MEANINGFUL USE STAGE 2 Summary of Proposed Rule (EP)

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1 MEANINGFUL USE STAGE 2 Summary of Proposed Rule (EP) The Meaningful Use Stage 2 Notice of Proposed Rule Making (NPRM) has been released and entered a 60-day comment period (March 7-May 6, 2012). HealthInsight has summarized the information from the NPRM in this document. The proposed start date for Stage 2 is Jan 1, 2014 for Eligible Professionals (EP) Stages of Meaningful Use Timeline 1 st Year Stage of Meaningful Use TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD Total Objectives (EPs) Stage 1 Stage 2 Eligible Professionals Eligible Professionals 15 core objectives 17 core objectives 5 of 10 menu objectives 3 of 5 menu objectives 20 total objectives 20 total objectives Objectives / Measures Stage 1 to Stage 2 Objective / Measure Computerized Physician Order Entry (CPOE) e-prescribing Demographics recorded (race, ethnicity, pref language) Stage 1 Final Minimum Requirement More than 30% of patients have a CPOE medication order if they have any med orders More than 40% of prescriptions for eligible providers More than 50% of patients Stage 2 NPRM Minimum Requirement More than 60% of medication, laboratory and radiology orders entered using CPOE Exclusion: Any EP who writes fewer than 100 medication, laboratory and radiology orders during the EHR Required for EP - More than 50% of prescriptions for eligible providers Exclusion: Any EP who writes fewer than 100 prescriptions during the EHR reporting period or does not have a pharmacy within their organization and there are no pharmacies that accept electronic prescriptions within 25 miles of the EP's practice location at the start of his/her EHR More than 80% of patients

2 Vital signs recorded More than 50% of patients over 2 Split vitals: BP is more than 80% of patients over 3; Height/Weight is more than 80% of all patients Exclusion: Any EP who sees no patients 3 years or older is excluded from recording blood pressure. Smoking status More than 50% of patients over 13 More than 80% of patients over 13 recorded Exclusion: Any EP that neither sees nor admits any patients 13 years old or older. Decision support rule Implement one clinical decision Implement 5 intervention rules + drug/drug and drug/allergy support intervention Incorporate lab results Menu option, more than 40% of Required, for more than 55% of lab results as structured data Generate list of patients by specific condition Send reminders for preventive, follow-up care Electronic copies of discharge instructions Electronic copies of Online access to lab results Menu option, one list Menu option; more than 20% of patients under 5 or over 65 More than 50% of hospital patients who request it Required, more than 50% of patients who request it Menu option, more than 10% of patients Policies: An EP may withhold information from the clinical summary if they believe substantial harm may arise from its disclosure through online access. Policies: An EP may withhold information from the clinical summary if they believe substantial harm may arise from its disclosure through an after-visit clinical summary. An EP can choose whether to offer the summary electronically or on paper by default, but at the patient's request must make the other form available. Exclusion: Any EP who orders no lab tests whose results are either in a positive/ negative or numeric format during the EHR Required Required for EPs, 10% of all patients seen in the last 24 months Exclusion: Any EP who has had no office visits in the 24 months before the EHR Replaced by dual requirement: 1) more than 50% of patients have online access within 4 business days and, 2) more than 10% of patients have used the capability to view (access), rd download or transmit to 3 party their information; includes a list of required elements, some of which are newly proposed, such as: demographic info, smoking status, care plan field with goals and instructions (see Additional Areas section for definition of care plan), additional known care team members. Maintain policies from Stage 1 on withholding potentially harmful information Exclusion: Any EP who neither orders nor creates any of the information listed for inclusion as part of this measure may exclude both measures. Any EP that conducts 50 percent or more of his or her patient encounters and any EH located in a county that does not have 50 percent or more of its housing units with 4Mbps 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. Visit summaries More than 50% of office visits Provide summary for more than 50% of office visits within 24 provided to patients within three business days hours, includes a list of required elements, some of which are newly proposed, such as: demographic info, smoking status, care plan field with goals and instructions (see Additional Areas section for definition of care plan), recommended patient decision aids, if applicable. Maintain policies from Stage 1 on withholding potentially harmful information and electronic vs. paper summary. reporting period Provide patient specific educational materials Menu option, more than 10% of patients Required, more than 10% of all patients. EHR needs to be used to ID materials, can be stored elsewhere

3 Secure messaging No requirement More than 10 % of patients have sent at least one message to EP. Medication reconciliation Summary of care record transmitted between providers at transitions in care Submit immunization data Conduct security analysis Menu option, performed for more than 50% of transitions of care visits Menu option, performed for more than 50% of transitions (can be on paper) Menu option, perform one test Conduct or review security analysis reporting period Required, more than 65% of transitions of care visits Exclusion: Any EP who was not the recipient of any transitions of care during the EHR Replaced by dual requirement: 1) for more than 65% of care transitions; 2) must be electronic for 10% (further explanation of electronic : transmit a summary of care record using Certified EHR Technology to a recipient with no organizational affiliation and using a different Certified EHR Technology vendor than the sender for more than 10% of transitions of care and referrals); includes a list of required elements, some of which are newly proposed, such as: demographic info, smoking status, care plan field with goals and instructions (see Additional Areas section for definition of care plan), additional known care team members. Exclusion: Any EP who neither transfers a patient to another setting nor refers a patient to another provider during the EHR reporting period is excluded from both measures. Required, successful ongoing submission of data Exclusions: 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 the jurisdiction's immunization registry or immunization information system during the EHR reporting period; or (2) the EP operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required or receiving electronic immunization data in the specific standards required for Certified EHR Technology at the start of their EHR reporting period. For the second scenario, there is no exclusion if an entity designated by the immunization registry can receive electronic immunization data submissions. For example, if the immunization registry cannot accept the data directly or in the version of HL7 used by the provider's Certified EHR Technology, but has designated a Health Information Exchange to do so on their behalf, the provider could not claim the 2nd exclusion previously noted. Expanded to include encryption of data at rest Ability to view images No requirement Menu option: more than 40% of all imaging results are accessible through EHR Exclusion: Any EP who does not perform diagnostic interpretation of scans or tests whose result is an image during the EHR Family history Not required Menu option: more than 20% of patients have family history recorded as structured data Submit syndromic surveillance data Menu option, perform one test Required for hospitals, menu option for EPs, successful ongoing submission of data 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 eligible hospital or CAH does not have an

4 emergency or urgent care department; or (3) the EP operates in a jurisdiction for which no public health agency is capable of accepting the specific standards required or receiving electronic syndromic surveillance data in the specific standards required by ONC for EHR certification for 2014 at the start of their EHR As was described under the immunization registry measure, the third exclusion does not apply if the public health agency has designated an HIE to collect this information on its behalf and that HIE can do so in the specific Stage 2 standards and/or the same standard as the provider's Certified EHR Technology. Submit information to Not required Menu option: successful ongoing submission to cancer registry cancer registries Exclusions: Any EP that meets at least 1 of the following criteria may be excluded from this objective: (1) The EP does not diagnose or directly treat cancer; or (2) the EP operates in a jurisdiction for which no public health agency is capable of receiving electronic cancer case information in the specific standards required under Stage 2 at the beginning of their EHR Submit information to Not required Menu option: successful ongoing submission to specialized specialized registries registry Exclusions: Any EP that meets at least 1of the following criteria may be excluded from this objective: (1) The EP does not diagnose or directly treat any disease associated with a specialized registry; or (2) the EP operates in a jurisdiction for which no registry is capable of receiving electronic specific case information in the specific standards required under Stage 2 at the beginning of their EHR Report clinical quality Core requirement with specified CQMs are no longer a meaningful use core objective, but measures measures reporting CQMs is still a requirement for meaningful use 15 measures for hospitals, 6 for EPs 24 measures for hospitals, 12 for EPs, submit electronically (final measures with final rule, but expect additional measures targeted to pediatrics, oral health, obstetrics, and behavioral health) Drug-drug and drugallergy checking Drug-formulary checking Option to submit once for both MU and PQRS Enabled No longer a stand-alone measure now combined as part of decision support Menu option No longer a stand-alone measure requirement for e-rx Incorporated as a Electronically exchange patient information Maintain medication list, problem list, and medication allergy list Perform one test More than 80% of patients have an entry or indication of none Replaced by specific requirement for transitions in care No longer stand-alone measures, must be included in the electronic record for patient access and transmitted at transitions in care. Additional Areas Covered in the Proposal General Area Care Plan definition relative to Stage 2 proposed measures Stage 2 NPRM We propose to describe a care plan as the structure used to define the management actions for the various conditions, problems, or issues. For purposes of meaningful use measurement, we propose that 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). We encourage EPs to develop the most robust care plan that is warranted by the situation. We also welcome comments on both our description of a care plan and whether a description is necessary for purpose of meaningful use.

5 EP hardship exemptions for payment adjustments Medicaid-specific changes Proposed Exemptions for payment adjustments (disincentives) on an application basis: Insufficient internet access two years prior to the payment adjustment year Newly practicing EPs for two years Extreme circumstances such as unexpected closures, natural disaster, EHR vendor going out of business, etc. Applications need to be submitted no later than July 1 of year before the payment adjustment Other Possible Exemption Discussed in NPRM Concerned that the combination of 3 barriers would constitute a significant hardship: o Lack of direct interaction with patients o Lack of need for follow-up care for patients o Lack of control over the availability of Certified EHR Technology Do not believe any one of these barriers taken independently constitutes a significant hardship Discussion as to whether any specialty may nearly uniformly face all 3 barriers Expanded definition of a Medicaid encounter: To include any encounter with an individual receiving medical assistance under 1905(b), including Medicaid expansion populations (e.g. CHIP) To permit inclusion of patients on panels seen within 24 months instead of just 12 To permit patient volume to be calculated from the most recent 12 months, instead of on the CY To include zero-pay Medicaid claims Proposed the inclusion of additional children s hospitals that do not have a CMS Certification Number (CCN) Changes Proposed to Stage 1 Objectives / Measures Objective / Measure Stage 1 Final Proposed Stage 1 Changes Computerized Physician Order Entry (CPOE) Denominator: Unique patient with at least one medication in their med list Denominator: Number of medication orders during the EHR Reporting Period Vital signs Age limits: Age 2 for Blood Pressure & Height/Weight Optional in 2013, Required in Age limits: Age 3 for Blood Pressure, no age limit for Height/Weight Test of Health Information Exchange E-Copy and Online Access Public Health Objectives Exclusion: All three elements not relevant to scope of practice One test of electronic transmission of key clinical information Objective: Provide patients with e-copy of upon request Objective: Provide electronic access to Immunizations, Reportable Labs, Syndromic Surveillance Exclusion: Allows BP to be separated from height/weight Both are Optional in 2013, Required in Requirement removed effective 2013 Replacement Objective: Provide patients the ability to view online, download and transmit their Required in Addition of except where prohibited to all three; effective 2013 Access the full Stage 2 NPRM from the federal register here: This material was prepared by HealthInsight as part of our work as the Regional Extension Center for Nevada and Utah, under grant #90RC0033/01 from the Office of the National Coordinator, Department of Health and Human Services.

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