Understanding Meaningful Use Stage 2

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2 Agenda Review MU Timeline MU 2 Overview Review of major changes EEHR Timeline & Proposed Functionality Q&A 2

3 Stage of MU by first payment year First Payment Year TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD If there will be a Stage 4 of meaningful use, we expect to update this table in the rulemaking for Stage 3. NOTE: Medicare penalties we begin being assess 2015 for EP not attesting 3

4 Reporting periods Provider Type Reporting Period Year 1 EP 90 days Anytime immediate following the 1 calendar year end of the 90-day reporting (January 1 period, but no later than February December 31) 28 of the following calendar year. 2 months following the end of the EHR reporting period (January 1 February 28) Eligible Hospital / CAH 90 days Anytime immediate following the end of the 90-day reporting period, but no later than November 30 of the following fiscal year. 2 months following the end of the EHR reporting period (October 1 November 30) Submission Period Year 1 Subsequent Reporting Periods 1 fiscal year (October1 September 30) Subsequent Submission Periods If you begin program participation in 2014, the 90 continues days of demonstrating MU must conclude three months prior to the end of the year. 4

5 Road to Meaningful Use Stage 2 5 Proposed Stage 2 Ruling 60 Day Comment Period 2011 Q3 Q Q1 Q2 HITPC Recommendations on Stage 2 Q3 Q4 Q1 Q2 Stage 2 Ruling 2014 Q3 Q4 Q1 Q2 Q3 Proposed Stage 2 Reporting Period (For Stage /2012 Reporting) Ambulatory Considerations 2 Clinical Decision Support Patient Portal Requirements Emphasis on information exchange Stretch of MU Stage 1 Goals Clinical Quality Measures Stage 1-44 Stage 2 125* Q4

6 Road to Meaningful Use Stage 2 Allscripts comments on NPRM 6

7 Key themes Continuing the drive to value-driven healthcare Raising the bar on most measures Adding new administrative & clinical measures Special emphasis on information exchange Clinical measures Registries Administrative measures Attestation More flexibility and options, including changes for 2013 Special emphasis on penalties, reviews and appeals 7

8 Summary of Major Provisions Stage 1 Stage 2 EP Measures 15 core, 5 of 10 menu 17 core, 3 of 5 menu EH Measures 14 core, 5 of 10 menu 16 core, 2 of 4 menu EP CQM 6 CQMs out of CQMs out of 125 EH CQM 6 CQMs out of CQMs out of 49 8

9 Stage 2 goals from ONC & CMS Expand upon the Stage 1 criteria Encourage the use of Health IT for continuous quality improvement at the point of care Encourage the exchange of information in the most structured format possible Stage 2 MU criteria include rigorous HIEs Demand requirements for eprescribing Incorporate structured laboratory results Electronically transmit patient care summaries to support transitions in care across unaffiliated providers, settings and EHR systems Information follows the patient (Stage 3 also) Nearly every optional Stage 1objective to be required in Stage 2 9

10 Stage 2 State Flexibility with IR/SS States will have the flexibility with the public health measures in Stage 2 similar to that of Stage 1 True for Medicare and Medicaid participation States may also specify the means of transmission of the data or otherwise change the public health measure 10

11 Stage 2 Exclusion Criteria Allowances for exclusions would change for both Stages 1 & 2 beginning in 2014 At that point, should focus solely on those objectives they can meet rather than those for which they have exclusion Exclusions just for EPs who are unable to meet certain objectives because of scope of practice New exclusion criteria when necessary for new objectives will be added as needed Almost every menu objective in Stage 2 will be core in Stage 3 11

12 Stage 2 Multiple Practices/Locations EP must still have 50% or more of outpatient encounters at a practice/location or practices/locations equipped with Certified EHR Technology can be fulfilled in a single or multiple locations. Starting in 2013, will no longer allow the practice of creating a record in one location with no EHR and then later entering information in a practice location with a certified EHR Do not have to include patients in reporting denominators that are seen at practices/locations that are not equipped with Certified EHR Technology as long as the EP clears the 50% threshold described above 12

13 Stage 2 Denominators Include all patients in the denominators of all of the measures (except those not seen at a location with a certified EHR) Create a uniform set of denominators Proposed denominators for EPs Unique patients seen by the EP during the EHR reporting period (stratified by age or previous office visit) Number of orders (medication, labs, radiology) Office visits, and Transitions of care/referrals. 13

15 Common themes of small changes Increase of thresholds More stringent parameters Movement of Menu to Core 15

16 Increase of Thresholds erx Stage 1: More than 40% must be transmitted electronically Stage 2: More than 65% are compared to at least one drug formulary and transmitted electronically Record patient demographics More than 50% of patient demographic data must be recorded as structured data. More than 80% of all unique patients have demographics recorded as structured data. Record vital signs and chart changes More than 50% of patients >2 years old must have height, weight and blood pressure recorded as structured data More than 80% of patients >3 years old must have blood pressure measured and all patients have height and weight recorded as structured data. 16

17 Increase of Thresholds Record smoking status More than 50% of patients age 13 or older have smoking status recorded as structured data More than 80% of patients age 13 or older have smoking status recorded as structured data Lab results More than 40% of clinical lab results are in positive/negative or numerical format and stored as structured data Move to core requirement. More than 55% of all clinical lab tests are incorporated as structured data. 17

18 More Stringent Parameters Provide patients with clinical summaries for each office visit Provide clinical summaries for more than 50% of all visits within 3 business days Provide clinical summaries for more than 50% of all visits within 24 hours Privacy and Security Conduct a security risk analysis, implement security updates and correct identified issues Conduct a security risk analysis, implement security updates and correct identified issues, including data at rest. 18

19 Move to Core from Menu Lab results More than 40% of clinical lab results are in positive/negative or numerical format and stored as structured data Move to core requirement. More than 55% of all clinical lab tests are incorporated as structured data. Generate list of patients by specific condition Move to core requirement. Send reminders to patients per patient preference More than 20% of patients aged 65 or older or 5 or younger must be sent appropriate reminders. Move to core requirement. More than 10% of all unique patients who had a visit within past 24 months were sent a reminder, per patient preference. 19

20 Move to Core from Menu Patient-specific education resources More than 10% of patients are provided patient-specific education resources. Move to core requirement. Perform medication reconciliation Perform med reconciliation for more than 50% of transitions of care Move to core requirement. Perform medication reconciliation for more than 65% of transitions of care. Submission of electronic immunization data Must perform at least one test of data submission and follow-up submission to immunization registries. Move to core requirement. Successful ongoing submission of electronic immunization data to a registry or reporting system for entire EHR reporting period. 20

22 Areas of major change CPOE Secured Messaging Patient Access: View, Download, Transmit Transitions of Care Clinical Decision Support 22

23 CPOE More than 60% of meds, lab, and rad orders created Core by the EP during the reporting period use CPOE # of orders in the denominator recorded using CPOE # of med, rad, and lab orders created by the EP during the reporting period = 60% Exclusion: Any EP who fewer of 100 meds, labs, and radiology orders COMBINED 23

24 CPOE EP Requirements Further defining CPOE CPOE should be used the first time the order becomes part of the record, before any action can be taken on the order removing the possibility that a record of the order could be created prior to CPOE This means that the originating provider (whose judgment creates the order) must personally use the CPOE function or verbally communicate the order to someone else who will use the CPOE function Provider is responsible for including the orders in their denominators if they are not recorded using CPOE 24

25 Patient Access Provide patients the ability to view online, download, and transmit their health information within 4 business days of the information being available to the EP Core 2 Report Calculations Report #1 # of patients in the den. who have timely (within 4 business days after the information is available to the EP) online access to their health information online #of unique patients seen by the EP during the reporting period = 65% Exclusion: Next slide 25

26 Patient Access Core Report #2 # of unique patients (or their authorized representatives) in the den. who have viewed online or downloaded or transmitted to a third party the patient's health information #of unique patients seen by the EP during the reporting period = 10% Exclusion: Any EP who neither orders nor creates any of the information listed for inclusion as part of this measure may exclude both measures. Any EP that conducts 50% or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the reporting period may exclude only the second measure. 26

27 Patient Access EP Requirements Patients must be able to access this information on demand This includes that patients with disabilities need equal access Its not just about the patient, but also their authorized representatives that can access their health info Patients have to grant access to those representatives with the exception of minors Still uses the same business day logic as in stage 1 Reporting A patient who views their info online, downloads it from the internet, or uses the internet to transmit it to a third party would count for the numerator New exclusions about the counties without high-speed internet 27

28 Patient Access EP Requirements The following information must be made available within 4 days of the info being available to the EP: Patient name Provider's name and office contact information Problem list Procedures Laboratory test results Medication list Medication allergy list Vital signs (height, weight, blood pressure, BMI, growth charts*) Smoking status Demographic information (preferred language, gender, race, ethnicity, date of birth) Care plan field, including goals* and instructions Any additional known care team members* beyond the referring or transitioning provider and the receiving provider. Provider needs to be able to not send specific information when needed at the provider s discretion 28

29 Secured Messaging Use secure electronic messaging to communicate with Core patients on relevant health information # of patients in the den. who send a secure electronic message to the EP using the electronic messaging function of CEHRT during the reporting period. # of unique patients seen by the EP during the reporting period = 10% Exclusion: Any EP who has no office visits during the reporting period 29

30 Secured Messaging EP Requirements Secure Message must contain relevant health info Secure Messaging can occur through: with necessary safeguards Patient portals PHR Stand along messaging applications Patient must take action for provider to meet this measure CMS wants comments about behavioral health 30

31 Transitions of Care (TOC) Calculation EP who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary care record for each transition of care or referral Core 2 Report Calculations Report #1 # of TOC and referrals in the denominator where a summary of care record was provided # of TOC and referrals during the reporting period for which the EP was the transferring or referring provider = 65% Exclusion: Any EP who neither transfers a patient to another setting nor refers a patient to another provider during the EHR reporting period is excluded from both measures. 31

32 Transitions of Care (TOC) Calculation Core Report #2 # of TOC & referrals in the denominator where a summary of care record was electronically transmitted using CEHRT to a recipient with no org affiliation and using a different CEHRT vendor than the sender # of TOC and referrals during the reporting period for which the EP was the transferring or referring provider = 10% Exclusion: Any EP who neither transfers a patient to another setting nor refers a patient to another provider during the EHR reporting period is excluded from both measures. 32

33 Clinical Decisions Support (CDS) Use clinical decision support to improve Core performance on high-priority health conditions Threshold 5 Clinical Decision Support + DUR Alert Exclusion: None 33

34 CDS EP Requirements User must use 5 Clinical Decision Support rules and they must be related to 5 or more Quality Measures Related = intent is to improve performance of the Clinical Quality Measure User does not need to show improvement in the Quality Measure. If user doesn't have an applicable CQM, they can choose to do another related to patient care User must have enabled DUR interactions for the entire reporting period 34

35 CDS EP Requirements Intervention must be done at a relevant point of time in the workflow, before action is taken on the patient ex. create a trigger that prompts the provider to ask about influenza immunization when a patient is 50 years or older. 35

36 TOC Reporting Considerations Exchange Key Clinical Information from Stage 1 was combined into this measure Combined Maintain Active Med List, Problem List, and Med Allergy list into this measure EP must verify med/prob/allergies and they cannot be blank Denominator If the referral is sent to a provider has access to the system, the referral does not count in the denominator Sending Electronically: USB, CD, Fax does not count 36

37 TOC Workflow Requirements Summary of Care Document must contain the following (if available on the patient) Patient name Referring or transitioning provider's name and Care plan field, including goals and instructions office contact information (EP only) for various conditions, problems, and issue Procedures Relevant past diagnoses Laboratory test results Vital signs (height, weight, blood pressure, BMI, Care Plan is defined as the management actions Care Plan = Problem (focus) + Goal (Target outcome) + Instructions given to patient Goal is defined as target or measure to be achieved in the process of patient care (expected outcome) An up-to-date problem list of current and active diagnoses growth charts) Smoking status An active medication list Demographic information (preferred language, An active medication allergy list gender, race, ethnicity, date of birth) Any additional known care team members beyond the referring or transitioning provider and the receiving provider 37

39 Stage 2 Reporting - EPs Report 12 CQMs from a menu of 125 Includes most of the current 44 Must include at least 1 CQM from each of the 6 domains All begin in 2014 for both Stage 1 and Stage 2 Examples of new measures pediatric, obstetric, behavioral/mental health, HIV medical visits, antiretroviral therapy, oral health many geared towards Medicaid providers 39

40 Stage 2 Reporting - EPs Online submission via XML files May submit as an individual or group Possible aggregation of performance here (!) unlike the batch reporting with the measures, which must remain individual Can only be done beginning in second year of MU Three group options: Different NPIs / one TIN: all members of group must report all CQMs as a group Different NPIs / one TIN, participating in the Medicare Shared Savings Program and Pioneer ACO model who use Certified EHR to submit ACO measures: all measures must be extracted by the Certified EHR Medicare EPs who satisfactorily report PQRS CQMs using Certified EHR Technology 40

41 CQM reporting options (2014) Option 1a: 12 measures, including at least 1 from each of 6 domains (NPRM Table 8) Option 1b: 11 core measures (NPRM Table 6) + 1 menu measure (NPRM Table 8) Option 2: Successfully report through PQRS Must continue to comply with PQRS as it evolves ONC will finalize Option 1a or 1b 41

43 Enterprise EHR Roadmap 11.3 Patient Goals Patient Care team Clinical Decision Support Pop. Health Improvements Orders Usability Improvements Usability & VOC Improvements DUR Enhancements Clinical Item Contention (also in ) Patient Education Connected Community Patient Portal Improvements Referral Improvements Connected Community Regulatory Enhanced Community Portal ADX Integration 1.0 Meaningful Use Stage 2 Quality Measure Support SureScripts NCPDP 10.6 STD EPCS & Pharm Directory 4.4 Maintenance Performance & Technology Enhancements Q Q Q New Features Distribution of scheduled reports New filter options Multi-Organization Support Quality Measure Drill Down Problem Usability Improvements My Priority Problem Lists Problem Impression Usability Defects Regulatory Maintenance Q Q Stimulus Reporting 2.0 New Features New Features New Features Q Focus of 11.4 & Improved Usability while meeting regulatory req s Connected Community ADX integration 1.5 Patient Portal Costume Forms ICD-10 Support Innovation Projects (Wombat, New Note, Humedica, App Store, Voice Enablement)

46 Improving Quality, Safety, Efficiency... Requirement Stage 1 Standard Stage 2 Standard 1 CPOE More than 30% of patients with at least one medication must have at least one medication ordered via CPOE More than 60% of medication, labs, and radiology orders are recorded using CPOE. No requirement to order electronically. 2 erx More than 40% must be transmitted electronically More than 65% are compared to at least one drug formulary and transmitted electronically 3 Record patient demographics More than 50% of patient demographic data must be recorded as structured data. More than 80% of all unique patients have demographics recorded as structured data. 4 Record vital signs and chart changes More than 50% of patients >2 years old must have height, weight and blood pressure recorded as structured data 5 Record smoking status More than 50% of patients age 13 or older have smoking status recorded as structured data More than 80% of patients >3 years old must have blood pressure measured and all patients have height and weight recorded as structured data. More than 80% of patients age 13 or older have smoking status recorded as structured data 6 Clinical Decision Support Implement one clinical decision support rule and track compliance with that rule Implement five clinical decision support rules related to 5 or more clinical quality measures And Implement drug-drug and drug-allergy interaction checks 46

47 Improving Quality, Safety, Efficiency... Requirement Stage 1 Standard Stage 2 Standard 7 Lab results More than 40% of clinical lab results are in positive/negative or numerical format and stored as structured data Move to core requirement. More than 55% of all clinical lab tests are incorporated as structured data. 8 Generate list of patients by specific condition for use in quality improvement, reduction of disparities, research or outreach. Generate one list of patients with a specific condition. Move to core requirement. 9 Send reminders to patients per patient preference for preventative and follow up care More than 20% of patients aged 65 or older or 5 or younger must be sent appropriate reminders. Move to core requirement. More than 10% of all unique patients who had a visit within past 24 months were sent a reminder, per patient preference. M1 Imaging results. New measure. More than 40% of all scans and tests ordered by EP are accessible through the certified EHR. M2 Record patient family health history as structured data New measure. More than 20% of all unique patients have a structured data entry for one or more first-degree relatives. 47

48 Engage Patients & Families Requirement Stage 1 Standard Stage 2 Standard New Requirement. 50% of all unique patients provided online access to their health information within 4 business days after it is available to the EP (subject to EP discretion) And More than 10% unique patients view, download, or transmit their info to a third party. 10 Provide patients with ability to view online, download & transmit their health information. 11 Provide patients with clinical summaries for each office visit Provide clinical summaries for more than 50% of all visits within 3 business days Provide clinical summaries for more than 50% of all visits within 24 hours 12 Use EHR technology to identify patient-specific education resources as provide to patients as appropriate. More than 10% of patients are provided patient-specific education resources. Move to core requirement. 13 Use secure electronic messaging. New requirement. A secure message was sent using the Certified EHR by more than 10% of unique patients seen. 48

49 Improve Care Coordination Requirement Stage 1 Standard Stage 2 Standard 14 Perform medication reconciliation Perform med reconciliation for more than 50% of transitions of care Move to core requirement. Perform medication reconciliation for more than 65% of transitions of care. 15 Provide summary of care record for patients referred or transitioned to another provider. Summary of care records are provided for at least 50% of patient transitions or referrals. Move to core. 1. provide a summary of care for 65% of transitions or referrals; and 2. transmit summary of care record to a recipient with no organizational affiliation and who uses a different certified technology vendor than the sender for more than 10% of transitions or referrals. 49

50 Improve Population & Public Health Requirement Stage 1 Standard Stage 2 Standard 24 Submission of electronic immunization data Must perform at least one test of data submission and follow-up submission to immunization registries. Move to core requirement. Successful ongoing submission of electronic immunization data to a registry or reporting system for entire EHR reporting period. M3 Syndromic surveillance data to public health agencies Must perform at least one test of data submission and follow-up submission to public health agencies for syndromic surveillance. Successful ongoing submission of electronic immunization data to a public health agency for entire EHR reporting period. M4 Report cancer cases to cancer registry New measure. Successful ongoing submission of cancer case information to a cancer registry for entire EHR reporting period. M5 Report specific cases to specialized, non-cancer registry New measure. Successful ongoing submission of specific case information to a specialized, non-cancer registry for entire EHR reporting period. 50

51 Ensure Adequate Privacy Requirement 25 Privacy and Security Stage 1 Standard Stage 2 Standard Conduct a security risk analysis, implement security updates and correct identified issues Conduct a security risk analysis, implement security updates and correct identified issues, including data at rest. 51