Meaningful Use Stage 1 and 2 Your Survival Guide!

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1 Meaningful Use Stage 1 and 2 Your Survival Guide! Dr. Gross is on the Vision Expo Conference Advisory Board Dr. Henry and Dr. Gross are affiliated with EHRGURU.NET and have lectured for numerous companies including Topcon, First Insight, and the AOA Jay W. Henry, O.D., M.S. Philip J. Gross, O.D.

2 Thank You to Our Sponsor!

3 Game Plan Meaningful Use Stage 1 and Stage 2: Objective requirements Clinical implications of each objective Objective exemptions Objective compliance How to navigate the different stages

4 Meaningful Use

5 Meaningful Use Meaningful use is the set of standards defined by the Centers for Medicare & Medicaid Services (CMS) Incentive Programs that governs the use of electronic health records and allows eligible providers and hospitals to earn incentive payments by meeting very specific criteria The overall goal of meaningful use is to promote the spread of electronic health records to improve health care in the United States

6 Meaningful Use Specific Goals of Meaningful Use Improve quality of health care Improve safety, efficiency and reduce health disparities Engage patients and families in their care Improve Care Coordination Improve population and public health Ensure adequate privacy and security protections for personal health information

7 Meaningful Use: The Next Stages All providers will complete two years of Stage 1 Meaningful Use (MU) before advancing to the Stage 2 criteria in their 3 rd or 4 th year. Maximum Payment by Start Year Annual Incentive Payment by Stage of Meaningful Use $44,000 $18,000 $12,000 $8,000 $4,000 $2, $44,000 $18,000 $12,000 $8,000 $4,000 $2, $39,000 $15,000 $12,000 $8,000 $4, $24,000 $12,000 $8,000 $4,000

8 Meaningful Use: Reporting Period First year of participation Providers must demonstrate meaningful use for any continuous 90-day reporting period All subsequent years of participation except 2014 Providers must demonstrate meaningful use for a full year EHR reporting period (entire calendar year) For 2014 only (unless it s your first year of participation) All providers regardless of their stage of meaningful use are only required to demonstrate meaningful use for a 3-month EHR reporting period For Medicare EHR incentive program it is fixed to a quarter of the calendar year (1/1 3/31, 4/1-6/30, 7/1 9/30, 10/1 12/31) For Medicaid EHR incentive program the reporting period is not fixed

9 Reporting Periods YEAR 1 All Other Years 2014 Unless it is your first year

10 Meaningful Use Objectives Meaningful use established a core and menu structure for objectives that providers must achieve Core objectives are objectives that all providers must meet Some have exclusions which could exempt you from having to complete that objective (If you exempt from an objective you get credit as if you did it) Menu objectives allow the providers to select from a list a certain number of objectives to meet Some have exclusions which could exempt you from having to complete that objective

11 Stage 1 Changes CMS has announced changes to Stage 1 Meaningful Use objectives Some changes take effect Jan. 1 st, 2013 Some changes take effect in 2014 but are optional for 2013 We will cover all of these changes in the following slides. Fasten your seatbelts!

12 Stage 1 Change on Exclusions to Menu Items Beginning in 2014 You will no longer be permitted to count an exclusion toward the minimum of 5 menu objectives if there are other menu objectives which you can achieve In other words, a provider cannot select a menu objective and claim an exclusion for it if there are other menu objectives they can meet EPs will not be penalized for selecting a menu objective and claiming the exclusion if they would also qualify for the exclusions for all the remaining menu objectives

13 Meaningful Use: Stage 1 vs. Stage 2 Original Stage 1 criteria for Eligible Professionals 15 core objectives 5 of 10 menu objectives (1 must be public health) 20 total objectives Stage 2 criteria for Eligible Professionals 17 core objectives 3 of 6 menu objectives 20 total objectives

14 Stage 1 and Stage 2 Objectives For Stage 1 Information Follow For Stage 2 Information Follow 15 Stage 1 Core Objectives 10 Stage 1 Menu Objectives 17 Stage 2 Core Objectives 6 Stage 2 Menu Objectives

15 Beginning of Stage 1 Core Objectives Beginning of Stage 2 Core Objectives

16 Stage 1 Core Objectives 1. Computerized provider order entry (CPOE) 2. Drug-drug and drug-allergy checks 3. E-Prescribing (erx) 4. Record patient demographics 5. Maintain an up to date problem list of current and active diagnoses 6. Maintain active medication list 7. Maintain active medication allergy list 8. Record and chart changes in vital signs 9. Record smoking status for patients 13 years or older 10. Implement clinical decision support 11. Report ambulatory clinical quality measures to CMS / States 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

17 Stage 2 Core Objectives 1. Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders 2. Generate and transmit permissible prescriptions electronically (erx) 3. Record demographic information 4. Record and chart changes in vital signs 5. Record smoking status for patients 13 years old or older 6. Use clinical decision support to improve performance on high-priority health conditions 7. Provide patients the ability to view online, download and transmit their health information 8. Provide clinical summaries for patients for each office visit 9. Protect electronic health information created or maintained by the Certified EHR Technology 10. Incorporate clinical lab-test results into Certified EHR Technology 11. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach 12. Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care 13. Use certified EHR technology to identify patient-specific education resources 14. Perform medication reconciliation 15. Provide summary of care record for each transition of care or referral 16. Submit electronic data to immunization registries 17. Use secure electronic messaging to communicate with patients on relevant health information

18 CPOE: Computerized Provider Order Entry More than 30% of all unique patients seen by the EP with at least one medication in their medication list must have at least one medication order entered using CPOE You can be excluded from meeting this objective if you write fewer than 100 prescriptions during the reporting period More than 60% of medication, 30% of laboratory, and 30% of radiology orders created by the EP during the EHR reporting period must be recorded using CPOE You can be excluded from meeting this objective if you write fewer than 100 prescriptions during the reporting period

19 CPOE Changes Stage 1: > 30% of unique patients with a medication order have at least one medication ordered using CPOE Stage 2: Based on total number of medication, lab, radiology orders not unique patients with a medication order Increases % of medication orders: > 60% of medication orders Adds Lab and Radiology orders: > 30%

20 Stage 1 CPOE Alternate Measure Optional Change 2013 and beyond Beginning in 2013, CMS has added an optional alternate measure for Stage 1 CPOE EPs may select either the original CPOE or the alternate CPOE measure for Stage 1 Alternate Measure More than 30% of all medication orders, created by the EP, during the EHR reporting period are recorded using CPOE

21 Computerized Provider Order Entry Clinical Significance? Directly entering orders into a computer has the benefit of reducing errors by minimizing the ambiguity of hand-written orders, but a much greater benefit is seen with the combination of CPOE and clinical decision support tools Implementation of CPOE is being increasingly encouraged as an important solution to the challenge of reducing medical errors, and improving health care quality and efficiency

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23 Drug-Drug and Drug-Allergy Checks EP has enabled the functionality to automatically check for drug-drug or drugallergy interactions for the entire EHR reporting period There is no exclusion for this objective. No longer a separate objective for Stage 2 It has been incorporated into the Stage 2 Clinical Decision Support measure

24 Drug-Drug and Drug-Allergy Changes Stage 1: EP has enabled the functionality to automatically check for drug-drug or drug-allergy interactions for the entire EHR reporting period Stage 2: No longer an objective has been incorporated and combined into Clinical Decision Support Measure

25 Drug-Drug and Drug-Allergy Checks Clinical Significance? You are responsible for understanding the potential negative interaction a medication you prescribe may have when combined with another medication the patient is already taking Remember this goes back to the importance of keeping an active medication list up to date for each patient Lipitor and Biaxin is there a problem with this combination? Oral antibiotic and Oral contraceptive is there a problem? If we are using a certified EHR with eprescribing, this should occur as part of the ordering of the medications Be sure this feature is turned on and active for you entire reporting period

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27 Electronic Prescribing More than 40% of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology You can be excluded from meeting this objective if you write fewer than 100 prescriptions during the reporting period More than 50% of prescriptions are compared to a drug formulary and transmitted electronically You can be excluded from meeting this objective if you write fewer than 100 prescriptions during the reporting period or Do not have a pharmacy within your organization and there are no pharmacies that accept electronic prescriptions within 10 miles of the EP's practice location at the start of his/her EHR reporting period

28 Electronic Prescribing Changes Stage 1: > 40% of permissible prescriptions transmitted electronically Stage 2: Increases % of prescriptions transmitted by erx to > 50% of permissible prescriptions Adds prescriptions are also queried for a drug formulary

29 E-Prescribing Change 2013 and Beyond Beginning Jan 1 st, 2013 new additional exclusion: Any EP who does not have a pharmacy within their organization and there are no pharmacies that accept electronic prescriptions within 10 miles of the EP's practice location at the start of his/her EHR reporting period can take an exclusion on Electronic Prescribing

30 E-Prescribing (erx) Clinical Significance? Improves medication safety Better management of medication costs Improved prescribing accuracy and efficiency Increase practice efficiency Reducing health care costs Reduction of adverse drug events

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32 Patient Demographics More than 50% of all unique patients seen by the EP have demographics recorded Preferred language, Race, Ethnicity, Gender, Date of Birth No Exclusion More than 80% of all unique patients seen by the EP have demographics recorded. Preferred language, Race, Ethnicity, Gender, Date of Birth No Exclusion

33 Patient Demographics Changes Stage 1: > 50% of unique patients have demographic data stored as structured data Stage 2: Increases percentage to > 80% of unique patients have demographic data stored as structured data

34 Patient Demographics Details Preferred language Ask what is your preferred language and let patient select or write in Ethnicity (federal definition) Hispanic or Latino Not Hispanic or Latino Race (Federal definition, one or more that apply) American Indian or Alaska Native Asian Black or African American White Native Hawaiian or Other Pacific Islander For Race and Ethnicity refuse to specify may be recorded and is a valid response

35 Record demographics Clinical Significance? Many studies indicate that African Americans are 3x more likely to develop POAG, and have an increased risk of hypertensive retinopathy Latinos have an increased risk of diabetes Whites have an increased risk of AMD Patient with central distorted vision --- proper age, race, and gender for central serous?

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37 Maintain an Up-to-Date Problem List More than 80% of all unique patients seen by the EP have at least one entry or an indication that no problems are known for the patient recorded as structured data There is no exclusion for this objective No longer a separate objective for Stage 2 It has been incorporated into the Stage 2 Summary of Care Document at Transitions of Care and Referrals

38 Maintain an up-to-date list of current and active diagnosis (problem list) Clinical Significance? This is an ongoing list of active problems or diagnosis Creating this list will allow you to immediately understand your patient's overall health The problem lists states the most important health problems facing a patient You will know they are diabetic and you need to do additional clinical testing for diabetic retinopathy, or that they have POAG and need additional clinical testing done We typically already record problems or diagnosis just be sure to list them in the proper fields in your EHR

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40 Maintain Active Medication List More than 80% of all unique patients seen by the EP have at least one medication recorded or an indication that the patient is not currently prescribed any medication recorded There is no exclusion for this objective. No longer a separate objective for Stage 2 It has been incorporated into the Stage 2 Summary of Care Document at Transitions of Care and Referrals

41 Maintain active medication list Clinical Significance? We should be checking all patients medication list at each visit because many of the meds have ocular side effects If they tell you they are on a diabetic medication that will alert you to the need for additional testing for retinopathy or macular edema as well We now need to indicate a negative if no prescribed medications exist In other words, we have to make sure that the record shows no prescribed medications

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43 Maintain Active Medication Allergy List More than 80% of all unique patients seen by the EP have at least one medication allergy recorded or an indication that the patient has no known medication allergies recorded. There is no exclusion for this objective No longer a separate objective for Stage 2 It has been incorporated into the Stage 2 Summary of Care Document at Transitions of Care and Referrals

44 Maintain active medication allergy list Clinical Significance? We should be checking all patients allergy status at each visit so we don t prescribe a medication that could cause an allergic or anaphylactic reaction We now need to indicate a negative if no medication allergies exist In other words, we have to make sure that the record shows no active medication allergies

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46 Record and Chart Changes in Vital Signs For more than 50% of all unique patients age 2 and over seen by the EP, height, weight and blood pressure are recorded as structured data BMI should be calculated and displayed Plot and display growth and BMI charts for 2-20 years You can be excluded if: You don t see any patients 2 years or older or You believe all 3 of these vital signs are NOT relevant to your scope of practice For more than 80% of all unique patients seen by the EP, blood pressure (for patients age 3 and over only) and height and weight (for all ages) are recorded as structured data. BMI should be calculated and displayed, Plot and display growth and BMI charts for 0-20 years You may be excluded if you: See no patients 3 years or older Believe that all 3 vital signs of height/length, weight, and blood pressure have no relevance to your scope of practice You are excluded from recording blood pressure if you believe that height/length and weight are relevant to your scope of practice, but blood pressure is not You are excluded from recording height/length and weight if you believe that blood pressure is relevant to your scope of practice, but height/length and weight are not

47 Vital Signs Changes Stage 1: Vital signs must be recorded for more than 50% of all unique patients age 2 and over Plot and display growth and BMI charges for 2-20 years Stage 2: Increases percentage to > 80% of unique patients Increases age on blood pressure to age >3 Plot and display growth and BMI charts for 0-20 years Reduces age on height and weight to birth (all ages) New exclusion for height/weight only New exclusion for blood pressure only

48 Stage 1 Vital Signs Changes Optional 2013 / Required 2014 The measure amends the age limit for vital signs to: Blood pressure for patients ages 3 and over Height and weight for patients of all ages

49 Stage 1 Vital Signs Changes Optional 2013 / Required 2014 The measure amends the exclusions as well: If you see no patients 3 years or older you are excluded from recording blood pressure If you believe that all three vital signs of height, weight, and blood pressure have no relevance to your scope of practice you are excluded from recording all three of them If you believe that height and weight are relevant to your scope of practice, but blood pressure is not, you are excluded from recording blood pressure If you believe that blood pressure is relevant to your scope of practice, but height and weight are not, you are excluded from recording height and weight

50 Record and chart changes in vital signs Clinical Significance? Many clinical studies have shown an increased risk of AMD, glaucoma, and Cataracts in overweight patients BMI is calculated as weight (lbs) / height 2 (inches) x 703 BMI of is normal, > 25 is overweight, >30 is Obese Height/weight/BMI: Can add height and weight to patient questionnaire Suggest starting with patient attestation for height and weight but move to actually measuring it The BMI is a function of the software Blood pressure: We should be doing this on all patients Helps in the diagnosis of hypertensive retinopathy You will be surprised how many patients have significantly elevated BP and you may be the one to prevent them from having a stroke

51 Record and chart changes in vital signs Clinical Significance? Recent study found that after 6 years of age, the probability of obesity in adulthood exceeded 50% for obese children Recent study found that atherosclerosis starts in childhood and the presence of obesity is highly correlated Large prospective study found Obese men has 1.46 to 2.40 times the risk of death Obese women had 1.51 to 2.76 times the risk of death According to the World Health Organization 51% of cerebrovascular disease deaths are attributable to high systolic blood pressure, 45% of ischemic heart disease deaths are attributable to high systolic blood pressure, The leading cause of cardiovascular death worldwide is high blood pressure

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53 Record Smoking Status for Patients 13 Years or Older More than 50% of all unique patients 13 years old or older seen by the EP have smoking status recorded as structured data You can be excluded from this objective if you do not see any patients who are age 13 years or older More than 80% of all unique patients 13 years old or older seen by the EP have smoking status recorded as structured data You can be excluded from this objective if you do not see any patients who are age 13 years or older

54 Smoking Status Changes Stage 1: > 50% of unique patients 13 years or older have smoking status recorded as structured data Stage 2: Increases % to > 80% of unique patients 13 years or older have smoking status recorded as structured data

55 Record smoking status for patients 13 years or older Clinical Significance? We know and should advise any patients who are smoking that they have an increased risk for AMD as well as glaucoma, and cataracts Consider adding questions to the patient registration form to get the information on status Have this information recorded during history taking This must be recorded in the EHR as structured data and it will be tracked by the EHR for compliance

56 Record smoking status for patients 13 years or older Clinical Significance? Tobacco is the single greatest cause of disease and premature death in America today and is responsible for: More than 435,000 deaths annually $96 billion annually in medical expenses $97 billion annually in lost productivity When compared with non-smokers, smoking is estimated to increase the risk of: Coronary heart disease by 2 to 4 times Stroke by 2 to 4 times Men developing lung cancer by 23 times Women developing lung cancer by 13 times Death from chronic obstructive lung diseases by 12 to 13 times

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58 Clinical Decision Support Rule Implement one clinical decision support rule that will trigger alerts for providers when they have patients with certain diagnosis or conditions No exclusion Measure 1: Implement five clinical decision support interventions related to four or more clinical quality measures for the entire EHR reporting period Measure 2: The EP has enabled and implemented the functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period For Measure 2, you can be excluded if you write fewer than 100 medication orders during the reporting period

59 Clinical Decision Support Changes Stage 1: One clinical decision support rule enabled related to your specialty Stage 2: 5 Rules are now required based on four clinical quality measures (to be covered next) plus drug-drug and drug-allergy interaction checks If there are not four clinical quality measures related to your scope of practice or patient population, the clinical decision support interventions must be related to high-priority health conditions

60 Clinical Decision Support Details Clinical Decision Support: Functionality that builds upon the foundation of an EHR to provide persons involved in care processes with general and person-specific information, intelligently filtered and organized, at appropriate times, to enhance health and health care

61 Implement clinical decision support Clinical Significance? These are rules designed to help us meet the standard of care in terms of testing and follow up care Examples: If a patient has an active medication of Plaquenil listed, has a macular visual field, color vision testing, and a SD OCT been ordered? When an IOP is above a specific level, a warning of possible glaucoma is triggered If a diagnosis of glaucoma is entered, is the patient scheduled or have they had a VF or a scanning laser within the last 6-12months

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63 Report Clinical Quality Measures Beginning in 2013 no longer a separate objective Has been incorporated into the definition of a Meaningful EHR user You still must provide aggregate numerator, denominator, and exclusions through attestation or be part of the PQRS Electronic Reporting Pilot No longer a separate objective but providers must still submit CQM s to achieve meaningful use Starting in 2014, all CQMs will be submitted electronically to CMS

64 Clinical Quality Measures 2013 and Beyond Clinical quality measures, or CQMs, are tools that help us measure and track the quality of healthcare services provided by eligible professionals CQMs measure many aspects of patient care including: outcomes clinical processes, patient safety efficient use of healthcare resources, care coordination patient engagements, population and public health clinical guidelines

65 Clinical Quality Measures 2013 and Beyond Although clinical quality measure (CQM) reporting has been removed as a core objective for EPs, all providers are required to report on CQMs in order to demonstrate meaningful use Beginning in 2014, all providers regardless of their stage of meaningful use will report on CQMs in the same way

66 Report ambulatory clinical quality measures to CMS for 2013 Only Every EP must report on clinical quality measures to demonstrate Meaningful Use Your certified EHR will track and produce a report with your clinical quality measures data (numerators and denominators). You will utilize this report when you complete your attestation There are no thresholds or percentages that you must meet. You just need to report the data exactly as it is contained in your EHR report

67 Report ambulatory clinical quality measures to CMS for 2013 Only You must report on: 3 Core measures (If you don t collect data on one or more of the 3 core measures, you can use a measure from the alternate core list as a replacement) AND 3 measures that are relevant to Optometry from an additional Menu list of 38 items

68 Report ambulatory clinical quality measures to CMS for 2013 Only The 3 core clinical quality measures are: Core Clinical Quality Measure National Quality Forum (NQF) and / or PQRS Measure Number Hypertension: Blood Pressure Measurement Preventive Care and Screening Measure Pair: a. Tobacco Use Assessment b. Tobacco Cessation Intervention NQF 0013 NQF 0028 Adult Weight Screening and Follow-up NQF 0421 PQRS 128

69 Report ambulatory clinical quality measures to CMS for 2013 Only The 3 alternate core clinical quality measures are: Alternate Core Clinical Quality Measure National Quality Forum (NQF) and / or PQRS Measure Number Weight Assessment and Counseling for Children and Adolescents Preventive Care and Screening: Influenza Immunization for Patients 50 Years Old NQF 0024 NQF 0041 PQRS 110 Childhood Immunization Status NQF 00038

70 Report ambulatory clinical quality measures to CMS for 2013 Only Additional Clinical Quality Measures You must pick 3 from the list of 38. Optometry relevant shown below Additional Clinical Quality Measures Primary Open Angle Glaucoma: Optic Nerve Evaluation Diabetic Retinopathy: Documentation of presence or absence of macular edema and level of severity of retinopathy Diabetic Retinopathy: Communication with the physician managing ongoing diabetes care National Quality Forum (NQF) and / or PQRS Measure Number PQRS 12 PQRS 18 PQRS 19 Diabetes: Eye exam PQRS 117

71 Report ambulatory clinical quality measures to CMS for 2013 Only Clinical Significance? Again these remind us of the clinical importance of blood pressure measurement, tobacco use assessment and cessation advice, as well as weight and BMI calculations This information is important because it is being utilized as a measure of quality of clinical care for your patients Your certified EHR does the work! It will track and calculate the measures as you enter clinical data You must report these numbers when you attest If you have a zero in the denominator on one or more of the core clinical quality measures replace it with one (or more) measures from the alternate list Choose 3 measures from the additional list that are relevant to Optometry Remember there are no minimum values that you must obtain you just report the numbers from your certified EHR report

72 Report ambulatory clinical quality measures to CMS for 2013 Only Need help understanding CQMs for 2013?? CQM webpage easures.asp#topofpage User guide o_cqms.pdf You tube video

73 Report ambulatory clinical quality measures to CMS for 2014 Beginning in 2014, all providers regardless of their stage of meaningful use will report on CQMs in the same way For 2014, CMS is not requiring the submission of a core set of CQMs Instead CMS has identified two recommended core sets of CQMs, one for adults and one for children CMS encourages eligible professionals to report from the recommended core set to the extent those CQMs are applicable to your scope of practice and patient population

74 Report ambulatory clinical quality measures to CMS for 2014 CMS selected the recommended core set of CQMs for EPs based on analysis of several factors: Conditions that contribute to the morbidity and mortality of the most Medicare and Medicaid beneficiaries Conditions that represent national public health priorities Conditions that are common to health disparities Conditions that disproportionately drive healthcare costs and could improve with better quality measurement Measures that would enable CMS, States, and the provider community to measure quality of care in new dimensions, with a stronger focus on parsimonious measurement Measures that include patient and/or caregiver engagement

75 Report ambulatory clinical quality measures to CMS for 2014 EPs must report on 9 out of 64 total CQMs Providers must select CQMs from at least 3 of the 6 key health care policy domains (listed below) recommended by the Department of Health and Human Services National Quality Strategy 1. Patient and Family Engagement 2. Patient Safety 3. Care Coordination 4. Population and Public Health 5. Efficient Use of Healthcare Resources 6. Clinical Processes/Effectiveness

76 Report ambulatory clinical quality measures to CMS for 2014 Adult Recommended Core Measures Controlling High Blood Pressure Use of High-Risk Medications in the Elderly Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Use of Imaging Studies for Low Back Pain Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan Documentation of Current Medications in the Medical Record Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Closing the referral loop: receipt of specialist report Functional status assessment for complex chronic conditions

77 Report ambulatory clinical quality measures to CMS for 2014 Pediatric Recommended Core Measures Appropriate Testing for Children with Pharyngitis Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents Chlamydia Screening for Women Use of Appropriate Medications for Asthma Childhood Immunization Status Appropriate Treatment for Children with Upper Respiratory Infection (URI) ADHD: Follow-Up Care for Children Prescribed Attention- Deficit/Hyperactivity Disorder (ADHD) Medication Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan Children who have dental decay or cavities

78 Report ambulatory clinical quality measures to CMS for 2014 Beginning in 2014, all Medicare-eligible providers beyond their first year of demonstrating meaningful use must electronically report their CQM data to CMS EPs can electronically report with the following methods: Physician Quality Reporting System (PQRS) Electronic submission of samples of patient-level data. EPs can also report as group using the PQRS GPRO tool. EPs who electronically report using this PQRS option will meet both their EHR Incentive Program and PQRS reporting requirements CMS-designated transmission method Electronic submission of aggregate-level data

79 Report ambulatory clinical quality measures to CMS for 2014 Need help understanding CQMs for 2014?? CQM webpage Guidance/Legislation/EHRIncentivePrograms/20 14_ClinicalQualityMeasures.html

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83 Patient Electronic Copy and Access More than 50% of all patients who request an electronic copy of their health information are provided the electronic copy within 3 business days. You may be excluded if none of your patients requests an electronic copy of their health information Measure 1: More than 50% of all unique patients are provided timely (within 4 business days after the info is available to the EP) online access to their health information Measure 2: More than 5% of all unique patients view, download, or transmit to a 3rd party their health information You can be excluded if you neither order nor create any of the info listed for inclusion (see next slide) You can be excluded if you conduct 50% or more of encounters in a county that does not have 50% or more housing units with 3Mbps broadband availability

84 Patient Electronic Copy and Electronic Access Changes Stage 1: Only required for patients who request and electronic copy Stage 2: Must be done for > 50% of unique patients Now being held accountable for the patients to utilize the information: More than 5% of all unique patients (or authorized representative) view, download, or transmit to a 3rd party their health information You must provide: patient name, provider's name and office contact information, current and past problem list, procedures. laboratory test results, current medication list and medication history, current medication allergy list and medication allergy history, vital signs, smoking status, demographic information care plan field(s), including goals and instructions, and any known care team members including the primary care provider (PCP) of record You may be excluded if you don t create any of the above listed information (except patient name, provider name and office info)

85 Stage 1 Electronic Copy and Electronic Access to Health Information Changes Required 2014 Original Stage 1 core objective replaced Provide patients with electronic copy of health info upon request Original Stage 1 menu objective replaced Provide patients with timely electronic access to their health information within 4 business days 2014 New stage 1 objective: More than 50% of unique patients are provided timely (within 4 business days) online access to their health information

86 Patient Electronic Copy and Electronic Access Clinical Significance for Stage 1? This reinforces the importance of involving your patients in their own healthcare For stage 1 when a patient makes a request, EPs must provide the patient with all of the health information they have available electronically within 3 business days At a minimum includes: diagnostic test results, problem list, medication lists, medication allergies Certified software will generate this report The media could be any electronic form such as patient portal, PHR, CD, USB fob, etc. EPs are expected to make reasonable accommodations for patient preference Per HIPAA rules, you may charge a fee for this service

87 Patient Electronic Copy and Electronic Access Clinical Significance for Stage 2? Patient access will allow patients to understand what clinical testing was completed during an encounter as well as the results of those tests Online electronic access through either a patient portal or personal health record (PHR) will satisfy this objective The minimal information to be included is: Lab test results, problem list, medication list, and medication allergy list You may withhold information from the electronic copy in accordance with HIPAA

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90 Provide Clinical Summaries for Patients for Each Office Visit Clinical summaries must be provided to patients within 3 business days of visit for more than 50% of all office visits You may be excluded if you have no office visits Clinical summaries must be provided to patients or authorized representatives within 1 business days for more than 50% of all office visits You may be excluded if you have no office visits

91 Provide Clinical Summaries Changes Stage 1: You have 3 business days to provide summary Stage 2: You have 1 business day to provide summary

92 Provide clinical summaries for patients for each office visit Clinical Significance? At completion of the exam, the EHR would take the key clinical data elements from the electronic record and create a summary of the findings which can be given to the patient to help them better understand their overall health The clinical summary can be provided through a personal health record, patient portal on the web site, secure , electronic media such as CD or USB fob, or printed copy. If the EP chooses an electronic media, they would be required to provide the patient a paper copy upon request

93 Provide clinical summaries for patients for each office visit Clinical Significance? Enhances the ability of patients to remember and, if necessary, convey to family members, the content of interactions with their care team Supports greater patient engagement in making good choices about healthy behaviors Summaries should include items such as: updated medication list, vital signs, reason for visit, problem list, medications / immunizations, lab tests ordered / results, and follow up appointments An EP may choose to withhold particular information if they believe substantial harm may arise from disclosure

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96 Capability to Exchange Key Clinical Information This objective is eliminated from Stage 1 in 2013 and is no longer an objective This objective is not required for Stage 2

97 Protect Electronic Health Information Conduct or review a security risk analysis and implement security updates as needed and correct identified security deficiencies as part of the process No exclusion Conduct or review a security risk analysis including addressing the encryption/security of data at rest and implement security updates as needed and correct identified security deficiencies as part of the process No exclusion

98 Protect electronic health information A major goal of the Security Rule is to protect the privacy of individuals health information while allowing covered entities to adopt new technologies to improve the quality and efficiency of patient care This is similar to the current HIPAA security rules You must conduct or review a security risk analysis and implement updates as necessary Should be done once prior to end of reporting period Your software vendor should be able to provide you with tools to complete the risk analysis

99 Protect electronic health information HIPAA protects the privacy of individually identifiable health information, called protected health information (PHI) Security Rule protects a subset of information covered by the Privacy Rule, which is all individually identifiable health information a covered entity creates, receives, maintains or transmits in electronic form. The Security Rule calls this information electronic protected health information (e-phi)

100 Protect electronic health information The Security Rule requires covered entities to maintain reasonable and appropriate administrative, technical, and physical safeguards for protecting e-phi Specifically, covered entities must: Ensure the confidentiality, integrity, and availability of all e- PHI they create, receive, maintain or transmit; Identify and protect against reasonably anticipated threats to the security or integrity of the information; Protect against reasonably anticipated, impermissible uses or disclosures; and Ensure compliance by their workforce

101 Protect electronic health information The Security Rule require covered entities to perform risk analysis as part of their security management processes A risk analysis process includes, but is not limited to, the following activities: Evaluate the likelihood and impact of potential risks to e- PHI; Implement appropriate security measures to address the risks identified in the risk analysis; Document the chosen security measures and, where required, the rationale for adopting those measures; 10 and Maintain continuous, reasonable, and appropriate security protections

102 Protect electronic health information Administrative Safeguards Are Required Security Management Process: Must identify and analyze potential risks to e-phi, and implement security measures that reduce risks and vulnerabilities to a reasonable and appropriate level Security Personnel: Must designate a security official who is responsible for developing and implementing its security policies and procedures Information Access Management: Implement policies and procedures for authorizing access to e-phi only when such access is appropriate based on the user or recipient's role (role-based access) Workforce Training and Management: Must provide for appropriate authorization and supervision of workforce members who work with e- PHI. You must train all workforce members regarding security policies and procedures, and you must have and apply appropriate sanctions against workforce members who violate policies and procedures Evaluation: Must perform a periodic assessment of how well your security policies and procedures meet the requirements of the Security Rule

103 Protect electronic health information Physical Safeguards Are Required Facility Access and Control: Must limit physical access to facilities while ensuring that authorized access is allowed Workstation and Device Security: Must implement policies and procedures to specify proper use of and access to workstations and electronic media. Must have in place policies and procedures regarding the transfer, removal, disposal, and re-use of electronic media, to ensure appropriate protection of electronic protected health information (e-phi)

104 Protect electronic health information Technical Safeguards Are Required Access Control: Must implement technical policies and procedures that allow only authorized persons to access electronic protected health information (e-phi) Audit Controls: Must implement hardware, software, and/or procedural mechanisms to record and examine access and other activity in information systems that contain or use e-phi Integrity Controls: Must implement policies and procedures to ensure that e-phi is not improperly altered or destroyed. Electronic measures must be put in place to confirm that e-phi has not been improperly altered or destroyed Transmission Security: Must implement technical security measures that guard against unauthorized access to e-phi that is being transmitted over an electronic network

105 Protect electronic health information Required and Addressable Implementation Specifications The "required" implementation specifications must be implemented. The "addressable" designation does not mean that an implementation specification is optional it permits covered entities to determine whether the addressable implementation specification is reasonable and appropriate for that covered entity If it is not, the Security Rule allows the covered entity to adopt an alternative measure that achieves the purpose of the standard, if the alternative measure is reasonable and appropriate

106 Protect electronic health information Organizational Requirements Covered Entity Responsibilities: If a covered entity knows of an activity or practice of a business associate that constitutes a material breach or violation of the business associate s obligation, the covered entity must take reasonable steps to cure the breach or end the violation. Violations include the failure to implement safeguards that reasonably and appropriately protect e-phi

107 Protect electronic health information Policies and Procedures and Documentation Requirements Must adopt reasonable and appropriate policies and procedures to comply with the provisions of the Security Rule. Must maintain, until six years after the later of the date of their creation or last effective date, written security policies and procedures and written records of required actions, activities or assessments Updates: Must periodically review and update your documentation in response to environmental or organizational changes that affect the security of electronic protected health information (e-phi)

108 Protect electronic health information Enforcement and Penalties for Noncompliance Compliance: The Security Rule establishes a set of national standards for confidentiality, integrity and availability of e-phi. The Department of Health and Human Services (HHS), Office for Civil Rights (OCR) is responsible for administering and enforcing these standards, in concert with its enforcement of the Privacy Rule, and may conduct complaint investigations and compliance reviews

109 End of Stage 1 Core Objectives Continued Stage 2 Core Objectives Beginning of Stage 1 Menu Objectives

110 Stage 1 Menu Objectives 1. Drug formulary checks 2. Incorporate clinical lab-test results 3. Generate lists of patients by specific conditions 4. Send reminders to patients for preventive / follow-up care 5. Electronic access to health information for patients 6. Patient specific education resources 7. Medication reconciliation 8. Summary of care record for transitions of care 9. Submit electronic data to immunization registries 10. Submit electronic syndromic surveillance data to public health agencies

111 Drug Formulary Checks EP has enabled functionality for a drug formulary checks and has access to at least one internal or external formulary for the entire reporting period You can be excluded from meeting this objective if you write fewer than 100 prescriptions during the reporting period No longer a separate objective for Stage 2 It has been incorporated into the Stage 2 e-prescribing measure

112 Drug Formulary Changes Stage 1: Menu Item Stage 2: Removed as an objective Incorporated into the e-prescribing measure for Stage 2

113 Drug Formulary Checks Clinical Significance? When you prescribe a medication you will now need to consider if that medication is the best choice both for the condition and for the patient s medication formulary For example would it be best to prescribe Vigamox if it is nonformulary or would it make more sense to utilize Zymar instead if it is on the formulary? For each clinical condition there may be multiple medications that work This is a function of your certified EHR software e- prescribing system Be sure the functionality is turned on and active for your entire reporting period

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115 Incorporate Clinical Lab-Test Results More than 40% of all clinical lab test results ordered by the EP during the reporting period (whose results are in a +/- or numerical format) are incorporated in the EHR as structured data You can be excluded from this objective if you did not order any lab tests during the reporting period or if none of the lab tests ordered have results in a positive / negative or numerical format More than 55% of all clinical lab test results ordered by the EP during the reporting period (whose results are in a +/- or numerical format) are incorporated in the EHR as structured data You can be excluded from this objective if you did not order any lab tests during the reporting period or if none of the lab tests ordered have results in a positive / negative or numerical format

116 Clinical Lab-Test Results Changes Stage 1: Menu objective Requires > 40% of discrete lab test results to be stored as structured data Stage 2: Core objective Increased the percentage to > 55% of discrete lab test results to be stored as structured data

117 Incorporate clinical lab-test results Clinical Significance? This allows us to order lab tests directly from our EHR to a lab It will allow quicker lab orders and the results will be returned electronically Easier for us to order lab tests for conditions like recurring uveitis, diabetics, Graves disease This applies to lab results ordered by you during the reporting period whose results are either positive/negative or numerical format Typically blood, urine, path reports Many of us could take the exemption for not ordering any lab tests whose results are either in a positive/negative or numeric format during the EHR reporting period

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119 Generate Lists of Patients by Specific Conditions Generate at least one report listing patients of the EP with a specific condition No exclusion Generate at least one report listing patients of the EP with a specific condition No exclusion

120 Patient Lists Changes Stage 1: Menu Objective Stage 2: Core Objective No other changes

121 Generate lists of patients by specific conditions Clinical Significance? There may be times when you need to know every patient in your office that has a certain condition to offer them a new best treatment that becomes available New glaucoma medication or treatment option New contact lens material or type of lens All certified EHRs can generate a list of patients based on certain conditions The objective does not dictate the reports which must be generated An EP can determine which reports are most useful to their care efforts

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123 Patient Reminders (Stage 1) Preventive Care (Stage 2) More than 20% of all patients 65 years or older or 5 years or younger were sent the appropriate reminder during the reporting period You can be excluded from this objective if you have no patients 65 years or older or 5 years old or younger More than 10% of all unique patients who have had 2 or more office visits within the 24 months before the beginning of the reporting period were sent a reminder, per pt. preference when available You can be excluded if you have no office visits in the 24 months before the EHR reporting period

124 Patient Reminders / Preventive Care Changes Stage 1: Menu objective Required 20% of all patients 65 years or older or 5 years or younger to be sent reminder Stage 2: Core Measure Lowered the percentage to 10% but now includes all unique patients who have had 2 or more office visits within the 24 months before the beginning of the reporting period

125 Send Reminders to Patients for Preventive / Follow Up Care Clinical Significance? This allows us to properly follow up with our patients who need further care Do some of your patients with POAG need to follow up for an OCT or VF Do a group of your diabetic patients need to return for a DFE This is fairly easy to do in all certified EHR software There is no specific requirements for the reminders You have the discretion to determine the frequency, means of transmission and form of the reminder limited only by the requirements of HIPAA

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128 Electronic Access to Health Information for Patients At least 10% of all unique patients seen by the EP are provided timely (within 4 business days of being updated in the EHR) electronic access to their health information. You can be excluded from this objective if you do not order or create any of the following: Lab results, Problem list, Medication list, Medication allergy list This objective is no longer a measure for Stage 2

129 Stage 1 Electronic Access to Health Information for Patients Changes Required 2014 This objective will be eliminated from Stage 1 in 2014 New 2014 Measure: More than 50% of all unique patients seen by the EP during the EHR reporting period are provided timely (within 4 business days after the information is available to the EP) online access to their health information subject to the EP's discretion to withhold certain information

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132 Patient Specific Education Resources More than 10% of all unique patients seen by the EP are provided patient specific education resources No exclusion Patient-specific education resources identified by the EHR are provided to patients for more than 10% of all unique patients with office visits You can be excluded if you have no office visits during the reporting period

133 Patient Specific Educational Resources Changes Stage 1: Menu Objective Percentage required is 10% of all unique patients seen are given educational resources Stage 2: Core Objective Percentage remains at 10% but now is all unique patients with office visits Exclusion now available for EPs with no office visits

134 Patient specific education resources Clinical Significance? It is our job as a doctor to properly educate our patients on all of their clinical findings and diagnosis as well as risks and benefits of each treatment option Certified EHRs have the ability to identify patient specific educational resources based on the problem list, medication list, or lab test results The EHR technology should be used to suggest the patient educational resources The resources do not have to be stored within or generated by the EHR. AMD or ERM = Amsler Grid AMD = AREDS information as well

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