1 A Beginner s Guide to Meaningful Use Stage 1 for Doctors of Optometry
2 Meaningful Use and EHRs 2 There s been a lot of talk about implementing EHRs and meaningful use in eyecare practices. But there is also a lot of confusion surrounding meaningful use. In fact, you might have heard good and bad things about the program. That s why we ve teamed up with VitalHealth Software to sort it all out and tell you everything you need to know about getting started. Some concerns about meaningful use and EHRs that you ve heard may sound like this: Productivity is bound to drop because the entire practice has to get used to the new system, when everything works just fine as is! I want to spend time seeing more patients, not more time entering large amounts of data! Getting an EHR isn t worth it! I will never be able to recover the implementation cost.
3 Meaningful Use and EHRs 3 Despite the risks and disadvantages you may have heard, meaningful use is meant to benefit your practice and your patients. The Meaningful Use Program was introduced in 2009 as part of the HITECH Act to promote the use of electronic health records (EHRs) in an effort to make healthcare more consistent, transparent, and allow for the measurement of quality of care. Electronic Health Records allow healthcare providers to record patient information electronically instead of using paper records. It also allows records to be shared across care providers. But the real key to EHRs is the ability to analyze data using the processing power of computers. This is even more powerful when performed in the cloud. Purchasing an EHR? Find out why you should choose a cloud-based solution!
4 Meaningful Use and EHRs 4 Early adopters of the Meaningful Use Program qualify for incentive payments will be the last year that a doctor can register for payments. And 2015 will be the first year of payment adjustments, which means lower reimbursements to your practice for care provided to Medicare patients. As of February 2013, $96 million has been given out to optometrists and $74 million to ophthalmologists who participated in the program. The incentive program is a great way to offset the cost of your initial EHR investment, but beyond that, meaningful use is all about increasing patient care and efficiency. So why not embrace a change for the better? More than 11,000 ODs have registered for the program. And *85% of doctors who have adopted an EHR reported satisfaction with the system. Now is the best time to start! *
5 5 Table of Contents Meaningful Use At Your Practice.. 6 Financial Incentives Stage Attestation. 22 Being Audited Planning for Meaningful Use. 30 Resources 35
6 6 Meaningful Use At Your Practice Benefits of EHRs Eligibility How Meaningful Use Works
7 Meaningful Use At Your Practice 7 Before we get started, it is important to note that the Meaningful Use Program is a project that your entire practice needs to be committed to. On top of completing the stages, you need to make sure that you follow best practices even after receiving your incentive payments. It will affect every aspect of your practice, and is essentially a change management tool. Think of it as a weight loss challenge. It s not just about losing the weight, but also keeping it off, which means making a lifestyle change. We understand that change can be hard, especially when it involves getting the entire practice on board. But we assure you that the benefits outweigh the risks, and it isn t as hard as you think! Patients expect their eyecare provider to have high-tech equipment in their practice, and they want to know that their records are safe and accurate. Show your patients that you are up-to-date. Become a thorough, more sophisticated eye care provider. You ll be able to enhance patient care, get work done easier and faster, and make more money in the long run!
8 Benefits of EHRs 8 If you are meaningfully using an EHR at your practice, you can look forward to providing better patient care as well as experiencing the following benefits: Improve communications between various systems and provide convenience for patients visiting multiple doctors.
9 Getting Started 9 Remember, meaningful use is not about purchasing or replacing an EHR. It s not enough for your practice to just own a certified EHR or simply move paper records to the computer. You have to show that you are using it in ways that can positively affect the care of your patients by meeting all of the objectives established by the Center for Medicare and Medicaid Services (CMS). The CMS defines the minimum functional requirements that EHRs must meet in order to demonstrate Meaningful Use of the technology. The CMS also oversees the providers attestation and distribution of incentives. So you think you re ready to take on meaningful use? Let s get started!
10 Meaningful Use Eligibility 10 There are two different EHR incentive programs that you could participate in: The Medicare Incentive Program and Medicaid Incentive Program. Optometrists and ophthalmologists qualify as eligible professionals. Check your eligibility. Program Differences Eligibility Medicare Incentive Program Max incentive: $44,000 Last year to receive incentives: 2014 Doctors of Optometry Ophthalmologist Optometrist Medicaid Incentive Program Max incentive: $63,750 Last year to receive incentives: 2016 Ophthalmologist and optometrist, but only if: 30% or more of your patients are Medicaid patients Your practice is in either of these states: AL, IL, KY, OH, LA, MD, MI, NJ, SC, VA Most eye doctors will only be eligible for the Medicare Incentive Program, but if you are eligible for both, you must choose the plan you would like to participate in when you register. Switching from Medicare to Medicaid and vice versa is allowed only once after the first incentive payment is initiated. We will be focusing more on the Medicare Incentive Program, but more information about the Medicaid Incentive Program can be found in the Resources page at the end of the ebook.
11 Meaningful Use: How Does it Work? 11 The EHR Incentive Program currently consists of 4 stages. Each stage will have its own set of requirements to meet in order to demonstrate meaningful use. Stage 1, 2, and 3 have been fully defined. There are 6 basic steps to how meaningful use works: 1. The government defines the program and criteria Medicare EHR Incentive Program: Run by CMS Medicaid EHR Incentive Program: Run by the state s program 2. EHR vendors implement required criteria in EHR systems 3. Third party authorized testing and certification bodies verify that EHR vendor products indeed meet the MU criteria 4. Care providers adopt a certified EHR 5. Care providers then attest to meaningful use by submitting usage reports 6. Upon successful attestation, providers receive incentive payments
13 Meaningful Financial Incentives Use 13 The Meaningful Use Program provides participating professionals with financial incentives to stimulate adoption. Incentive payments are only made to the participating optometrist and ophthalmologist. Eyecare practices cannot participate in incentive programs. You can designate a practice to receive the incentive funds on your behalf, but the practice cannot claim the money even if the EHR belongs to the practice. You can receive up to $44,000 over five consecutive years under the Medicare EHR Incentive Program. The incentive payment is 75% of your Medicare allowed charges up to a maximum annual cap. Do the math! As you will see in the table on the next page, the maximum amount you can receive in your first year is $18,000. Based on the 75% cap, you can receive: A maximum of $18,000 if you made $24,000 or more 75% of what you made, if you make less than $24,000
14 Year to Receive incentives Meaningful Medicare Payment Use 14 The amount of your incentive payment for both Medicare and Medicaid depends on when you begin participating. The table shows the incentive amounts broken down by the year you start participating in the program. Starting Year of Participation and later 2011 $18, $12,000 $18, $8,000 $12,000 $18, $4,000 $8,000 $12,000 $12, $2,000 $4,000 $8,000 $8,000 $ $2,000 $4,000 $4,000 $0 Total $44,000 $44,000 $39,000 $24,000 $0 * To get the maximum incentive payment you must have begun participation in If you do not start by 2014, you will not be eligible to receive any incentive payments.
15 Meaningful Penalties Use 15 What If I Don t Participate? If you are eligible and choose not to participate by 2015, your practice will be penalized through lower reimbursements for care provided to Medicare patients. Medicare eligible professionals who participate in the program but do not meet the requirements for meaningful use by 2015 (or in each subsequent year) are subject to payment adjustments to their Medicare reimbursements that start at 1% per year, up to a maximum 5% annual adjustment.
16 16 Stage 1 Meaningful Use Requirements Core Objectives Menu Objectives Clinical Quality Measures
17 Meaningful Stage 1: Requirements Use 17 You have to meet the following measures in Stage 1 in order to receive a payment: 15 Core Objectives Everyone who participates in the program must meet these objectives. 5 Menu Objectives You only have to report on 5 out of 10 menu objectives. You can choose objectives that is the most relevant to the workflow of your practice. Every objective has an associated measure which shows the minimum requirement needed to achieve each objective. There are also exclusions specific to each objective. If the objective does not apply to you, it still counts as having met the objective. 6 Clinical Quality Measures (CQM) These are based on calculated data. Most certified EHRs will produce a report with CQM data. All you have to do is enter the data exactly as your EHR produced it. But you will have to report on: 3 core CQMs 3 out of 38 additional CQMs
18 Meaningful Stage 1: Core Use Objectives Core Objectives: Must Report on All Computerized Provider Order Entry (CPOE) 2. Drug-drug and drug-allergy checks 3. Maintain an up-to-date problem list of current and active diagnoses 4. E-Prescribing (erx) 5. Maintain active medication list 6. Maintain active medication allergy list 7. Record demographics 8. Record and chart changes in vital signs 9. Record smoking status for patients 13 years or older 10. Report ambulatory clinical quality measures to CMS 11. Implement clinical decision support 12. Provide patients with an electronic copy of their health information, upon request 13. Provide clinical summaries for patients for each office visit 14. Capability to exchange key clinical information 15. Protect electronic health information Things to look for on CMS site: 18 Measures Exclusions Way to attest: Yes/No or percentage calculations
19 Meaningful Stage 1: Menu Use Objectives Menu Objectives: Report on Only 5 out of 10 Objectives 1. Implement drug formulary checks 2. Incorporate clinical lab-test results into EHR as structured data 3. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach 4. Send patient reminders per patient preference for preventive/follow-up care 5. Provide patients with timely electronic access to their health information 6. Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate 7. Perform medication reconciliation 8. Provide summary care record for each transition of care or referral 9. Capability to submit electronic data to immunization registries or immunization information systems and actual submission 10. Capability to submit electronic syndromic surveillance data to public health agencies and actual submission 19 ALERT! One of the 5 objectives must be 9 or 10
20 Clinical Meaningful Quality Use Measures 20 CQMs: Report on 6 (3 Core and 3 Additional) There are 3 core requirements to report: 1. Hypertension: Blood Pressure Measurement 2. Preventive Care and Screening Measure Pair: a) Tobacco Use Assessment b) Tobacco Cessation Intervention 3. Adult Weight Screening and Follow-up If the data produced by your EHR or your calculations indicates a zero for one or more of the core CQMs, then you must choose one or more alternate core CQMs from this list: 1. Weight Assessment and Counseling for Children and Adolescents 2. Preventive Care and Screening: Influenza Immunization for Patients 50 Years Old or Older 3. Childhood Immunization Status
21 Clinical Meaningful Quality Use Measures 21 Clinical Quality Measures: Report on 6 There are 3 additional requirements to report that you choose from a list of 38. But these 5 measures are the most relevant to eyecare: 1. Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation 2. Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy 3. Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care 4. Smoking and Tobacco Use Cessation, Medical Assistance: a) Advising Smokers and Tobacco Users to Quit b) Discussing Smoking and Tobacco Use Cessation Medications 5. Diabetes: Eye Exam View Full List of 38 Additional CQMs
22 22 Attestation Attesting for Stage 1 Reporting CQMs
23 Meaningful Attestation for Use Medicare 23 Stage 1 attestation is a legal statement that shows that you have met all of the requirements of the Medicare EHR Incentive Program. Note that you will have to meet requirements for 90 days in year 1 and a full year in year 2. (View details on Page 31) The process of attestation happens through the same system where you initially registered. ( During the attestation process, you will answer yes/no questions and report the percentages met on the core objectives, menu objectives, and clinical quality measures. Practice With the Attestation Calculator If you would like some practice before attesting, this calculator allows you to enter your core and menu objective information to see if you have met all of the requirements for the program.
24 Meaningful Attestation for Use Medicare 24 As soon as you submit your attestation you will immediately find out whether or not you have successfully met the core and menu objectives of the program. If you are not successful, you can edit any information that was entered incorrectly and resubmit your attestation. Or you can resubmit for a different 90-day reporting period with new information. If you are successful, the CMS will perform a number of internal checks to be sure you are eligible for payment. You should then receive your EHR incentive payment in approximately 4-8 weeks following attestation.
25 Meaningful Reporting on Use CQMs Reporting on CQMs during attestation are done differently depending on which year you begin reporting There are 2 options for CQM reporting if you are currently in the process: Attestation (As mentioned on page 23) Electronic Reporting Pilots through PQRS (Physician Quality Reporting System) Check your eligibility for PRQS Beginning in 2014, you will be required to report CQMs using the new 2014 criteria regardless of whether you are participating in Stage 1 or Stage 2 of the EHR Incentive Program. To successfully report CQMs electronically for 2014, the CMS is providing a set of electronic specifications for Clinical Quality Measures (ecqms) for electronic reporting. These electronic specifications contain multiple parts which allow certified EHR technology systems to be programmed to accurately capture, calculate, and report CQMs. 25
26 26 Being Audited Auditors How To Prepare Best Practices
27 Meaningful Being Audited Use 27 As we all know, receiving money from the government is never easy. If you re waiting for your payment check, you might be surprised to receive a letter saying you are being audited instead! We understand that you are no expert in meaningful use and you may have entered some errors unintentionally. But if you ever receive that dreaded letter or phone call, stay calm and be prepared. There are two kinds of audits: pre and post payment audits. Pre payment audits start before you receive your payment, and post payment audits might involve repayments. There is no need to panic when being audited. Here are some things about auditors you should be aware of: Many audits are triggered automatically and are not necessarily the result of suspicious activity (CMS will audit between 5% to 10% of the attestation documents it receives) Auditors are not usually experts in eyecare, so make sure you defend yourself well and are able to provide sufficient records Auditor s conclusions are often incorrect and should be challenged Assistance is available from state associations, and you should seek legal advice if necessary
28 Meaningful How To Prepare Use 28 You must be able to defend yourself when being audited, even when you believe the auditor has made a mistake. Here are some ways you can be prepared: Document everything! Especially the reason you answered yes/no during the attestation process. You should also keep all documentation for at least 5 years after attestation Send all records requested as soon as possible; do not delay compliance Do not alter any records that you send in Contact the auditor and maintain contact so you are clear of expectations they have. The vendor of your certified EHR can also provide support Audits will remain in your records and increase your chances of being audited in the next stages. It also increases the chances of other ODs who work in the same practice of being audited. So if you are being audited, notify your practice immediately
29 Meaningful Best Practices Use 29 If you did not get audited in Stage 1, don t assume that you won t be in the next stages. You should still be prepared in case it happens. These are some best practices to implement: Conduct internal audits of each doctor at your practice every 6-12 months. Commit all doctors and staff to focus on compliance. Keeping good records should not only be done in fear of being audited. It ultimately enhances patient care by facilitating communication between patients and staff, and assisting you in remembering what you did if the patient returns or has more questions.
30 30 Planning for Meaningful Use Plan for Completion Registration
31 Meaningful Getting Started Use 31 Stage 1 Reporting Time Meet the requirements and report data for a continuous 90 day period in Year 1 and a full year in Year 2 Reporting Period Meet the requirements and report data for a full year in Year 2: From January 1 to December 31 A popular option is to start on October 1 and attest in the following full calendar year after the 90 day reporting time. Submission Period Anytime immediately following the end of the 90-day reporting period, but no later than February 28 of the following calendar year.
32 Plan for Completion 32 Timeline: The table below shows when you can expect to complete all stages of meaningful use depending on when you started. Start Year Stage of Meaningful Use * TBD: Stage 4 has not been fully defined TBD TBD TBD TBD TBD TBD TRB TBD TBD TBD TBD TBD TBD TBD Participation Timeline Use this timeline to determine which year you will demonstrate Stage 1, 2, and 3 of meaningful use. It will also provide the length of time you are required to demonstrate meaningful use at each stage and the maximum incentive payment for each year you participate.
33 Table Explained 33 It will take 5 to 6 years to complete all three stages for both the Medicare and Medicaid Incentive Program. But under Medicare, the program has to be completed consecutively. Start Year Stage of Meaningful Use TBD TBD TBD TBD TBD TBD TRB TBD TBD TBD TBD TBD TBD TBD Stage 2 will only begin in So even if you have completed Stage 1 in 2011, your status will still fall under Stage 1 in Medicare: Starting Stage 1 in 2014 is the last year to receive payment ($24,000) and you ll complete the program by 2019.
34 Stage Registration 1 34 Ready to Get Started on Meaningful Use? Start by getting registered at You will need: National Provider Identifier Number National Plan and Provider Enumeration System (NPPES) account Active PECOS account: PECOS is a database of physicians who have enrolled or re-enrolled in Medicare. You must be listed or active in PECOS to participate in the EHR Incentive Program. Registering does not mean that you have to participate. You can cancel your registration at any time. By registering, you will be able to check your eligibility and other issues that could interfere with, or delay, your participation. You are allowed to let a 3 rd party, such as an office manager, to register on your behalf.
35 35 Resources Stage 1 CMS Resources Stage 2 Meaningful Use - Summary What VisionWeb Can Do For You
36 Stage 1 Stage 1 CMS Resources 36 The following are resources about Meaningful Use from the CMS site. (Links on the PDF do not open in a new tab if viewed on a browser. We recommend that you download the PDF before accessing the links.) EHR Incentive Programs Overview Eligibility Chart: Choosing a Program Comprehensive Guide to Medicare EHR Incentive Program Stage 1 Overview Core and Menu Set Objectives Core CQM Requirements Additional CQM Requirements Reporting CQMs: PQRS Eligibility (2013) and 2014 CQM Tipsheet
37 Stage 1 Stage 1 CMS Resources Continued 37 The following are resources about Meaningful Use from the CMS site. (Links on the PDF do not open in a new tab if viewed on a browser. We recommend that you download the PDF before accessing the links.) Registration Guide PECOS Attestation Guide Attestation Calculator Reporting CQMs through PQRS Electronic Specifications for Clinical Quality Measures Participation Timeline: Planning for Completion Difference between Medicare and Medicaid Program Comprehensive Guide to Medicaid EHR Incentive Program
38 Meaningful Stage 2 Meaningful Use Use 38 Most ODs who complete Stage 1 will follow through the entire meaningful use process. And we recommend that you do the same. Stage 2 will only start in 2014, but remember that you have to complete the program consecutively, so you should start preparing for the next stage as soon as you complete attestation for Stage 1. Here is a quick summary of Stage 2 requirements: 17 Core Objectives 3 Menu Objectives 12 Clinical Quality Measures (CQM) 9 out of 64 clinical quality measures 3 out of 6 additional clinical quality measures In Stage 2, you will be expected to demonstrate meaningful use for a larger portion of your patient population.
39 Stage 1 What VisionWeb Can Do For You 39 Get ready for our latest most efficient method of management solutions, and processing claims. VisionWeb presents to you UPRISE, Surprisingly Simple, and So Much More than Practice Management & EHR. VisionWeb presents to you UPRISE, a new way of looking at the eye care industry that is affordable and easy to use! Learn more about a better practice management and EHR solutions!
40 Stage Subscribe 1 to VisonWeb s Blog 40 Already Completed Stage 1 and Ready to Take the Next Step with Meaningful Use Stage 2? Subscribe to The VisionWeb blog for alerts on the next ebook! The VisionWeb Blog is also here to help you with every aspect of your practice! What you ll learn: Best practices for optical dispensing Tips to increase electronic claims processing efficiency Social media and marketing advice Latest industry trends Cloud computing updates Practice management tips Meaningful Use Advice
41 VisionWeb provides software and technology services to streamline and simplify the eyecare industry. Through our online ophthalmic product ordering and electronic claim filing solutions, our technology helps eyecare practices, laboratories, manufacturers, and payers drive out inefficiency, increase customer satisfaction, and improve their bottom line. For more information, visit VitalHealth Software was founded as a collaboration between Mayo Clinic and the Noaber Foundation, and offers the industry s leading cloud-based ehealth application development platform. Our unique, model-driven application development environment has delivered widely implemented solutions for disease management, collaborative health management and personalized health management. For more information, visit
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Meaningful Use Criteria for Eligible and Eligible Professionals (EPs) Under the Electronic Health Record (EHR) meaningful use final rules established by the Centers for Medicare and Medicaid Services (CMS),
STAGE 2 MEANINGFUL USE CORE AND MENU MEASURES FOR ELIGIBLE PROFESSIONALS CORE MEASURES must meet all CPOE for Medication, Laboratory and Radiology Orders Objective: Use computerized provider order entry
Adopting an EHR & Meaningful Use Learn how to qualify for the EHR Incentive Program The materials in this presentation, or prepared as part of this presentation, are provided for informational purposes
Meaningful Use Stage 2 Deciphered Providers Face More Stringent Requirements and Greater Challenges In 2014, the federal government will raise the bar for healthcare providers when Meaningful Use Stage
Meaningful Use Updates Stage 2 and 3 Julia Moore, Business Analyst SMC Partners, LLC July 8, 2015 Stage 2 Requirements 2015 EPs beyond 1st year of MU must report on a full year of data EPs in 1 st year
Stage 2 Final Rule Overview: Updates to Stage 1 and New Stage 2 Requirements The Centers for Medicare and Medicaid Services (CMS) issued the Stage 2 Final Rule on September 4, 2012. The Stage 2 Final Rule
Meaningful Use Stage 2 Administrator Training 1 During the call please mute your line to reduce background noise. 2 Agenda Review of the EHR Incentive Programs for Stage 2 Meaningful Use Measures and Corresponding
EHR Meaningful Use Guide for Stage I (2011) HITECH Attestation Version 2.0 Updated May/June 2014 7500 Six Forks Road, Suite 200 Raleigh, NC 27615 1.866.643.7778 email@example.com 1 Ge ng Started This
Chapter 1 Where to Begin? Auditing the Current EHR System After implementation, allow for a period of stabilization, so physicians and employees can gain more comfort using the electronic health record
Meaningful Use Rules Proposed for Electronic Health Record Incentives Under HITECH Act By: Cherilyn G. Murer, JD, CRA Introduction On December 30, 2009, The Centers for Medicare & Medicaid Services (CMS)
MEANINGFUL USE Stages 1 & 2 OVERVIEW Meaningful Use is the third step in the journey to receive funds under the CMS EHR Incentive Programs. Meaningful Use (MU) is the utilization of certified electronic
CORE OBJECTIVES (16 total) Stage 1 vs. Stage 2 Comparison Table for Eligible Hospitals and CAHs Last Updated: August, 2012 Stage 1 Objective Use CPOE for medication orders directly entered by any licensed
Meaningful Use in 2015 and Beyond Changes for Stage 2 Jennifer Boaz Transformation Support Specialist Proprietary 1 Definitions AIU = Adopt, Implement or Upgrade EP = Eligible Professional API = Application
Medicaid EHR Incentive Program Focus on Stage 2 Kim Davis-Allen, Outreach Coordinator Kim.firstname.lastname@example.org Understanding Participation Program Year Program Year January 1 st - December 31st. Year
Insight Software, LLC 3050 Universal Blvd Ste 120 Weston FL 33331-3528 Tel. 877-882-7456 www.myvisionexpress.com Meaningful Use of Certified EHR Technology with My Vision Express* Eligible Professional
This chart reflects the applicability and potential achievability of MU requirements for an anesthesiologist who: - Provides surgical anesthesia and writes fewer than 100 outpatient prescriptions per year
Office of Medical Assistance Programs Electronic Health Record (EHR) Incentive Program Stage 2 Final Rule Update Part 2 November 7, 2012 Medical Assistance HIT Initiative 1 Office of Medical Assistance
MDeverywhere, Inc. Presents 2014 CMS EHR Incentive Program Requirements: What Providers Need To Know Presented by: Kristen Heffernan Director Product Management & Marketing, Henry Schein MicroMD Agenda
The American Recovery and Reinvestment Act of 2009, Meaningful Use and the Impact on Netsmart s Public Health Clients Updated November 2011 Netsmart Note: The Health Information Technology for Economic
MEETING MEANINGFUL USE IN MICROMD -STAGE TWO- Presented by: Anna Mrvelj EMR Training Specialist 1 Proposed Rule On April 15, 2015 CMS Issued a new proposal rule for the Medicare and Medicaid EHR Incentive
Meaningful Use for Dummies: Deciphering Final meaningful use stage 2 criteria indicates stronger focus on patient engagement, HIE. Check out this chart to find out more about the meaningful use program.
MEDICAL ASSISTANCE STAGE 2 SUMMARY OVERVIEW On September 4, 2012, CMS published a final rule that specifies the Stage 2 Meaningful Use criteria that eligible professionals (EPs), eligible hospitals (EHs)
Stage 1 Meaningful Use for Specialists NYC REACH Primary Care Information Project NYC Department of Health & Mental Hygiene 1 Today s Agenda Meaningful Use Overview Meaningful Use Measures Resources Primary
Medicare & Medicaid EHR Incentive Program Meaningful Use Stage 1 Requirements Summary 2010 What are the Requirements of Stage 1 Meaningful Use? Basic Overview of Stage 1 Meaningful Use: Reporting period