Connecticut Medicaid Electronic Health Record Incentive Program

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1 1. What is the Electronic Health Record (EHR) Incentive Program? The EHR incentive program was established by the Health Information Technology for Economic and Clinical Health (HITECH) Act of the American Recovery & Reinvestment Act of The program aims to transform the nation s health care system and improve the quality, safety, and efficiency of patient health care through the use of electronic health records. Effective July 13, 2010, the U.S. Department of Health Services (HHS), the Centers for Medicare & Medicaid Services (CMS) and the Office of National Coordinator (ONC) released the final rule providing the parameters and requirements for the Medicaid EHR incentive program under the HITECH Act. The Department of Social Services (DSS) is in the process of developing a system to manage incentive payments for Connecticut s eligible providers. 2. What is an Electronic Health Record? An EHR is a systematic collection of electronic health information on individual patients. EHR s are patient health records in a digital format which includes a range of data in comprehensive or summary form, such as demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal stats like age The purpose of the EHR is to collect complete records and weight, and billing information. The purpose of the EHR is to collect complete records of patient encounters and allowing the automation and streamlining of the workflow in health care settings and increasing safety through evidence-based decision support, quality management, and outcomes reporting. 3. What is a CMS EHR Certification ID? Eligible Hospitals are required to obtain a CMS EHR Certification ID using either of the following Web sites to link to the Office of the National Coordinator for Health Information Technology (ONC) at: Or at the CMS EHR Incentive Program link at: The CMS EHR Certification Number is required for attestation for the Medicaid Incentive Program. 4. What does it mean to adopt, implement, or upgrade a certified EHR system? Adopt Acquire, purchase, or install a certified EHR system. Implement Install or commence use of certified EHR technology and have started one of the following: o A training program for the certified EHR technology; o Data entry of patient demographic and administrative data into the EHR; o Establishment of data exchange agreements and a relationship between the provider s certified EHR technology and other providers (such as laboratories, pharmacies, or health information exchanges).

2 Upgrade Expand the available functionality of certified EHR technology capable of meeting meaningful use requirements at the practice site, including staffing, maintenance, and training, or upgrade from existing EHR technology to certified EHR technology per the Office of the National Coordinator (ONC) EHR certification criteria. Some examples of upgrading the existing EHR technology are the addition of clinical decision support, e-prescribing functionality, and computerized physician order entry. 5. When does the program start? Medicaid EHR Incentive programs are voluntarily offered by individual states Connecticut began accepting registrations for the CT Medicaid EHR Incentive Program in July When can I register and where do I register? CMS encourages Eligible Hospitals to start the registration process for the Medicare and Medicaid EHR Incentive Program(s) as soon as possible. CMS launched the Medicare and Medicaid EHR Incentive Program Registration and Attestation System in January Providers applying for either incentive payment program must begin by registering with the CMS EHR Incentive Program Registration and Attestation System through this site: IMPORTANT NOTE: Once registered with CMS, CMS will pass the Medicaid registration record to the state. Hospitals that select the CT Medicaid Incentive Program will have the record placed into a pending status at CMS until CT s program is able to receive the record. Once CT is able to receive the CMS record it will be matched to the hospital information in the Medicaid Management Information System (MMIS). 7. What do I need in order to register? In order to register, providers will need to have: PECOS Enrollment - All EHs must have enrollment information in PECOS to register for the EHR Incentive Programs. PECOS is the Medicare Provider Enrollment, Chain, and Ownership System and manages, tracks, and validates enrollment data for Medicare providers and suppliers. If a provider has never enrolled in PECOS, they will need to do so ( ). If a hospital enrolled in Medicare before November, 2003 and has not updated their enrollment information since then, they will also need to enroll through PECOS. If a hospital enrolled in Medicare after November, 2003 or enrolled before November 2003 and has updated its Medicare enrollment information since November 2003, no further action is required. Providers can check to see if they are enrolled in PECOS at the link provided above. CMS Identity and Access Management (I&A) User ID and Password A National Provider Identifier (NPI). Hospitals will also need a CMS Certification Number (CCN) An active web user account in the National Plan and Provider Enumeration System (NPPES). Taxpayer Identification Number (TIN) or Employer Identification Number (EIN). More information about these requirements (including PECOS and NPPES links) can be found at

3 When registering at CMS, please enter the EHR Certification Number. Although this number is not required for registering at CMS, it will be required for registration for the CT Medicaid EHR Incentives Payment Program. IMPORTANT NOTE: Once registered with CMS, CMS will pass the Medicaid registration record to the state. Hospitals that select the CT Medicaid Incentive Program will have the record placed into a pending status at CMS until CT s program is able to receive the record through the Medical Assistance Provider Incentive Repository (MAPIR). Once CT is able to receive the CMS record it will be matched to the hospital information in the Medicaid Management Information System (MMIS). More detailed information on the CMS registration can be found in the EHR Hospital Registration User Guide: 8. What is CT s Medical Assistance Provider Incentive Repository (MAPIR)? MAPIR is a web-based application that will interface with the CMS Medicare & Medicaid EHR Incentive Program Registration and Attestation System for the exchange of data regarding state selection and subsequent provider payments. MAPIR will utilize the information received from the CMS EHR system to match the provider information in the MMIS. The data that will be matched is the NPI, provider TIN, and CCN. Upon MAPIR s receipt of the CMS registration information, providers will be notified to log into MAPIR, via the secure provider web portal, to view and validate the information MAPIR has received from the CMS EHR Registration and Attestation system. For the CT Medicaid EHR Incentive Program, EHs will have to provide and attest to the following information: EHR Certification Number for the EHR Technology adopted, implemented or upgraded, Patient Volume (acute care hospitals), Data on Medicaid discharges, total discharges, Medicaid inpatient days, total inpatient days, hospital s total charges and charity care charges. The Department will utilize the hospital cost report data that is reported to the Office of Health Care Access (OHCA), to audit the information submitted in the hospital s attestation. DSS and HP will provide more detailed information as MAPIR progresses through development. 9. What do I need to do to access MAPIR when it is available? Designated individuals from the hospital will be able to access MAPIR via the secure provider portal at Each hospital will need to designate the appropriate individual(s) in the organization to apply for the CT Medicaid EHR Incentive Payment Program. Designated individuals within the hospital should contact their hospital s Master User to create a clerk account that can be used to access MAPIR via the secure provider portal.

4 In addition, each hospital will need to provide HP with its CMS Certification Number CCN (previously known as the Medicare provider number). The MMIS needs to store this information in order to match the data provided by the CMS Registration and Attestation System. Please go to the following link and fill out the information requested: The following information will be required: National Provider Identifier (NPI) Hospital Name Automated Voice Response System (AVRS) ID CMS Certification Number (CCN) This will be matched with the information provided by CMS Contact name(s) and (s) of authorized individuals attesting to adoption, implementation, or upgrading of certified EHR technology and patient volume. Contact telephone number(s) 10. How are some providers eligible for Medicaid? In order to qualify for incentives under the Medicaid EHR Incentive program, acute care hospitals must meet specific patient volume requirements. Children's hospitals are eligible but not subject to patient volume requirements. To qualify for an EHR incentive payment, Medicaid eligible hospitals must meet one of the following criteria: Be an acute care hospital, which includes Critical Access Hospitals, with at least 10% Medicaid patient volume (Last four digits of the CMS Certification Number (CCN) of the hospital falls between or ) Be a children s hospital (CCN between ) 11. What is the difference between the Medicare & Medicaid EHR Incentive programs? Medicare Implemented by the Federal Government Hospitals must successfully demonstrate meaningful use of certified EHR technology to receive incentive payments in Year 1 Medicaid Voluntary for States to implement - Connecticut is targeting July 2011 to begin accepting registrations for the CT Medicaid EHR Incentive Program Providers can qualify for an EHR incentive payment for adopting, implementing upgrading or demonstrating meaningful use of certified EHR technology in the first participation year. Required to demonstrate meaningful use of certified EHR technology in each subsequent year to qualify for further EHR payments.

5 Payment reductions begin in 2015 for providers that do not demonstrate Meaningful Use Meaningful Use definition is common for Medicare Last year a provider may initiate program is 2014; Last year to register is 2016; Payment adjustments begin in 2015 Incentive amounts are linked to the participation year and decrease year by year. Once a participant receives an incentive payment, they are locked into a payment year succession. No Medicaid payment reductions. States can adopt certain additional requirements for Meaningful Use Last year a provider may initiate program is 2016; Last year to register is 2016 Incentives can be paid for nonconsecutive participation (i.e. you can skip participation years) through 2015 for EHs. 12. How do I know if the hospital is eligible? Hospital Eligibility Information An eligible hospital for Medicaid incentive payments is an acute care hospital with at least 10% Medicaid patient volume, or a children's hospital (no Medicaid volume requirements). Acute care hospitals for the Medicaid incentive program include short term general stay hospitals where the average length of stay is 25 days or fewer and the last four digits of the CMS Certification Number (CCN) falls between or This includes some specialty hospitals, cancer hospitals, and CAHs. Children's hospitals will have a CCN between and will not be pediatric wings of larger hospitals. NOTE: Medicaid acute care hospitals that are also Medicare subsection (d) hospitals) may receive incentive payments from both Medicare and Medicaid if they meet all eligibility criteria. DSS will provide incentive payments to eligible hospitals over a 3-year period. Incentive payments to hospitals will be distributed at 50, 30 and 20% respectively. In the first year of the incentive program, the EH must demonstrate that during the payment year, it has adopted, implemented, or upgraded certified EHR technology. In the two subsequent payment years, the EH must demonstrate that it has been a meaningful user during the EHR reporting period for the applicable payment year. 13. How is patient volume calculated? A Medicaid enrolled acute care hospital must annually meet patient volume requirements. To calculate Medicaid patient volume, divide The total CT Medicaid encounters in any representative, continuous 90-day period in the preceding fiscal year; by The total encounters in the same 90-day period. For purposes of calculating hospital patient volume a Medicaid encounter means

6 Services rendered to a Medicaid FFS, Medicaid for Low Income Adults (MLIA) or HUSKY A individual per inpatient discharge where Medicaid, MLIA or HUSKY A paid for part or all of the service, or paid for part or all of the individual s premiums, co-payments and/or cost-sharing; or, Services rendered in an emergency department (ED) in any one day where Medicaid, MLIA or HUSKY A paid for part or all of the service, or paid for part or all of the individual s premiums, copayments and/or cost-sharing. EXAMPLE: The hospital is applying to the EHR Incentive Program in Federal Fiscal Year 2011 (Oct 1, 2010 Sept 30, 2011). The following is an example of a representative, consecutive 90-day period from the previous federal fiscal year April 1, 2010 June 29, FFY 2010 Medicaid FFS, MLIA, and HUSKY A Inpatient Discharges and ED Visits 2,225 Total Hospital Inpatient Discharges and ED Visits 6,725 The eligibility calculation is as follows: (Medicaid Discharges + Medicaid ED Visits) (Total Discharges + Total ED Visits) (2,225) = Medicaid Patient Volume (6,725) 33% 14. What is meaningful use? I keep hearing about it, but I don't understand what it means. Meaningful Use refers to the three main components of Meaningful Use specified by the ARRA: The use of a certified EHR in a meaningful manner, such as e-prescribing. The use of certified EHR technology for electronic exchange of health information to improve quality of health care. The use of certified EHR technology to submit clinical quality and other measures. To demonstrate meaningful use, providers need to show they are using certified EHR technology in ways that can be measured significantly in quality and in quantity. Eligible hospitals will need to demonstrate meaningful use in their second and third year of participation in the CT Medicaid incentive program in order to receive additional incentive payments. Additional information is available at the following link: In the first year of the incentive program, the EH must demonstrate that during the payment year, it has adopted, implemented, or upgraded certified EHR technology.

7 In the two subsequent payment years, the EH must demonstrate that it has been a meaningful user during the EHR reporting period for the applicable payment year. 15. How much are the incentive payments being made to hospitals? An EH may receive a Medicaid incentive payment from only one State in a payment year. The rule allows for the payment to be paid over a minimum 3-year period and maximum 6-year period. DSS has selected the 3-year period for the payments to be made. The total hospital incentive payments received over the 3 payment years of the program cannot be greater than the aggregate EHR amount. No single incentive payment for a payment year can exceed 50 percent of the aggregate EHR hospital incentive payment. And no incentive payment over a 2-year period may exceed 90 percent of the aggregate EHR hospital payment amount. No hospital may begin receiving incentive payments for any year after Fiscal Year (FY) 2016, and after FY 2016, a hospital may not receive an incentive payment unless it received an incentive payment in the prior fiscal year. Prior to FY 2016, payments can be made to eligible hospitals on a non-consecutive, annual basis for the fiscal year. Calculating the overall incentive payment is a multi-step process and utilizes hospital data on total discharges to compute a growth rate which is used to determine projected eligible discharges. A base amount of $2,000,000 is added to the eligible discharge amount and a transition factor is applied to arrive at the overall EHR amount. The overall EHR amount needs to be adjusted for charity care before Medicaid s share can be calculated. Hospitals will be required to provide and attest to the following information for the incentive payment to be calculated: Total Discharges (inpatient) for the most recent 4 fiscal years Total Number of Medicaid Inpatient Bed Days Total Charges for All Discharges Total Charges for Charity Care for all discharges 16. How is the Connecticut Medicaid incentive payment calculated? This is an example of the steps that will be followed to calculate incentive payments to eligible hospitals. MAPIR will be making these calculations based on data the hospital will enter into MAPIR at the time of registration and attestation. The aggregate EHR hospital incentive payment is calculated as the product of the [overall EHR amount] times [the Medicaid Share Calculating the overall EHR amount is a multistep process and requires the hospital to provide the following information:

8 Total Hospital Discharges (Sum of all inpatient discharges) for the most recent 4 years, Total Number of Medicaid Inpatient Bed Days (Medicaid FFS, MLIA and HUSKY A managed care patients), Medicaid discharges (Inpatient discharges for Medicaid FFS, MLIA and HUSKY A managed care patients), Hospital s total charges for all patients, and Charity Care Charges for all discharges Step 1: Calculating the Average Annual Growth Rate: To calculate the average annual growth rate the hospital will report the total discharges from the 4 most recent hospital fiscal year cost reports. Total discharges are the sum of all inpatient discharges. Fiscal Year Total Discharges Calculating Annual Growth rate Average Annual Growth Rate ,900 26,900 25,800 25,800 = 4.3% ,800 25,800 24,700 24,700 = 4.5% ,700 24,700-23,500 23,500 = 5.1% , = growth rate = = 4.6% Average Annual Growth Rate 4.6% Step 2: Apply the Average Annual Growth Rate to the Base Number of Discharges projected out over the next 3 years; The number of discharges for the Base Year of Fiscal Year 2010 is multiplied by the average annual growth rate of 4.6%.

9 Projected Inpatient Discharges Fiscal Year 2010 Fiscal Year 2011 Fiscal Year 2012 Fiscal Year , X 28, X 29,432 X ,786 Step 3: Determine the number of eligible discharges and multiply by the appropriate discharge payment amount 1. For the first through the 1,149 th discharge, $0 2. For the 1,150 th through the 23,000 th discharge, $200 per discharge 3. For any discharge greater than the 23,000 th, $0 In this example, discharges for each year were greater than both1,149 and 23,000, so the maximum number of discharges that can be counted are 21,851 (23,000 1,149) which then gets multiplied by the $200 per discharge. Fiscal Year Calculated Discharges Eligible $200 Per Discharge Eligible Discharge Payment ,900 21,851 $200 $4,370, ,137 21,851 $200 $4,370, ,432 21,851 $200 $4,370, ,786 21,851 $200 $4,370,200 Step 4: Add the Base Year Amount of $2,000,000 per payment year to the eligible discharge payment

10 Fiscal Year Base Year Amount Eligible Discharge Payment Total Eligible Payment Discharge 2010 $2,000,000 + $4,370,200 = $6,370, $2,000,000 + $4,370,200 = $6,370, $2,000,000 + $4,370,200 = $6,370, $2,000,000 + $4,370,200 = $6,370,200 Step 5: Multiply the Medicaid Transition Factor to the Eligible Discharge Payment to arrive at the Overall EHR Amount The transition factor equals 1 for year 1, ¾ for year 2, ½ for year 3 and ¼ for year 4. All four years are then added together. Total Fiscal Year Eligible Discharge Payment Medicaid Transition Factor Overall Amount EHR 2010 $ 6,370,200 X 1 = $ 6,370, $ 6,370,200 X 0.75 = $ 4,777, $ 6,370,200 X 0.5 = $ 3,185, $ 6,370,200 X 0.25 = $ 1,592,550 Total EHR Amount $ 15,925,500 Step 6: Calculate the Medicaid Share The next step requires that the Medicaid Share be applied to the total EHR amount. The Medicaid Share is the percentage of inpatient bed-days (Medicaid, MLIA and HUSKY A managed care) divided by the estimated total inpatient bed days adjusted for charity care. To calculate the Medicaid Share, the hospital

11 will need to provide the following information from the hospital fiscal year that ends during the federal fiscal year prior to the fiscal year that serves as the first payment year: Total Number of Inpatient Medicaid Bed Days Total Inpatient Days Total Charges for All Discharges Total Charity Care for All Discharges 7,000 21,000 $ 10,000,000 $ 1,300,000 Calculate the Non-Charity Care ratio by subtracting charity care from total charges for all discharges and dividing by total charges for all discharges The charity care adjustment is the percentage of the total charges that are not associated with charity care. Total charges $10,000, Charity Care $1,300,000 = $8,700,000 $8,700,000 $10,000,000 = 87% Charity Adjustment Care 87% Calculate the Medicaid Share: Medicaid Share = Medicaid Inpatient Bed-Days ( Total Inpatient Bed-Days X Charity Care Adjustment) 7,000 (21,000 X.87) = ,270 Medicaid Share 38.3% Step 7: Calculate the aggregate incentive amount. To arrive at the aggregate incentive amount multiply the overall EHR Amount of $15,925,500 by the Medicaid Share of 38.3%. $15,925,500 X.383 = $6,099,467 Total Incentive Payment Amount $6,099,467

12 This is the total Incentive Amount a hospital can receive for this example Step 8: Distribute Incentive Payments over a 3 year period: The Department will issue hospital incentive payments over a 3 year period. The following illustrates the payments in 3 consecutive years at 50, 30 and 20% respectively. The hospital would need to continue to meet the eligibility requirements and meaningful use criteria in all incentive payment years. 50% 30% 20% $3,049,734 $1,829,840 $1,219, Can I receive the maximum allowable incentive payments if they total more than the cost of purchasing my EHR system? Yes, the incentives are not based on the cost of purchasing EHR technology. As long as a hospital meets all necessary requirements for qualifying for incentive payments, they may receive the maximum allowed amount regardless of what their EHR technology or implementation costs were. 18. The Recovery Act requires the electronic exchange of health information. Is there funding to pay for connectivity between clinical practices and hospitals? Will there be federal guidance, or will this be hashed out at a local/community level? The Office of the National Coordinator has established 56 Health Information Exchange Cooperative Programs to assist States and territories' efforts to rapidly build capacity for exchanging health information across the health care system both within and across stales. These exchanges will play a critical role in facilitating the exchange capacity of clinicians, laboratories, pharmacies and hospitals, etc in their jurisdictions to help them in meeting the health information exchange requirements which are part of meaningful use. More information on ONC's Health Information Exchange grantees can be found here: home/ Are nursery days and nursery discharges (for newborns) included as acute-inpatient services in the calculation of hospital incentives for the Medicare and Medicaid EHR Incentive Programs? No, nursery days and discharges are not included in inpatient bed-day or discharge counts in calculating hospital incentives. We exclude nursery days and discharges because they are not considered acute inpatient services based on the level of care provided during a normal nursery stay. Pages and of the Stage 1 final rule preamble explain that for the Medicare calculation, the statutory language clearly restricts discharges and inpatient bed-days to those from the acute care portion of a hospital. This is because of the definition of eligible hospital in section 1886(n)(6)(B) of the Social Security Act. Page of the Stage 1 final rule explains that statutory parameters placed on Medicaid incentive payments to hospitals are largely based on the methodology applied to Medicare incentive payments.

13 Therefore, as Medicaid is held to the same parameters as Medicare, the same limitations on counting inpatient bed-days and total discharges apply to Medicaid hospital incentive calculations. To view the Stage 1 final rule for the Medicare and Medicaid EHR incentive programs, please visit: It seems that each State has the latitude to define the 12-month period from which to derive the Medicaid share data for the purposes of the Medicaid Electronic Health Record (EHR) Incentive Program. Neither the preamble nor the regulatory text of the Stage 1 final rule explicitly stipulate that the 12-month period selected by the state for the Medicaid share data needs to be in the federal fiscal year (FY_ before the hospital's FY that serves as the first payment year. Am I correct in this interpretation? In other words, a state could use two different 12-month periods to calculate the discharge-related amount and the Medicaid share? No, this is not correct. The regulation is clear that the discharge-related amount must be calculated using a 12-month period that ends in the Federal fiscal year before the hospital s fiscal year that serves as the first payment year. 42 CFR (g)(1)((i)(B). This statement also was made in the preamble, where we stated: For purposes of administrative simplicity and timeliness, we require that States use data on the hospital discharges from the hospital fiscal year that ends during the Federal fiscal year prior to the fiscal year that serves as the first payment year 75 FR In addition, the regulation indicates that the period that is used for the Medicaid share is the same period as that used for the discharge-related amount. See 42 CFR (g)(2)(i) referring to the 12-month period selected by the State. Use of the in (g)(2) indicates that this is the same 12-month period that is used under (g)(1). In addition, we believe that using different periods for the Medicaid share versus the discharge-related amount would lead to inaccurate estimates, as data would be drawn from inconsistent periods. To view the Stage 1 final rule, please visit: For calculation of a Medicaid hospital s electronic health record (EHR) incentive payment, is the estimated growth rate for hospitals most recent three years based on growth in total days or growth in discharges? (The data sources for these are different.) The average annual growth rate should be for discharges (see 1903(t)(5)(B), referring to the annual rate of growth of the most recent 3 years for discharge data. ) We agree that the sources are different. Hospitals would probably have to use MMIS or auditable hospital records to get accurate discharge data rate of growth. To view the Stage 1 final rule, please visit: What is the reporting period for eligible hospitals participating in the Medicaid Electronic Health Record (EHR) Incentive Program? For an eligible hospital or critical access hospital's first payment year, the EHR reporting period is a continuous 90-day period within a Federal fiscal year. In subsequent years (except 2014), the EHR reporting period for eligible hospitals and critical access hospitals (CAHs) is the entire Federal fiscal

14 year. In 2014, an eligible hospital or CAH can use either the entire Federal fiscal year or a 3-month period aligned with the quarters of the Federal fiscal year. 23. Are there any changes in the EHR Incentive Programs Stage 2 Rule to the base year for the Medicaid hospital incentive payment calculation? Yes. Previously Medicaid eligible hospitals calculated the base year using a 12 month period ending in the Federal fiscal year before the hospital's fiscal year that serves as the first payment year. In an effort to encourage timely participation in the program, (g)(1)(i)(B) of the Stage 2 Rule was amended to allow hospitals to use the most recent continuous 12 month period for which data are available prior to the payment year. This change went into effect upon publication of the Stage 2 Rule. Only hospitals that begin participation in the program after the publication date of the Stage 2 Rule (i.e., program years 2013 and later) will be affected by this change. Hospitals that began participation in the program prior to the Stage 2 Rule will not have to adjust previous calculations. 24. If patients are dually eligible for Medicare and Medicaid, can they be counted twice by hospitals in their calculations for incentive payment if they are applying for both Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs? For purposes of calculating the Medicaid share, a patient cannot be counted in the numerator if they would count for purposes of calculating the Medicare share. Thus, in this respect the inpatient bed day of a dually eligible patient could not be counted in the Medicaid share numerator. (See 1903(t)(5)(C), stating that the numerator of the Medicaid share does not include individuals described in section 1886(n)(2)(D)(i). ) In other respects; however, the patient would count twice. For example, in both cases, the individual would count in the total discharges of the hospital. To view the Stage 1 final rule, please visit: Can eligible hospitals round their patient volume percentage when calculating patient volume in the Medicaid Electronic Health Records (EHR) incentive program? To participate in the Medicaid EHR incentive program, acute care hospitals are required to demonstrate a patient volume of at least 10% Medicaid patients over a 90-day period in the prior fiscal year preceding the hospital's payment year or in the 12 months before attestation. Hospitals' patient volume may be rounded from 9.5% and higher to 10%. 26. Who can I contact if I still have questions? Connecticut Medicaid Electronic Health Record Incentive Program representatives are available at (toll free in-state) M F from 8 am until 5 pm or by at ctmedicaid-ehr@hp.com for further questions 27. Are there any changes in the EHR Incentive Programs Stage 2 Rule to the base year for the Medicaid hospital incentive payment calculation?

15 Yes. Previously Medicaid eligible hospitals calculated the base year using a 12 month period ending in the Federal fiscal year before the hospital's fiscal year that serves as the first payment year. In an effort to encourage timely participation in the program, (g)(1)(i)(B) of the Stage 2 Rule was amended to allow hospitals to use the most recent continuous 12 month period for which data are available prior to the payment year. This change went into effect upon publication of the Stage 2 Rule. Only hospitals that begin participation in the program after the publication date of the Stage 2 Rule (i.e., program years 2013 and later) will be affected by this change. Hospitals that began participation in the program prior to the Stage 2 Rule will not have to adjust previous calculations. 28. For meaningful use Stage 2's transitions of care and referrals objective, in what ways can I meet the second measure that requires more than 10% of the summary care records I provide for transitions of care and referrals to be electronically transmitted? An EP, eligible hospital, or CAH could use 3 distinct approaches (which could also be used in combination) to meet this measure. The first two rely solely on the use of CEHRT, while the third is slightly different. For the first two approaches, this measure can only be met if the EP, eligible hospital, or CAH uses the capabilities and standards included as part of its Certified EHR Technology (CEHRT) to electronically transmit summary care records for transitions of care and referrals (specifically those capabilities certified to the certification criterion adopted by ONC at 45 CFR (b)(2) transitions of care create and transmit transition of care/referral summaries, which specifies standards for data content and transport). For the third approach, the EP, eligible hospital, or CAH must use its CEHRT to create a summary care record for transitions of care and referrals, but instead of using a transport standard specified in ONC s certification criterion at 45 CFR (b)(2) (included as part of its CEHRT) to electronically transmit the summary care record, the EP, eligible hospital, or CAH may use a NwHIN Exchange participant to facilitate the electronic transmission to the recipient. The NwHIN Exchange is now known as ehealth Exchange and a list of participants can be found here. The following are more detailed explanations of each permitted approach. We also emphasize that regardless of the way an EP, eligible hospital, or CAH chooses to transmit the summary of care record, such a transmission will only count in the numerator if it is received by the provider to whom the sending provider is referring or transferring the patient. 1. 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. 2. 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

16 CEHRT s SOAP-based capability (natively or combined with an intermediary) would be able to count all of those transmissions in their numerator. 3. 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. We note that for this third approach, the regulation also permits an EP, eligible hospital, or CAH to count in their numerator instances where a summary care record for transitions of care or referrals was received via electronic exchange facilitated in a manner consistent with the governance mechanism ONC establishes for the nationwide health information network. ONC has not yet established a governance mechanism for the nationwide health information network. Until ONC establishes such a governance mechanism, this specific option will not be available. 29. Both the Stage 1 and Stage 2 objective and measure for protecting electronic health information created or maintained by Certified EHR Technology privacy and security contain the phrase implement security updates as necessary and correct identified security deficiencies as part of the provider's risk management process. Does this mean that all security deficiencies must be fully corrected prior to attestation? Not necessarily. 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. 30. If multiple eligible professionals or eligible hospitals contribute information to a shared portal or to a patient's online personal health record (PHR), how is it counted for meaningful use when the patient accesses the information on the portal or PHR? This answer is relevant to the following meaningful use measure: For Eligible Professionals: More than 5 percent of all unique patients seen by the eligible professional during the EHR reporting period (or their authorized representatives) view, download or transmit to a third party their health information.

17 For Eligible Hospitals and Critical Access Hospitals: More than 5 percent of all unique patients (or their authorized representatives) who are discharged from the inpatient or emergency department (Place of Service 21 or 23) of an eligible hospital or CAH view, download or transmit to a third party their information during the EHR reporting period. If an eligible professional sees a patient during the EHR reporting period, the eligible professional may count the patient in the numerator for this measure if the patient (or an authorized representative) views online, downloads, or transmits to a third party any of the health information from the shared portal or online PHR. The same would apply for an eligible hospital or CAH if a patient is discharged during the EHR reporting period. The respective eligible professional, eligible hospital, or CAH must have contributed at least some of the information identified in the Stage 2 final rule to the shared portal or online PHR for the patient. However, the respective provider need not have contributed the particular information that was viewed, downloaded, or transmitted by the patient. Although availability varies by state and geographic location, some Health Information Exchanges (HIEs) provide shared portal or PHR services. If a provider uses an HIE for these services to make information available to patients, in order to meet meaningful use requirements the provider must use an HIE that is certified as an EHR Module for that purpose. The HIE must be able to verify whether a particular provider actually contributed some of the information identified in the Stage 2 final rule to the shared portal or PHR for a particular patient. If a provider elects to use the HIE for these shared portal or PHR services, the provider must include the HIE s certification number as part of their attestation. 31. Can an eligible professional (EP) or hospital charge patients a fee to have access to the Certified Electronic Health Records (EHR) Technology solution that is used to meet the meaningful use objective of providing patients the ability to view online, download and transmit their health information? We do not believe it would be appropriate for the EP or hospital to charge the patient a fee to access the Certified EHR Technology solution regardless of whether the solution is in the form of a provider-specific portal, an online personal health record, community portal or some other solution. This is consistent with the position taken in the Stage 1 final rule (75 FR 44358) and reiterated in the Stage 2 final rule (77 FR 53999) with regard to the meaningful use objective to provide patients with clinical summaries of office visits. Access to the Certified EHR Technology solution would be provided to satisfy the requirements of the view online, download and transmit objective, rather than in response to a request from a patient. We note that the charging of fees for health information provided in response to a patient s request is governed by the HIPAA Privacy Rule. To view the Stage 1 final rule for the Medicare and Medicaid EHR incentive programs, please visit: To view the Stage 2 final rule for the Medicare and Medicaid EHR incentive programs, please visit: If an eligible hospital (EH) or critical access hospital (CAH) does not have any reportable lab results during the EHR reporting period (for example, the EH or CAH outsources all lab testing to a commercial lab or does not perform any lab tests for conditions that are reportable in their jurisdiction) can they be excluded from the requirement in the Electronic Health Records (EHR) Incentive programs to submit reportable lab results to a public health agency?

18 If an EH or CAH does not perform lab testing for conditions that are reportable, per the reporting requirements in their jurisdiction, they would not be able to submit reportable data during their normal course of their operations. Performing a test with the public health agency for Stage 1 meaningful use or attempting to establish ongoing submission for Stage 2 meaningful use would not benefit the EH/CAH or the public health agency. Therefore, the EH or CAH can be excluded from this requirement. However, if jurisdictional regulations require submission of reportable lab results from the ordering facility, the facility that ordered the lab testing, and the EH or CAH also serves as the ordering facility, then they would be required to submit reportable lab results and would not be excluded. The EH or CAH that can be excluded, for the reason state above, should indicate the following exclusion when attesting: For Stage 1: No public health agency to which the eligible hospital or CAH submits such information has the capacity to receive the information electronically For Stage 2: Operates in a jurisdiction for which no public health agency is capable of receiving electronic reportable laboratory results in the specific standards required for Certified EHR Technology at the start of their EHR reporting period. 33. If a hospital operates in a jurisdiction where a public health agency (PHA) has the ability to accept certain reportable laboratory results electronically and in the required standards, but the hospital does not generate those particular reportable laboratory results, how must the hospital attest to the core measure for Electronic Reportable Laboratory Results? If laboratory results generated by a hospital do not align with those that are defined as reportable by the PHAs with jurisdiction over the hospital, either because the laboratory results are not reportable or because the PHA does not support electronic submission of those particular results or both, the hospital can attest to the exclusion to this measure. The reasoning is based on exclusion one in Stage 2 of this objective. An eligible hospital or critical access hospital (CAH) operating in a jurisdiction for which no public health agency is capable of receiving electronic reportable laboratory results in the specific standards required for Certified Electronic Health Records (EHR) Technology at the start of the EHR reporting period may be excluded from this objective. For example, a hospital can claim an exclusion for this objective if: - The hospital conducts tests X, Y and Z and those are not reportable or not accepted electronically by any public health agencies. - There are PHAs that accept tests A, B and C, but the hospital is incapable of conducting these tests. This answer assumes the hospital is not otherwise required by law to report the lab results that are considered reportable by the PHA.. Frequently Used Acronyms AIU Adopt / Implement / Upgrade

19 ARRA American Recovery & Reinvestment Act CCN CMS Certification Number CFR Code of Federal Regulations CMS Centers for Medicare & Medicaid Services DSS CT Department of Social Services ED Emergency Department EH Eligible Hospital EHR Electronic Health Record EIN Employer s Identification Number FFS Fee-for-Service FFY Federal Fiscal Year HP Hewlett Packard Enterprise Services I&A Identification & Authentication System MAPIR Medical Assistance Provider Incentive Repository MLIA Medicaid for Low Income Adults MMIS Medicaid Management Information System NPI National Provider Identifier NPPES National Plan and Provider Enumeration System OHCA Office of Healthcare Access ONC Office of the National Coordinator TIN Tax Identification Number