last Updated: 6/23/2015 For Ophthalmology practices, radiology orders can be ordered within NextGen KBM version 8.3x and higher: Nextgen Recommended Workflow: Clarification from the AAO regarding CPOE for Radiology/Imaging Orders: The CMS definition can be interpreted to include such ophthalmic tests as OCT, ophthalmic ultrasound, and others. Ophthalmologists should check with their EHR vendor to determine if orders for these ophthalmic tests can be entered electronically. If so, they must be entered to comply with the measure. Ophthalmologists should clearly document their policy for which tests must be entered using CPOE and retain this documentation in the event of an audit. The ophthalmology workflow for placing radiology/imaging orders via CPOE is as follows: 1. On the Provider template, scroll down to Additional Navigation. 2. Click the link for Tests Today : 3. On the Task Tests OPH pop up template, select the applicable test(s) using the checkboxes on the right side of the pop up: o For the purposes of CPOE Radiology/Imaging, only OCT, HRT/ONA, Ultrasound A-Scan, IOL Master, and Ultrasound B-Scan will count towards the measure o If prompted, select eye side (OD, OS, OU) and select the proper billing code

10 Core Objective 1 of 17 Last Updated: 6/23/ Fill in the remaining fields as applicable and/or appropriate for the test(s) such as Indication, Description, Study eye, Comment o Note: Attach a template? will prompt the user, after clicking Save & Task, to attach a template, document, image, or ICS image to the task 5. Once the pop up has been completed, click Save & Task o The rendering provider or a CPOE authorized user MUST be logged into NextGen EHR and click Save & Task for the order to count towards the measure If you utilize tasking, you can assign the test s task to the appropriate staff member. Otherwise, simply click Cancel to skip this window

11 Core Objective 1 of 17 Last Updated: 6/23/2015

12 Core Objective 1 of 17 Last Updated: 6/23/2015 The test(s) will now appear in the Appt Requests/Orders section under the Orders header on the Provider template: To view the order details, (1) click to highlight the order and (2) click Edit: The Documented by field should be either the rendering provider or CPOE authorized user for the order to count towards the measure: Note: It is recommended that the specific testing template (such as the OCT template) be used to document interpretations, findings, and other details. However, the order status can be updated from Ordered to Completed within this pop-up. o It is recommended that orders be marked as completed as to avoid lists of pending tests in the orders grid and on the EHR documents which may cause confusion.

13 Objective 1 Measure 3: Laboratory Orders Meaningful Use Stage 2: Eligible Professional Core Objective 1 of 17 Last Updated: 6/23/2015 NextGen Measure Report & Analysis DENOMINATOR: Number of all L type orders during the reporting period* NUMERATOR: The number of laboratory orders included in the denominator that have been entered by the EP or by an externally credentialed staff member. THRESHOLD: The resulting percentage (Numerator Denominator) must be more than 30 percent in order for an EP to meet this measure. EXCLUSION: Any EP who writes fewer than 100 laboratory orders during the EHR reporting period. *Lab orders not setup in the NextGen HQM Portal will not be included in the denominator NextGen Data Entry Requirements & Suggested Workflow All laboratory orders should be entered into the NextGen Ambulatory EHR Orders module in order to be accurately counted. The hand-written lab orders are not captured. User Workflow for Denominator: All laboratory orders during the reporting period. All laboratory orders must be in the Orders module. A laboratory order can be entered in NextGen KBM and then submitted to the Orders module. User Workflow for Numerator: All laboratory orders from the denominator that are entered by the provider or by an externally credentialed staff member meets the numerator requirements. Orders placed within the NextGen KBM needs to be processed or submitted to the Orders module. A provider or externally credentialed staff member does not need to be the user that processes or submits the order. Use the Process and Submit Lab/Radiology Orders pop-up with NextGen KBM, Version 8.3.x and higher. The process pop-up can be launched from multiple places within the NextGen KBM including (but not limited to): o My Plan o Lab Master o Diagnostic Studies o Intake OPH (using My Plan link) o Intake (using My Plan Link) o Intake Allergy (using My Plan link) o Intake Dermatology (using My Plan link)

14 Core Objective 1 of 17 Last Updated: 6/23/2015 Special Considerations Refills from the Inbox do not count in the denominator for the CPOE Medication Orders Core Measure. However, medication renewals from the Medications Module do count in the denominator for the CPOE Medication Orders Core Measure. The rendering provider or externally credentialed staff member must be logged into the EHR when handling a medication renewal in the Medications Module. The measure is not tied to a patient seen or to a particular visit during the reporting period. All prescriptions that are printed, faxed, or e-prescribed and which are not DME, not narcotic, and not OTC are included in the denominator.

15 Core Objective 2 of 17 Last Updated: 5/21/2015 Objective Measure Exclusion Changes From Stage 1 e-prescribing (erx) Generate and transmit permissible prescriptions electronically (erx). More than 50 percent of all permissible prescriptions, or all prescriptions, written by the EP are queried for a drug formulary and transmitted electronically using certified EHR technology. Any EP who: (1) Writes fewer than 100 permissible prescriptions during the EHR reporting period. (2) Does not have a pharmacy within their organization and there are no pharmacies that accept electronic prescriptions within 10 miles of the EP's practice location at the start of his/her EHR reporting period. Increased from 40% to 50% Combined Drug Formulary Menu Measure with erx Core Measure Added Pharmacies within 10 miles exclusion CMS Definition of Terms Permissible Prescriptions The concept of only permissible prescriptions refers to the current restrictions established by the Department of Justice on electronic prescribing for controlled substances in Schedule II-V. (The substances in Schedule II-V can be found at Any prescription not subject to these restrictions would be permissible. Prescription The authorization by an EP to a pharmacist to dispense a drug that the pharmacist would not dispense to the patient without such authorization. CMS Attestation Requirements Attestation Type: NUMERATOR / DENOMINATOR/THRESHOLD/EXCLUSION Attestation Details: DENOMINATOR: Number of prescriptions written for drugs requiring a prescription in order to be dispensed other than controlled substances during the EHR reporting period; or Number of prescriptions written for drugs requiring a prescription in order to be dispensed during the EHR reporting period. NUMERATOR: The number of prescriptions in the denominator generated, queried for a drug formulary and transmitted electronically using CEHRT. THRESHOLD: The resulting percentage must be more than 50 percent in order for an EP to meet this measure. EXCLUSIONS: Any EP who: 1. Writes fewer than 100 permissible prescriptions during the EHR reporting period; or 2. Does not have a pharmacy within their organization and there are no pharmacies that accept electronic prescriptions within 10 miles of the EP's practice location at the start of his/her EHR reporting period. CMS Additional Information The provider is permitted, but not required, to limit the measure of this objective to those patients whose records are maintained using certified EHR technology (CEHRT). Authorizations for items such as durable medical equipment, or other items and services that may require EP authorization before the patient could receive them, are not included in the definition of prescriptions. These are excluded from the numerator and the denominator of the measure. Instances where patients specifically request a paper prescription may not be excluded from the denominator of this measure. The denominator includes all prescriptions written by the EP during the EHR reporting period. As electronic prescribing of controlled substances is now possible, providers can choose to include all prescriptions or only permissible prescriptions as long as the decision applies to all patients and for the entire EHR reporting period.

16 Core Objective 2 of 17 Last Updated: 5/21/2015 The determination of whether a prescription is a ''permissible prescription'' for purposes of this measure should be made based on the guidelines for prescribing Schedule II-V controlled substances in effect on or before January 13, An EP needs to use CEHRT as the sole means of creating the prescription, and when transmitting to an external pharmacy that is independent of the EP's organization such transmission must use standards adopted for EHR technology certification. EPs should include in the numerator and denominator both types of electronic transmissions (those within and outside the organization) for the measure of this objective. For purposes of counting prescriptions "generated and transmitted electronically," we consider the generation and transmission of prescriptions to occur concurrently if the prescriber and dispenser are the same person and/or are accessing the same record in an integrated EHR to creating an order in a system that is electronically transmitted to an internal pharmacy. Providers can use intermediary networks that convert information from the certified EHR into a computer-based fax in order to meet this measure as long as the EP generates an electronic prescription and transmits it electronically using the standards of CEHRT to the intermediary network, and this results in the prescription being filled without the need for the provider to communicate the prescription in an alternative manner. Prescriptions transmitted electronically within an organization (the same legal entity) do not need to use the NCPDP standards. However, an EP's EHR must meet all applicable certification criteria and be certified as having the capability of meeting the external transmission requirements of (b). In addition, the EHR that is used to transmit prescriptions within the organization would need to be CEHRT. For more information, refer to ONC s FAQ at In order to meet this objective and measure, an EP must use the capabilities and standards of CEHRT at 45 CFR (b)(3) and 45 CFR (a)(10).

17 Objective 2 Measure: e-prescribing Meaningful Use Stage 2: Eligible Professional Core Objective 2 of 17 Last Updated: 5/21/2015 NextGen Measure Report & Analysis DENOMINATOR: The number of permissible prescriptions (non-narcotic, not DME, not OTC, not prescribed elsewhere) that are printed, faxed, or e-prescribed during the reporting period. NUMERATOR: The numerator of medications in the denominator that are e-prescribed during the reporting period. THRESHOLD: The resulting percentage (Numerator Denominator) must be more than 50 percent in order for an EP to meet this measure. EXCLUSION 1: Any EP that writes fewer than 100 permissible prescriptions during the reporting period. EXCLUSION 2: Any EP that does not have a pharmacy within their organization and there are no pharmacies that accept electronic prescriptions within 10 miles of the EP's practice location at the start of his/her EHR reporting period. NextGen Data Entry Requirements & Suggested Workflow User workflow for Denominator: All prescriptions that are not DME, non-narcotic, not OTC, and which are printed, faxed or e-prescribed are in the denominator. Settings can be configured so that a patient s formulary can be automatically queried in the background when the Medications Module is opened. Practices should ensure that this setting is enabled. User workflow for Numerator: All prescriptions from the denominator that are e-prescribed will meet the numerator requirements o The NG HQM Reports query the Last Audit column in the Medications Module to determine if the medication was e-prescribed. NextGen Recommended Setup Medication Module Set-Up: It is recommended that each user enable the Last Audit column from within the NextGen EHR Medications Module to display the method by which medications are transmitted to pharmacies. To enable the Last Audit column:

18 Core Objective 2 of 17 Last Updated: 5/21/ Click on Grid Preferences 2. Select the Set Columns to Display option 3. Highlight the Last Audit option 4. Select Add 5. Utilize the Move Up or Move Down buttons to rearrange the ordering of the columns in the Medications Module. Then click OK ** Note: This is a user specific setting. Each user must set the specific columns they would like to display within the Medications Module under their own NextGen login. Special Considerations Refills from the Inbox do not count in the denominator for the CPOE Medication Orders Core Measure. However, medication renewals from the Medications Module do count in the denominator for the CPOE Medication Orders

19 Core Objective 2 of 17 Last Updated: 5/21/2015 Core Measure. The rendering provider or externally credentialed staff member must be logged into the EHR when handling a medication renewal in the Medications Module. The measure is not tied to a patient seen or to a particular visit during the reporting period. All prescriptions that are printed, faxed, or e-prescribed and which are not DME, not narcotic, and not OTC are included in the denominator.

20 Core Objective 3 of 17 Last Updated: 12/4/2014 Objective Measure Exclusion Changes From Stage 1 Record Demographics Record all of the following demographics: a) Preferred language b) Sex c) Race d) Ethnicity e) Date of birth. More than 80 percent of all unique patients seen by the EP have demographics recorded as structured data. No exclusion. Increased from 50% to 80% Demographic information will now be required in the clinical summary (patient plan) as a part of Core Measure #8 TSI recommends that practices begin collecting the patient s preferred contact method and address in addition to the required demographics listed above because that information will help with other MU objectives. CMS Definition of Terms Preferred Language The language by which the patient prefers to communicate. Race vs. Ethnicity Race is most closely associated with observable characteristics while ethnicity focuses on upbringing and heritage. Ethnicity is also typically tied to religious beliefs, nationality, geographic origin, linguistic characteristics, and cultural groups. (Hispanic and non-hispanic are the minimum choices required. A full listing can be found at Racial groups can be composed of individuals from different ethnicities. Unique Patient If a patient is seen by an EP more than once during the EHR reporting period, then for purposes of measurement that patient is only counted once in the denominator for the measure. All the measures relying on the term unique patient relate to what is contained in the patient s medical record. Not all of this information will need to be updated or even be needed by the provider at every patient encounter. This is especially true for patients whose encounter frequency is such that they would see the same provider multiple times in the same EHR reporting period. CMS Attestation Requirements Attestation Type: NUMERATOR / DENOMINATOR/THRESHOLD Attestation Details: DENOMINATOR: Number of unique patients seen by the EP during the EHR reporting period. NUMERATOR: Number of patients in the denominator who have all the elements of demographics (or a specific notation if the patient declined to provide one or more elements or if recording an element is contrary to state law) recorded as structured data. THRESHOLD: The resulting percentage (Numerator Denominator) must be more than 50 percent in order for an EP to meet this measure. EXCLUSION: None.

21 Core Objective 3 of 17 Last Updated: 12/4/2014 CMS Additional Information Race and ethnicity codes should follow current federal standards published by the Office of Management and Budget ( If a patient declines to provide all or part of the demographic information, or if capturing a patient s ethnicity or race is prohibited by state law, such a notation entered as structured data would count as an entry for purposes of meeting the measure. In regards to patients who do not know their ethnicity, EPs should treat these patients the same way as patients who decline to provide race or ethnicity identify in the patient record that the patient declined to provide this information. EPs are not required to communicate with the patient in his or her preferred language in order to meet the measure of this objective. The term gender in the Stage 1 objective is replaced with the term sex for Stage 2. In order to meet this objective and measure an EP must use the capabilities and standards of certified electronic health record technology (CEHRT) at 45 CFR (a)(3).

22 Objective 3 Measure: Record Demographics Meaningful Use Stage 2: Eligible Professional Core Objective 3 of 17 Last Updated: 12/4/2014 NextGen Measure Report & Analysis DENOMINATOR: The number of unique patients seen during the EHR reporting period. NUMERATOR: The numerator will include all patients in the denominator that have all five of the following demographics recorded: preferred language, sex, race, ethnicity, and date of birth. THRESHOLD: The resulting percentage (Numerator Denominator) must be more than 80 percent in order for an EP to meet this measure. EXCLUSION: No exclusion NextGen Data Entry Requirements & Suggested Workflow When a patient is entered into NextGen EPM, ensure that race, language, date of birth, ethnicity, and sex (i.e. gender) are recorded. An alternative within the NextGen KBM is to navigate to the patient demographics template and record the required elements. User Workflow for Denominator: For this measure, all data elements for the denominator are captured in the Procedures module or from the Visit Type that is selected in NextGen KBM 8.3.x and higher. For practices that do not utilize NextGen EPM the visit type must be selected in order to have patients increment the denominator for this measure. o Workflow for all specialties except Retina: From Intake (NextGen KBM, Version 8.3.x and higher, for multiple specialties) select visit type. o Workflow for Retina only: From CC-HPI-ROS-OPH (NextGen KBM, Version 8.3.x and higher) select visit type (select the appropriate check box to populate the master_im_.visit_type field).

23 Core Objective 3 of 17 Last Updated: 12/4/2014 User Workflow for Numerator: Ensure that the patient has an entry for race, language, date of birth, ethnicity, and gender (sex). o From the Demographics screen on the Add/Modify Patient Information screen in NextGen EPM: o From the Patient Demographics template (NextGen KBM, Version 8.3.x and higher): o For clients who don t use NextGen EPM see image below:

24 Core Objective 3 of 17 Last Updated: 12/4/2014 TSI Tip Record Contact Preference - Collecting the patient s demographics will satisfy the requirement for this measure, but it is best practice to additionally collect the patient s preferred contact method. Preferred contact method will be needed for Core Objective 12. o From the Demographics screen on the Add/Modify Patient Information screen in NextGen EPM: o Select a contact preference from the Contact Preference drop-down list NOTE: Selecting a value from the contact preference list does not automatically change the order of the contact methods on the left. The contact preference selected in the Contact Preference field trumps the preferential ordering of the list. PhoneTree and Population Health (add-on modules) look to this field when contacting patients via their preferred method. It is optional to rearrange the ordering of the contact preference but if you wish to do so you will need to use the blue arrows on the right to manually order the patient s preferences. Example: If a patient s preferred contact method is 2-Voice Reminder-Day Phone, but the Home Phone field is still listed as #1, PhoneTree will defer to the Contact Preference field and contact the patient via Day Phone. NOTE: If the Contact Preference field is not visible within NextGen EPM, or if your contact preference drop down list does not contain the correct contact preference options that are listed above, please open the following ticket with the TSI Helpdesk (helpdesk@tsihealthcare.com): Please customize our EPM Contact Preference field with the standard contact options for Meaningful Use.

25 Core Objective 3 of 17 Last Updated: 12/4/2014 o From the Patient Demographics template (NextGen KBM, Version 8.3.x and higher): o For clients who don t use NextGen EPM, document the patient s preferred contact method via the preferred contact method field on the Patient Demographics template in NextGen EHR. Special Considerations: Practices should not attempt to guess the patient s race and/or ethnicity as this information will be included in Patient Portal and Clinical Summaries.

26 Core Objective 4 of 17 Objective Measure Exclusion Changes from Stage 1 Record Vital Signs Record and chart changes in the following vital signs: Height/length and weight (no age limit) Blood pressure (ages 3 and over) Calculate and display body mass index (BMI); and plot and display growth charts for patients 0-20 years, including BMI. More than 80 percent of all unique patients seen by the EP have blood pressure (for patients age 3 and over only) and/or height and weight (for all ages) recorded as structured data. Any EP who: 1. Sees no patients 3 years or older is excluded from recording blood pressure. 2. Believes that all 3 vital signs of height/length, weight, and blood pressure have no relevance to their scope of practice is excluded from recording them. 3. Believes that height/length and weight are relevant to their scope of practice, but blood pressure is not, is excluded from recording blood pressure. 4. Believes that blood pressure is relevant to their scope of practice, but height/length and weight are not, is excluded from recording height/length and weight. Increased from 50% to 80% Split into two separate measures (BP vs. H&W) CMS Definition of Terms Unique Patient If a patient is seen by an EP more than once during the EHR reporting period, then for purposes of measurement that patient is only counted once in the denominator for the measure. All the measures relying on the term unique patient relate to what is contained in the patient s medical record. Not all of this information will need to be updated or even be needed by the provider at every patient encounter. This is especially true for patients whose encounter frequency is such that they would see the same provider multiple times in the same EHR reporting period. CMS Attestation Requirements Attestation Type: NUMERATOR/ DENOMINATOR/THRESHOLD/EXCLUSION Attestation Details: DENOMINATOR: Number of unique patients seen by the EP during the EHR reporting period. NUMERATOR: Number of patients in the denominator who have at least one entry of their height/length and weight (all ages) and/or blood pressure (ages 3 and over) recorded as structured data. THRESHOLD: The resulting percentage must be more than 80 percent in order for an EP to meet this measure. EXCLUSIONS: 1. Any EP who sees no patients 3 years or older is excluded from recording blood pressure. 2. Any EP who believes that all 3 vital signs of height/length, weight, and blood pressure have no relevance to their scope of practice is excluded from recording them. 3. Any EP who believes that height/length and weight are relevant to their scope of practice, but blood pressure is not, is excluded from recording blood pressure. 4. Any EP who believes that blood pressure is relevant to their scope of practice, but height/length and weight are not, is excluded from recording height/length and weight.

27 Core Objective 4 of 17 CMS Additional Information The provider is permitted, but not required, to limit the measure of this objective to those patients whose records are maintained using certified EHR technology. If the EP meets exclusion (3) or exclusion (4) they must both attest to the exclusion and report the numerator and denominator for the remaining elements of the measure. The only information required to be inputted by the provider is the height and weight, and/or blood pressure of the patient. The certified EHR technology will calculate BMI and the growth chart if applicable to patient based on age. Height, weight, and blood pressure do not have to be updated by the EP at every patient encounter. The EP can make the determination based on the patient s individual circumstances as to whether height, weight, and blood pressure need to be updated. Vital sign information can be entered into the patient's medical record in a number of ways including: direct entry by the EP; entry by a designated individual from the EP s staff; data transfer from another provider electronically, through an HIE or through other methods; or data entered directly by the patient through a portal or other means. Some of these methods are more accurate than others, and it is up to the EP to determine the level of accuracy needed to care for their patient and how best to obtain this information. In order to meet this objective and measure, an EP must use the capabilities and standards of certified EHR technology (CEHRT) at 45 CFR (a)(4).

28 Core Objective 4 of 17 Objective 4 Measure: Vital Signs Recorded NextGen Measure Report & Analysis DENOMINATOR: The number of unique patients (age 3 or over for blood pressure) seen during the reporting period. NUMERATOR: Number of patients in the denominator who have at least one entry of their height, weight, and blood pressure (ages 3 and over) recorded as structured data. THRESHOLD: The resulting percentage (Numerator Denominator) must be more than 80 percent in order for an EP to meet this measure. EXCLUSION 1: Sees no patients 3 years or older is excluded from recording blood pressure. EXCLUSION 2: Believes that all 3 vital signs of height, weight, and blood pressure have no relevance to their scope of practice is excluded from recording them. EXCLUSION 3: Believes that height and weight are relevant to their scope of practice, but blood pressure is not, is excluded from recording blood pressure. EXCLUSION 4: Believes that blood pressure is relevant to their scope of practice, but height and weight are not, is excluded from recording height/length and weight. NextGen Data Entry Requirements & Suggested Workflow For patients over the age of 3 years on the date of encounter, enter a blood pressure, weight, and height. All specialties have access to vital signs entry templates. User Workflow for Denominator For this measure, all data elements for the denominator are captured in the Procedures module or from the Visit Type that is selected in NextGen KBM 8.3.x and higher. For practices that do not utilize NextGen EPM the visit type must be selected in order to have patients increment the denominator for this measure. o Workflow for all specialties except Retina: From Intake (NextGen KBM, Version 8.3.x and higher, for multiple specialties) select visit type. o Workflow for Retina only: From CC-HPI-ROS-OPH (NextGen KBM, Version 8.3.x and higher) select visit type (select the appropriate check box to populate the master_im_.visit_type field).

29 Core Objective 4 of 17 User Workflow for Numerator For patients over the age of 3 years on the date of encounter enter a blood pressure, weight, and height. For patients of all ages document weight and height. All specialties have access to vital signs entry templates from within NextGen KBM 8.3.x and higher. The workflow for documenting the patient s vital signs is detailed below based on specialty. Workflow for all specialties except OBGYN, Ophthalmology, and Retina: 1. From *Intake (NextGen KBM, Version 8.3.x and higher, used for multiple specialties), launch the Vital Signs Entry pop-up template by clicking Add 2. Then document BP, Height, and Weight.

30 Core Objective 4 of 17 Workflow for OBGYN 1. From Prenatal Detail in the OBGYN workflow enter height 2. Then launch the OB_Flowsheet to enter BP and weight 3. Then you MUST click the Share Vitals/Urine Dipstick button to load the BP and weight results to the Vital Signs template.

31 Core Objective 4 of 17 Workflow for Ophthalmology 1. From Intake OPH, launch the Vital Signs (Lite) entry pop-up template by clicking Add 2. Enter the BP, Height, and Weight. Workflow for Retina 1. From Home OPH, use the left navigation pane and then select Vital Signs to launch the Vital Signs (Lite) pop-up template. Enter the BP, Height, and Weight.

32 Core Objective 4 of 17 Special Considerations: BP can be recorded before the age of 3 and meet numerator requirements for blood pressure. The client must determine reporting options (All vitals, BP only, height and weight only).

33 Core Objective 5 of 17 Objective Measure Exclusion Changes from Stage 1 Record Smoking Status Record smoking status for patients 13 years old or older. More than 80 percent of all unique patients 13 years old or older seen by the EP have smoking status recorded as structured data. Any EP who sees no patients 13 years or older. Increased from 50% to 80% CMS Definition of Terms Unique Patient If a patient is seen by an EP more than once during the EHR reporting period, then for purposes of measurement that patient is only counted once in the denominator for the measure. All the measures relying on the term unique patient relate to what is contained in the patient s medical record. Not all of this information will need to be updated or even be needed by the provider at every patient encounter. This is especially true for patients whose encounter frequency is such that they would see the same provider multiple times in the same EHR reporting period. CMS Attestation Requirements Attestation Type: NUMERATOR/DENOMINATOR/THRESHOLD/EXCLUSION Attestation Details: DENOMINATOR: Number of unique patients age 13 or older seen by the EP during the EHR reporting period. NUMERATOR: Number of patients in the denominator with smoking status recorded as structured data. THRESHOLD: The resulting percentage must be more than 80 percent in order for an EP to meet this measure. EXCLUSION: An EP who sees no patients 13 years or older would be excluded from this requirement. CMS Additional Information The provider is permitted, but not required, to limit the measure of this objective to those patients whose records are maintained using certified EHR technology. This is a check of the medical record for patients 13 years old or older. If this information is already in the medical record available through certified EHR technology, an inquiry does not need to be made every time a provider sees a patient 13 years old or older. The frequency of updating this information is left to the provider and guidance is provided already from several sources in the medical community. In order to meet this objective and measure, an EP must use the capabilities and standards of CEHRT at 45 CFR (a)(11).

34 Core Objective 5 of 17 Objective 5 Measure: Record Smoking Status NextGen Measure Report & Analysis DENOMINATOR: The number of unique patients seen during the reporting period that are 13 years and older. NUMERATOR: The number of patients in the denominator with their smoking status recorded as structured data. THRESHOLD: The resulting percentage (Numerator Denominator) must be more than 80 percent in order for an EP to meet this measure. EXCLUSION 1: Any EP who sees no patients 13 years or older. NextGen Data Entry Requirements & Suggested Workflow User Workflow for Denominator: For this measure, all data elements for the denominator are captured in the Procedures module or from the Visit Type that is selected in NextGen KBM 8.3.x and higher. For practices that do not utilize NextGen EPM the visit type must be selected in order to have patients increment the denominator for this measure. o Workflow for all specialties except Retina: From Intake (NextGen KBM, Version 8.3.x and higher, for multiple specialties) select visit type. o Workflow for Retina only: From CC-HPI-ROS-OPH (NextGen KBM, Version 8.3.x and higher) select visit type (select the appropriate check box to populate the master_im_.visit_type field).

35 Core Objective 5 of 17 User Workflow for Numerator: For this measure, record smoking status if the patient is 13 years or older. All specialties have access to the Social History Tobacco pop-up template in the NextGen KBM. o The Social History Tobacco pop-up template can be accessed from the following templates (not limited to): - History OPH - Histories - OPH - Histories - Histories Cardiology - Histories Dermatology - Histories Allergy - Histories Obstetrics o This pop-up template is used for documenting the patient s Smoking Status. When you select the smoking status, the associated SNOMED code is assigned. o When you select No/never, Yes, Unknown for tobacco use, a smoking status is automatically assigned based on the tobacco use. The smoking status can then be updated or modified, when the smoking status is updated or modified, the associated SNOMED code is updated. Special Considerations: Documenting smoking status for patients over the age of 13 as discreet data counts towards the numerator for Core Objective 5 for Meaningful Use. TSI Healthcare recommends also documenting tobacco use status as this counts towards Clinical Quality Measures.

36 Core Objective 6 of 17 Last Updated: 12/4/2014 Clinical Decision Support Rule Objective Use clinical decision support to improve performance on high-priority health conditions. Measure(s) Measure 1: Implement five clinical decision support interventions related to four or more clinical quality measures at a relevant point in patient care for the entire EHR reporting period. Absent four clinical quality measures related to an EP s scope of practice or patient population, the clinical decision support interventions must be related to high-priority health conditions. Measure 2: The EP has enabled and implemented the functionality for drug-drug and drugallergy interaction checks for the entire EHR reporting period. Exclusion For the second measure, any EP who writes fewer than 100 medication orders during the EHR reporting period. Changes Increased from 1 to 5 clinical decision support rules from Stage 1 Incorporates the Drug-Drug and Drug-Allergy measure from Stage 1 CMS Definition of Terms Clinical Decision Support HIT functionality that builds upon the foundation of an EHR to provide persons involved in care processes with general and person-specific information, intelligently filtered and organized, at appropriate times, to enhance health and health care. CMS Attestation Requirements Attestation Type: YES/NO Attestation Details: REQUIREMENT: EPs must attest YES to implementing five clinical decision support interventions and enabling and implementing functionality for drug-drug and drug-allergy interaction to meet this measure. EXCLUSION: For the second measure, any EP who writes fewer than 100 medication orders during the EHR reporting period. CMS Additional Information If none of the CQMs are applicable to an EP's scope of practice, the EP should implement CDS interventions that he or she believes will drive improvements in the delivery of care for the high-priority health conditions relevant to their patient population. CMS will not issue additional guidance on the selection of appropriate clinical decision support rules for Stage 2 Meaningful Use. This determination is best left to the EP taking into account their workflow, patient population, and quality improvement efforts. The need for inclusion of attributes for each CDS intervention also applies to drug-drug and drug-allergy interventions as well as interventions based on self-generated evidence. Drug-drug and drug-allergy interaction alerts are separate from the 5 clinical decision support interventions and do not count towards the 5 required for this first measure. In order to meet this objective and measure, an EP must use the capabilities and standards of CEHRT at 45 CFR (a)(8) and (a)(2).

37 Core Objective 6 of 17 Last Updated: 12/4/2014 Objective 6 Measure 1: Clinical Decision Support NextGen Measure Report & Analysis REQUIREMENT: The provider must attest yes to implementing five clinical-decision support interventions for the entire EHR reporting period. There is not a HQM report for this measure. It is the client s responsibility to retain supporting documentation that this measure was successfully completed. EXCLUSION: none NextGen Setup, Data Entry Requirement & Suggested Workflow Within NextGen EHR version 5.8, there are many clinical decision support options the provider can enable to satisfy this objective. It is up to each practice to determine which clinical decision support rule(s) they would like to implement and to retain supporting documentation of the clinical decision support rules. The options we will review in this guidebook are as follows: Option 1: CQM Check Option 2: Medline Plus Connect Clinical Decision Support Rules Option 3: Geriatric, Pediatric, and Drug-Disease Interaction Checks. Option 1: CQM Check NextGen KBM, Version 8.3.x and higher has a Clinical Quality Measure check (CQM Check) template that can be configured according to the CQMs that each provider would like to track. The CQM check template provides the user with a status snapshot as to whether the provider has satisfied the documentation requirements for any Clinical Quality Measures that apply to that particular patient. For questions regarding the setup of the CQM Check template please open a ticket with the TSI Healthcare Helpdesk. The CQM Check Template can be accessed from within the templates in NextGen KBM 8.3.x and higher, from the left navigation bar, or from within the MU Check template. o From the *Finalize template, click CQM Check:

38 Core Objective 6 of 17 Last Updated: 12/4/2014 o The CQM Check template will then provide more information regarding whether or not the measure has been satisfied:

39 Core Objective 6 of 17 Last Updated: 12/4/2014 Option 2: Medline Plus Connect Clinical Decision Support Rules NextGen Version 5.8 and higher has several clinical decision support rule applications enabled out of the box. These out of the box clinical decision support resources can be accessed from the Diagnosis and Problems modules, Medications module, Allergy module, Procedures module, and Orders module results. By default the clinical decision support rule applications will launch an educational article provided by Medline Plus Connect. Advanced Auditing captures when users click to access the external site (Medline Plus Connect). Because some components of this objective query Advanced Auditing, modifying settings in Advanced Auditing may impact numerator results. These Medline Plus clinical decision support resources can be accessed from within various modules in NextGen Version 5.8. Problems Module 1. From the Problems or Diagnosis Module, right-click on a problem or diagnosis then select Resources 2. Then click on Clinical Decision Support, to launch the website specified in NextGen File Maintenance. a. Medline Plus Connect is setup by default in File Maintenance Medication Allergies Module 1. From the Medication Allergies module, right-click on an allergy and then select Resources. 2. Then click on Clinical Decision Support to launch the Clinical Decision website specified in NextGen File Maintenance.

40 Core Objective 6 of 17 Last Updated: 12/4/2014 Orders Module 1. From the Orders Module, right-click on a lab result and then select Resources. 2. Click on Clinical Decision Support to launch the Clinical Decision website specified in the NextGen File Maintenance. Procedures Module 1. From within the Procedures module, right-click on a lab procedure and then select Resources 2. Click on Clinical Decision Support to launch the Clinical Decision website specified in the NextGen File Maintenance.

41 Core Objective 6 of 17 Last Updated: 12/4/2014 Option 3: Geriatric, Pediatric, and Drug-Disease Interaction Checks From within NextGen System Administrator drug-age interactions (geriatric and pediatric) and also drug-disease interactions can be enabled. Once enabled these interactions will alert a user if there is a contraindication when a medication is entered into the system. 1. Open System Administrator 2. Open the View drop-down list and select Universal Preferences 3. Open the Medication folder 4. Ensure drug-condition, geriatric precautions, and pediatric precautions are enabled (i.e. set to a level of 1 or higher)

42 Core Objective 6 of 17 Last Updated: 12/4/ Gather the Attestation Information popup screenshot from within NextGen EHR to show which DUR alerts are enabled. a. In NextGen Ambulatory EHR, select View > Attestation. (Provider must be logged in.) b. The Attestation Information window displays showing the current date.

43 Core Objective 6 of 17 Last Updated: 12/4/2014

44 Core Objective 6 of 17 Last Updated: 12/4/2014 Objective 6 Measure 2: Drug Drug and Drug Allergy Checks NextGen Measure Report & Analysis REQUIREMENT: This is a self-attestation measure. The provider must attest that the drug-drug and drug-allergy interaction checks were enabled for the entire reporting period. There is no HQM report for this measure. Client should retain documentation this objective was accomplished. EXCLUSION: Any EP who writes fewer than 100 medication orders during the EHR reporting period. NextGen Setup & Suggested Workflow Ensure drug-drug and drug allergy interaction checks are enabled for the entire reporting period. Modifications to interactions checks are captured using Advanced Auditing (if settings are not disabled). Ensure settings are enabled within NextGen System Administrator: o Access NextGen System Administrator and select View > Universal Preferences. o On the Preferences window, select the Medication preference folder to display the Medication preferences. Ensure that the Allergy Interaction Level Display Minimum has a value of 1 or higher. Ensure that the Check Interaction preference is set to True. Ensure that the Interaction Level Display Minimum has a value of 1 or higher.

45 Core Objective 6 of 17 Last Updated: 12/4/2014 In NextGen Ambulatory EHR, select View > Attestation. (Provider must be logged in.) The Attestation Information window displays showing the current date. o Attestation Information for NextGen Ambulatory EHR, version 5.8 and higher.

46 Special Considerations Meaningful Use Stage 2: Eligible Professional Core Objective 6 of 17 Last Updated: 12/4/2014 This is a self-attestation measure. Ensure that the provider has enabled five clinical decision support interventions in addition drug-drug and drug-allergy interactions are enabled for the entire reporting period. It is the practice s responsibility to retain documentation for this measure in the event of an audit.

47 Core Objective 7 of 17 Last Updated: 3/24/2015 Patient Electronic Access Objective Provide patients the ability to view online, download and transmit their health information within four business days of the information being available to the EP. Measure(s) Measure 1: More than 50 percent of all unique patients seen by the EP during the EHR reporting period are provided timely (available to the patient within 4 business days after the information is available to the EP) online access to their health information. Measure 2: More than 5 percent of all unique patients seen by the EP during the EHR reporting period (or their authorized representatives) view, download, or transmit to a third party their health information. Exclusions Any EP who: 1. Neither orders nor creates any of the information listed for inclusion as part of both measures, except for "Patient name" and "Provider's name and office contact information may exclude both measures. 2. 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 3Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may exclude only the second measure. (Please reference the following website: fixed-broadband-deployment-map) Change from Stage 1 Changed from Menu to Core Increase from 10% to 50% Incorporates View/Download/Transmit CMS Definition of Terms Access When a patient possesses all of the necessary information needed to view, download, or transmit their information. This could include providing patients with instructions on how to access their health information, the website address they must visit for online access, a unique and registered username or password, instructions on how to create a login, or any other instructions, tools, or materials that patients need in order to view, download, or transmit their information. View The patient (or authorized representative) accessing their health information online. Transmission Any means of electronic transmission according to any transport standard(s) (SMTP, FTP, REST, SOAP, etc.). However, the relocation of physical electronic media (for example, USB, CD) does not qualify as transmission although the movement of the information from online to the physical electronic media will be a download. Business Days Business days are defined as Monday through Friday excluding federal or state holidays on which the EP or their respective administrative staffs are unavailable. Diagnostic Test Results All data needed to diagnose and treat disease. Examples include, but are not limited to, blood tests, microbiology, urinalysis, pathology tests, radiology, cardiac imaging, nuclear medicine tests, and pulmonary function tests.

48 Core Objective 7 of 17 Last Updated: 3/24/2015 CMS Attestation Requirements Attestation Type: NUMERATOR/DENOMINATOR/THRESHOLD/EXCLUSION Attestation Details: Objective 7 Measure 1: Patient Electronic Access DENOMINATOR: Number of unique patients seen by the EP during the EHR reporting period. NUMERATOR: The number of patients in the denominator who have timely (within 4 business days after the information is available to the EP) online access to their health information. THRESHOLD: The resulting percentage must be more than 50 percent in order for an EP to meet this measure. EXCLUSION: None Objective 7 Measure 2: Download/View/Transmit DENOMINATOR: Number of unique patients seen by the EP during the EHR reporting period. NUMERATOR: The number of unique patients (or their authorized representatives) in the denominator who have viewed online, downloaded, or transmitted to a third party the patient's health information. THRESHOLD: The resulting percentage must be more than 5 percent in order for an EP to meet this measure. EXCLUSIONS: 1. Any EP who neither orders nor creates any of the information listed for inclusion as part of both measures, except for "Patient name" and "Provider's name and office contact information," may exclude both measures. 2. Any EP that 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 3Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may exclude only the second measure. (Please reference the following website: CMS Additional Information The following information must be made available online: Patient name, provider's name and office contact information, current and past problem list, procedures. 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, demographic information (preferred language, sex, race, ethnicity, date of birth), care plan field(s), including goals and instructions, and any known care team members including the primary care provider (PCP) of record unless the information is not available in certified EHR technology (CEHRT), is restricted from disclosure due to any federal, state or local law regarding the privacy of a person s health information, including variations due to the age of the patient or the provider believes that substantial harm may arise from disclosing particular health information in this manner. Replaces the Stage 1 core objective for EPs of "Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies) upon request" and the Stage 1 menu objective for EPs of "Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, and allergies) within 4 business days of the information being available to the EP." This objective aligns with the Fair Information Practice Principles (FIPPs), in affording baseline privacy protections to individuals. Both of the measures for this objective must be met using CEHRT.

49 Core Objective 7 of 17 Last Updated: 3/24/2015 Objective 7 Measure 1: Patient Electronic Access NextGen Measure Report & Analysis DENOMINATOR: The number of unique patients seen during the reporting period. NUMERATOR: If the practice has enabled the Personal Health Record (PHR) download functionality and the patient has an enrollment status of enrollment pending or enrollment completed the patient will automatically meet the numerator requirements. THRESHOLD: The resulting percentage (Numerator Denominator) must be more than 50 percent in order for an EP to meet this measure EXCLUSION 1: Any EP that neither orders nor creates any of the information listed for inclusion as part of both measures, except for "Patient name," "Provider's name, and Office contact information, may exclude both measures. EXCLUSION 2: Any EP that 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 3Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may exclude only the second measure. NextGen Data Entry Requirements & Suggested Workflow User Workflow for Denominator: For this measure, all data elements for the denominator are captured in the Procedures module or from the Visit Type that is selected in NextGen KBM 8.3.x and higher. For practices that do not utilize NextGen EPM the visit type must be selected in order to have patients increment the denominator for this measure. o Workflow for all specialties except Retina: From Intake (NextGen KBM, Version 8.3.x and higher, for multiple specialties) select visit type. o Workflow for Retina only: From CC-HPI-ROS-OPH (NextGen KBM, Version 8.3.x and higher) select visit type (select the appropriate check box to populate the master_im_.visit_type field).

50 Core Objective 7 of 17 Last Updated: 3/24/2015 NextGen Recommended Setup Prior to the beginning of the provider s reporting period ensure that the Personal Health Record (PHR) Download Functionality is enabled within NextMD File Maintenance setup. 1. Log-in to File Maintenance 2. Select NextMD 3. Open Online Practice Settings 4. Open the Web Modules tab 5. Ensure Personal Health Record is enabled

51 Core Objective 7 of 17 Last Updated: 3/24/2015 User Workflow for Numerator: If PHR is enabled, ensure each patient is provided a token code prior to the first qualifying encounter or up to four business days after the first qualifying encounter. o From Patient Portal Enrollment screen: Patients that have a status of Enrollment Pending or Enrollment Completed will satisfy the numerator requirements. **Note: If a patient is offered enrollment in the Patient Portal and declines to participate or does not have an address the provider can still receive credit for this patient. In circumstances such as these, please ensure your staff members are providing the appropriate documentation (see below): 1a. If the patient declines to participate in the patient portal ensure your staff enters Decline in the address field on the Patient Portal enrollment screen. 2. Ensure a Patient Portal enrollment token code has been generated for the patient 3. Click OK at the bottom of the patient portal enrollment screen 4. Acknowledge the invalid warning notification by clicking OK again

52 Core Objective 7 of 17 Last Updated: 3/24/2015 **TSI Healthcare does not recommend the following workflow** Even though s are not required for enrollment, leaving the field blank is not recommended due to patients not having a notification address unless they add in their or SMS text messaging information into the My Information section for Portal notifications which is very unlikely. 1b. if the patient does not have an address leave the address field on the Patient Portal enrollment screen blank. 2. Ensure a Patient Portal enrollment token code has been generated for the patient 3. Give the patient their enrollment token 4. Click OK at the bottom of the patient portal enrollment screen 5. Acknowledge the invalid warning notification by clicking OK again o After you click OK the patient should move into the status of enrollment pending

53 Core Objective 7 of 17 Last Updated: 3/24/ The patient can complete their enrollment using their enrollment token, date of birth, and last name. o Direct the patient to NextMD.com and instruct them to click Enroll Now and accept the Terms and Conditions o Inform them to enter the required information by clicking the I do not have an address checkbox o The patient then clicks submit to create their login credentials:

54 Core Objective 7 of 17 Last Updated: 3/24/2015 Objective 7 Measure 2: Download/View/Transmit NextGen Measure Report & Analysis DENOMINATOR: The number of unique patients seen during the reporting period. NUMERATOR: The number of patients included in the denominator that have C-CDA viewed, downloaded, or transmitted their health information. THRESHOLD: The resulting percentage (Numerator Denominator) must be more than 5 percent in order for an EP to meet this measure. EXCLUSION 1: Any EP that neither orders nor creates any of the information listed for inclusion as part of both measures, except for "Patient name," "Provider's name, and Office contact information, may exclude both measures. EXCLUSION 2: Any EP that 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 3Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may exclude only the second measure. (Please reference the following website: NextGen Data Entry Requirements & Suggested Workflow User Workflow for Denominator: For this measure, all data elements for the denominator are captured in the Procedures module or from the Visit Type that is selected in NextGen KBM 8.3.x and higher. For practices that do not utilize NextGen EPM the visit type must be selected in order to have patients increment the denominator for this measure. o Workflow for all specialties except Retina: From Intake (NextGen KBM, Version 8.3.x and higher, for multiple specialties) select visit type. o Workflow for Retina only: From CC-HPI-ROS-OPH (NextGen KBM, Version 8.3.x and higher) select visit type (select the appropriate check box to populate the master_im_.visit_type field).

55 Core Objective 7 of 17 Last Updated: 3/24/2015 User Workflow for Numerator: This measure requires a patient or authorized representative to perform an action in the NextGen Patient Portal. From NextGen Patient Portal, the patient or authorized representative must view, download, or transmit their health information. Patients should be instructed to: 1. Click on My Chart tab at the top of the Patient Portal website and select Request Health Record 2. Click the orange Submit button o Once the medical record is ready to be viewed the patient can select the View my Chart button from the My Chart tab at the top of the Patient Portal Website which allows the patient or representative to view the health record and also download or transmit. Special Considerations The PHR, using the NextGen Patient Portal, allows patient access to their health information without staff intervention. Enabling the PHR access and providing token codes allows for the patient to have access to their information without document uploads to the NextGen Patient Portal. A token code can be provided even if the patient does not provide an address, or does not have an address. Documents cannot be sent to NextGen Patient Portal unless the patient has finalized their enrollment. attachments are not calculated by the report, and therefore do not count toward the numerator criteria. Please reference the following website:

56 Core Objective 8 of 17 Clinical Summaries Objective Provide clinical summaries for patients for each office visit. Measure Clinical summaries provided to patients or patient authorized representatives within 1 business day for more than 50 percent of all office visits. Exclusion Any EP who has no office visits during the EHR reporting period. Change from Stage 1 Change from 3 business days to 1 business day CMS Definition of Terms Clinical Summary An after-visit summary that provides a patient with relevant and actionable information and instructions containing in no particular order: Patient name, provider's name and office contact information, date and location of the visit, reason for the office visit, current problem list, current medication list, current medication allergy list, procedures performed during the visit, immunizations or medications administered during the visit, vital signs taken during the visit (or other recent vital signs), laboratory test results, list of diagnostic tests pending, clinical instructions, future appointments, referrals to other providers, future scheduled tests, demographic information maintained within certified electronic health record technology (CEHRT) (sex, race, ethnicity, date of birth, preferred language), smoking status, care plan field(s), including goals and instructions, recommended patient decision aids (if applicable to the visit). Office Visit Office visits include separate, billable encounters that result from evaluation and management services provided to the patient and include: (1) Concurrent care or transfer of care visits, (2) Consultant visits, or (3) Prolonged Physician Service without Direct (Face-To-Face) Patient Contact (tele-health). A consultant visit occurs when a provider is asked to render an expert opinion/service for a specific condition or problem by a referring provider. CMS Attestation Requirements Attestation Type: NUMERATOR/DENOMINATOR/THRESHOLD/EXCLUSION Attestation Details: DENOMINATOR: Number of office visits by the EP during the EHR reporting period. NUMERATOR: Number of office visits in the denominator where the patient or a patient-authorized representative is provided a clinical summary of their visit within one (1) business day. THRESHOLD: The resulting percentage must be more than 50 percent in order for an EP to meet this measure. EXCLUSION: EPs who have no office visits during the EHR reporting period would be excluded from this requirement. CMS Additional Information The provider is permitted, but not required, to limit the measure of this objective to those patients whose records are maintained using certified electronic health record technology (CEHRT). The provision of the clinical summary is limited to the information contained within CEHRT. The clinical summary can be provided through a PHR, patient portal on the web site, secure , electronic media such as CD or USB fob, or printed copy. If the EP chooses an electronic media, they would be required to provide the patient a paper copy upon request. They may also default to providing paper copies, in which case an electronic form of the EP s choice would need to be provided upon request. If an EP believes that substantial harm may arise from the disclosure of particular information, an EP may choose to withhold that particular information from the clinical summary. Providers may not charge patients a fee to provide this information. When a patient visit lasts several days or a patient is seen by multiple EPs, a single clinical summary at the end of the visit should be counted only once in both the numerator and denominator.

57 Core Objective 8 of 17 In the event that a clinical summary is offered to and subsequently declined by the patient, that patient may still be included in the numerator of the measure. In circumstances where there is no information available to populate one or more of the fields previously listed, either because the EP can be excluded from recording such information (for example, vital signs) or because there is no information to record (for example, no medication allergies or laboratory tests), an indication that the information is not available in the clinical summary would meet the measure of this objective.

58 Core Objective 8 of 17 Objective 8 Measure: Clinical Summaries NextGen Measure Report & Analysis DENOMINATOR: The number of office visits conducted by the EP during the EHR reporting period. NUMERATOR: The numerator will include all patients in the denominator that are provided the clinical summary within 1 business day, refuse the clinical summary, or patients that have their enrollment status as Enrollment Pending or Enrollment Completed if the PHR is enabled. **Note: Even though the NextGen reports will give your providers credit towards this measure if the PHR download functionality has been enabled and if the patient has been offered enrollment in the Patient Portal, TSI Healthcare strongly recommends practices provide the patient with a copy of the patient plan. CMS provided further clarification that the patient plan is intended to be encounter specific rather than a summary of the patient s personal health record. THRESHOLD: The resulting percentage (Numerator Denominator) must be more than 50 percent in order for an EP to meet this measure. EXCLUSION: Any EP s who have no office visits during the reporting period. NextGen Data Entry Requirements & Suggested Workflow User Workflow for Denominator: For this measure, all data elements for the denominator are captured in the Procedures module or from the Visit Type that is selected in NextGen KBM 8.3.x and higher. For practices that do not utilize NextGen EPM the visit type must be selected in order to have patients increment the denominator for this measure. o Workflow for all specialties except Retina: From Intake (NextGen KBM, Version 8.3.x and higher, for multiple specialties) select visit type. o Workflow for Retina only: From CC-HPI-ROS-OPH (NextGen KBM, Version 8.3.x and higher) select visit type (select the appropriate check box to populate the master_im_.visit_type field).

59 Core Objective 8 of 17 User Workflow for Numerator: Ensure that the Patient Plan, Plan, or Card_docpatientticket is generated and provided to the patient for each office visit. (If a custom document is used, ensure that the custom document is generated for each encounter or office visit.) 1. To generate the Patient Plan document, from the SOAP template, click the Patient Plan icon in the Assessment/Plan section. 2a. If NextGen Patient Portal is in use and the patient has completed their enrollment, there is an available trigger that will automatically upload the Patient Plan to the patient s Portal account. (Please contact the TSI Healthcare Helpdesk for assistance in setting this up.) o When uploading the Patient Plan to patient s portal account you will see this pop up which will allow you to attach your standardized Patient Plan message to the patient: Click once on the appropriate standard response to preview it, double-click on the appropriate standard response to send it to the patient

60 Core Objective 8 of 17 2b. If the patient has not completed their Patient Portal enrollment, you will receive this pop up. The document will still generate as expected but you should print the patient plan off instead. **Note: If a patient refuses a copy of the patient plan the provider can still receive credit for this patient if this refusal is documented correctly within NextGen. Should a patient refuse or not wish to accept a copy of their Patient Plan, this can be documented from the Checkout template o Select the Refused check box for patient plan within 1 business days of the encounter.

61 Core Objective 8 of 17 Special Considerations: Simply generating the Plan does not satisfy the requirements for this measure. The patient must be offered a paper copy or an electronic copy via the Patient Portal. In the event of an audit, simply generating the plan and failing to offer the patient a printed copy or a copy via the Patient Portal could result in non-compliance. If NextGen Patient Portal is in use, enabling PHR access and providing a token code to the patient either before the qualifying encounter or up to 1 business day after the qualifying encounter meets the numerator requirements. However, according to CMS the An office visit based measure is each office visit during the reporting period. If the patient has 5 office visits during the reporting period, then the denominator increases by 5 times and the numerator increases up to 5 times. Custom Plan documents may be added in the NextGen HQM Portal.

62 Core Objective 9 of 17 Protect Electronic Health Information Objective Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities. Measure Conduct or review a security risk analysis in accordance with the requirements under 45 CFR (a) (1), including addressing the encryption/security of data stored in CEHRT in accordance with requirements under 45 CFR (a)(2)(iv) and 45 CFR (d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the provider's risk management process for EPs. Exclusion No exclusion. Changes from Stage 1 Inclusion of encryption of data at rest CMS Attestation Requirements Attestation Type: YES/NO Attestation Details: Eligible professionals (EPs) must attest YES to having conducted or reviewed a security risk analysis in accordance with the requirements under 45 CFR (a)(1) and implemented security updates as necessary and corrected identified security deficiencies prior to or during the EHR reporting period to meet this measure. CMS Additional Information EPs must conduct or review a security risk analysis of CEHRT including addressing encryption/security of data, and implement updates as necessary at least once prior to the end of the EHR reporting period and attest to that conduct or review. The testing could occur prior to the beginning of the first EHR reporting period. However, a new review would have to occur for each subsequent reporting period. The parameters of the security risk analysis are defined 45 CFR (a)(1) which was created by the HIPAA Security Rule. Meaningful use does not impose new or expanded requirements on the HIPAA Security Rule nor does it require specific use of every certification and standard that is included in certification of EHR technology. More information on the HIPAA Security Rule can be found at In order to meet this objective and measure, an eligible hospital or CAH must use the capabilities and standards of CEHRT at 45 CFR (d)(4), (d)(2), (d)(3), (d)(7), (d)(1), (d)(5), (d)(6), (d)(8), and (d)(9).

63 Core Objective 9 of 17 Objective 9 Measure: Protect Electronic Health Information NextGen Measure Report & Analysis There is no NextGen HQM Report for this measure. It remains the responsibility of each practice to perform the necessary security and risk analyses to meet this requirement. NextGen Data Entry Requirements & Suggested Workflow It remains the responsibility of each practice to perform the necessary security and risk analyses to meet this requirement, and to retain all supporting documentation for this measure. Clients should keep a copy of their analysis for up to 6 years in the event of an audit. This analysis should be reviewed and updated each participating program year. If additional assistance is needed in order to accomplish this objective then the client should contact a third party HIPAA expert organization. Additional resources from CMS and the National Institute of Standards and Technology (NIST) are available at (The password is success). Special Considerations This is a self-attestation measure. It remains the client s responsibility to ensure that a security risk analysis is performed or reviewed, and to retain all supporting documentation for this measure. This must be completed once for every Meaningful Use reporting period. EPs must conduct or review a security risk analysis of CEHRT including addressing encryption/security of data, and implement updates as necessary at least once prior to the end of the EHR reporting period and attest to that conduct or review. The testing could occur prior to the beginning of the first EHR reporting period. However, a new review would have to occur for each subsequent reporting period. The parameters of the security risk analysis are defined 45 CFR (a)(1) which was created by the HIPAA Security Rule. Meaningful Use does not impose new or expanded requirements on the HIPAA Security Rule nor does it require specific use of every certification and standard that is included in the certification of EHR technology. More information on the HIPAA Security Rule can be found at Providers are not required to attest that a specific security update has been implemented or a specific security deficiency has been corrected by the attestation date as the timing of security updates and deficiency corrections is driven by the provider s risk management process. The scope of that security risk analysis must include data created or maintained by the provider s Certified EHR Technology. As long as the provider meets the requirements under 45 CFR (a)(1),including the requirement to "Implement security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level to comply with [45 CFR ] (a)," then the provider s risk management process drives the timeline for the implementation of security updates and correction of security deficiencies, not the date a provider chooses to submit the meaningful use attestation. Providers are not attesting to having made a specific security update has been implemented or a specific security deficiency by the attestation date as the timing of security updates and deficiency corrections is driven by the provider s risk management process. This objective and measure do not impose security requirements beyond those within the HIPAA Security Rule

64 Core Objective 10 of 17 Objective Measure Exclusion Changes From Stage 1 Clinical Lab Test Results Incorporate Clinical Lab Test Results into EHR as structured data. More than 55 percent of all clinical lab tests results ordered by the EP during the EHR reporting period whose results are either in a positive/negative or numerical format are incorporated in Certified EHR Technology as structured data. An EP who orders no lab tests whose results are either in a positive/negative or numeric format during the EHR reporting period. Moved from Menu to Core Increase from 40 percent to 55 percent CMS Definition of Terms None CMS Attestation Requirements Attestation Type: NUMERATOR/DENOMINATOR/THRESHOLD/EXCLUSION Attestation Details: DENOMINATOR: Number of lab tests ordered during the EHR reporting period by the EP whose results are expressed in a positive or negative affirmation or as a number. NUMERATOR: Number of lab test results whose results are expressed in a positive or negative affirmation or as a number which are incorporated as structured data. THRESHOLD: The resulting percentage must be more than 55 percent in order for an EP to meet this measure. EXCLUSION: If an EP orders no lab tests whose results are either in a positive/negative or numeric format during the EHR reporting period they would be excluded from this requirement. EPs must select YES next to the appropriate exclusion, then click the APPLY button in order to attest to the exclusion. CMS Additional Information The provider is permitted, but not required, to limit the measure of this objective to labs ordered for those patients whose records are maintained using certified EHR technology. The structured data for the numeric/quantitative test results may include positive or negative affirmations and/or numerical format that would include a reference range of numeric results and/or ratios. Structured data does not need to be electronically exchanged in order to qualify for the measure of this objective. The EP is not limited to only counting structured data received via electronic exchange, but may count in the numerator all structured data entered through manual entry through typing, option selecting, scanning, or other means. Lab results are not limited to any specific type of laboratory or to any specific type of lab test. The Medicare and Medicaid EHR Incentive Programs do not specify the use of code set standards in meeting the measure for this objective. However, the Office of the National Coordinator for Health Information Technology (ONC) has adopted Logical Observation Identifiers Names and Codes (LOINC ) version 2.27, when such codes were received within an electronic transaction from a laboratory, for the entry of structured data for this measure and made this a requirement for EHR technology to be certified. Provided the lab result is recorded as structured data and uses the standards above, there does not need to be an explicit linking between the lab result and the order placed by the physician in order to be counted in the numerator. In order to meet this objective and measure, an EP must use the capabilities and standards of CEHRT at 45 CFR (b)(5).

65 Core Objective 10 of 17 Objective 10 Measure: Clinical Lab Test Results NextGen Measure Report & Analysis DENOMINATOR: The number of lab tests ordered during the reporting period that are scheduled during the reporting period, are not ordered elsewhere, and have not been canceled. NUMERATOR: The number of lab tests included in the denominator with lab results that are documented as structured data during the reporting period. THRESHOLD: The resulting percentage (Numerator Denominator) must be more than 55 percent in order for an EP to meet this measure. EXCLUSION: Any EP who orders no lab test where results would be recorded as structured data during the reporting period NextGen Data Entry Requirements & Suggested Workflow User Workflow for Denominator: All data elements for the Denominator are captured in the Orders module. o From Orders Module Ensure all lab results are placed including ALL labs completed by the practice or by a third party. User Workflow for Numerator: All data elements for the Numerator are captured in the Orders module. o From Orders Module Ensure order results are entered as structured data.

66 Core Objective 10 of 17 User Workflow for Exclusions: Labs that are scheduled outside of the providers reporting period and labs that are ordered elsewhere can be excluded from calculations if documented correctly within NextGen. Exclusion 1: Future Lab Orders 1. The Scheduled Date/Time field is used to exclude future orders. From Orders Module Go to Test Details 2. Enter Scheduled Date/Time. Exclusion 2: Labs Ordered Elsewhere The Ordered Elsewhere checkbox is used to exclude orders that were ordered elsewhere. (For example, if a patient brought lab results in that were ordered through a different provider and your practice entered this data into the Orders module in your EHR.) 1. From Orders Module Go to Test Details 2. Check the Ordered Elsewhere checkbox

67 Core Objective 10 of 17 Special Considerations: Lab Descriptions that may produce unstructured results varies based on practice. Test descriptions must be identified by the provider and the Lab List MU_Lab_Unstructured requires Client Customization on the NextGen HQM Portal. Each panel should increment for each of the test components individually. If a panel has five different tests, the Denominator/Numerator should increment by five times. A document or image would not be a valid result for meeting numerator performance.

68 Core Objective 11 of 17 Last Updated: 1/12/2015 Objective Measure Exclusion Change From Stage 1 Patient Lists Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach. Generate at least one report listing patients of the EP with a specific condition. No exclusion. Moved from Menu to Core CMS Definition of Terms Specific Conditions -- Those conditions listed in the active patient problem list. CMS Attestation Requirements Attestation Type: YES/NO Attestation Details: Eligible professionals (EPs) must attest YES to having generated at least one report listing patients of the EP with a specific condition to meet this measure. CMS Additional Information This objective does not dictate the report(s) which must be generated; therefore an EP or a member of the EP's staff could generate the list and meet this measure. An EP is best positioned to determine which reports are most useful to their care efforts. The report generated could cover every patient whose records are maintained using certified EHR technology (CEHRT) or a subset of those patients at the discretion of the EP. Each EHR reporting period should be identified with a different report. Reports generated in past EHR reporting periods cannot be used to satisfy this measure in the current EHR reporting period.

69 Objective 11 Measure: Patient Lists NextGen Measure Report & Analysis Meaningful Use Stage 2: Eligible Professional Core Objective 11 of 17 Last Updated: 1/12/2015 There is no NextGen HQM report for this objective. o Since this is not a percentage based measure this will not show on the HQM MU 2 Objectives report It is the client s responsibility to generate at least one report listing their patients with a specific condition, and to retain supporting documentation for up to 6 years that this objective was successfully accomplished Each EHR reporting period should be identified with a different report. Reports generated in past EHR reporting periods cannot be used to satisfy this measure in the current EHR reporting period. NextGen Data Entry Requirements & Suggested Workflow To generate a report: 1. Log-in to NextGen EHR: 2. Open the File menu 3. Click on Reports 4. Select Generate Report 5. Select the Practice or By Enterprise option

70 Core Objective 11 of 17 Last Updated: 1/12/ Select the Problems option 7. Click on the ellipsis button 8. Free text the desired problem in the description field 9. Click the Search button 10. Highlight the diagnosis and click the single arrow button 11. Click Ok

71 Core Objective 11 of 17 Last Updated: 1/12/2015 If you wish to filter the report by provider you can do so by doing the following: 1. Select the Provider option 2. Click on the Ellipsis button 3. Free text the provider s name 4. Click on the Search button 5. Highlight the providers name and click the single arrow button 6. Click OK Then you should select the desired columns that you want to include in the report by: o Selecting the columns option o Selecting the checkbox beside the appropriate columns

72 Core Objective 11 of 17 Last Updated: 1/12/2015 Click OK to generate report Export the report as an MS Excel file, and then Save. You can also memorize the report to the EHR system by clicking on the Save icon Special Considerations Ensure that a list of patients with specific conditions is generated and is saved in the event of an audit. Each EHR reporting period should be identified with a different report. Reports generated in past EHR reporting periods cannot be used to satisfy this measure in the current EHR reporting period.

73 Core Objective 12 of 17 Last Updated: 12/4/2014 Objective Measure Exclusion Change From Stage 1 Preventive Care Reminders Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care and send these patients the reminders, per patient preference. More than 10 percent of all unique patients who have had 2 or more office visits with the EP within the 24 months before the beginning of the EHR reporting period were sent a reminder, per patient preference when available. Any EP who has had no office visits in the 24 months before the EHR reporting period. Changed from Menu to Core Reminders for care that is not already scheduled CMS Definition of Terms Patient Preference The method of communication that patients prefer to receive their reminders such as (but not limited to) mail, phone or secure messaging. Active Patients Patients with at least two office visits in the last 24 months. CMS Attestation Requirements Attestation Type: NUMERATOR/DENOMINATOR/THRESHOLD/EXCLUSION Attestation Details: DENOMINATOR: Number of unique patients who have had two or more office visits with the EP in the 24 months prior to the beginning of the EHR reporting period. NUMERATOR: Number of patients in the denominator who were sent a reminder per patient preference when available during the EHR reporting period. THRESHOLD: The resulting percentage must be more than 10 percent in order for an EP to meet this measure. EXCLUSION: Any EP who has had no office visits in the 24 months before the EHR reporting period. CMS Additional Information The provider is permitted, but not required, to limit the measure of this objective to those patients whose records are maintained using certified EHR technology (CEHRT). EPs meet the aspect of per patient preference of this objective if they are accommodating known reasonable requests in accordance with the HIPAA Privacy Rule, as specified at 45 CFR (b), which is the guidance established for accommodating patient requests. An EP should use clinically relevant information stored within the CEHRT to identify patients who should receive reminders. To count for the measure, reminders for preventive/follow-up care must be for care that the patient is not already scheduled to receive. Reminders for referrals or to engage in certain activities are also included in this objective and measure. Reminders must be sent using the preferred communication medium only when it is known by the provider. This is limited to the type of communication (phone, mail, secure messaging, etc.) and does not extend to other constraints like time of day. Patients may decline to provide their preferred communication medium in which case the provider may select the communication medium. A patient may also decline to receive reminders. In order to meet this objective and measure, an EP must use the capabilities and standards of CEHRT at 45 CFR (a)(14).

74 Objective 12 Measure: Preventative Care Meaningful Use Stage 2: Eligible Professional Core Objective 12 of 17 Last Updated: 12/4/2014 NextGen Measure Report & Analysis DENOMINATOR: The number of unique patients seen for two or more office visits within 24 months before the beginning of the reporting period that have not been documented as expired or have not been documented as being discharged from the practice. NUMERATOR: The number of patients in the denominator who were sent a reminder with the type documented and whose preferred contact method was available on the date the reminder was sent. The reminder must be sent using the preferred contact method (if available) and the date sent must be during the reporting period. If the preferred contact method is not available on the date the reminder is sent and the reminder was sent using other contact method then this will increment the numerator so long as the date sent is during the reporting period. THRESHOLD: The resulting percentage must be more than 10 percent in order for an EP to meet this measure. EXCLUSION: Any EP who had no office visits in the 24 months before the EHR reporting period. NextGen Data Entry Requirements & Suggested Workflow This is a two part measure that first focuses on collecting the patient s preferred contact method. The second part of the measure checks to see that the patient is sent a clinically relevant reminder per the patient s contact preference (if available) and has documentation in the EHR of the reminder being sent. User Workflow for Denominator: For this measure, all data elements for the denominator are captured in the Procedures module or from the Visit Type that is selected in NextGen KBM 8.3.x and higher. For practices that do not utilize NextGen EPM the visit type must be selected in order to have patients increment the denominator for this measure. o Workflow for all specialties except Retina: From Intake (NextGen KBM, Version 8.3.x and higher, for multiple specialties) select visit type. o Workflow for Retina only: From CC-HPI-ROS-OPH (NextGen KBM, Version 8.3.x and higher) select visit type (select the appropriate check box to populate the master_im_.visit_type field).

75 Core Objective 12 of 17 Last Updated: 12/4/2014 User Workflow for Documenting the Patient s Preferred Contact Method: From the Demographics screen on the Add/Modify Patient information screen in NextGen EPM: Select a contact preference from the Contact Preference drop-down list NOTE: Selecting a value from the contact preference list does not automatically change the order of the contact methods on the left. The contact preference selected in the Contact Preference field trumps the preferential ordering of the list. PhoneTree and Population Health (add-on modules) look to this field when contacting patients via their preferred method. It is optional to rearrange the ordering of the contact preference but if you wish to do so you will need to use the blue arrows on the right to manually order the patient s preferences. Example: If a patient s preferred contact method is 2-Voice Reminder-Day Phone, but the Home Phone field is still listed as #1, staff should defer to the Contact Preference field and contact them via Day Phone. NOTE: If the Contact Preference field is not visible within NextGen EPM, or if your contact preference drop down list does not contain the correct contact preference options that are listed above, please open the following ticket with the TSI Helpdesk (helpdesk@tsihealthcare.com): Please customize our EPM Contact Preference field with the standard contact options for Meaningful Use.

76 Core Objective 12 of 17 Last Updated: 12/4/2014 **Practices that do not use NextGen EPM see Special Considerations for instructions on how to document the patients preferred contact method** User Workflow for Numerator: Ensure that the patient has a reminder recorded. Reminders are manually entered on the Patient Demographics template in NextGen EHR. NextGen Population Health (an add-on module) may be used to automate reminders and documentation. o From Patient Demographics Template Scroll down to the Reminder Section Enter Reminder Type, Contact Method, Date Sent, and click Add in the reminder section o If Preferred Contact Method is available on the date the reminder is sent, the preferred contact method must be used in order to meet numerator requirements. o If Preferred Contact is not available on the date the reminder is sent, other contact method can be used. o Note: To meet the Numerator criteria, you must have the Type, Contact method set as Preferred (if available) and Date Sent (within the reporting period) populated. Be sure to click the Add button to save the information to the grid. User Workflow for Exclusion: o From the Alerts pop-up, select the Patient has expired check box to expire the patient.

77 Core Objective 12 of 17 Last Updated: 12/4/2014 o Or select the Discharged from this practice or Patient has expired checkbox to discharge the patient. Special Considerations The reminder must be provided during the EHR reporting period to meet numerator requirements. Per CMS: Reminders should be limited to new action that needs to be taken and not of actions that are already taken. For example, a reminder to schedule your next mammogram is a reminder to take action, while a reminder that your next mammogram is scheduled for next week is a reminder of action already taken. So we clarify that reminders for preventive/follow-up care should be for care that the patient is not already scheduled to receive (Page of the Federal Register 9/14/12). Patients may decline to receive reminders however per CMS we believe that this will be rare enough and will not affect the ability of an EP to meet this measure (Page of the Federal Register 9/14/12). For practices that do not use NextGen EPM, they can capture the patients preferred contact method via the Patients Demographic template within in NextGen EHR (see image below). Practices that are interested in Population Health should open a ticket with the TSI Helpdesk (helpdesk@tsihealthcare.com) to obtain additional information.

78 Core Objective 13 of 17 Objective Measure Exclusion Change From Stage 1 Patient-Specific Education Resources Use clinically relevant information from Certified EHR Technology to identify patientspecific education resources and provide those resources to the patient. Patient-specific education resources indentified by Certified EHR Technology are provided to patients for more than 10 percent of all unique patients with office visits seen by the EP during the EHR reporting period. Any EP who has no office visits during the EHR reporting period. Moved from Menu to Core EHR must suggest relevant, patient-specific education resources CMS Definition of Terms Patient-Specific Education Resources identified by Certified EHR Technology Resources or a topic area of resources identified through logic built into certified EHR technology which evaluates information about the patient and suggests education resources that would be of value to the patient. Unique Patient If a patient is seen by an EP more than once during the EHR reporting period, then for purposes of measurement that patient is only counted once in the denominator for the measure. All the measures relying on the term unique patient relate to what is contained in the patient s medical record. Not all of this information will need to be updated or even be needed by the provider at every patient encounter. This is especially true for patients whose encounter frequency is such that they would see the same provider multiple times in the same EHR reporting period. CMS Attestation Requirements Attestation Type: NUMERATOR/DENOMINATOR/THRESHOLD/EXCLUSION Attestation Details: DENOMINATOR: Number of unique patients with office visits seen by the EP during the EHR reporting period. NUMERATOR: Number of patients in the denominator who were provided patient-specific education resources identified by the Certified EHR Technology. THRESHOLD: The resulting percentage must be more than 10 percent in order for an EP to meet this measure. EXCLUSION: Any EP who has no office visits during the EHR reporting period. CMS Additional Information Unique patients with office visits means that to count in the denominator a patient must be seen by the EP for one or more office visits during the EHR reporting period, but if a patient seen by the EP more than once during the EHR reporting period, the patient only counts once in the denominator. Education resources or materials do not have to be stored within or generated by the certified EHR. However, the provider should utilize certified EHR technology (CEHRT) in a manner where the technology suggests patientspecific educational resources based on the information stored in the CEHRT. The provider can make a final decision on whether the education resource is useful and relevant to a specific patient. While CEHRT must be used to identify patient-specific education resources, these resources or materials do not have to be stored within or generated by the CEHRT. Certified EHR technology is certified to use the patient's problem list, medication list, or laboratory test results to identify the patient-specific educational resources. The EP may use these elements or additional elements within CEHRT to identify educational resources specific to patients' needs. The EP can then provide these educational resources to patients in a useful format for the patient (such as, electronic copy, printed copy, electronic link to source materials, through a patient portal or PHR).

79 Core Objective 13 of 17 If resources or topic area of resources are not identified by CEHRT and provided to the patient then it will not count in the numerator. The education resources will need to be provided prior to the calculation and subsequent attestation to meaningful use. In order to meet this objective and measure, an EP must use the capabilities and standards of CEHRT at 45 CFR (a)(15).

80 Core Objective 13 of 17 Objective 13 Measure: Patient Specific Education Resources NextGen Measure Report & Analysis DENOMINATOR: The number of unique patients seen during the reporting period. NUMERATOR: The number of patients in the denominator who have a HealthWise document saved to an encounter, a HealthWise or medication monograph document viewed or printed, an external patient education document viewed or printed, or an education order completed as part of a suggestion from a Health Promotion Plan during the EHR reporting period. THRESHOLD: The resulting percentage (Numerator Denominator) must be more than 10 percent in order for an EP to meet this measure. EXCLUSION: Any EP who has no office visits during the EHR reporting period. NextGen Data Entry Requirements & Suggested Workflow User Workflow for Denominator For this measure, all data elements for the denominator are captured in the Procedures module or from the Visit Type that is selected in NextGen KBM 8.3.x and higher. For practices that do not utilize NextGen EPM the visit type must be selected in order to have patients increment the denominator for this measure. o Workflow for all specialties except Retina: From Intake (NextGen KBM, Version 8.3.x and higher, for multiple specialties) select visit type. o Workflow for Retina only: From CC-HPI-ROS-OPH (NextGen KBM, Version 8.3.x and higher) select visit type (select the appropriate check box to populate the master_im_.visit_type field).

81 Core Objective 13 of 17 User Workflow for Numerator: Patient Specific Education Resources can be provided several ways through NextGen EHR during the EHR reporting period: 1. HealthWise document saved to an encounter or sent to Patient Portal 2. Medline Plus Connect External Education viewed or printed 3. Medication monograph document viewed or printed 4. An education order completed as part of suggestion from a Health Promotion Plan Although all 4 patient education options listed above will be reviewed in this whitepaper, Option 1 (utilizing Healthwise) is the preferred and recommended option from both a user standpoint as well as an auditing standpoint. Healthwise Patient Education Module Module directs the user to a specific educational document focused on overarching diagnoses and procedures Educational document can be saved directly to the patient s EHR encounter for easy reference and auditing Educational document can be sent directly to the patient s NextGen Patient Portal account with one click Educational documents are formatted to be printerfriendly Medline Plus Connect External Education Module performs a generic search for educational documents without always directing the user to a specific educational document Unable to save the educational document to the patient s EHR encounter Unable to send the educational document to the patient s NextGen Patient Portal account Educational documents are not formatted to be printerfriendly Medication Monograph Unable to save the monograph to the patients EHR encounter Unable to send the educational document to the patient s NextGen Patient Portal account Health Promotion Plan Does not provide educational material for the patient (is simply an order placed within NextGen EHR) Unable to send the educational document to the patient s NextGen Patient Portal account Is only geared towards patients with specific conditions (i.e. overweight, hypertension, or depressed)

82 Core Objective 13 of HealthWise document saved to an encounter The user workflow for this option is as follows: Click Internal Patient Education from the Problem or Procedure EHR modules to launch the HealthWise Patient Education Browser. The document must be saved to the patient s encounter in order to count towards this measure s numerator. o From the Problems module: 1. Right click on the diagnosis. 2. Scroll down and click on the Info Resources option. 3. Click on the Internal Patient Education option. This will launch the HealthWise Patient Education Browser. 4. From the HealthWise Patient Education Browser you have several options: Click Save to Encounter to save the educational document to the patient s encounter. OR Click Send to Patient Portal to save the educational document to the patient s encounter AND send to the Patient s Portal account in one click. **Please Note: if you click Select and then print the educational document, the educational document will NOT be automatically saved. Therefore, this will not increment the numerator. You must save the educational document to the encounter FIRST and then print.

83 Core Objective 13 of 17 o From the Procedures module: 1. Highlight the procedure. 2. Click on the Resources option. 3. Click on the Internal Patient Education option. This will launch the HealthWise Patient Education Browser. 4. From the HealthWise Patient Education Browser you have several options: Click Save to Encounter to save the educational document to the patient s encounter. OR Click Send to Patient Portal to save the educational document to the patient s encounter AND send to the Patient s Portal account in one click. **Please Note: if you click Select and then print the educational document, the educational document will NOT be automatically saved. Therefore, this will not increment the numerator. You must save the educational document to the encounter FIRST and then print.

84 Core Objective 13 of Medline Plus Connect External Education viewed or printed The user workflow for this option is as follows: Click External Patient Education from the Problem, Procedure, Medication Allergy, or Orders modules to launch the external education website. The External Patient Education website URL can be modified by using NextGen File Maintenance. Medline Plus is the default External Patient Education source. o From the Medication Allergies module: 1. Right click on the allergy. 2. Scroll down and click on the Resources option. 3. Click on the External Patient Education option. This will launch the external education website. The External Patient Education website URL can be modified by using NextGen File Maintenance. Medline Plus is the default External Patient Education source. o From the Orders module: 1. Right click on the order result. 2. Scroll down and click on the Info Resources option. 3. Click on the External Patient Education option. This will launch the external education website. The External Patient Education website URL can be modified by using NextGen File Maintenance. Medline Plus is the default External Patient Education source.

85 Core Objective 13 of Medication Monograph viewed or printed The third user workflow for satisfying the numerator of this measure is as follows: Click Monograph from the Medications Module to launch the medication s monograph. (A monograph is an informational pamphlet provided by the pharmacy when a patient fills a prescription.) The monograph can either be viewed or printed in order to increment the numerator for this measure it does not need to be saved to the patient s chart. o From the Medications Module: 1. Highlight the medication. 2. Scroll down and click on the Info Resources option. 3. Select the Monograph option. This will launch the Medication Monograph pop-up. **Please note: The medication monograph can either be viewed or printed in order to increment the numerator for this measure it cannot need be saved to the patient s chart. 4. Health Promotion Plan education items The fourth user workflow for satisfying the numerator of this measure is as follows: Click the Health Promotion Plan link to document a plan for depression, diet and physical activity, or hypertension. (Health Promotion Plans are new to KBM 8.3. and currently only create plans to address depression, diet and physical activity, or hypertension). o From the *Intake template (NextGen KBM, Version 8.3.x and higher, used for multiple specialties). 1. Scroll down to the Vital Signs section. 2. Click on the Health Promotion Plan link. This will launch the Health Promotion Plan pop up template.

86 Core Objective 13 of From the Health Promotion Plan pop up template you have several options based on what plan you select: For the Depression Plan, you can launch the suggested education in the Follow up section. For the BMI Plan, you can launch the suggested education from both the Diet and the Physical Activity sections. For the Hypertension Plan, you can launch the suggested education from the Diet, Physical activity and Lifestyle sections. (See Appendix for list of qualifying Health Promotion Plan suggested education.) **Please note: After the appropriate plan and suggested education is selected you must click Add to complete the order and to increment the numerator for this measure. Special Considerations Education must be suggested by the EHR to be included in the numerator. While the education must be suggested by the EHR, the education does not need to be stored within the EHR. Some components of this objective query Advanced Auditing. Modifying settings in the Education section in Advanced Auditing may impact numerator results. TSI FAQ Q: Can my practice continue to use our patient education brochures? A: For the purposes of this measure, you must use a Context-Aware Retrieval Application (Infobutton) that is HL7 Version 3 ( (b) and (b)(1) or (2)). For the purposes of this measure, the certified EHR technology should use the patient's problem list, medication list, or laboratory test results to identify the patient-specific educational resources.

87 Core Objective 14 of 17 Objective Measure Exclusion Change From Stage 1 Medication Reconciliation The EP who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation. The EP performs medication reconciliation for more than 50 percent of transitions of care in which the patient is transitioned into the care of the EP. An EP who was not the recipient of any transitions of care during the EHR reporting period. Moved from Menu to Core Measure CMS Definition of Terms Medication Reconciliation -- The process of identifying the most accurate list of all medications that the patient is taking, including name, dosage, frequency, and route, by comparing the medical record to an external list of medications obtained from a patient, hospital, or other provider. Relevant Encounter An encounter during which the EP performs a medication reconciliation due to new medication or long gaps in time between patient encounters or for other reasons determined appropriate by the EP. Essentially an encounter is relevant if the EP judges it to be so. (Note: Relevant encounters are not included in the numerator and denominator of the measure for this objective.) Transition of Care The movement of a patient from one clinical setting (inpatient, outpatient, physician office, home health, rehab, long-term care facility, etc.) to another or from one EP to another. At a minimum, transitions of care include first encounters with a new patient and encounters with existing patients where a summary of care record (of any type) is provided to the receiving provider. The summary of care record can be provided either by the patient or by the referring/transiting provider or institution. CMS Attestation Requirements Attestation Type: NUMERATOR/DENOMINATOR/THRESHOLD/EXCLUSION Attestation Details: DENOMINATOR: Number of transitions of care during the EHR reporting period for which the EP was the receiving party of the transition. NUMERATOR: Number of transitions of care in the denominator where medication reconciliation was performed. THRESHOLD: The resulting percentage must be more than 50 percent in order for an EP to meet this measure. EXCLUSION: If an EP was not on the receiving end of any transition of care during the EHR reporting period they would be excluded from this requirement. EPs must select YES next to the appropriate exclusion in order to attest to the exclusion. CMS Additional Information Only patients whose records are maintained using certified EHR technology must be included in the denominator for transitions of care. In the case of reconciliation following transition of care, the receiving EP should conduct the medication reconciliation. The electronic exchange of information is not a requirement for medication reconciliation. The measure of this objective does not dictate what information must be included in medication reconciliation. Information included in the process of medication reconciliation is appropriately determined by the provider and patient.

88 Core Objective 14 of 17 In order to meet this objective and measure the EP must use the capabilities and standards of CEHRT at 45 CFR (b)(4), (g)(1), and (g)(2).

89 Core Objective 14 of 17 Objective 14 Measure: Medication Reconciliation NextGen Measure Report & Analysis DENOMINATOR: The number of transitions into care in which the patient was seen and a summary of care record was received as well as new patients during the EHR reporting period for which the EP was the receiving party of the transition. NUMERATOR: The number of transitions of care in the denominator where medication reconciliation was performed or an indication that the patient is not taking any active medications. THRESHOLD: The resulting percentage (Numerator Denominator) must be more than 50 percent in order for an EP to meet this measure. EXCLUSION: Any EP who has no transitions into care during the reporting period. NextGen Data Entry Requirements & Suggested Workflow User Workflow for Denominator: For this measure, all data elements for the denominator are captured in the Procedures module or from the Visit Type that is selected in NextGen KBM 8.3.x and higher. For practices that do not utilize NextGen EPM the visit type must be selected in order to have patients increment the denominator for this measure. o Workflow for all specialties except Retina: From Intake (NextGen KBM, Version 8.3.x and higher, for multiple specialties) select visit type. o Workflow for Retina only: From CC-HPI-ROS-OPH (NextGen KBM, Version 8.3.x and higher) select visit type (select the appropriate check box to populate the master_im_.visit_type field).

90 Core Objective 14 of 17 o Document a New patient using either CPT or documenting a new patient within NextGen KBM. From Intake (NextGen KBM, Version 8.3.x and higher, used for multiple specialties) select New patient visit type o Using CC-HPI-ROS (Retina Workflow) select New or Consult. o The New patient radio button is available on the following templates (including but not limited to): Home Page Allergy *Intake Intake Allergy Master IM BH Home OBGYN Home Home Page - Behavioral Health Home Page OPH Intake Cardiology Intake OPH Intake Dermatology Intake - Mohs Procedure -ORo Document summary of care record received From *Intake (NextGen KBM, Version 8.3.x and higher, used for multiple specialties): 1. Scroll down to the Medications table. 2. Ensure the Summary of Care Received checkbox is selected.

91 Core Objective 14 of 17 This box would be checked on encounters for which your practice received a summary of care record for this patient from another provider. For example, you would check this box if a patient s referring doctor faxed records to your office. o The Summary of care received check box is available on the following templates (including but not limited to): Home Page Allergy History OPH Intake Allergy *Home Page Anticoagulation History *Intake BH Home GI Physician Procedure Home Page - Behavioral Health Master IM BH - Nursing Note Medication Review BH - Psychiatric Evaluation Home Page Obstetrics Home Page Cardiology OBGYN Home Home Page Home Page OPH Intake Cardiology Intake OPH Home Page Dermatology Home Page ORT Intake Dermatology Home Page PC SOAP Dermatology Intake - Mohs Procedure ASC Home OPH Home Page - Physical Therapy o Additionally, when a C-CDA (Electronic Summary of Care Record) is received the patient is included in the Denominator. User Workflow for Numerator: The user workflow for the numerator is as follows: Ensure that medication reconciliation is documented before or during the reporting period, or if the patient is not currently taking any medications ensure no medications is selected on the qualifying denominator encounter. There are two options for reconciling medications: o Option 1: Manual Reconciliation o Option 2: External/Electronic Reconciliation The option used will depend on whether or not an electronic file was received for the patient, or if the patient s medication history was downloaded from Surescripts (External/Electronic Reconicliaton). If not, you will perform a manual medication reconciliation.

92 Core Objective 14 of 17 Option 1: Manual Reconciliation o From *Intake (NextGen KBM, Version 8.3.x and higher, used for multiple specialties): 1. Scroll down to the Medications table and click the Reconcile button. 2. Under Reconciliation Type, ensure the Manual Reconciliation checkbox is selected (as opposed to an Electronic Reconciliation). 3. Go through and reconcile the patient s medications. Medications can be reconciled individually or all at one time. To reconcile medications one by one: I. Ensure the Review adherence checkbox is selected. II. Open the Medication Adherence dropdown list, which shows you the options you may select to describe changes to each individual medication. III. Without actually clicking, ask the patient about the medication listed and any changes they wish to report. Select the appropriate option from the Medication Adherence dropdown list. IV. Then highlight the medication V. The medication will then drop down to the Medication Reviewed section with a status of verified

93 Core Objective 14 of 17 To reconcile all medications at one time: I. Click on the Review All- Taken As Directed button 4. Click Save & Close. o Once the reconciliation has been completed on the Medication Review template, the Medications Reconciled checkbox will automatically be checked on the Medications table. **Note: The Medications Module collapsible panel allows users to make modifications to the patient s current medication list from within the reconcile pop-up. Option 2: External/Electronic reconciliation o If the medications are downloaded using SureScript s Medication History Download, or if the medications are imported through a file, you must complete an Electronic Reconciliation. (For more information about the Electronic Reconciliation, see TSI Healthcare s Route ICD-10 website and the 5.8 training and documentation on Medication Reconciliation.)

94 Core Objective 14 of 17 o The Medications reconciled check box is available on the following templates (including but not limited to): Home Page Allergy *Home Page Intake Allergy *Intake Anticoagulation History Colonoscopy GI BH Home GI Physician Procedure Home Page - Behavioral Health Master IM BH - Nursing Note Home Page Obstetrics BH - Psychiatric Evaluation OBGYN Home Home Page Cardiology Home Page OPH Intake Cardiology Intake OPH Home Page Dermatology Home Page ORT Intake Dermatology Home Page PC SOAP Dermatology Intake - Mohs Procedure ASC Home OPH Home Page - Physical Therapy History OPH Option 3: Document No Medications on Qualifying Encounter If the patient is not currently taking any medications ensure that the No Medications checkbox is selected. This can be documented from within the Medications module or from with the templates in NextGen KBM. o From From *Intake (NextGen KBM, Version 8.3.x and higher, used for multiple specialties): 1. Scroll down to the Medications table. 2. Select the No Medications checkbox. o From History OPH (NextGen KBM, Version 8.3.x and higher, used for Retina Only): 1. Ensure the No active ocular meds AND No systemic meds at this time checboxes are selected (if applicable to the patient).

95 Core Objective 14 of 17 o The No medications check box is available on the following templates (including but not limited to): Home Page Allergy ASC Home OPH Intake Allergy *Home Page Anticoagulation History *Intake BH Home GI Physician Procedure Home Page - Behavioral Health Master IM BH - Nursing Note Home Page Obstetrics BH - Psychiatric Evaluation Home Page OPH BH Psychopharm Intake OPH Home Page Cardiology Home Page ORT Intake Cardiology Home Page PC Home Page Dermatology Intake - Mohs Procedure Intake Dermatology Home Page - Physical Therapy SOAP Dermatology Special Considerations Relevant encounter an encounter which the EP performs a medication reconciliation due to new medication or long gaps in time between patient encounters or for other reasons determined appropriate by the EP. Essentially an encounter is relevant if the EP judges it to be so. For this objective, relevant encounters are not included in the numerator and denominator of the measure.

96 Core Objective 15 of 17 Objective Measure Exclusion Change From Stage 1 Summary of Care The EP who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary care record for each transition of care or referral. EPs must satisfy both of the following measures in order to meet the objective: Measure 1: The EP who transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 50 percent of transitions of care and referrals. Measure 2: The EP who transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 10 percent of such transitions and referrals either (a) electronically transmitted using CEHRT to a recipient or (b) where the recipient receives the summary of care record via exchange facilitated by an organization that is a NwHIN Exchange participant or in a manner that is consistent with the governance mechanism ONC establishes for the NwHIN. Measure 3: An EP must satisfy one of the following criteria: Conducts one or more successful electronic exchanges of a summary of care document, as part of which is counted in "measure 2" (for EPs the measure at 495.6(j)(14)(ii)(B) with a recipient who has EHR technology that was developed designed by a different EHR technology developer than the sender's EHR technology certified to 45 CFR (b)(2). Conducts one or more successful tests with the CMS designated test EHR during the EHR reporting period. Any EP who transfers a patient to another setting or refers a patient to another provider less than 100 times during the EHR reporting period is excluded from all three measures. Moved from Menu to Core Measure Incorporates transmitting Summary of Care Record electronically Must transmit Summary of Care Record to another EHR or a CMS Test EHR CMS Definition of Terms Transition of Care The movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory, specialty care practice, long-term care, home health, rehabilitation facility) to another. At a minimum this includes all transitions of care and referrals that are ordered by the EP. Summary of Care Record A summary of care record must include the following elements: Patient name, referring or transitioning provider's name and office contact information (EP only), procedures, encounter diagnosis, immunizations, laboratory test results, vital signs (height, weight, blood pressure, BMI), smoking status, functional status, including activities of daily living, cognitive and disability status, demographic information (preferred language, sex, race, ethnicity, date of birth), care plan field, including goals and instructions, care team including the primary care provider of record and any additional known care team members beyond the referring or transitioning provider and the receiving provider, reason for referral, current problem list (EPs may also include historical problems at their discretion), current medication list, and current medication allergy list.

97 Core Objective 15 of 17 Problem List At a minimum a list of current, active and historical diagnoses. We do not limit the EP to just including diagnoses on the problem list. Active/current medication list A list of medications that a given patient is currently taking. Active/current medication allergy list A list of medications to which a given patient has known allergies. Allergy An exaggerated immune response or reaction to substances that are generally not harmful. Care Plan The structure used to define the management actions for the various conditions, problems, or issues. A care plan must include at a minimum the following components: problem (the focus of the care plan), goal (the target outcome) and any instructions that the provider has given to the patient. A goal is a defined target or measure to be achieved in the process of patient care (an expected outcome). CMS Attestation Requirements Attestation Type: NUMERATOR/DENOMINATOR/THRESHOLD/EXCLUSION Attestation Details: OBJECTIVE 15 MEASURE 1: Summary of Care Record DENOMINATOR: Number of transitions of care and referrals during the EHR reporting period for which the EP was the transferring or referring provider. NUMERATOR: Number of transitions of care and referrals in the denominator where a summary of care record was provided. THRESHOLD: The percentage must be more than 50 percent in order for an EP to meet this measure. EXLCUSION: Any EP who transfers a patient to another setting or refers a patient to another provider less than 100 times during the EHR reporting period is excluded from all three measures. OBJECTIVE 15 MEASURE 2: Summary of Care Records Sent Electronically DENOMINATOR: Number of transitions of care and referrals during the EHR reporting period for which the EP was the transferring or referring provider. NUMERATOR: The number of transitions of care and referrals in the denominator where a summary of care record was a) electronically transmitted using CEHRT to a recipient or b) where the recipient receives the summary of care record via exchange facilitated by an organization that is a NwHIN Exchange participant or in a manner that is consistent with the governance mechanism ONC establishes for the nationwide health information network. The organization can be a third-party or the sender's own organization. THRESHOLD: The percentage must be more than 10 percent in order for an EP to meet this measure. EXCLUSION: Any EP who transfers a patient to another setting or refers a patient to another provider less than 100 times during the EHR reporting period is excluded from all three measures. OBJECTIVE 15 MEASURE 3: Summary of Care Records Sent Electronically (TEST) This is a self attestation measure (YES/NO) The EP attests YES to one of the two criteria: 1. Conducts one or more successful electronic exchanges of a summary of care document, as part of which is counted in "measure 2" (for EPs the measure at 495.6(j)(14)(ii)(B) with a recipient who has EHR technology that was developed designed by a different EHR technology developer than the sender's EHR technology certified to 45 CFR (b)(2). -OR- 2. Conducts one or more successful tests with the CMS designated test EHR during the EHR reporting period. EXCLUSION: Any EP who transfers a patient to another setting or refers a patient to another provider less than 100 times during the EHR reporting period is excluded from all three measures.

98 Core Objective 15 of 17 CMS Additional Information Only patients whose records are maintained using certified EHR technology must be included in the denominator for transitions of care. The EP that transfers or refers the patient to another setting of care or provider should provide the summary of care document. It is for this provider that has the most recent information on the patient that may be crucial to the provider to whom the patient is transferred or referred. The EP can send an electronic or paper copy of the summary care record directly to the next provider or can provide it to the patient to deliver to the next provider, if the patient can reasonably expected to do so and meet Measure 1. If the provider to whom the referral is made or to whom the patient is transitioned to has access to the medical record maintained by the referring provider then the summary of care record would not need to be provided, and that patient must not be included in the denominator for transitions of care. To count in the numerator of any measure, the EP must verify these three fields for current problem list, current medication list, and current medication allergy list are not blank and include the most recent information known by the EP or hospital as of the time of generating the summary of care document. To count in the numerator of measure 2, the summary of care record must be received by the provider to whom the sending provider is referring or transferring the patient. o To count in the numerator of measure 2, one of the following three transmission approaches must be used: Use of the transport standard capability required for certification. As required by ONC to meet the CEHRT definition, every EP, eligible hospital, and CAH, must have EHR technology that is capable of electronically transmitting a summary care record for transitions of care and referrals according to the primary Direct Project specification (the Applicability Statement for Secure Health Transport). Thus, EPs, eligible hospitals, or CAHs that electronically transmit summary care records using their CEHRT s Direct capability (natively or combined with an intermediary) would be able to count all such electronic transmissions in their numerator. o Use of the SOAP-based optional transport standard capability permitted for certification. As part of certification, ONC permits EHR technology developers to voluntarily seek certification for their EHR technology s capability to perform SOAP based electronic transmissions. EHR technology developers who take this approach would enable their customers to also use this approach to meet the measure. Thus, EPs, eligible hospitals, or CAHs that electronically transmit summary care records using their CEHRT s SOAP-based capability (natively or combined with an intermediary) would be able to count all of those transmissions in their numerator. o Use of CEHRT to create a summary care record in accordance with the required standard (i.e., Consolidated CDA as specified in 45 CFR (b)(2)), and the electronic transmission is accomplished through the use of an ehealth Exchange participant who enables the electronic transmission of the summary care record to its intended recipient. Thus, EPs, eligible hospitals, or CAHs who create standardized summary care records using their CEHRT and then use an ehealth Exchange participant to electronically transmit the summary care record would be able to count all of those transmissions in their numerator. See related FAQ. In order to meet this objective and measure, an EP must use the capabilities and standards of CEHRT at 45 CFR (b)(1), (b)(2), (g)(1), and (g)(2).

99 Core Objective 15 of 17 Objective 15 Measure 1: Summary of Care Record NextGen Measure Report & Analysis DENOMINATOR: The number of transitions of care and referrals during the EHR reporting period for which the EP was the transferring or referring provider. NUMERATOR: The number of transitions of care and referrals in the denominator where a summary of care record was provided. The summary of care record date processed must be during the EHR reporting period. THRESHOLD: The resulting percentage must be more than 50 percent in order for an EP to meet this measure. EXCLUSION: Any EP who transfers a patient to another setting or refers a patient to another provider less than 100 times during the EHR reporting period is excluded from all three measures. NextGen Data Entry Requirements & Suggested Workflow Recommended Workflow The EP who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide a summary of care record for each transition of care or referral. User Workflow for Denominator The user workflow for the Denominator (All Measures) is as follows: All data elements for the Denominator of this measure are captured in: o Option 1: PHI Log Template Is used to document referrals and transitions of care o Option 2: Referrals Pop-Up Is used to document referrals Option 1: PHI Log Template Workflow PHI Log Workflow for Denominator: Create a new PHI Log entry and ensure the transition of care checkbox is selected. The PHI Log can be accessed in two ways: 1a.The PHI Log can be accessed via the Patient Information bar (if it has been setup in file maintenance). 1b. The PHI Log can also be accessed via the Patient History toolbar Patient Demographics tab

100 2. Click Add to create a new entry. Meaningful Use Stage 2: Eligible Professional Core Objective 15 of If the Date Processed, Transition of Care, and Physician Approved Disclosure fields are completed on the PHI Log then the patient will populate the denominator.

101 Core Objective 15 of 17 PHI Log Workflow for Numerator: Document a summary of care record was sent via the PHI log template. 1. Ensure the following fields are completed on the PHI Log: - Date processed - Transition of care checkbox - Summary of care record sent checkbox - Physician approved disclosure radio button The provider will only receive credit if the Yes option is selected - Physician name 2. Then Save Option 2: Referrals Pop-Up Workflow Referrals Pop-Up Workflow for Denominator: From the *Intake template (NextGen KBM, Version 8.3.x and higher, used for multiple specialties): 1. Scroll down to the Orders Table 2. Open the Referrals pop-up

102 Core Objective 15 of If Specialty, Obstetrics, Therapies, or DME information is populated as well as the diagnosis then the patient will populate the denominator Referrals Pop-Up Workflow for Numerator: o Option 1 Via the Referral Pop-Up before the referral order is placed (For Referrals only) o Option 2 Via the Referrals Pop-Up after the referral order is placed (For Referrals only) Workflow for Option 1: Document a summary of care record was sent via the Referrals pop-up at the time the referral order is created: 1. Ensure the Continuity of Care Document/Record checkbox is marked before the Add button is clicked.

103 Core Objective 15 of 17 Workflow for Option 2: Document a summary of care record was sent via the Referrals pop-up after the referral order is placed: 1. Go to the Orders table via the Intake template 2. Highlight the referral 3. Click Edit 4. Ensure the Continuity of Care Document/Record sent checkbox is marked. Then click Save.

104 Core Objective 15 of 17 Objective 15 Measure 2: Summary of Care Records Sent Electronically NextGen Measure Report & Analysis DENOMINATOR: The number of transitions of care and referrals during the EHR reporting period for which the EP was the transferring or referring provider. NUMERATOR: The number of transitions of care and referrals in the denominator where a summary of care record was sent electronically. THRESHOLD: The resulting percentage must be more than 10 percent in order for an EP to meet this measure. EXCLUSION: Any EP who transfers a patient to another setting or refers a patient to another provider less than 100 times during the EHR reporting period is excluded from all three measures. NextGen Data Entry Requirements & Suggested Workflow User Workflow for Denominator The workflow for the denominator of this measure is the same as Measure 1. User Workflow for Numerator The Direct Connect Interface is required in order to accomplish this measure. For more information about Direct Connect please send an to interface@tsihealthcare.com. The user workflow for sending a C-CDA (Summary of Care Record) electronically is as follows: MORE INFORMATION TO COME

105 Core Objective 15 of 17 Objective 15 Measure 3: Summary of Care Records Sent Electronically (TEST) NextGen Measure Report & Analysis REQUIREMENT: The EP must satisfy one of the following criteria: 1. Conduct one or more successful electronic exchanges of a summary of care document with a recipient who has an EHR technology that was developed by a different EHR technology developer than the sender s EHR technology -OR- 2. Conduct one or more successful tests with the CMS designated test EHR during the EHR reporting period. THRESHOLD: The provider must attest to Measure 3 and save documentation in the event of an audit. EXCLUSION: Any EP who transfers a patient to another setting or refers a patient to another provider less than 100 times during the EHR reporting period is excluded from all three measures. NextGen Data Entry Requirements & Suggested Workflow User Workflow for Numerator Measure 3 The EP attests YES to one of the two criteria: 1. Conducts one or more successful electronic exchanges of a summary of care document, as part of which is counted in measure 2 (for EPs the measure at 495.6(j)(14)(ii)(B) with a recipient who has EHR technology that was developed designed by a different EHR technology developer than the sender s EHR technology certified to 45 CFR (b)(2). OR 2. Conducts one or more successful tests with the CMS designated EHR during the EHR reporting period. o CMS and the ONC have a created a tool, called the Randomizer, to assist practices with the testing part of this measure. o For more information and to register your practice please visit the following website: Special Considerations In order to exclude referral orders to providers within the same practice or enterprise the provider name must be entered on the referral order when the referral order is created. Measure 2 utilizes the Advanced Auditing to determine when a Summary of Care record is electronically sent. Disabling items within the Interoperability section of Advanced Auditing impacts numerator results. The EP can send an electronic or paper copy of the summary of care record directly to the next provider or can provide it to the patient to deliver to the next provider if the patient can reasonably be expected to do so and meet Measure 1.

106 Core Objective 16 of 17 Objective Measure Exclusion Change From Stage 1 Immunization Registries Data Submission Capability to submit electronic data to immunization registries or immunization information systems except where prohibited, and in accordance with applicable law and practice. Successful ongoing submission of electronic immunization data from certified EHR to an immunization registry or immunization information system for the entire EHR reporting period. Any EP that meets one or more of the following criteria may be excluded from this objective: 1. 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 or immunization information system during the EHR reporting period; 2. the EP operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required for CEHRT at the start of their EHR reporting period; 3. the EP operates in a jurisdiction where no immunization registry or immunization information system provides information timely on capability to receive immunization data; or 4. the EP operates in a jurisdiction for which no immunization registry or immunization information system that is capable of accepting the specific standards required by CEHRT at the start of their EHR reporting period can enroll additional EPs. Moved from Menu to Core Measure CMS Definition of Terms None CMS Attestation Requirements Attestation Type: YES/NO Attestation Details: The EP must attest YES to meeting one of the following criteria under the umbrella of ongoing submission. Ongoing submission was already achieved for an EHR reporting period in a prior year and continues throughout the current EHR reporting period using either the current standard at 45 CFR (f)(1) and (f)(2) or the standards included in the 2011 Edition EHR certification criteria adopted by ONC during the prior EHR reporting period when ongoing submission was achieved. Registration with the PHA or other body to whom the information is being submitted of intent to initiate ongoing submission was made by the deadline (within 60 days of the start of the EHR reporting period) and ongoing submission was achieved. Registration of intent to initiate ongoing submission was made by the deadline and the EP or hospital is still engaged in testing and validation of ongoing electronic submission. Registration of intent to initiate ongoing submission was made by the deadline and the EP or hospital is awaiting invitation to begin testing and validation. EXCLUSIONS: Any EP that meets one or more of the following criteria may be excluded from this objective: 1. Does not administer any of the immunizations to any of the populations for which data is collected by their jurisdiction's immunization registry or immunization information system during the EHR reporting period;

107 Core Objective 16 of Operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required for CEHRT at the start of their EHR reporting period 3. Operates in a jurisdiction where no immunization registry or immunization information system provides information timely on capability to receive immunization data; or 4. Operates in a jurisdiction for which no immunization registry or immunization information system that is capable of accepting the specific standards required by CEHRT at the start of their EHR reporting period can enroll additional EPs. CMS Additional Information In determining whether the PHA has the capacity, CMS anticipates developing a centralized repository for this information, including a deadline for the PHA to submit information. If the PHA fails to provide information to this centralized repository by the deadline, the provider could claim the exclusion. In the event, that we are unable to develop a centralized repository, providers will make the determination of PHA capacity by working directly with the PHA as is currently the case for Stage 1 of meaningful use. The second exclusion does not apply if an entity designated by public health agency can receive electronic syndromic surveillance data submissions. For example, if the public health agency cannot accept the data directly or in the standards required by CEHRT, but if it has designated a Health Information Exchange to do so on their behalf and the Health Information Exchange is capable of accepting the information in the standards required by CEHRT, the provider could not claim the second exclusion. If EPs prior to CY 2014 have achieved successful ongoing submission using EHR technology certified to the 2011 Edition EHR certification criteria (HL only), it is acceptable to continue this ongoing submission and meet the Stage 2 measure for as long as HL continues to be accepted by the PHA in that jurisdiction. In order to meet this objective and measure, an EP must use the capabilities and standards of CEHRT at 45 CFR (f)(3).

108 Core Objective 16 of 17 Objective 16 Measure: Immunization Data Submission NextGen Measure Report & Analysis There is no NextGen HQM Report for this measure. It remains the responsibility of each practice to retain all supporting documentation for this measure. NextGen Data Entry Requirements & Suggested Workflow The NextGen Immunization Interface is required for this measure. Please contact TSI Healthcare at for more information about Immunization Interfaces. Website URLs have been provided below only to assist clients in finding information for their particular state. Immunization data that is collected varies state to state. (The URLs are current as of November 23, If the web URL is not up to date then you should contact your state for more information). Alabama Alaska Arizona Arkansas eaningfuluse/pages/default.aspx California Colorado DCEED/CBON/ Connecticut 60&dphNav=%7C&dphNav_GID=1993 Delaware Georgia Florida Hawaii Idaho lthmeaningfulusereporting/tabid/2486/default.aspx Illinois px Indiana Iowa ingfuluse.html Kansas Kentucky Louisiana sp (Immunization main page - must reach out according to region) Maine Maryland chealthobjectives_main.aspx Massachusetts ograms/id/isis/meaningful-use-and-publichealthobjectives.html Michigan Minnesota Mississippi 0,356,html Missouri Montana /index.shtml

109 Core Objective 16 of 17 Nebraska Use.aspx Nevada New Hampshire New Mexico sessionid=0a e5740bb5058c9546baac478f241 a86af74.e3moanasah4pe3mla3mka3ilbi1ynknvrklolq znp65in0 New York _guidance/ North Carolina ge.htm North Dakota Ohio n%20reporting.aspx Oklahoma redness/meaningful_use_submissions_of_public_healt h_measures/ Oregon ces/healthcareprovidersfacilities/meaningfuluse/pages /index.aspx Pennsylvania alassistance/medicalassistancehealthinformationtechno logyinitiative/meaningfuluse/index.htm Rhode Island unizationinterface/index.php South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington viders/healthcareprofessionsandfacilities/datareportin gandretrieval/electronichealthrecordsmeaningfuluse.a spx Washington DC West Virginia Wisconsin m Wyoming Special Considerations In determining whether the PHA has the capacity, CMS anticipates developing a centralized repository for this information, including a deadline for the PHA to submit information. If the PHA fails to provide information to this centralized repository by the deadline, the provider could claim the exclusion. In the event, that we are unable to develop a centralized repository, providers will make the determination of PHA capacity by working directly with the PHA as is currently the case for Stage 1 of meaningful use. The second exclusion does not apply if an entity designated by the immunization registry or immunization information system can receive electronic immunization data submissions. For example, if the immunization registry cannot accept the data directly or in the standards required by CEHRT, but if it has designated a Health Information Exchange to do so on their behalf and the Health Information Exchange is capable of accepting the information in the standards required by CEHRT, the provider could not claim the second exclusion.

110 Core Objective 16 of 17 In order to meet this objective and measure, an EP must use the capabilities and standards of CEHRT at 45 CFR (f)(1) and (f)(2). However, if EPs prior to CY 2014 have achieved successful ongoing submission using EHR technology certified to the 2011 Edition EHR certification criteria (HL only), it is acceptable to continue this ongoing submission and meet the Stage 2 measure for as long as HL continues to be accepted by the immunizations information system or immunization registry.

111 Core Objective 17 of 17 Last Updated: 1/23/2015 Objective Measure Exclusion Change From Stage 1 Use Secure Electronic Messaging Use secure electronic messaging to communicate with patients on relevant health information. A secure message was sent using the electronic messaging function of CEHRT by more than 5 percent of unique patients (or their authorized representatives) seen by the EP during the EHR reporting period. Any EP who has no office visits during the EHR reporting period, or any EP 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 3Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period. New Measure CMS Definition of Terms Secure Message Any electronic communication between a provider and patient that ensures only those parties can access the communication. This electronic message could be or the electronic messaging function of a PHR, an online patient portal, or any other electronic means. CMS Attestation Requirements Attestation Type: DENOMINATOR/NUMERATOR/THRESHOLD/EXCLUSION Attestation Details: DENOMINATOR: Number of unique patients seen by the EP during the EHR reporting period. NUMERATOR: The number of patients or patient-authorized representatives in the denominator who send a secure electronic message to the EP that is received using the electronic messaging function of CEHRT during the EHR reporting period. THRESHOLD: The resulting percentage must be more than 5 percent in order for an EP to meet this measure. EXCLUSION: Any EP who has no office visits during the EHR reporting period, or any EP 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 3Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period. CMS Additional Information An EP or staff member could decide that a follow-up telephone call or office visit is more appropriate to address the concerns raised in the electronic message. There is not an expectation that the EP must personally respond to electronic messages to the patient. In order to meet this objective and measure, an EP must use the capabilities and standards of CERT at 45 CFR (e)(3).

112 Core Objective 17 of 17 Last Updated: 1/23/2015 Objective 17 Measure: Use Secure Electronic Messaging NextGen Measure Report & Analysis DENOMINATOR: The number of unique patients seen by the EP during the EHR reporting period. NUMERATOR: The number of patients or patient authorized representatives in the denominator who send a secure electronic message to the EP. THRESHOLD: The resulting percentage must be more than 5 percent in order for an EP to meet this measure. EXCLUSION: Any EP who has no office visits during the EHR reporting period or any EP who conducts 50 percent or more of their 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 their EHR reporting period. NextGen Data Entry Requirements & Suggested Workflow User Workflow for Denominator: For this measure, all data elements for the denominator are captured in the Procedures module or from the Visit Type that is selected in NextGen KBM 8.3.x and higher. For practices that do not utilize NextGen EPM the visit type must be selected in order to have patients increment the denominator for this measure. o Workflow for all specialties except Retina: From Intake (NextGen KBM, Version 8.3.x and higher, for multiple specialties) select visit type. o Workflow for Retina only: From CC-HPI-ROS-OPH (NextGen KBM, Version 8.3.x and higher) select visit type (select the appropriate check box to populate the master_im_.visit_type field).

113 Core Objective 17 of 17 Last Updated: 1/23/2015 User Workflow for Numerator: The numerator is met by a patient or an authorized representative of the patient sending a secure electronic message from the NextGen Patient Portal to the Practice. Patients can either compose brand new messages from the Patient Portal website or reply to a message that the practice sent to the patient from within the Inbox on the Patient Portal Website. Option 1: From NextGen Patient Portal The patient or authorized representative will need to click on the Mail tab, select Compose Message, and send a message to the provider. Any message category the patient selects will increment the numerator for this measure. Option 2: From the NextGen Patient Portal inbox the patient or authorized representative can reply to a message that the practice has sent the patient from within the NextGen Patient Portal inbox.

114 Core Objective 17 of 17 Last Updated: 1/23/2015 Once the patient or authorized representative submits the secure message, it can be accessed from the NextGen EHR Inbox. **Please note the numerator queries whether the patient submitted a secure message. It does not query for a response from the provider. Special Considerations A secure message must be sent during the EHR reporting period to meet the numerator criteria. The provider does not have to be the direct recipient. If a patient sees two providers within the same practice during the EHR reporting period AND sends a secure message, both providers will receive numerator credit.

115 Menu Objective 1 of 6 Objective Measure Exclusion Change From Stage 1 Syndromic Surveillance Data Submission Capability to submit electronic syndromic surveillance data to public health agencies except where prohibited, and in accordance with applicable law and practice. Successful ongoing submission of electronic syndromic surveillance data from CEHRT to a public health agency for the entire EHR reporting period. Any EP that meets one or more of the following criteria may be excluded from this objective: 1. the EP is not in a category of providers that collect ambulatory syndromic surveillance information on their patients during the EHR reporting period; 2. the EP operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data in the specific standards required by CEHRT at the start of their EHR reporting period; 3. the EP operates in a jurisdiction where no public health agency provides information timely on capability to receive syndromic surveillance data; or 4. the EP operates in a jurisdiction for which no public health agency that is capable of accepting the specific standards required by CEHRT at the start of their EHR reporting period can enroll additional EPs. No change Menu Measure exclusions no longer qualify ( count ) as a Menu Objective unless no other Menu Measures apply. CMS Definition of Terms Public Health Agency -- An entity under the jurisdiction of the U.S. Department of Health and Human Services, tribal organization, State level and/or city/county level administration that serves a public health function. CMS Attestation Requirements Attestation Type: YES/NO Attestation Details: EPs must attest YES to successful ongoing submission of electronic syndromic surveillance data from CEHRT to a public health agency for the entire EHR reporting period. Ongoing submission was already achieved for an EHR reporting period in a prior year and continues throughout the current EHR reporting period. Registration with the PHA or other body to whom the information is being submitted of intent to initiate ongoing submission was made by the deadline (within 60 days of the start of the EHR reporting period) and ongoing submission was achieved. Registration of intent to initiate ongoing submission was made by the deadline and the EP or hospital is still engaged in testing and validation of ongoing electronic submission. Registration of intent to initiate ongoing submission was made by the deadline and the EP or hospital is awaiting invitation to begin testing and validation. EXCLUSIONS: Any EP that meets one or more of the following criteria may be excluded from this objective: 1. the EP is not in a category of providers that collect ambulatory syndromic surveillance information on their patients during the EHR reporting period; 2. the EP operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data in the specific standards required by CEHRT at the start of their EHR reporting period;

116 Menu Objective 1 of 6 3. the EP operates in a jurisdiction where no public health agency provides information timely on capability to receive syndromic surveillance data; or 4. the EP operates in a jurisdiction for which no public health agency that is capable of accepting the specific standards required by CEHRT at the start of their EHR reporting period can enroll additional EPs. CMS Additional Information In determining whether the PHA has the capacity, CMS anticipates developing a centralized repository for this information, including a deadline for the PHA to submit information. If the PHA fails to provide information to this centralized repository by the deadline, the provider could claim the exclusion. In the event, that we are unable to develop a centralized repository, providers will make the determination of PHA capacity by working directly with the PHA as is currently the case for Stage 1 of meaningful use. The second exclusion does not apply if an entity designated by public health agency can receive electronic syndromic surveillance data submissions. For example, if the public health agency cannot accept the data directly or in the standards required by CEHRT, but if it has designated a Health Information Exchange to do so on their behalf and the Health Information Exchange is capable of accepting the information in the standards required by CEHRT, the provider could not claim the second exclusion. If EPs prior to CY 2014 have achieved successful ongoing submission using EHR technology certified to the 2011 Edition EHR certification criteria (HL only), it is acceptable to continue this ongoing submission and meet the Stage 2 measure for as long as HL continues to be accepted by the PHA in that jurisdiction. In order to meet this objective and measure, an EP must use the capabilities and standards of CEHRT at 45 CFR (f)(3).

117 Menu Objective 1 of 6 Menu Objective 1 Measure: Syndromic Surveillance Data Submission NextGen Measure Report & Analysis There is no NextGen HQM Report for this measure. It remains the responsibility of each practice to retain supporting documentation that this measure was successfully accomplished. NextGen Data Entry Requirements & Suggested Workflow The NextGen Public Health Interface is required to accomplish this measure. If you are interested in setting up an interface for submission of syndromic surveillance data please submit an to interface@tsihealthcare.com Syndromic surveillance data that is collected varies from state to state. Do not assume based on specialty that your practice/provider does not collect information that is submitted. Website URLs have been provided below only to assist clients in finding information for their particular state. (The URLs are current as of November 23, If the web URL is not up to date, contact your state.) Practices should contact their State Department of Public Health to determine what syndromic surveillance information should be collected. Alabama Alaska Arizona Arkansas eaningfuluse/pages/default.aspx California Colorado DCEED/CBON/ Connecticut 60&dphNav=%7C&dphNav_GID=1993 Delaware Georgia Florida Hawaii Idaho lthmeaningfulusereporting/tabid/2486/default.aspx Illinois px Indiana Iowa ingfuluse.html Kansas Kentucky Louisiana Maine Maryland chealthobjectives_main.aspx Massachusetts ograms/id/isis/meaningful-use-and-publichealthobjectives.html Michigan Minnesota Mississippi 0,356,html

118 Menu Objective 1 of 6 Missouri Montana /index.shtml Nebraska Use.aspx Nevada - No up to date information on syndromic surveillance - contact state for information New Hampshire New Mexico - No dedicated site found for syndromic surveillance contact state and local public health agency for information New York _guidance/ North Carolina ge.htm North Dakota Ohio 20Surveillance.aspx Oklahoma redness/meaningful_use_submissions_of_public_healt h_measures/ Oregon ces/healthcareprovidersfacilities/meaningfuluse/pages /index.aspx Pennsylvania alassistance/medicalassistancehealthinformationtechno logyinitiative/meaningfuluse/index.htm Rhode Island - No dedicated site found for syndromic surveillance contact state and local public health agency South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington viders/healthcareprofessionsandfacilities/datareportin gandretrieval/electronichealthrecordsmeaningfuluse.a spx Washington DC West Virginia Wisconsin m Wyoming Special Considerations None

119 Menu Objective 2 of 6 Objective Measure Exclusion Change From Stage 1 Electronic Notes Record electronic notes in patient records. Enter at least one electronic progress note created, edited and signed by an EP for more than 30 percent of unique patients with at least one office visit during the EHR reporting period. The text of the electronic note must be text searchable and may contain drawings and other content. No Exclusion. New measure Menu Measure Exclusions no longer qualify ( count ) as a Menu Objective unless no other Menu Measures apply. CMS Definition of Terms Electronic Notes Defined as electronic progress notes. CMS will rely on providers own determinations and guidelines defining when progress notes are necessary to communicate individual patient circumstances and for coordination with previous documentation of patient observations, treatments and/or results in the electronic health record. CMS Attestation Requirements Attestation Type: NUMERATOR/DENOMINATOR/THRESHOLD Attestation Details: DENOMINATOR: Number of unique patients with at least one office visit during the EHR reporting period for EPs during the EHR reporting period. NUMERATOR: The number of unique patients in the denominator who have at least one electronic progress note from an eligible professional recorded as text searchable data. THRESHOLD: The resulting percentage must be more than 30 percent in order for an EP to meet this measure. CMS Additional Information Any EP as defined for the Medicare or Medicaid EHR Incentive Programs may author, edit, and provide an electronic signature for the electronic notes in order for them to be considered for this measure. An EP or authorized provider may author, edit and sign the note in any manner including dictation, conversion of written notes to text searchable notes, direct entry into the EHR or any other method as long as the end result is a text searchable note that is the information that the EP or authorized provider wanted to note. Non-searchable notes do not qualify, but this does not mean that all of the content has to be character text. Drawings and other content can be included with searchable text notes under this measure. In order to meet this objective and measure, an EP must use the capabilities and standards of CEHRT at 45 CFR (a)(9).

120 Menu Objective 2 of 6 Menu Objective 2 Measure: Electronic Notes NextGen Measure Report & Analysis DENOMINATOR: The number of unique patients with at least one office visit during the EHR reporting period. NUMERATOR: The number of unique patients in the denominator who have at least one electronic progress note from an eligible professional recorded as text searchable data. Must also be signed by the EP. THRESHOLD: The resulting percentage must be more than 30 percent in order for an EP to meet this measure. EXCLUSION: There are no exclusions for this measure. NextGen Data Entry Requirements & Suggested Workflow User Workflow for Denominator All data elements for the Denominator for this measure are captured in the Procedures module and using Visit Type. From *Intake (NextGen KBM, Version 8.3.x and higher, used for multiple specialties) select visit type. From the CC-HPI-ROS-OPH template (NextGen KBM, Version 8.3.x and higher) select Visit Type (select the appropriate check box to populate the master_im_.visit_type field).

121 Menu Objective 2 of 6 User Workflow for Numerator 1. From the *SOAP template, under the Assessment/Plan section, click the Generate Note icon to generate the Master Document (master_im) (NextGen KBM, Version 8.3.x and higher): 2. Ensure the Master Document is generated and signed off on by the provider for each patient encounter. A provider can sign off on the Master Document in the Provider Approval Queue (PAQ). a. First, click the PAQ icon in the Top Toolbar: b. The PAQ will open. On the left side panel, a list of all documents pending signature will display. To the right, a preview panel will allow the provider to review the document pending signature directly from the PAQ.

122 Menu Objective 2 of 6 c. To sign the document, click the Accept button: Note: All NextGen documents are text searchable. Open a document and then use your keyboard keys CTRL + F to launch the Find Text search box within document NextGen EHR 5.8 and higher. Special Considerations None.

123 Menu Objective 3 of 6 Objective Measure Exclusion Change From Stage 1 Imaging Results Imaging results consisting of the image itself and any explanation or other accompanying information are accessible through CEHRT. More than 10 percent of all tests whose result is one or more images ordered by the EP during the EHR reporting period are accessible through CEHRT. Any EP who orders less than 100 tests whose result is an image during the EHR reporting period; or any EP who has no access to electronic imaging results at the start of the EHR reporting period. New Measure Menu Measure Exclusions no longer qualify ( count ) as a Menu Objective unless no other Menu Measures apply. CMS Definition of Terms Imaging The description of radiology services from the Stage 2 CPOE objective is the minimum description of imaging. We describe radiologic services as any imaging service that uses electronic product radiation. Electronic product radiation is defined at 21 CFR as: "any ionizing or nonionizing electromagnetic or particulate radiation, or any sonic, infrasonic, or ultrasonic wave that is emitted from an electronic product as the result of the operation of an electronic circuit in such product." If the provider desires to include other types of imaging services that do not rely on electronic product radiation they may do so as long as the policy is consistent across all patients and for the entire EHR reporting period. Accessible through Either incorporation of the image and accompanying information into CEHRT or an indication in CEHRT that the image and accompanying information are available for a giving patient in another technology and a link to that image and accompanying information. Incorporation of the Image The image and accompanying information is stored by the CEHRT. A Link to the Image and Accompanying Information A link to where the image and accompanying information is stored is available in CEHRT. This link must conform to the certification requirements associated with this objective in the ONC final rule published elsewhere in this issue of the Federal Register. No Access None of the imaging providers used by the EP provide electronic images and any explanation or other accompanying information that are accessible through their CEHRT at the start of the EHR reporting period. CMS Attestation Requirements Attestation Type: NUMERATOR/DENOMINATOR/THRESHOLD/EXCLUSION Attestation Details: DENOMINATOR: Number of tests whose result is one or more images ordered by the EP during the EHR reporting period. NUMERATOR: The number of results in the denominator that are accessible through CEHRT. THRESHOLD: The resulting percentage must be more than 10 percent in order to meet this measure. EXCLUSION: Any EP who orders less than 100 tests whose result is an image during the EHR reporting period; or any EP who has no access to electronic imaging results at the start of the EHR reporting period. CMS Additional Information There are no limitations on the resolution of the image. Storing the images natively in CEHRT is one way to make them accessible through CEHRT, but there are many other ways and native storage is not required by the objective and measure.

124 Menu Objective 3 of 6 Images and imaging results that are scanned into the CEHRT may be counted in the numerator of this measure. In order to meet this objective and measure, an EP must use the capabilities and standards of CEHRT at 45 CFR (a)(12).

125 Menu Objective 3 of 6 Menu Objective 3 Measure: Imaging Results NextGen Measure Report & Analysis DENOMINATOR: The number of R type tests/orders whose result is one or more images ordered by the EP during the EHR reporting period and is not a R type order that are not radiology orders listed in the HQM portal. NUMERATOR: The number of results in the denominator that have an image available within the Orders module or a context specific link is available within the Orders module to the image. THRESHOLD: The resulting percentage must be more than 10 percent in order for an EP to meet this measure. EXCLUSION: Any EP who orders less than 100 tests whose result is an image during the EHR reporting period or any EP who has no access to electronic imaging results at the start of the EHR reporting period. NextGen Data Entry Requirements & Suggested Workflow Recommended Workflow All radiology orders should be entered into the NextGen EHR Orders module in order to be accurately counted. The radiology or imaging orders that are hand-written are not captured. User Workflow for Denominator Radiology The user workflow for Denominator is as follows: o All radiology orders are captured during the reporting period. All radiology orders must be in the Orders module. A radiology order can be entered within NextGen KBM and then submitted to the Orders module:

126 Menu Objective 3 of 6 o Orders placed within the NextGen KBM needs to be processed/submitted to the Orders module. A provider or externally credentialed staff member does not need to be the user that processes or submits the order. You can use the Process and Submit Lab/Radiology Orders pop-up with NextGen KBM, Version 8.3.x and higher. The process pop-up can be launched from multiple places within the NextGen KBM including (but not limited to): My Plan Diagnostic Studies Intake OPH (using My Plan link) *Intake (using My Plan Link) Intake Allergy (using My Plan link) Intake Dermatology (using My Plan link) Process and Submit Lab/Radiology Orders (NextGen KBM, Version 8.3.x and higher User Workflow for Numerator Radiology Option 1: Attaching the Image in the Orders Module The first way to access the radiology image is to attach the image directly to the order in the NextGen Orders Module. Once the image is attached, a user can select the image from the History tool bar to view the image. 1. To enter the result for a radiology or imaging order, open the Orders Module by clicking the test tube icon in the bottom right of the patient history toolbar.

127 Menu Objective 3 of 6 2. This will open the Orders Module to the results tab. Switch to the orders tab. 3. Next, highlight the order that you would like to update. Click on the results section. This section allows you to view or enter results for an order.

128 Menu Objective 3 of 6 4. You can enter structured data results as well as import and link reports, documents, and/or images using the tabs in the results section. For the purposes of meeting this measure, we will need to import and link an image. To import and link a document or image, click on the New Document and Images Entry tab.

129 Menu Objective 3 of 6 5. On the left, you will see all radiology tests that have been placed as part of the order. If there are multiple tests, be sure to click the appropriate test first. 6. Next, you may either browse to a folder on your computer that is accessible to the EHR to import the image or you can link any EHR document(s), image(s), or scanned ICS image(s) that are associated with the same encounter in which the order was placed. a. To browse to a folder on your computer that is accessible to the EHR, click the Browse File System button.

130 Menu Objective 3 of 6 Please note that clients who are hosted on the TSI ASP, you can access your computer s local hard drive, or C drive, through the V drive in your Citrix environment. For example, select a report or image on your local hard drive by navigating to My Computer in Citrix then selecting C$, also known as the V drive. After double clicking on the V drive, select the report or image to import and click open. b. Next, select the appropriate category, type a description, and enter the service date and time. Please note that, because the description becomes the document type name in the category view, TSI Healthcare recommends implementing standard naming conventions for all the images or reports you may import for consistency. This will aid in organization and image/report retrieval for the end user.

131 Menu Objective 3 of 6 7. The other option is to link EHR documents, images, and/or scanned ICS images to the order. To do this, click the search EHR button. This will give you a list of all documents, images, and/or scanned ICS images associated with today s encounter. Note: For scanned ICS images to show in this list, they must be associated with the selected encounter during the filing process. Any ICS images not associated with an encounter would not display here. 8. Place checkmarks next to each document and/or image you would like to link to the order then click OK.

132 Menu Objective 3 of 6 9. All items that we have linked to this order will display to the right. Note: The clear button will clear ALL documents and images that have been selected for this order. 10. The final step is to link the selected documents and/or images to the order by clicking the Link button.

133 Menu Objective 3 of 6 If the selected documents are not the final results, you can change the Document Status to preliminary, partial, corrected, etc. before clicking the Link button. 11. After clicking the Link button, you will see a confirmation pop up that these items have been linked to the order. Option 2: Radiology Interface The second way to access an image in the NextGen Ambulatory EHR is using a radiology interface in which a URL is sent and the URL provides a link to the image within EHR. Special Considerations Please direct any questions regarding imaging and/or radiology interfaces to interface@tsihealthcare.com Denominator: This measure is during the reporting period. The items ordered outside of the reporting period does NOT increment the numerator or denominator. The image can be made available during or after the EHR reporting period to meet numerator requirements. Per NIST testing criteria for (a)(12) - the images and narrative interpretations (where available) are accessible to the user within the EHR system OR via a context-sensitive link to an external application that provides access to images and their associated narrative interpretations, OR via a context-sensitive link to an external application that provides access with narrative interpretations stored within the EHR; and 2) that the user accesses these images and narrative interpretations without requiring additional patient lookup or imaging test selection (additional provider login for a 3rd party application is permitted).

134 Menu Objective 4 of 6 Last Updated: 1/23/2015 Objective Measure Exclusion Change From Stage 1 Family Health History Record patient family health history as structured data. More than 20 percent of all unique patients seen by the EP during the EHR reporting period have a structured data entry for one or more first-degree relatives. Any EP who has no office visits during the EHR reporting period. New measure Menu Measure Exclusions no longer qualify ( count ) as a Menu Objective unless no other Menu Objectives apply. CMS Definition of Terms First Degree Relative A family member who shares about 50 percent of their genes with a particular individual in a family. First degree relatives include parents, offspring, and siblings. CMS Attestation Requirements Attestation Type: NUMERATOR/DENOMINATOR/THRESHOLD/EXCLUSION Attestation Details: DENOMINATOR: Number of unique patients seen by the EP during the EHR reporting period. NUMERATOR: The number of patients in the denominator with a structured data entry for one or more firstdegree relatives. THRESHOLD: The resulting percentage must be more than 20 percent in order to meet this measure. EXCLUSION: Any EP who has no office visits during the EHR reporting period. CMS Additional Information This measure is a minimum and not a limitation on the health history that can be recorded. For patients who are asked about their family health history, but do not know their family history, it is acceptable for the provider to record the patient's family history as "unknown." Standards require CEHRT to be able to use SNOMEDCT or the HL7 Pedigree standard to record a patient's family health history. Either a structured data entry of "unknown" or any structured data entry identified as part of the patient's family history and conforming to the standards of CEHRT at 45 CFR (a)(13) must be in the provider's CEHRT for the patient to count in the numerator. In order to meet this objective and measure, an EP must use the capabilities and standards of CEHRT at 45 CFR (a)(13).

135 Menu Objective 4 of 6 Last Updated: 1/23/2015 Menu Objective 4 Measure: Family Health History NextGen Measure Report & Analysis DENOMINATOR: The number of unique patients seen during the EHR reporting period. NUMERATOR: The number of patients in the denominator with family history recorded as structured data for a first degree relative. THRESHOLD: The resulting percentage must be more than 20 percent in order for an EP to meet this measure. EXCLUSION: Any EP who has no office visits during the EHR reporting period. NextGen Data Entry Requirements & Suggested Workflow User Workflow for Denominator The user workflow for Denominator is as follows: The data elements are captured in the Procedures module or using the Visit Type: From *Intake (NextGen KBM, Version 8.3.x and higher, used for multiple specialties) select visit type. From CC-HPI-ROS-OPH template (NextGen KBM, Version 8.3.x and higher) select visit type (select appropriate check box to populate the master_im_.visit_type field). User Workflow for Numerator Record family history as structured data for a first-degree relative. Family history can be entered in all specialty workflows within NextGen KBM, Version 8.3.x and higher. The templates in which family history may be accessed include (but not limited to): *Histories (Used by most specialties in NextGen KBM, Version 8.3.x and higher) Histories Allergy BH CA Social History Family History Cardiology Home Page Cardiology History OPH Histories Obstetrics Histories OPH Histories - Dermatology

136 Menu Objective 4 of 6 Last Updated: 1/23/ Go to the Histories template 2. Open the Family History pop-up by clicking Add. 3. Select your specialty - The Family Health History pop-up is used for all specialties. Select Specialty to display history items based on specialty selected.