Program Year 2015: Public Health Reporting Objective & Supporting Documentation
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1 Program Year 2015: Public Health Reporting Objective & Supporting Documentation Valorie A. Vigil, Staff Manager Benjamin Rogers, Program Manager December 2015 New Mexico Human Services Department Medical Assistance Division Systems Bureau NM Medicaid EHR Incentive Program
2 PY 2015: General Information For PY 2015, all providers must attest to objectives and measures using EHR technology certified to the 2014 Edition. All providers are required to attest to a single set of objectives and measures (Modified Stage 2). This replaces the core and menu objectives structure of previous stages. For EPs, there are 10 objectives, including one consolidated Public Health Reporting Objective. 2
3 PY 2015: General Information To assist providers who may have already started working on Meaningful Use in 2015, there are alternate exclusions and specifications within individual objectives for providers who were previously scheduled to be in Stage 1 of Meaningful Use. These include: Allowing providers who were previously scheduled to be in a Stage 1 EHR Reporting Period for 2015 to use a lower threshold for certain measures. Allowing these Stage 1 providers to exclude for Stage 2 measures in 2015 for which there is no Stage 1 equivalent. 3
4 PY 2015: EHR Reporting Period In 2015 only, the EHR Reporting Period for all providers will be any continuous 90-day period. EPs may select an EHR Reporting Period of any continuous 90-day period from January 1, 2015 through December 31, The 90-day period can encompass 91 or 92 days but it cannot include fewer than 90 days. A one-year EHR reporting period will not be an option for PY EHs may select an EHR Reporting Period of any continuous 90-day period from October 1, 2014 through December 31,
5 PY 2015: Public Health Reporting What s different in Program Year 2015 for Public Health reporting? Only one Public Health Objective with multiple measures Measure language changes from... Performed at least one test of certified EHR technology s capacity to provide electronic data... (Stage 1) Successful ongoing submission of electronic data... (Stage 2) To: The EP or EH is in active engagement with a public health registry or specialized registry 5
6 PY 2015: Active Engagement What demonstrates Active Engagement? Under the new rule, there are three definition options (see Final Rule, page 62818) Option 1: Completed Registration to Submit Data; must be done with a public health registry (NM DOH) within 60 days of start of EHR Reporting Period. Option 2: Testing and Validation; provider is in testing and validation during the EHR Reporting Period (On-Boarding process). Provider must respond to NM DOH invitation to begin On-Boarding process within 30 days of the invitation. Option 3: Production; during EHR Reporting Period, provider has completed On- Boarding process, moved to production, and is electronically submitting data to DOH; or, is electronically submitting data to a specialized registry. 6
7 PY 2015: Active Engagement EPs and EHs may choose different Active Engagement options for each of the Public Health measures. Example: an EP or EH may be submitting immunization data to the NMSIIS registry (Option 3) but may have just registered for syndromic surveillance during the EHR Reporting Period (Option 1). 7
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9 Objective 10: Public Health Reporting Separate Public Health reporting objectives have been consolidated into one objective with three measure options for EPs and four measure options for EHs (see Final Rule, page 62824) EPs must be in Active Engagement on two of the three measures EHs must be in Active Engagement on three of the four measures Measure 1 Immunization Registry Measure 2 Syndromic Surveillance Measure 3 Specialized Registry Measure 4 Electronic Reportable Laboratory Results (EHs only) 9
10 Objective 10: Public Health Reporting EPs and EHs may be considered to have met the Public Health Objective even if they can claim regular exclusions for all measures. When attesting to PY 2015 in the State Level Registry, the system will offer the Stage 1 alternate specification only to those who were scheduled to be in Stage 1 in PY When attesting to PY 2015 in the State Level Registry, the system will offer the Stage 2 alternate exclusions only to those who were scheduled to be in Stage 2 in PY
11 Objective 10: Public Health Reporting: EPs Measure 1 Immunization Registry Measure 2 Syndromic Surveillance Measure 3 Specialized Registry ALTERNATE SPECIFICATION EPs Stage 1 An EP scheduled to be in Stage 1 in 2015 may meet only one measure to meet objective. Measure 1 Immunization Registry Measure 2 Syndromic Surveillance Measure 3 Specialized Registry ALTERNATE EXCLUSIONS EPs Stage 2 An EP scheduled to be in Stage 2 in 2015 may take alternate exclusions for Measures 2 and 3 if the EP did not intend to attest to two Public Health measures. 11
12 Objective 10: Public Health Reporting: EHs Measure 1 Immunization Registry Measure 2 Syndromic Surveillance Measure 3 Specialized Registry Measure 4 Electronic Reportable Lab Results Measure 1 Immunization Registry Measure 2 Syndromic Surveillance Measure 3 Specialized Registry Measure 4 Electronic Reportable Lab Results ALTERNATE SPECIFICATION EHs Stage 1 An EH scheduled to be in Stage 1 in 2015 may meet only two measures to meet this objective. ALTERNATE EXCLUSION EHs Stage 2 An EH scheduled to be in Stage 2 in 2015 may take an alternate exclusion for only Measure 3. 12
13 Objective Immunization Measure and Exclusions for EPs/EHs EP/EH operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data from the provider at the start of the EHR Reporting Period. Alternate Specifications for Stage 1 EPs/EHs Public Health Reporting Measure 1 - Immunization Registry Reporting: The EP/EH is in active engagement with a public health agency to submit immunization data. Exclusions: Any EP/EH meeting one or more of the following criteria may be excluded from the measure: EP/EH does not administer any immunizations to any of the populations for which data is collected by its jurisdiction's immunization registry or immunization information system during the EHR Reporting Period; EP/EH operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required to meet the CEHRT definition at the start of the EHR Reporting Period; or Alternate Specification-EPs: EPs scheduled to be in Stage 1 in 2015 may meet the objective with only one Public Health measure. Alternate Specification-EHs: EHs scheduled to be in Stage 1 in 2015 may meet the objective with only two Public Health measures.
14 Objective Public Health Reporting Syndromic Surveillance Measure and Exclusions for EPs Measure 2 Syndromic Surveillance Reporting: The EP is in active engagement with a public health agency to submit syndromic surveillance data. Exclusions: Any EP meeting one or more of the following criteria may be excluded from the measure: The EP is not in a category of providers from which ambulatory syndromic surveillance data is collected by their jurisdiction's syndromic surveillance system; The EP operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data from EPs in the specific standards required to meet the CEHRT definition at the start of the EHR Reporting Period; or The EP operates in a jurisdiction where no public health agency has declared readiness to receive syndromic surveillance data from EPs at the start of the EHR Reporting Alternate Specification and Alternate Exclusion for EPs Alternate Specification-EPs: EPs scheduled to be in Stage 1 in 2015 may meet only one Public Health measure. Alternate Exclusion-EPs: An EP scheduled to be in Stage 2 can take an alternate exclusion for this measure if the EP did not intend to attest to two Public Health measures. This alternate exclusion only applies for PY (Based on CMS s answer to FAQ #12985.) php?faqid=12985&id=5005
15 Objective Syndromic Surveillance Measure and Exclusions for EHs Alternate Specification for EHs Public Health Reporting Measure 2 Syndromic Surveillance Reporting: The EH is in active engagement with a public health agency to submit syndromic surveillance data. Exclusions: Any EH meeting one or more of the following criteria may be excluded from the measure: The EH does not have an emergency or urgent care department; The EH operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data from EHs in the specific standards required to meet the CEHRT definition at the start of the EHR Reporting Period; or The EH operates in a jurisdiction where no public health agency has declared readiness to receive syndromic surveillance data from EHs at the start of the EHR Reporting Period. Alternate Specification-EHs: EHs scheduled to be in Stage 1 in 2015 may meet the objective with only two Public Health measures.
16 Objective Public Health Reporting Specialized Registry Measure and Exclusions for EPs Measure 3 Specialized Registry Reporting: The EP is in active engagement to submit data to a specialized registry. Exclusions: Any EP meeting at least one of the following criteria may be excluded from the measure: The EP does not diagnose or treat any disease or condition associated with, or collect relevant data that is collected by, a specialized registry in their jurisdiction during the EHR Reporting Period; The EP operates in a jurisdiction for which no specialized registry is capable of accepting electronic registry transactions in the specific standards required to meet the CEHRT definition at the start of the EHR Reporting Period; or The EP operates in a jurisdiction where no specialized registry for which the provider is eligible has declared readiness to receive electronic registry transactions at the beginning of the EHR Reporting Period. Alternate Specification and Alternate Exclusion for EPs Alternate Specification-EPs: EPs scheduled to be in Stage 1 in 2015 may meet only this measure. Alternate Exclusion-EPs: An EP scheduled to be in Stage 2 can take an alternate exclusion for this measure provided that the EP did not intend to attest to two Public Health measures. This alternate exclusion only applies for PY (Based on CMS s answer to FAQ #12985.) php?faqid=12985&id=5005
17 Objective Public Health Reporting Specialized Registry Measure and Exclusions for EHs Measure 3 Specialized Registry Reporting: The EH is in active engagement to submit data to a specialized registry. Exclusions: Any EH meeting at least one of the following criteria may be excluded from the measure: The EH does not diagnose or treat any disease or condition associated with, or collect relevant data that is collected by, a specialized registry in their jurisdiction during the EHR Reporting Period; The EH operates in a jurisdiction for which no specialized registry is capable of accepting electronic registry transactions in the specific standards required to meet the CEHRT definition at the start of the EHR Reporting Period; or The EH operates in a jurisdiction where no specialized registry for which the provider is eligible has declared readiness to receive electronic registry transactions at the beginning of the EHR Reporting Period. Alternate Specification and Alternate Exclusion for EHs Alternate Specification-EHs: EHs scheduled to be in Stage 1 in 2015 may meet the objective with only two Public Health measures. Alternate Exclusion-EHs: An EH scheduled to be in Stage 2 can take an alternate exclusion for this measure provided that the EH did not intend to attest to the Specialized Registry measure in Stage 2. This exclusion only applies for PY (Based on CMS s answer to FAQ #12985.) hp?faqid=12985&id=5005
18 Objective ERL Measure and Exclusions for EHs Alternate Specification for EHs Public Health Reporting Measure 4 Electronic Reportable Laboratory Result Reporting: The EH is in active engagement with a public health agency to submit electronic reportable laboratory results. Exclusions: Any EH meeting one or more of the following criteria may be excluded from this reporting measure: The EH does not perform or order lab tests that are reportable in its jurisdiction during the EHR reporting period; The EH operates in a jurisdiction for which no public health agency is capable of accepting the specific electronic reportable lab standards required to meet the CEHRT definition at the start of the EHR reporting period; or The EH operates in a jurisdiction where no public health agency has declared readiness to receive electronic reportable lab results from EHs at the start of the EHR reporting period. Alternate Specification-EHs: EHs scheduled to be in Stage 1 in 2015 may meet the objective with only two Public Health measures.
19 New Mexico DOH Website Register at NM DOH Website When registering, select all of the types of HL7 messages you plan to test: immunizations, syndromic surveillance, and electronic lab results (EHs only). If you ve registered for only one type, you can go back and register for other types. 19
20 Measure 1 - Immunization Registry Reporting Register at NM DOH Website If first test with DOH website fails, immediately register for the On-Boarding process. (Active Engagement Option 1) 20
21 Measure 2 Syndromic Surveillance Reporting Register at NM DOH Website If first test with DOH website fails, immediately register for the On-Boarding process. (Active Engagement Option 1) DOH confirmation should include a Syndromic Surveillance On-Boarding Guide. Work with vendor to test and resolve errors (On-Boarding process). (Active Engagement Option 2) 21
22 NM DOH Contacts Immunizations: Elizabeth Cisneros; (505) Syndromic Surveillance: Rafie McCullar; (505) Ramon Telles; (505)
23 Measure 3 Specialized Registry Reporting EPs may submit data for up to two specialized registries to meet the Public Health Objective. Data is not required to be reported in a specific format as long as it is submitted electronically and is submitted in accordance with the registry s standards. Registry must provide a signed letter confirming that data was received and on what date(s). It is the EP/EH s responsibility to ensure that data was submitted during the EHR Reporting Period. 23
24 Measure 3 Specialized Registry Reporting NM DOH does not have a specialized registry. Some Options for Specialized Registries: New Mexico Tumor Registry: Dr. Charles Wiggins (UNM) cwiggins@salud.unm.edu CDC s National Center for Health Statistics/National Health Care Surveys NCHSMUInfo@cdc.gov 24
25 Public Health Objective: Supporting Documentation Attach letter or from NM DOH supporting the Active Engagement option for each measure to which the EP attested, OR: Attach screenshot from NM DOH website- showing EP/practice s status during the EHR Reporting Period for the Active Engagement option that the EP selected for each Public Health measure: Option 1: Letter or screenshot shows registration date (date has to be within 60 days of the start of the EHR Reporting Period) Option 2: Letter or screenshot shows invitation date to begin On-Boarding process or shows testing in process Option 3: Letter or screenshot supports move to production or submission of data Save all communications and documents. The EHR Incentive Program retention period is six years. We suggest you save electronic and hard copies for audit purposes. 25
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28 New Mexico Program Contacts Program Registration: Call Option 6, then 2 EHRPROGRAMNM@xerox.com New Mexico Medicaid EHR Incentive Program Contacts Policy Questions: Valorie Vigil, Staff Manager at For Questions or to be added to our list, contact: Benjamin Rogers, Program Manager at Benjamin.rogers@state.nm.us ehr.incentives@state.nm.us 28
29 QUESTIONS??? 29
30 THANK YOU! 30
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