Meaningful Use Stage 2

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1 Meaningful Use Stage 2 Presented by: Sarah Leake, HTS Consultant HTS, a division of Mountain Pacific Quality Health Foundation 1

2 HTS Who We Are Stage 2 MU Overview Learning Objectives 2014 CEHRT Certification Stage 2 Overview of Objectives Details - Providers Detail - Hospitals 2014 CQM reporting Payment Adjustments Hardship Exemptions Take Aways! Q&A 2

3 A division of Mountain Pacific Quality Health Foundation The Regional Extension Center for MT/WY Assist healthcare facilities with utilizing Health Information Technology (HIT) to improve health care, quality, efficiency and outcomes Expertise in HIT, Meaningful Use, PQRS, PCMH, Project Management, LEAN and HIPAA Privacy and Security 3

4 The ONC's Regional Extension Centers (RECs), serve as a support and resource center to assist providers in EHR implementation and Health IT needs. RECs "bridge the technology gap" and help providers navigate the EHR adoption process from vendor selection and workflow review to implementation and meaningful use. Find a REC in your area and get more information about how RECs can help YOU! 4

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6 Learning Objectives (for Providers & Hospitals) Administrative and eligibility requirements and changes for MU stage 2 Reporting periods Reporting submission requirements Penalties/deadlines details Software requirements for Stage 2 Identify changes between MU Stage 1 and Stage 2 objectives/cqms Identify New/Modified Objectives/CQMs for Stage 2

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8 ** CMS has announced it s intent to extend Stage 2 through 2016 and start Stage 3 in

9 2014 MU/CQM Reporting = 3 months for all providers and Hospitals* All Medicare EPs and EHs in both stage 1 and stage 2 will select a three month reporting period, fixed to the quarter of the calendar year for the reporting of their MU objectives (Medicaid reporting periods may not be tied to a calendar quarter) Medicare EPs/EHs must submit CQMs electronically *Medicare EPs using CQMs reporting for PQRS must report CQMs for full calendar year 9

10 For 2014 attestation, all must attest with new 2014 version of E.H.R, regardless of stage of MU 10

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12 Most of the Menu Measures are now Core Measures Some Measures are combined and some eliminated Thresholds have been Raised Some New Objectives, but most are in the Menu selection Exclusions can not be used if you can meet any of the menu objectives 12

13 1. Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders 2. Generate and transmit permissible prescriptions electronically (erx) 3. Record demographic information 4. Record and chart changes in vital signs 5. Record smoking status for patients 13 years old or older 6. Use clinical decision support to improve performance on high-priority health conditions 7. Provide patients the ability to view online, download and transmit their health information 8. Provide clinical summaries for patients for each office visit 9. Protect electronic health information created or maintained by the Certified EHR Technology 10. Incorporate clinical lab-test results into Certified EHR Technology 11. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach 12. Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care 13. Use certified EHR technology to identify patient-specific education resources 14. Perform medication reconciliation 15. Provide summary of care record for each transition of care or referral 16. Submit electronic data to immunization registries 17. Use secure electronic messaging to communicate with patients on relevant health information 13

14 1. Submit electronic syndromic surveillance data to public health agencies 2. Record electronic notes in patient records 3. Imaging results accessible through CEHRT 4. Record patient family health history 5. Identify and report cancer cases to a State cancer registry 6. Identify and report specific cases to a specialized registry (other than a cancer registry) 14

15 1. Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders 2. Record demographic information 3. Record and chart changes in vital signs 4. Record smoking status for patients 13 years old or older 5. Use clinical decision support to improve performance on high-priority health conditions 6. Provide patients the ability to view online, download and transmit their health information within 36 hours after discharge. 7. Protect electronic health information created or maintained by the Certified EHR Technology 8. Incorporate clinical lab-test results into Certified EHR Technology 9. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach 10. Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate 11. Perform medication reconciliation 12. Provide summary of care record for each transition of care or referral 13. Submit electronic data to immunization registries 14. Submit electronic data on reportable lab results to public health agencies 15. Submit electronic syndromic surveillance data to public health agencies 16. Automatically track medications with an electronic medication administration record (emar) 15

16 1. Record whether a patient 65 years old or older has an advance directive 2. Record electronic notes in patient records 3. Imaging results accessible through CEHRT 4. Record patient family health history 5. Generate and transmit permissible discharge prescriptions electronically (erx) 6. Provide structured electronic lab results to ambulatory providers 16

17 Objective Stage 1 Stage 2 Measure Stage 1 Measure Stage 2 Demographics Core Core >50% >80% Vital Signs Core Core >50% >80% Smoking Status Core Core >50% >80% Lab Results into EHR Menu Core >40% >55% Patient Specific Education Menu Core >10% >10% Medication Reconciliation Menu Core >50% >50% Patient List by Condition Menu Core 1 List At least 1 Eligible Professionals Only Clinical Summaries after Visit Menu Core >50% >50% Patient Reminders Menu Core >20% >20% 17

18 Stage 1 CPOE Use EHR for MEDICATION orders for >30% of unique patients. Stage 2 CPOE 3 Measures based on orders created. 60% MEDICATION orders 30% LAB orders 30% RADIOLOGY orders Scope Expanded Exclusion for EP: Any EP who writes fewer than 100 medication, radiology, or laboratory orders during the EHR reporting period. 18

19 Stage 1 Objective EP EH Measure Timely Electronic Access to Health Information Electronic Copy of Health Information Electronic Copy of Discharge Instructions Stage 1 Measures combined into One Stage 2 Core Measure View, Download and Transmit to Third Party within 4 days. (EP) View, Download and Transmit to Third Party within 36 hours. (EH) NEW Core Measure n/a Menu >10% Core >50% n/a Core >50% Stage 2 2 Measures, >50% of unique patients have information available online >5% unique patients download or transmit their information. 20

20 The following information must be available to satisfy the objective and measure: Patient Name Admit and discharge date and location. Reason for hospitalization. Care team including the attending of record as well as other providers of care. Procedures performed during admission. Current and past problem list. Current medication list and medication history. Current medication allergy list and medication allergy history. Vital signs at discharge. Laboratory test results (available at time of discharge). Summary of care record for transitions of care or referrals to another provider. Care plan field(s), including goals and instructions. Discharge instructions for patient. Demographics maintained by hospital (sex, race, ethnicity, date of birth, preferred language). Smoking status. 21

21 Exclusions: Any EP or Hospital 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 may exclude only the second measure. 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. 22

22 Stage 1 EP EH Measure Stage 2 Summary of Care record for each Transition of Care Promote use of HIE for patient care. New Requirements. Core 3 Measures >50% patients referred to another setting of care are provided a Summary of Care record >10% referrals are Electronic At least one successful test to a different EHR developer than sender or with a CMS-designated test EHR. 23

23 Measure 1: Summary of Care can be Electronic or Paper directly to provider or the patient Not counted if Provider has access to the Record in EHR System The fields MUST be present with: Current problem list, Current medication list, and Current medication allergy list Exclusion: Provider of care that transfers a patient to another setting or refers a patient to another provider <10 times during the EHR reporting period. 24

24 Measure 2: A summary of care record for more than 10% of such transitions and referrals must be sent either (a) electronically transmitted using CEHRT to a recipient or (b) where the recipient receives the summary of care record via exchange consistent with governance mechanism ONC establishes for Health Information exchange. Measure 3: Yes/No Conducts one or more successful electronic exchanges of summary of care document, as part of which is counted in "measure 2" or Conducts one or more successful tests with the CMS designated test EHR during the EHR reporting period. 25

25 Prior to 2014 Objective EP EH Measure Calculate and Transmit CMS Quality Measures Core Hospitals or CAH 15 EP - 6 CHANGE IN REPORTING From 2014 Participation Year Clinical Quality Measures are now incorporated into the definition of a meaningful user rather than part of Core Set Measures. To meet Stage 2 Meaningful Use status: 16 of 29 CQMs required for EH/CAH 9 of 64 Measures for EP More details to follow. 26

26 Stage 1 EP EH Stage 2 One Core, one Menu for EP All Core for EH 27

27 Eligible Providers, Hospitals or CAHS must attest YES to meeting one of the following criteria under the umbrella of ongoing submission: 1 Ongoing submission was already achieved for an EHR reporting period in a prior year and continues throughout the current EHR reporting period. 2 Registration with the public health agency 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. 3 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. 4 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 28

28 a) The EP or EH operations in an area where no PHA is capable of receiving in the specific E.H.R standards b) The EP or EH operates in an area where no PHA provides timely information on capability to receive. c) The EP or EH operates in an area where no PHA that is capable of accepting specific EHR standards is unable to enroll new participants at the start of E.H.R reporting period is replaced by electronic reportable lab results /immunization registries /electronic syndromic surveillance data 29

29 Immunization (EP and EH) The Provider, eligible hospital or CAH 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 Syndromic Surveillance Any eligible hospital or CAH that does not have an emergency or urgent care department. (EH only) The EP is not in a category of providers that collects ambulatory syndromic surveillance information on their patients. (EP only) 30

30 ealth/meaningfuluse/index.shtml 31

31 Registration of Intent Contacts: Electronic Laboratory Reporting (ELR) Stacey Anderson, NBS Coordinator/Epidemiologist, Montana DPHHS (direct) Syndromic Surveillance Joel Merriman, Syndromic Surveillance/HAI Coordinator, Montana DPHHS (direct) Immunizations Deb Belleau, Immunization Data Exchange Coordinator Communicable Disease Control & Prevention Bureau, DPHHS (406) Cancer Registry Laura Williamson, Epidemiologist and Program Manager (406)

32 The Wyoming Department of Health Total Health Record (THR) hopes to begin on boarding providers and hospitals for electronic submission of Immunizations and Electronic Labs by March 1, The first step to begin this process is for your vendor to complete and sign the Security Assurance Agreement and return to Linda Cramer. Provider Information: _2013.html Contact: Linda Cramer HIT Manager Wyoming Dept. of Health - Medicaid (o) (c)

33 In Stage 1, eligible professionals must conduct or review a security risk analysis in accordance with the requirements under 45 CFR (a) (1) and implement security updates as necessary and correct identified security deficiencies as part of its risk management process. In Stage 2, eligible professionals need to meet the same security risk analysis requirements as Stage 1, but must also address the encryption/security of data at rest. 34

34 A Security Risk Analysis needs to be conducted during each reporting period for Stage 1 and Stage 2 Emphasis on the need to address encryption/security of the data at rest. Show progress on Risk Management Plan Ability to produce an electronic EHR audit log for specified time and ability to sort for periodic monitoring and required action. 35

35 Objective NEW! Electronic Medication Administration Record (emar) [EH only] NEW Core! >10% Exclusion: Any hospital or CAH with an average daily inpatient census of fewer than 10 patients Secure Messaging [EP only] NEW Core! >5% Exclusion: 1) Provider has no office visits during the reporting period. 2) Broadband limitations in area of practice. 36

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37 Objective: Record electronic notes in patient records. Measure: Enter at least one electronic progress note for >30% of unique patients. The text must be searchable and may contain drawings and other content. Exclusions: None 38

38 Objective: Imaging results are accessible through Certified EHR Technology Measure: >10% of all tests whose result is one or more images ordered are accessible. Exclusions: EP - 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. EH - None Notes: No limitations on the resolution of the image. Native storage is not required by the objective and measure. Images and imaging results scanned into the CEHRT may count. 39

39 Objective: Record patient family health history as structured data. Measure >20% of all unique patients seen by the EP or Hospital during the EHR reporting period have a structured data entry for one or more first-degree relatives. Exclusions: An EP who has no office visits 40

40 Objective: Capability to identify and report cancer cases to a public health central cancer registry, except where prohibited, and in accordance with applicable law and practice. Measure: Successful ongoing submission of cancer case information from CEHRT to a public health central cancer registry for the entire EHR reporting period. Exclusions: The EP does not diagnose or directly treat cancer; PLUS (Same as the Other Public Health Measures) 41

41 Objective: Capability to identify and report specific cases to a specialized registry (other than a cancer registry), except where prohibited, and in accordance with applicable law and practice. Measure: Successful ongoing submission of specific case information from CEHRT to a specialized registry for the entire EHR reporting period. Exclusions: 1) The EP does not diagnose or directly treat any disease associated with a specialized registry sponsored by a national specialty society for which the EP is eligible, or the public health agencies in their jurisdiction; PLUS (Same as the Other Public Health Measures) 42

42 Objective: Generate and transmit permissible discharge prescriptions electronically (erx). Measure >10% of hospital discharge medication orders for permissible prescriptions (for new, changed, and refilled prescriptions) are queried for a drug formulary and transmitted electronically using certified EHR technology. Exclusions: Does not have an internal pharmacy that can accept electronic prescriptions and is not located within 10 miles of any pharmacy that accepts electronic prescriptions at the start of their EHR reporting period. 43

43 Objective: Provide structured electronic lab results to ambulatory providers. Measure: Hospital labs send structured electronic clinical lab results to the ordering provider >20% of electronic lab orders received. Exclusions: None 44

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45 EPs must meet all 17 core objectives: Core Objective Measure Stage 2 Change 1. CPOE Use CPOE for more than 60% of medication, 30% of laboratory, and 30% of radiology Up from 30% of just medication orders 2. E-Rx E-Rx for more than 50% Up from 40% 3. Demographics Record demographics for more than 80% Drug/formulary checks folded into this measure from Stage 1 menu item Up from 50% 4. Vital Signs Record vital signs for more than 80% Up from 50% 5. Smoking Status Record smoking status for more than 80% Up from 50% 46

46 EPs must meet all 17 core objectives: Core Objective Measure Stage 2 Change 6. Clinical Decision Support Implement 5 clinical decision support interventions + drug/drug and drug/allergy Up from one CDSI rule Must be linked to at least 4 Clinical Quality Measures (CQMs) 7. Labs Incorporate lab results for more than 55% 8. Patient List Generate patient list by specific condition Drug/drug and drug/allergy folded into this measure Up from 40% and no longer a menu item No longer a menu item 47

47 EPs must meet all 17 core objectives: Core Objective 9. Preventive Reminders 10. Patient Access (Provide patients the ability to view online, download and Measure Use EHR to identify and provide reminders for preventive/follow-up care for more than 10% of patients with two or more office visits in the last 2 years Provide online access to health information for more than 50% with more than 5% actually accessing Stage 2 Change No longer a menu item, but down from 20% and does not include the entire patient database No longer a menu item and up from 10% on part #1. Replaces electronic access and electronic copy of medical record. Must give URL, login/password and instruction info to patient Part #2 is new and requires patient action to meet the measure and additional software. Exclusion for providers in areas with limited 48

48 EPs must meet all 17 core objectives: Core Objective Measure Stage 2 Change 11. Visit Summaries Provide office visit summaries for more than 50% of office visits within 1 business day Down from three business days, percent is the same (50%) 12. Education Resources Use EHR to identify and provide education resources more than 10% No longer a menu item 13. Secure Messages More than 5% of patients send secure messages to their EP New for Stage 2 Requires patient action to meet the measure 14. Rx Reconciliation Medication reconciliation at more than 50% of transitions of care No longer a menu item 49

49 EPs must meet all 17 core objectives: Core Objective Measure Stage 2 Change 15. Summary of Care Provide summary of care document for more than 50% of transitions of care and referrals with 10% sent electronically and at least one sent to a recipient with a different EHR vendor or successfully testing with CMS test EHR No longer a menu item 10% sent electronically is a new requirement - at least one sent to a recipient with a different EHR vendor 16. Immunizations Successful ongoing transmission of immunization data No longer a menu item Requires more than just a test to meet this measure 17. Security Analysis Conduct or review security analysis and incorporate in risk management process 50

50 EPs must select 3 out of 6 menu objectives: Menu Objective Measure Stage 2 Change 1. Imaging Results More than 20% of imaging results are accessible through Certified EHR Technology 2. Family History Record family health history for more than 20% 3. Syndromic Surveillance Successful ongoing transmission of syndromic surveillance data New for Stage 2 New for Stage 2 Requires more than just a test to meet this measure 51

51 EPs must select 3 out of 6 menu objectives: Menu Objective Measure Stage 2 Change 4. Cancer Successful ongoing transmission of cancer case information New for Stage 2 5. Specialized Registry Successful ongoing transmission of data to a specialized registry 6. Progress Notes Enter an electronic progress note for more than 30% of unique patients New for Stage 2 (does not include cancer registry, immunization or syndromic registries) New for Stage 2 any searchable note can be dictated just not scanned 52

52 Resources on CMS EHR Incentive Program Site Stage 2 Meaningful Use Specification Sheet Table of Contents for Eligible Professionals (October 2012) ALL Stage 2 EHR Meaningful Use Specification Sheets for Eligible Professionals (October 2012) Stage 2 Overview Tipsheet (August 2012) Stage 1 vs. Stage 2 Comparison Table for Eligible Professionals (August 2012) Pocket Guide com/research/itsc/resources/2012/mu-pocket-guide pdf 53

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55 Hospitals must meet all 16 core objectives: Core Objective Measure Stage 2 Change 1. CPOE Use CPOE for more than 60% of medication, 30% of laboratory, and 30% of radiology 2. Demographics Record demographics for more than 80% 3. Vital Signs Record vital signs for more than 80%. Blood pressure for age 3 and over and ht/wt for all ages. 4. Smoking Status Record smoking status for more than 80% Up from 30% of just medication orders Up from 50% Up from 50% Up from 50% 56

56 Hospitals EPs must meet all 16 core objectives: Core Objective Measure Stage 2 Change 5. Interventions Implement 5 clinical decision support interventions + drug/drug and drug/allergy 6. Labs Incorporate lab results for more than 55% 7. Patient List Generate patient list by specific condition 8. emar emar is implemented and used for more than 10% of medication orders Up from one CDSI rule Must be linked to 4 Clinical Quality Measures (CQMs) Drug/drug and drug/allergy folded into this measure Up from 40% No longer a Menu objective No longer a Menu objective New for Stage 2 57

57 Hospitals must meet all 16 core objectives: Core Objective Measure Stage 2 Change 9. Patient Access Provide electronic copy of health information for more than 50% of patients within 36 hrs of request and more than 5% view, download or transmit their health information. 10. Education Resources Use EHR to identify and provide education resources for more than 10% of patients No Longer a Menu objective. Added 5% view, download and transmit. No Longer a Menu objective 58

58 Hospitals must meet all 16 core objectives: Core Objective Measure Stage 2 Change 11. Rx Reconciliation 12. Summary of Care Medication reconciliation at more than 50% of transitions of care Provide summary of care document for more than 50% of transitions of care and referrals. with 10% sent electronically using CEHRT or sent thru NwHIN or ONC governance mechanism No Longer a Menu objective No longer a menu item 10% sent electronically is a new requirement. 59

59 Hospitals must meet all 16 core objectives: Core Objective Measure Stage 2 Change 13. Immunizations Successful ongoing transmission of immunization data 14. Labs Successful ongoing submission of reportable laboratory results 15. Syndromic Surveillance 16. Security Analysis Successful ongoing submission of electronic syndromic surveillance data Conduct or review security analysis and incorporate in risk management process No longer a menu item Requires more than just a test to meet this measure No longer a menu item Requires more than just a test to meet this measure No longer a menu item Requires more than just a test to meet this measure Address the encryption/security of data at rest. 60

60 Hospitals must select 3 out of 6 menu objectives: Menu Objective Measure Stage 2 Change 1. Progress Notes Enter an electronic progress note for more than 30% of unique patients 2. E-Rx More than 10% electronic prescribing (erx) of discharge medication orders 3. Imaging Results More than 20% of imaging results are accessible through Certified EHR Technology New for Stage 2 New for Stage 2 New for Stage 2 61

61 Hospitals must select 3 out of 6 menu objectives: Menu Objective Measure Stage 2 Change 4. Family History Record family health history for more than 20% 5. Advanced Directives Record advanced directives for more than 50% of patients 65 years or older 6. Labs Provide structured electronic lab results to EPs for more than 20% New for Stage 2 New for Stage 2 62

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63 In 2014, EPs must report on 9 of the 64 approved CQMs Recommended core CQMs - encouraged but not required 9 CQMs for the adult population 9 CQMs for the pediatric population Selected CQMs must cover at least 3 of the National Quality Strategy domains Eligible Hospitals and CAHs must report on 16 of 29 approved CQMs Selected CQMs must cover at least 3 of the National Quality Strategy domains 64

64 Patient and Family Engagement Patient Safety Care Coordination Population and Public Health Efficient Use of Healthcare Resources Clinical Processes/Effectiveness Guidance/Legislation/EHRIncentivePrograms/Downloads/EP_MeasuresTab le_posting_cqms.pdf Guidance/Legislation/EHRIncentivePrograms/Downloads/2014_CQM_EH_ FinalRule.pdf 65

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68 *For purposes of avoiding a payment adjustment, Medicare EPs and eligible hospitals that are in their first year of demonstrating meaningful use in the year immediately preceding a payment adjustment year must submit their CQM data no later than October 1 (EPs) or July 1 (eligible hospitals) of such preceding year. 69

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71 2014 year 1 of MU (must be on 2014 version of E.H.R) To avoid 2015 Medicare penalties: Last day to start 3 month reporting period = 7/1/14 Last day of 3 month reporting period = 9/30/14 Attestation must be submitted by = 10/1/14 Will not avoid 2015 Medicare penalties Last day to start 3 month reporting period = 10/1/14 Last day of 3 month reporting period = 12/31/14 Attestation must be submitted by = 2/28/15 That s 1 day! 72

72 2014 year 1 of MU (must be on 2014 version of E.H.R) To avoid 2015 Medicare penalties (NOT CAHs): Last day to start 3 month reporting period = 4/1/14 Last day of 3 month reporting period = 6/30/14 Attestation must be submitted by = 7/1/14 Will not avoid 2015 Medicare penalties (CAHs can use these dates, and will not get penalized) Last day to start 3 month reporting period = 7/1/14 Last day of 3 month reporting period = 9/30/14 Attestation must be submitted by = 11/30/14 That s 1 day! 73

73 Payment adjustment & Hardship Exemption Tip Sheets for EPs: Guidance/Legislation/EHRIncentivePrograms/Downl oads/paymentadj_hardshipexceptipsheetforep.pdf Payment adjustment & Hardship Exemption Tip Sheets for Hospitals and CAHs Guidance/Legislation/EHRIncentivePrograms/Downl oads/paymentadj_hardshipexceptipsheetforhospit als.pdf 74

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75 Montana (2 counties) Wyoming (no counties) 76

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77 Everyone must be on a 2014 certified version for 2014 attestation, regardless of stage of MU 2014 attestation is a 3 month period tied to a quarter Electronic submission of CQMs required in 2014 (for Medicare) full year reporting if tied to PQRS Half of Stage 2 Objectives are Menu to Core and/or Increase in Threshold. Objectives emphasize patient engagement and utilizing health IT in clinical care. 78

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79 Upcoming Webinars: February 19, 1-2 pm (MDT) - HIPAA Privacy and Security March 19, 1-2 pm (MDT) - Understanding & Reporting 2014 Clinical Quality Measures for EPs and EHs 80

80 Sarah Leake Health Technology Consultant

81 Heath Technology Services EHR incentive Program Website: General Info on CQMs: Guidance/Legislation/EHRIncentivePrograms/ClinicalQualityMeasures.html CQM Tipsheet: Guidance/Legislation/EHRIncentivePrograms/Downloads/ClinicalQualityMeasuresTipsheet.pdf Payment Adjustment and Hardship tipsheet: Guidance/Legislation/EHRIncentivePrograms/Downloads/PaymentAdj_HardshipExcepTipSheetf orep.pdf Guidance/Legislation/EHRIncentivePrograms/Downloads/PaymentAdj_HardshipExcepTipsheetf orhospitals.pdf 82

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