Ready or Not, Here it Comes: Meaningful Use Audits, Appeals and Stage 3

Transcription

1 Ready or Not, Here it Comes: Meaningful Use Audits, Appeals and Stage 3 OHIO HOSPITAL ASSOCIATION ANNUAL MEETING JUNE 8, 2015 Catherine C. Costello, JD Director, CliniSyncPLUS Ohio Health Information Partnership Jim Flynn, Esq. Partner Bricker & Eckler Bryn R. Hunt, Esq. Associate General Counsel Ohio Hospital Association 1 Background Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of American Recovery and Reinvestment Act of 2009 Meaningful use is defined in statute as demonstrating that certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of health care, such as promoting care coordination. 1

2 Certified EHR Technology (CEHRT) Certified EHR Technology = technology that meets certification criteria established by the Office of National Coordinator (interoperability) 2011 criteria 2014 criteria CEHRT Flexibility Rule (9/1/14) If unable to fully implement 2014 CEHRT due to delays in availability of technology upgrades 2015 (October, 2014 for hospitals) = must use 2014 CEHRT New 2015 Criteria proposed MU Regulations 42 C.F.R : Meaningful use objectives and measures for EPs, eligible hospitals and CAHs Stage 1 Final Rule July 28, 2010 (75 Fed. Reg ) = MU criteria beg Stage 2 Final Rule Sept. 4, 2012 (77 Fed. Reg ) = MU criteria beg Stage 3 Proposed Rule Mar. 30, 2015 MU criteria beginning 2018 Proposed Rule Modifications to MU for Apr. 15,

3 Stage 1 MU Stage 1 Meaningful Use EHs 14 core criteria and 5 of 10 menu criteria EPs 15 core criteria and 5 of 10 menu criteria After two years, must move to Stage 2 BUT Early adopters (2011) = 3 years AND Those who got to Stage 2 by 2014 can remain at Stage 2 for 3 years through 2016 (or 4 years, under proposed Stage 3 rule) If Stage 1 in 2013 or 2014, note changes Stage 2 MU Stage 2 Meaningful Use EHs 16 core criteria and 3 of menu criteria EPs 17 core criteria and 3 of 6 menu criteria After two years, must move to Stage 3 BUT Stage 2 = 3 years if started in 2014 (or 4 years based on Stage 3 proposed rule) Most differences = increased percentage of use Some menu criteria now core criteria Some core criteria eliminated or incorporated into 2014 EHR technology criteria 3

4 Helpful resources Stage 1 and Stage 2 MU Criteria tip sheets CMS Stage 1 vs. Stage 2 Comparison Tables Sign up for alerts from EHR Incentive Program: Guidance/Legislation/EHRIncentivePrograms/CMS_E HR_Listserv.html MU Counting Rules Unique patients (42 CFR 495.6(c)) Considering only those patients whose records are maintained using CEHRT (i.e., sufficient data was entered in the CEHRT to allow the record to be saved and not rejected for incomplete data) Denominator and numerator counts In all other cases, use all patient records in numerator and denominator 4

5 MU Counting Rules Hospitals counting Emergency Department admits Either of two methods permitted; must select one and apply consistently to all measures Observation Services method: All patients admitted to inpatient (POS 21) either directly or through the ED All patients initially presenting to ED (POS 23) and receive observation status (including POS 22) All ED visits (POS 23 only) but include all actions taken for such patients in ED and i/p Incentive payments for: Eligibility Eligible hospitals = acute care hospitals, critical access hospitals (CAHs), children s hospitals and cancer hospitals ( subsection (d) hospitals ) Eligible professionals (EPs) = MDs, DOs, dental medicine or surgery, chiropractors, podiatrists and optometrists (but not hospital-based EPs 90%+ services in hospital or ER) For Medicaid, EPs also include nurse practitioners, certified nurse midwives, and physician assistants who work for FQHC or RHC led by PA Medicare Advantage organizations for certain affiliated EPs and eligible hospitals 5

6 Medicare and Medicaid Program Participation Medicaid must meet minimum volume requirements (10% for hospital; 30% for EPs other than pediatricians at 20%) EPs can only receive incentive payments from EITHER Medicare or Medicaid, not both; before 2015, can switch one time Hospitals can get payments from both Medicare and Medicaid Payments Incentive Payment Amounts Hospitals* $2,000,000 + ($200 per discharge for 1,150 th 23,000 th discharges) x (Medicare Share) x (Transition Factor) Medicare Share = (# of Medicare and MA inpatient days) / (Total inpatient days x [(Total charges-charity care charges) / Total charges)] Transition Factor = 100% - year 1 75% - year 2 (year 1 if 2014 first MU year) 50% - year 3 (year 1 if 2015 first MU year) 25% - year 4 * - Critical Access Hospitals = cost reimbursement 6

7 Year to Year MU Transition Factors Payment for adopting by FY % 75% 50% 25% Payment for adopting in FY % 75% 50% 25% Payment for adopting in FY % 75% 50% 25% Payment for adopting in FY % 50% 25% Payment for adopting in FY % 25% Attestations Attestation of MU On-line submission (user guide available) Core measures (must satisfy all) Menu measures (must satisfy minimum number) Clinical quality measures (required by CMS) Due within 60 days after end of reporting period Hospitals = November 30; Physicians/EPs = February 28 But, CMS has been extending these deadlines in recent years 7

8 Reporting Periods Reporting Periods Hospitals = federal fiscal year basis (i.e., Oct. 1 Sept. 30) Physicians/EPs = calendar year basis Reporting period for first year of any stage = 90 days Reporting period for subsequent years = entire year Special for 2014: all reporting periods = 90 days Special for 2015 (?) proposed to be 90 days (rule yet to be finalized) 2016 & beyond currently proposed as all full year reporting periods Exclusions and Exceptions Exclusions certain exclusions from objectives and measures may be applicable Hospitals without sufficient internet access New hospitals and new EPs EPs who lack face-to-face or telemedicine interactions EPs who practice at multiple locations and lack control over use of CEHRT for 50% or more of their patient encounters Hardship exceptions case-by-case application Due 6 months prior to applicable payment adjustment CMS desk review ; notification sent to providers; reconsideration period allowed, but no appeal 8

9 Medicare Payment Adjustment (Hospitals) Medicare payment adjustment for IPPS hospitals that are not meaningful users of certified EHR technology Began in Federal Fiscal Year 2015 Applied to ¾ of the hospital update (not for CAHs) Reduced by 25% in FY15, 50% in FY16 & 75% in FY17 (and beyond) Two year look-back: Payment Adjustment Year Full Year EHR Reporting Period Note hardship exception deadlines = between lookback year and payment adjustment year (e.g., April 1, 2015 for 2016 adjustment based on 2014 MU) Other Medicare Payment Adjustments Critical Access Hospitals Reduction in reasonable cost reimbursement in FY15 & subsequent years From current 101% to % in FY15, % in FY16 & 100% in FY2017 (and beyond) Eligible Professionals Reduction in fee schedule For 2015, 99% (98% if subject to erx adjustment) For 2016, 98% For 2017 (and beyond), 97% 9

10 Audits Any provider that successfully demonstrated meaningful use for either Medicare or Medicaid EHR Incentive Program may be subject to an audit CMS, and its contractor, Figliozzi and Company, perform audits on Medicare and dually-eligible (Medicare and Medicaid) providers who are participating in the EHR Incentive Programs States, and their contractor, perform audits on Medicaid providers participating in the Medicaid EHR Incentive Program (Ohio just started) 19 Medicare Audits Pre- and post-payment audits Target 5-10% of providers subject to pre/postpayment audits Random audits and risk profile of suspicious/anomalous data If a provider continues to exhibit suspicious/anomalous data, could be subject to successive audits 20 10

11 Medicare Audits Audit notifications sent via !!! (from Notification includes an initial documentation request list 4 weeks to respond (but can request extensions) Always respond and acknowledge receipt and establish dialogue Follow up requests if items are still needed (2 weeks to respond) Final request if still outstanding items (2 weeks) notification of final audit results from CMS 21 Audit issues Documentation to support attestation of satisfying criteria electronic or paper form Examples of criteria and measures: Criteria Stage 1 Measure Stage 2 Measure Use computerized provider order entry (CPOE) for medication orders directly entered by authorized health care professionals More than 30% of all Unique patients with at least one medication ordered with CPOE More than 60% medication orders by CPOE; more than 30% lab orders by CPOE; more than 30% radiology orders by CPOE 11

12 Audit issues (cont d.) Criteria Stage 1 Measure Stage 2 Measure Implement drug-drug and drug-allergy interaction checks Maintain an up-to-date problem list of current and active diagnoses Record patient demographic information (e.g., preferred language, gender, race, date of birth, etc.) YES/NO More than 80% of all unique patients have at least one entry or indication of problems More than 50% of all Unique patients seen have demographics recorded as structured data YES/NO Not a Stage 2 criterion More than 80% of all Unique patients seen have demographics recorded as structured data Audit issues (cont d.) Types of documentation: Screenshots from the certified EHR system Reports generated by the certified EHR system Report should show CEHRT used Should link to CEHRT attestation Should be dated during attestation period Denominator records existing record systems (paper or electronic) Yes/No Functionality verifications Other 12

13 Audit Preparation Possible Audit Preparation Steps: Develop policies and practices for documenting electronic activities (e.g., screenshots) Get the right personnel involved, engaged Clinical (CMO, CMIO?) Technology Attestation / Financial Record-keeping and documentation Audit Preparation (cont d.) Possible Audit Preparation Steps (cont d.): Certified EHR Technology compliance Security Risk Assessment compliance Complete understanding of each of the applicable Stage 1 (including 2013 and 2014 changes) and Stage 2 MU criteria, objectives and measures Attestation compliance verification process Treat errors and remediation efforts same or similar way as overpayments Record retention 6 years 13

14 Appeals Critical access hospitals can appeal cost reimbursement discrepancies through cost report appeals (PRRB) Hospitals can appeal payment calculation and reconciliation discrepancies through cost report appeals CMS audit determinations follow informal process within CMS to exhaust administrative remedies for: Failed audits (pre-payment or post-payment) Failed reporting of meaningful use due to EHR technology Clinical Quality Measures e-reporting disputes Eligibility Other Appeals (cont d.) Process for appeal = online: Guidance/Legislation/EHRIncentivePrograms/Appeals.ht ml Failure to submit the appeal form within 30 days from the date of this letter will forfeit the option to appeal. One shot appeal must include all documentation supporting appeal Surmise audit flaws from audit process more than CMS audit determination letter 28 14

15 Appeals (cont d.) Stage 2 proposed rule proposed appeal procedures, but not adopted in final rules: We recognize that there is a procedural appeals process currently in effect, and in all cases, we will require that requests for appeals, all filings, and all supporting documentation and data be submitted through a mechanism and in a manner specified by us. We expect all providers to exhaust this administrative review process prior to seeking review in Federal Court. (Cite: 77 Fed. Reg ) Stage 3 proposed rule = no changes: We believe this process is primarily procedural and does not need to be specified in regulation. (80 Fed. Reg ) Seek judicial review of adverse determinations? OIG Audits / State Medicaid Audits OIG Work Plan State audit reports Florida = correct Louisiana and Massachusetts = incorrect Other state audits ongoing (e.g., Texas, Ohio) 15

16 OIG Audits / State Medicaid Audits New OIG audits of privacy and security audits 2014 and 2015 OIG Work Plans Re-audits of Figliozzi audits, potentially Business associates, EHR cloud service providers and EHR vendors On-site audit (2-3 weeks); interviews New State Medicaid audits of hospitals and physicians (their version of Figliozzi audits, but worse?) Stage 3 Meaningful Use as Proposed Ohio Hospital Association Annual Meeting Cathy Costello, JD Director, CliniSyncPLUS Ohio Health Information Partnership June 8,

17 Status of Meaningful Use Stage 3 Rules Proposed Stage 3 rule does not cover 2015 or 2016 MU reporting. Those years are covered in the 2015 MU proposed revisions. 33 Meaningful Use Stage 2 to Stage 3 Modified Stage 2: Transition Period: 2017 No Core and Menu Measures CQMs attested to manually; chart abstractions permittedconflicts with 2015 MU proposed rule Can attest to Stage 1, Stage 2 or Stage 3, depending on vendor upgrades and measure readiness Stage 3: 2018 and Beyond All attest to full year Stage 3 No core and menu measures CQMs are submitted electronically 34 17

18 Proposed Stage 3 Meaningful Use Hospitals Move from fiscal year reporting (October 1 September 30) to calendar year reporting (January 1 December 31) effective 2017 reporting period. Last quarter of 2016 for hospitals is a non-reporting quarter ( reporting gap ) except for CQMs. This conflicts with 2015 proposed rule which has hospitals moving to calendar year reporting in 2015 (Oct., 2014 Dec. 2015) Physicians/EPs Stay on same calendar year reporting cycle. As of 2017, new EPs will have to report for a full year in their 1 st year of reporting unless they are Medicaid EPs (90 days). All functionality will need to be electronic. 35 How Meaningful Use Changes in Stage 3 Proposed rule for Stage 3 looks different than Stage 2: There will be no core and menu measures, just options for many of the 8 reporting areas ( flexible measures). All reporting will be one year (except for 1 st year Medicaid). CQMs will be reported electronically; no chart abstraction or paper based measures. Unclear whether CQMs will be part of MU reporting or only used to satisfy PQRS and IQR reporting in one submission

19 How Meaningful Use Changes in Stage 3 Must have 2015 Edition EHR in place no later than beginning of 2018 reporting period. If EP/EH completed MU incentive program participation, then still required to report to avoid penalties. Updates to MU will be published every year in Physician Fee Schedule (PFS) rule published the last quarter of the year. Hospital measures may be updated as part of the IPPS rule. 37 New/Updated Terms Common Clinical Data Set (CCDS) Application Programming Interface (API) Patient Authorized Representative Clinical Information Reconciliation (CIR) Clinically Relevant Information for customizing clinical summaries 38 19

20 Measures Removed from Attestation (2015 and Stage 3) Original measures that are removed are either topped out (i.e., standards have been widely adopted as best practices) or appear elsewhere in MU reporting and are considered redundant for reporting purposes. Topped out or Duplicative measures: o Demographics o Medications o Medication Allergies o Vital Signs o Smoking o Patient List Deleted measures still remain part of the technical certification process as to functionality: advanced directives, lab results, e-mar, electronic results, family health history, results to providers. 39 Telehealth Telehealth: Seen by EP specifically includes telehealth visits & consults where EP doesn t actually see patient (EKG reads)

21 Stage 3 Objectives Protect Patient Health Information Clinical Decision Support Patient Electronic Access to Health Information Health Information Exchange 41 Electronic Prescribing Computerized Provider Order Entry Coordination of Care Through Patient Engagement Public Health & Clinical Data Registry Reporting Protect Patient Health Information OBJECTIVE: Protect electronic protected health information (ephi) created or maintained by the certified EHR technology through the implementation of appropriate technical, administrative, and physical safeguards. MEASURE: Conduct or review a security risk analysis for each reporting year that assesses the risks & vulnerabilities to ephi created/maintained by CEHRT. Any security updates or deficiencies identified should be included in the provider s risk management process & corrected as dictated by that process

22 Protect Patient Health Information Limited to annual security risk analysis to assess if technical, administrative & physical safeguards & risk management strategies are sufficient to reduce risks to ephi. Can conduct security risk assessment outside of reporting period (if reporting period is less than 1 year), but must be completed during the reporting year and prior to attestation. Encryption required for EHR system. 43 Electronic Prescribing OBJECTIVE: EPs Must generate & transmit permissible prescriptions electronically, and EHs/CAHs must generate and transmit permissible discharge prescriptions electronically. EP MEASURE: Greater > 80% of permissible drugs written by EP queried for drug formulary & transmitted electronically. EH MEASURE: Greater > 25% of permissible discharge meds that are new or changed prescriptions queried for drug formulary & transmitted electronically. EXCLUSION: < 100 erx written during reporting period or no pharmacy accepting erx within 10 miles

23 Electronic Prescribing Can include but not required to include controlled substances prescriptions in the calculation. Over the Counter (OTC) medicine not included. Sig field for free text directions is expanded and structured. Certification requirement: Bi-directional communication with pharmacies to allow electronic communication with prescriber on prescription changes or notices about whether a prescription has been picked up. 45 Clinical Decision Support No change from Stage 2; allows expanded CDS for use of order sets, etc. OBJECTIVE: Implement clinical decision support (CDS) interventions focused on improving performance on high-priority conditions. Must meet both measures. MEASURE 1: Implement 5 decision support interventions related to 4 or more CQMs at a relevant point in patient care for entire reporting period. MEASURE 2: Implement & enable functionality for drug-drug & drug-allergy interaction checks for entire reporting period. EXCLUSION: For the 2 nd measure, any EP who writes < 100 medication orders during reporting period

24 Computerized Provider Order Entry OBJECTIVE: Use CPOE for medication, laboratory & diagnostic imaging orders. Must meet all measures. MEASURE 1: >80% of medication orders are recorded using CPOE. MEASURE 2: >60% of laboratory orders are recorded using CPOE. MEASURE 3: >60% of diagnostic orders are recorded using CPOE. EXCLUSION: EP who writes < 100 of the given type of order. No exclusions for EH. 47 Computerized Provider Order Entry Radiology CPOE now expanded to diagnostic imaging and includes: Ultrasounds CT-scans MRIs All other diagnostic imaging 48 24

25 Computerized Provider Order Entry Expansion of personnel who can enter under CPOE: o Healthcare professional o Credentialed medical assistant o Medical staff member credentialed to and performing equivalent duties of a credentialed medical assistant. The medical staff member must be credentialed by a credentialing body other than their employer and perform such duties as part of their job title. Defer to provider s discretion to determine appropriateness of credentialing of medical staff member. 49 Computerized Provider Order Entry CPOE does not include: o Paper orders entered initially into the patient record then transferred to CEHRT by other individuals at a later point in time. o Orders entered that are non-compliant with CEHRT definition, then entered at a later point in time. o Protocol or standing orders may be excluded from CPOE calculation

26 Patient Electronic Access to Health Information OBJECTIVE: Provide electronic or API access to health information and educational resources. Must meet all measures. MEASURE 1: For >80% of unique patients, patient provided access to health information within 24 hours of availability (1) Using patient portal (2) Using an ONC-certified API used by 3 rd party app or device MEASURE 2: Use CEHRT to identify patient-specific educational resources & provide electronic access to those materials >35% of unique patients. EXCLUSION: EP with no office visits. EP/EH in area with insufficient broadband. 51 Patient Authorized Representative Patients often consult with & rely on family members or caregivers to help coordinate care, understand health information and make care decisions.. Patient-authorized representatives expected to act on patient s behalf & in patient s best interest. Patient-authorized representative access included in numerator. Providers encouraged to provide access in accordance with applicable laws. Consent issues still need to be addressed

27 Measure 1: Patient Electronic Access to Health Info EH, EP provides access to information to either patient or patient authorized representative Must be posted within 24 hours of availability Patient Portal Posting Not decided if one or both required 53 API direct access to EHR patient record Application Programming Interface (API) Allows providers to enable new functionality to support data access & patient exchange outside of portal. API is set of programming protocols Enables access to data through 3 rd party application More flexible than portal If API provides VDT then portal not needed separately Not decided how CMS is going to incorporate into the regulation 54 27

28 Coordination of Care through Patient Engagement OBJECTIVE: Use communication functions of certified EHR technology to engage patients or their authorized representatives about patient care. Must meet 2 of 3 measures. MEASURE 1: >25% of unique patients either view, download or transmit health info in portal or use ONC-approved API to access info. MEASURE 2: For >35% of unique patients, a secure message is sent to patient or in response to secure message sent by patient. MEASURE 3: For >15% of unique patients, either patient-generated health data or data from a non-clinical setting is incorporated into the EHR. 55 Measure Option 1: Portal/API Use 25% patients or patient authorized representatives required at the minimum to view the data. Hospitals move away from posting within 36 hours of discharge (Stage 2) to posting within 24 hours of availability (Stage 3). EPs move from posting within 4 business days of availability (Stage 2) to posting within 24 hours of availability (Stage 3). CMS raises the issue of how the patient s viewing through use of an API is going to be able to be calculated

29 Measure Option 2: Secure Messaging Moves from patient-generated to provider generated . Can count patient-generated s but only when provider responds ; how to measure response unclear. Includes s to other care team members when the patient is engaged in the message and has the ability to be an active participant in the conversation. CMS not sure if the measure applies only to initiating provider or includes receiving provider. 57 Measure Option 3: Patient-Generated Health Data/ Non-Clinical Data Includes data from either category or both categories listed: Information received from non-clinical setting Information received from patient Means non-ep, non-eh provider who does not have access to the EP/EH s EHR Patient generates the data on own or at the direction of a care team member E.g., Nutritionists, physical therapists, occupational therapists, psychologists, home health providers E.g., Recording vital signs, activity and exercise, medication intake, nutrition Examples include social service data, advanced directives, medical device data, fitness monitoring 58 29

30 Health Information Exchange OBJECTIVE: EP/EH must: (1) Provide a summary of care record when transitioning or referring their patient to another setting of care; (2) Retrieve a summary of care record upon the first patient encounter with a new patient; and (3) Incorporate summary of care information from other providers into their EHR. Must report on all 3 measures but only required to successfully meet 2 out of 3 measures to meet this objective. 59 Measures for Health Information Exchange Need to meet 2 out of 3 measures Send a summary of care document electronically for transitions of care or referrals Validate the information received through clinical information reconciliation for new patients Incorporate an electronic summary of care document from another provider or HIE into record for new patients 60 30

31 Health Information Exchange Measure 1 MEASURE 1: For >50% of transitions of care and referrals, the provider that transitions or refers patient to another setting of care must: (1) Create a summary of care record using CEHRT; and (2) Electronically exchange the summary of care record. MEASURE 1 EXCLUSION: EP only, neither transfers or refers patient to another provider during reporting period OR insufficient broadband. EH/CAH only, insufficient broadband. 61 Common Clinical Data Set Common MU Data Set changed to Common Clinical Data Set Addition of new data items including unique device identifier (UDI) for implantable devices. Updated vocabulary code sets. Compliant w/ C-CDA 2.0 Replacement of care plan fields to eliminate confusion. Care plan clarified to mean the plan of care, goals and health concerns for a single patient encounter or inpatient stay

32 Common Clinical Data Set Updated vocabulary codes: HL7 V3 for sex CDC Code system from PHIN VADS and OMB for Race & Ethnicity RFC 5646 for preferred language Sept 2014 Release of US Edition SNOMED CT codes for problems & procedures Feb 2, 2015 monthly edition of RxNorm for Medications LOINC 2.5 for labs LOINC codes, metadata & relevant UCUM unit of measure for vital signs 63 Common Clinical Data Set (CCDS) Required elements for CCDS are: Demographics Current problem list Current medication list Current medication allergy list All other fields may be left blank if information not available and still meet the summary of care requirements

33 Measure Option 1: Summary Sent for Transitions of Care Must take place between providers that have, at the minimum, different billing identities within the EHR program (e.g., different NPIs or CCNs). Can include transitions of care and referrals where the providers already have access to the CEHRT. Access can be read only or full access to the record. Can tailor the CCDS to send only information deemed clinically relevant; must maintain all data in CEHRT in case requested in the future. 65 Health Information Exchange Measure 2 MEASURE 2: For >40% of transitions or referrals received & provider has never before encountered patient, incorporates into EHR an electronic summary of care document from another source. If provider did not receive a C-CDA for the patient then queries at least one external source via HIE functionality. MEASURE 2 EXCLUSION: EP/EH total transitions received in which provider has never before encountered patient is < 100 during reporting period

34 Measure Option 2: Incorporation of Summary of Care into Record Patient must be a new patient where the provider has never before encountered the patient. No proposed limit on when a patient is considered a new patient. Can also query the Community Health Record (CHR) via the HIE for patient summary of care. If no record found, then do not count in denominator. Summary of care document must be ingested by CEHRT system to count, not just viewed. 67 Measure Option 2 Questions: Incorporation of Summary of Care into Record This measure completes the electronic transmission loop & support providers in using EHR to support the multiple roles a provider plays in Medical Neighborhood. What does incorporate into EHR really mean? How will never before encountered patient be defined? Should receipt of data for transitions of care include alerts (e.g., patient admission; patient discharge)? 68 34

35 Health Information Exchange Measure 3 MEASURE 3: >80% of transitions or referrals received & provider has never before encountered patient the provider performs a clinical information reconciliation for following 3 clinical information sets: (1) Medication review of patient s medication including name, dosage, frequency, and route of each medication. (2) Medication allergy review of patient s known allergic medications. (3) Current problem list review of the patient s current & active diagnoses. MEASURE 3 EXCLUSION: EP/EH total transitions received in which provider has never before encountered patient is < 100 during reporting period. 69 Measure Option 3: Clinical Information Reconciliation Defined as process of creating the most accurate patient-specific information in one or more categories. Must include reconciliation for the following 3 areas: 1. Medication 2. Medication allergy 3. Current problem list 70 35

36 Measure Option 3 Questions: Clinical Information Reconciliation Does not dictate what information must be reconciled. Information determined by the provider s clinical judgment of what is most relevant to patient s care. Issues not decided: o Automatic and manual reconciliation (need to consider origin o of data) o Who can do clinical information reconciliation o Impact on workflows of specialists o Additional exclusions 71 Public Health & Clinical Data Registry Reporting OBJECTIVE: EP/EH is in active engagement with a Public Health Agency (PHA) or Clinical Data Registry (CDR) to submit electronic public health data in a meaningful way using certified EHR technology, except where prohibited, and in accordance with applicable law and practice. Active engagement demonstrated by any of following: Completed registration to submit data Testing & validation Production EPs choose from measures 1 5 Attest to any combination of 3 measures. EHs choose from measures 1 6 Attest to any combination of 4 measures

37 Public Health & Clinical Data Registry Reporting Measure Measure 1: Immunization Registry Measure 2: Syndromic Surveillance Max times count towards EP objective Max times count towards EH objective Measure 3: Case Reporting 1 1 Measure 4: Public Health Registry Reporting Measure 5: Clinical Data Registry Reporting Measure 6: Electronic Reportable Lab Results N/A 1 73 Public Health & Clinical Data Registry Reporting Exclusions do not count towards total required reporting for either EPs or EHs. If are unable to meet total required measures because the available measures are less than the number required, then can count the exclusion (i.e., must show that provider is excluded from all other measures). Stage 3 replaces the term ongoing submission with active engagement

38 Public Health & Clinical Data Registry Reporting MEASURE 1: EP/EH in active engagement with Public Health Agency to submit immunization data & receive immunization forecasts and histories from PH immunization registry. MEASURE 1 EXCLUSION: Does not administer immunizations or operates in jurisdiction where no immunization registry is available. 75 Public Health & Clinical Data Registry Reporting MEASURE 2: EP/EH is in active engagement with Public Health Agency to submit syndromic surveillance data from non-urgent care ambulatory settings for EPs, or an emergency or urgent care department for EH/CAH. MEASURE 2 EXCLUSIONS: (1) EP: does not diagnose or treat any disease/condition associated with a syndromic surveillance in their jurisdiction. (2) EH/CAH: does not have an emergency or urgent care department. (3) EP/EH: PHA is not capable of receiving electronic syndromic surveillance data in the required standard to meet CEHRT definition at beginning of reporting period. (4) EP/EH: PHA has not declared readiness to receive syndromic surveillance data from EPs at start of reporting period

39 Public Health & Clinical Data Registry Reporting MEASURE 3: EP/EH is in active engagement with Public Health Agency to submit case reporting of reportable conditions as defined by state, territorial and local Public Health Agencies to monitor disease trends & support management of outbreaks. MEASURE 3 EXCLUSIONS: (1) Does not diagnose or treat any reportable diseases for which data is collected by jurisdictions reportable disease system. (2) PHA is not capable of receiving electronic case reporting data in the required standard to meet CEHRT definition at beginning of reporting period. (3) PHA has not declared readiness to receive electronic case reporting data at start of reporting period. 77 Public Health & Clinical Data Registry Reporting MEASURE 4: EP/EH is in active engagement with Public Health Agency to submit data to public health registries. Public health registry is a registry administered to collect data for public health purposes. May report to multiple registries to meet total # of required measures for this objective. MEASURE 4 EXCLUSIONS: (1) Does not diagnose or treat any disease or condition associated with public health registry. (2) PHA is not capable of receiving electronic registry transactions in the required standard to meet CEHRT definition at beginning of reporting period. (3) PHA has not declared readiness to receive electronic retistry transactions at start of reporting period

40 Public Health & Clinical Data Registry Reporting MEASURE 5: EP/EH is in active engagement to submit data to a clinical data registry. Clinical data registry is one that records information about the health status of patients & care they receive over varying periods of time. May report to multiple registries to meet total # of required measures for this objective. MEASURES 5 EXCLUSIONS: (1) Does not diagnose or treat any disease or condition associated with clinical data registry in their jurisdiction. (2) Clinical data registry is not capable of accepting electronic registry transactions in the required standard to meet CEHRT definition at beginning of reporting period. (3) Clinical data registry has not declared readiness to receive electronic registry transactions at start of reporting period. 79 Public Health & Clinical Data Registry Reporting MEASURE 6: EH/CAH is in active engagement with a Public Health Agency to submit electronic reportable laboratory results. MEASURE 6 EXCLUSIONS: (1) Does not perform or order laboratory tests that are reportable in their jurisdiction. (2) Operates in jurisdiction for which no PHA is capable of accepting the specific ELR standards to meet CEHRT definition at beginning of reporting period. (3) Operates in jurisdiction where no PHA has declared readiness to receive ELR at start of reporting period

41 Clinical Quality Measures (CQM) Reporting Reporting ecqms (electronic submission) optional in 2017 but required in Number of CQMs to report not specified; will address CQM reporting requirements in Medicare Fee Schedule (PFS or IQR) rules each year. Requiring vendors to be certified on more than minimum number of CQMs. EH/CAH full year reporting consisting of 4 quarterly data reporting periods. 81 STAGE 3 COMMENTS Ready or Not, Here is Comes: Meaningful Use Audits, Appeals and Stage 3 Bryn Hunt, Associate General Counsel & Director of Health Policy Ohio Hospital Association 41

42 HOSPITAL CONCERNS WITH STAGE 3 The American Hospital Association took a very strong stance urging CMS not to finalize Stage 3 at this time. They asked CMS to evaluate Stage 2 first and work from those findings. The AHA also commented on each of the proposed Stage 3 measures. OHA chose not to oppose the rule in it s entirety. We focused on the issues hospital members identified as being the most problematic in the Stage 3 rule. Ohio Hospital Association CELEBRATING 100 YEARS Insert Presentation Title Insert Audience/Group June 8, OHA COMMENTS PROPOSED RULE CMS solicited comments about whether 2017 should be a year where eligible hospitals report on the blended Stage 2 measures or whether those hospitals that are ready can report using the new Stage 3 measures. COMMENT We supported the optional approach to 2017 meaningful use reporting, permitting hospitals to either attest to Stage 3 measures if ready to do so, or to defer to 2018 if they need additional time. Ohio Hospital Association CELEBRATING 100 YEARS Stage 3 Comments OHA Annual Meeting June 8,

43 OHA COMMENTS PROPOSED RULE The Proposed Rule provided that beginning in CY 2017, hospital reporting would shift from the federal fiscal year to the calendar year. COMMENT We supported the proposed change in eligible hospital reporting from the federal fiscal year to the calendar year beginning in 2016 so long as the additional quarter to demonstrate meaningful use in 2015 remains. Ohio Hospital Association CELEBRATING 100 YEARS Stage 3 Comments OHA Annual Meeting June 8, OHA COMMENTS PROPOSED RULE The Stage 3 Proposed Rule stated that the attestation window would be January-February after each calendar year. COMMENT We suggested an additional month, through March each year, to complete the attestations. Ohio Hospital Association CELEBRATING 100 YEARS Stage 3 Comments OHA Annual Meeting June 8,

44 OHA COMMENTS PROPOSED RULE The Stage 3 Proposed Rule required eligible hospitals to implement 5 clinical decision support interventions related to 4 or more Clinical Quality Measures (CQMs). COMMENT We suggested additional hospital CQMs be developed to include more options focused on high priority health conditions applicable to children. Ohio Hospital Association CELEBRATING 100 YEARS Stage 3 Comments OHA Annual Meeting June 8, OHA COMMENTS PROPOSED RULE The Stage 3 Proposed Rule introduced an additional functionality for patient access known as application-program interfaces (APIs). The Proposed Rule requested comments on the use of API technology as an alternative to the patient portal, and whether its use should be mandatory or optional in Stage 3. COMMENT We recommended delaying the use of APIs until the technology is further developed in the market. Alternatively, if kept in the rule, we suggested that API use should be optional and should be allowed to be aggregated with the patient portal totals when calculating the numerator and denominator for this measure. Ohio Hospital Association CELEBRATING 100 YEARS Stage 3 Comments OHA Annual Meeting June 8,

45 OHA COMMENTS PROPOSED RULE As a patient engagement option, the Proposed Rule required that 25% of patients discharged from an eligible hospital view, download or transmit their health information through a patient portal or access such information through an API. COMMENT We recommended that the portal measure for view, download and transmit be kept at the threshold of 5% and the option for APIs be removed. Ohio Hospital Association CELEBRATING 100 YEARS Stage 3 Comments OHA Annual Meeting June 8, OHA COMMENTS PROPOSED RULE The Proposed Rule required that the eligible hospital communicate with the patient through secure messaging for more than 35% of the unique patients seen by the provider during the reporting period. COMMENT We suggested that the threshold be lowered to 5% to allow hospitals time to develop workflows for incorporating secure messaging into the care setting in a way that is meaningful for both the provider and the patient. Ohio Hospital Association CELEBRATING 100 YEARS Stage 3 Comments OHA Annual Meeting June 8,

46 OHA COMMENTS PROPOSED RULE The Proposed Rule required that eligible hospitals incorporate patient-generated health data or data obtained from a non-clinical setting into the patient s electronic health record for more than 15% of unique patients seen during the EHR reporting period. COMMENT PATIENT- GENERATED HEALTH DATA We recommended that this measure be offered as a 4th option in the patient engagement objective as a functionality measure, with the requirement that 2 out of 4 measures be fulfilled to meet the objective. OHA also recommended that if patient-generated health data is included as part of Stage 3, then the measure should only apply to patients whose care management is being supported by equipment selected by the provider and verified as to accuracy. Ohio Hospital Association CELEBRATING 100 YEARS Stage 3 Comments OHA Annual Meeting June 8, OHA COMMENTS PROPOSED RULE The Proposed Rule required that eligible hospitals incorporate patient-generated health data or data obtained from a non-clinical setting into the patient s electronic health record for more than 15% of unique patients seen during the EHR reporting period. COMMENT NON-CLINICAL DATA We recommended that this information be labeled supplementary clinical data and be captured in a structured setting such as through a C-CDA document retrievable through the community health record of the health information exchange (HIE) or the electronic referral of information via Direct Exchange. OHA also suggested that the measure should be a functionality measure rather than a threshold measure which would allow hospitals time to get accustomed to integrating this type of data into the EHR. Ohio Hospital Association CELEBRATING 100 YEARS Stage 3 Comments OHA Annual Meeting June 8,

47 OHA COMMENTS PROPOSED RULE The Proposed Rule required that for more than 50% of transitions of care and referrals, the eligible hospital that transitions or refers their patient to another setting or provider of care create a summary of care record using CEHRT and electronically exchange the summary of care record. COMMENT We suggested the electronic transitions of care measure be set at 20% for Stage 3 with the understanding that it would increase as reporting demonstrates that more providers are ready to receive summary of care documents electronically. Ohio Hospital Association CELEBRATING 100 YEARS Stage 3 Comments OHA Annual Meeting June 8, OHA COMMENTS PROPOSED RULE The Stage 3 Proposed Rule recommended that Measures 2 and 3 under the HIE Objective only apply when it is a new patient that has never been encountered before by the hospital. COMMENT We suggested new be limited to patients not seen or encountered within the past two years. Additionally, to avoid confusion among hospital systems, we asked for clarification for determining new patient status for patients seen at another hospital within the same system (which would thus be in the same EHR). Ohio Hospital Association CELEBRATING 100 YEARS Stage 3 Comments OHA Annual Meeting June 8,

48 OHA COMMENTS PROPOSED RULE The Proposed Rule requested advice on whether clinical information reconciliation should occur as a manual or automatic reconciliation. COMMENT Given the variation of size and staffing among hospital facilities, we supported allowing the option for either a manual or an automatic reconciliation process. Ohio Hospital Association CELEBRATING 100 YEARS Stage 3 Comments OHA Annual Meeting June 8, OHA COMMENTS PROPOSED RULE The Proposed Rule provided parameters for an eligible hospital to meet the public health and clinical data registry reporting measure when the public health agency or clinical data registry has limited resources to initiate the testing and validation process. COMMENT We urged CMS to consider the importance of common, clear and consistent methods for eligible hospitals to register their intent to report to these entities and/or obtain documentation of their status for audit purposes. Ohio Hospital Association CELEBRATING 100 YEARS Stage 3 Comments OHA Annual Meeting June 8,

49 OHA COMMENTS PROPOSED RULE The Proposed Rule required the eligible hospital to be in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories. COMMENT We recommended allowing an option for providers to meet this measure through active engagement for submission of immunization registry data even if the State s resources are unable to support bi-directional exchange at this time. Ohio Hospital Association CELEBRATING 100 YEARS Stage 3 Comments OHA Annual Meeting June 8, OHA COMMENTS PROPOSED RULE The Proposed Rule required the eligible hospital to be in active engagement with a public health agency to submit case reporting of reportable conditions and electronic reportable laboratory results, data to public health registries, and data to a clinical data registry. COMMENT We urged CMS to remove clinical data registry reporting as an option for Stage 3 until better guidelines are developed and a complete directory of qualified registries is available. Ohio Hospital Association CELEBRATING 100 YEARS Stage 3 Comments OHA Annual Meeting June 8,

50 Contact Information James Flynn, Partner Bricker & Eckler LLP Catherine C. Costello, Esq. CliniSyncPLUS / Ohio Health Information Partnership ccostello@ohiponline.org Bryn R. Hunt, Esq. Ohio Hospital Association bryn.hunt@ohiohospitals.org 99 50