Three Proposed Rules on EHRs:

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1 Three Proposed Rules on EHRs: CMS Modifications CMS Meaningful Use Stage 3 ONC s 2015 Edition Health IT (CEHRT) Lori Mihalich-Levin Mary Wheatley Ivy Baer Scott Wetzel Ethan Kendrick April 30, 2015 Slides for today s webinar can be found here: https://www.aamc.org/initiatives/patientcare/hit/

2 Three Proposed Rules from CMS & ONC Modifications comments due to CMS by June 15 MU Stage 3 comments due to CMS by May Edition Health IT comments due to ONC by May 29 2

3 Agenda Key Proposed Changes Medicare EHR Penalties/SGR Repeal Review of Stage 3 Objectives/Measures Clinical Quality Measures Certified Health IT Proposals (2015 Edition) AAMC requests feedback: CMS/ONC proposals Issues with the current requirements Use chat, raise hand, or us later 3

4 Key Proposed Changes For hospitals: align reporting period with the calendar year, rather than federal fiscal year Would start in 2015 (with 90-day reporting period) Attestation deadline would change to 2 months after end of calendar year (e.g., 2/29/16) NOTE: attestation would not be permitted until 1/1/16 (could delay hospital payments by one quarter) to get systems ready Your reactions? For hospitals & EPs: permit 90-day reporting period in 2015, instead of full year Require full year reporting period for all subsequent years Your reactions? 4

5 Who is eligible for 90-day period and when? YEAR Eligible Hospitals Eligible Professionals ALL EHs eligible for 90-day period, from 10/1/14 through 12/31/15 ALL EPs eligible for 90-day period from 1/1/15 through 12/31/15 90-day period for any EH or EP NEW to Meaningful Use; full calendar year for everyone else 90-day period for new Medicaid providers; full calendar year for everyone else 5

6 Key Proposed Changes For 2017 only: May REPEAT a year at 2016 stage OR advance to the next stage Exception: May not do Stage 3 in 2017 if using 2014 Edition CEHRT (Stage 3 requires EHR technology certified to 2015 edition) May NOT go back to an earlier stage 6

7 New Rules Change Timing of Stages 2015 Attest to modified version of Stage 2 with accommodations for Stage 1 providers 2016 Attest to modified version of Stage Attest to either modified version of Stage 2 or full version of Stage Attest to full version of Stage 3 Slide Source: CMS 7

8 Proposed Stages of Meaningful Use By Payment Year First Payment Payment Year & Stage of Meaningful Use Year for EP or Hospital Mod. 2 2 Mod. 2 or (used to require 3) Mod. 2 2 Mod. 2 or (used to require 3) Mod. 2 2 Mod. 2 or (used to require 3) Mod. 2 or Mod. 2 (was 2) , Mod. 2, or 3 (used to 3 3 Mod. 2 Mod. 2 3 (was 2) permit 2) , Mod. 2, or 3 (used to 3 3 Mod. 2 3 (was 1) permit 2) , Mod. 2, or 3 (used to (was 1) permit 1) Mod. = Modified

9 Key Proposed Changes Create single stage of MU objectives and measures (Stage 3) 8 objectives and 21 measures that align across EH, CAH, and EPs Optional in 2017 Mandatory in 2018 Note: in rule, CMS asks whether or not to provide the Stage 3 option for 2017 Eliminate topped out measures for Stages 1, 2, and 3 using two criteria: Statistically indistinguishable performance at 75 th and 99 th percentile Performance distribution curves at the 25 th, 50 th, and 75 th percentiles as compared to required measure threshold Seeking comments on topped out approach 9

10 Key Proposed Changes No more menu vs. core measures ALL required rule proposes this for Stages 1 & 2; MU Stage 3 rule proposes this for Stage 3 Flexible measure options, however, for: Coordination of Care through Patient Engagement Health Information Exchange Public Health Reporting Measure exclusions still available Paper-based formats no longer permitted for purposes of Stage 3 objectives and measures Can still use paper-based materials in practice setting (e.g. patient visit summaries) But no longer count them for MU Your reactions? 10

11 Key Proposed Changes For Stage 3, patient-authorized representatives count in numerator for patient engagement and patient electronic access measures Will continue to use attestation as the method for demonstrating MU requirements are met Hospitals eligible under both Medicare & Medicaid beginning in 2017, no longer have to attest to both (Medicaid attestation is enough) 11

12 12 Medicare EHR Penalties/ SGR Repeal

13 Medicare EHR Penalty/MIPS No modifications; existing hardship exceptions still apply For EPs: SGR Repeal Legislation will roll EHR penalties into new Merit-Based Incentive Performance System (MIPS) starting 2019 payments EHR Incentive will be worth 25% of the score No details in proposed rule For more information, please see the AAMC webinar on SGR Repeal: https://www.aamc.org/initiatives/patientcare/430180/sgrreformwebinar.html 13

14 14 Meaningful Use Stage 3 Objectives

15 Review of Objectives Some measures removed (e.g. BMI) First four objectives measures similar to Stage 2 Last four objectives significant changes Reminder: Use raise hand feature, enter question/chat, or us later Feedback on existing Stage 2 requirements Feedback on proposed changes 15

16 1: Protect Electronic Health Information Stage 2 Proposed Proposed Stage 3 Hospital, EP, CAH Conduct or review a security risk analysis in accordance with 45 CFR (a)(1) including addressing the security (to include encryption of data stored in CEHRT) and implement security updates as necessary Similar measure to Stage 2. Similar measure to Stage 2. Makes clarifications on timing and clarifies this is narrower than the HIPAA security requirement. Timing: Upon installation of CEHRT or upgrade to a new edition In subsequent years, must review the security risk analysis and make updates at least once per EHR reporting period 16

17 2: E-Prescribing Stage 2 Proposed Proposed Stage 3 EP (Core Measure): 50+% of all permissible prescriptions, or all prescriptions, written by the EP are queried for a drug formulary and transmitted electronically using CEHRT. Hospital/CAH (Menu): 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. EP Changes: Same measure for Stage 2 Alternative threshold (40+%) for 2015 Stage 1 EH/CAH Changes: Measure mandatory for Stage 2 Exclusion allowed for 2015 Stage 1 hospitals or Stage 2 hospitals that did not choose this as a menu option EP Changes: Threshold increases to 80+% Exclusions same EH/CAH Changes: Threshold increases to 25+% Only report for new or changed medications. Do not need to include refill medications Seeking comment on OTC drugs 17

18 18 3: Clinical Decision Support Stage 2 Proposed Proposed Stage 3 (Meet both measures) EP, EH, CAH must implement 5 CDS interventions related to four or more clinical quality measures at a relevant point in patient care for the entire EHR reporting period. Absent four CQM related to the EP/EH/CAH s scope of practice, the CDS interventions must be related to high-priority health conditions. It is suggested that one of the five clinical decision support interventions be related to improving healthcare efficiency. EP/EH/CAH has enabled the functionality for drug-drug and drugallergy interaction checks for the entire EHR reporting period. (Exclusion for EPs who write fewer than 100 medication orders.) No proposed changes to the measures. No proposed changes to the measures. Provides additional guidance as to the types of activities that could qualify as CDS Treatment guidelines in Million Hearts initiative Consulting on appropriate use of imaging services

19 4: Computerized Provider Order Entry Stage 2 Proposed Proposed Stage 3 (Meet 3 Measures) 60+% of medication orders are recorded using CPOE 30+% of laboratory orders are recorded using CPOE 30+% of radiology orders are recorded using CPOE For all three measures, restricted to orders created by the EP or the authorized providers in the EH/CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period. No change for Stage Alternative Measure for Stage 1: 30+% of all unique patients with at least one medication in the med list have at least one medication order entered using CPOE OR 30+% of medication orders are recorded using CPOE Provider may claim an exclusion from lab and radiology orders Changes: Expand radiology orders to include diagnostic imaging tests such as ultrasounds, MRI, and CT Increased thresholds for performance New Thresholds: 80+% of medication orders are recorded using CPOE 60+% of laboratory orders are recorded using CPOE 60+% of diagnostic imaging orders are recorded using CPOE 19

20 5: Patient Electronic Access to Health Information Stage 2 (2 Cores) Proposed Proposed Stage 3 (meet both) Measure: (EP) 50+% unique patients have access to their health information within 4 business days of its availability to EP, and can view, download and transmit to third party. (Hospital): 50+% of patients discharged from ED or inpatient have information online to view, download or transmit within 36 hrs of discharge Measure: (EP and hospital) 5+% of patients seen by EP view, download or transmit their health info to a third party Measure: (EP and hospital) Identify through CEHRT and provide patientspecific education resources to 10+% of patients Measure: (EPs) 50+% of patients have access w/in 4 business days after information is available to EP to their health information (Hospital) 50+% of patients have their info available online w/in 36 hours of discharge Measure: (EP and hospital) At least 1 patient views, downloads, or transmits his/her health info to a third party Measure: (EP and hospital) Identify through CEHRT and provide patientspecific education resources to 10+% of patients Measure 1: (EP and Hospital) for 80+% of patients: Access to view online, download and transmit health info within 24 hours of its availability to provider OR Access to ONC-certified API within 24 hours of its availability to the provider Measure 2: (EP and Hospital) Use clinically relevant information from CEHRT to identify and provide access to patient-specific educational resources for 35+% of patients 20

21 6: Coordination of Care Through Patient Engagement Stage 2 (2 Core Measures) Proposed Proposed Stage 3 (meet 2 of 3) Measure: (EP) 5+% of patients are sent a secure message using CEHRT Measure (EP): Fully enable capability for patient to send/receive a secure electronic message with the provider (yes/no attestation) Measure 1: 25+% of patients actively engage with EHR made accessible by provider (EP and hospital): 25+% of patients download or transmit their health info to a third party OR 25+% of patients access their health info through an ONCcertified API Measure 2: 35+% of patients are sent a secure message using electronic message function of the CEHRT or in response to secure message sent by patient Measure 3: For 15+% of patients incorporate patient-generated health data from non-clinical setting into CEHRT 21

22 7: Health Information Exchange Stage 2 (Core) Proposed Proposed Stage 3 (meet 2 of 3) Measure 1 (EP and hospital): summary of care when patient transitions to another care setting for 50+% of patients Measure 2: (EP and hospital): 10+% of patients for transition or referral to another setting provide summary of care electronically to recipient or by exchange facility by an organization that is a NwHIN Exchange participant Measure 3: (EP and hospital): one successful electronic exchange of summary of care with recipient who has EHR technology by different vendor; conducts one or more successful tests with CMS designated test EHR (yes/no) Measure 2 from Stage 2: must create summary of care using CEHRT and transmit electronically for 10+% of patients who transition to another setting of care or provider of care EP and hospital to provide summary of care record when patient transitions or is referred to another care setting Measure 1: 50+% create summary of care recording using CEHRT and electronically exchange summary of care record Measure 2: 40+% of new patient encounters, incorporate electronic summary of care document from a source other than the provider s EHR system into patient s EHR Measure 3: 80+% transitions or referrals for new patients, perform clinical information reconciliation See 2015 Edition: Common Clinical Data Set (CCDS) for required elements of summary of care and more 22

23 8: Public Health and Clinical Data Registry Reporting Stage 2 Proposed Proposed Stage 3 3 separate measures for hospitals: submitting electronic data to immunization registries, electronic reportable laboratory results to public health agencies, and electronic syndromic surveillance data to public health agencies. For EPs measure re: submitting electronic data to immunization registries. Consolidated public health reporting; active engagement with a Public Health Agency (PHA) or Clinical Data Registry (CDR). EPs to attest to 2 measures; hospitals to attest to 3 measures Measure 1: Bidirectional data exchange with immunization registry reporting Measure 2: Syndromic Surveillance Reporting Measure 3: Case Reporting to Public Health Agency (new option) Measure 4: Active engagement with Public Health Agency to submit data to public health registries Measure 5: Active engagement to submit data to clinical data registry Active engagement with public health agency or clinical data registry to submit electronic public health data using CEHRT. EP to pick from measures 1-5 and attest to 3. Hospital to pick from measures 1-6 and attest to 4 Same measures as for Measure 6: Hospital in active engagement with Public Health Agency to submit electronic reportable laboratory results

24 24 Clinical Quality Measures (CQMs)

25 Meaningful Use Stage 3 CQMs Takeaways: EPs and EHs can report via attestation through Starting 2018 EHR reporting period, CQMs must be reported electronically and quarterly (no attestation available) No substantial changes to the number of CQMs in the MU3 rule. Future changes will occur in the Inpatient Prospective Payment System (IPPS) and Physician Fee Schedule (PFS) rules. Hospitals must submit 16 CQMs across three National Quality Strategy (NQS) domains EPs must report 9 measures across three domains; or through approved PQRS method For more information, visit: Guidance/Legislation/EHRIncentivePrograms/index.html 25

26 Hospital MU EHR and IQR CQM Data Submission 2015 Meaningful Use (MU) EHR Incentive Program CQMs (Two Options) Inpatient Quality Reporting (IQR) E-specified Core Measures (Two Options) Attestation Electronic Report Voluntary Electronic Report Chart Abstraction Report once at the end of the EHR Reporting Period (90 or 365 days) Report once at the end of the EHR Reporting Period (90 or 365 days) Data submitted calendar quarter 1, 2, or 3 Fiscal year quarterly reporting period 26

27 Hospital MU EHR and IQR CQM Proposed Future Data Submission Meaningful Use (MU) EHR Incentive Program CQMs Inpatient Quality Reporting (IQR) E-Specified Core Measures Stage 3 Proposed Rule: Reporting changes to full calendar year starting 2017 Attestation for EHR Incentive goes away after 2017 CQM to be updated in annual IPPS and PFS proposed rules Electronically Report Submit Once Per Quarter IPPS Proposed Rule: Requires electronic submission for 2 quarters in CY 2016 as part of 2018 IQR program Confused? The vision is the rules across programs will be more aligned; but a transition needs to occur. 27

28 Other Important Information Electronic reporting, unlike attestation: Requires the most recent version of e-specifications EHR vendors must make CQM updates on an annual basis. CMS also proposes to remove the Quality Reporting Data Architecture Category III (QRDA-III) option for hospitals (under which aggregate level CQM data are submitted). CMS will continue to utilize the electronic reporting standard of QRDA-I patient-level data. 28

29 Feedback from members needed Has anyone been able to submit e-cqms? What are the barriers to e-submission? Are there any CQMs/Domains that are particularly burdensome? What other concerns do you have? 29

30 Edition Health Information Technology (Health IT) Certification Criteria, 2015 Edition Base Electronic Health Record (EHR) Definition, and ONC Health IT Certification Program Modifications

31 2015 Edition Goals Improve interoperability* Facilitate accessibility and exchange of data* ONC Health IT Certification Program CEHRT will be renamed Health IT Support EHR Incentive Programs Address health disparities* Privacy and security* Patient safety* Reliability and transparency* Certification flexibility 31 *Key proposals discussed in more detail

32 Improve Interoperability New Clinical Data Elements The Common Clinical Data Set (CCDS) includes key health data that should be exchanged using specified vocabulary standards and code sets as applicable. Patient name Sex Date of birth Race Ethnicity Preferred language Problems Smoking Status Medications Medication allergies Lab tests Lab values/results Vital signs Procedures Care team members Immunizations Unique device identifiers for implantable devices Assessment and plan of treatment Goals Health concerns ONC Interoperability Roadmap Goal Send, receive, find and use a common clinical data set to improve health and health care quality. Slide source: ONC Red = Proposed new elements= 32

33 Accessibility and Exchange Application Programming Interface (API) for the common data set Allows other programs to get or read common data elements Address Health Disparities Proposed standards Options for social, psychological, and behavioral data collection Accessibility-centered design Exchange of sensitive health information Seeking feedback on health disparity standards 33

34 Privacy and Security (P&S) P&S requirements based on function Shifts responsibility for P&S more towards the vendor HIPAA security still applies Patient safety Proposing relevant patient information to be exchanged through standard data and transactions Improving surveillance of certified health IT 34

35 Reliability and Transparency Strengthening transparency and disclosure requirements Developers to be more proactive in describing the types of limitations and additional costs that a user might pay to achieve use within the product s certification Randomized surveillance each year of 10% of certified Complete EHRs or certified Health IT Modules for patterns of non-compliance Seeking feedback on how to minimize burden, impact 35

36 Upcoming Webinars with CMS May 5 EHR Incentive Programs Proposed Rules Overview Webinar Date: Tuesday, May 5, 2015 Time: 11am 12pm ET Topics: CMS will provide a broad overview of both the Stage 3 and Modifications to Meaningful Use in 2015 through 2017 proposed rules and provide information about the comment submission process. Register: To participate, visit the registration webpage. May 7 Modifications to Meaningful Use in Overview Webinar Date: Thursday, May 7, 2015 Time: 1pm 2pm ET Topics: CMS will provide an overview of the Modifications to Meaningful Use in 2015 through 2017 proposed rule and provide information about the comment submission process. Register: To participate, visit the registration webpage. 36

37 Interested in HIT-related updates from AAMC? Join our Health IT list serv by sending a blank (leave the subject line and body blank) to (You will receive a confirmation to confirm your subscription; please respond to this e- mail as instructed in the message or your subscription will not be complete.) 37

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