How to Play by the (Final) Rules: An Overview of Meaningful Use Stage 2 and the Standards and Certification Criteria Final Rules

Transcription

1 How to Play by the (Final) Rules: An Overview of Meaningful Use Stage 2 and the Standards and Certification Criteria Final Rules Presented by: - Farzad Mostashari, MD, ScM National Coordinator for Health IT, ONC - Rob Anthony - Office of ehealth Standards and Services, CMS - Steve Posnack, MHS, MS, CISSP - Director of the Federal Policy Division, ONC Moderated by: - Kate Berry, CEO, NeHC August 24, 2012

2 Join the new NeHC membership program Benefits of being a NeHC member include: Visibility and public recognition as participating with an influential national health IT organization Members-only opportunities for networking with public and private sector health IT thought leaders Strategic workgroup and program-level leadership opportunities Unlimited access to NeHC University classes and materials at no charge Access to additional informational resources through members-only website content and newsletter Discounted sponsorship of NeHC conferences and meetings Semi-annual member briefings Learn more at or us at cellison@nationalehealth.org

3 NeHC Members My-Villages, Inc. Because it takes one

4 Upcoming NeHC University Programs August 28 & August 30 Noon to 1:30 PM ET: How to Play by the (Final) Rules: An Overview of Meaningful Use Stage 2 & the Standards and Certification Criteria Final Rules (Repeat Programs) Rob Anthony, CMS Steve Posnack, ONC Mark Your Calendar September 5: HIT Orientation 2:30 to 4 pm ET Gwenn Darlinger, Quest Diagnostics September 11: Rural Health IT Landscape 1 to 2:30 ET Chantal Worzala, American Hospital Association Earle Rugg, Rural Health IT Corporation

5 Presentation slides are now available! Recorded webinar will be on our websiteby 5:00PM ET. Full transcript will be available in approximately 7 to 10 days. Want more? You can also continue today s discussion by joining the Meaningful Use group in NeHC s online community:

6 Please enter your questions in the Q&A window at the bottom right of your screen You can also send us an at tweet a question using hashtag #NeHC, or comment on our Facebook page at

7 Medicare & Medicaid EHR Incentive Programs Stage 2 Final Rule Robert Anthony, Centers for Medicare & Medicaid Services NeHC

8 What is in the Rule Changes to Stage 1 of meaningful use Stage 2 of meaningful use New clinical quality measures New clinical quality measure reporting mechanisms Payment adjustments and hardships Medicaid program changes 8

9 What Stage 2 Means to You New Criteria Starting in 2014, providers participating in the EHR Incentive Programs who have met Stage 1 for two or three years will need to meet meaningful use Stage 2 criteria. Improving Patient Care Stage 2 includes new objectives to improve patient care through better clinical decision support, care coordination and patient engagement. Saving Money, Time, Lives With this next stage, EHRs will further save our health care system money, save time for doctors and hospitals, and save lives. 9

10 Stage 2 Eligibility 10

11 EHR Incentive Program Eligibility 1. In general, eligibility is determined by the HITECH Act. 2. There have been no changes to the HITECH Act. 3. Therefore the only eligibility changes are those within our regulatory purview under the Medicaid EHR Incentive Program. 11

12 Stage 2 Change: Hospital-Based EP Definition EPs can demonstrate that they fund the acquisition, implementation, and maintenance of CEHRT, including supporting hardware and interfaces needed for meaningful use without reimbursement from an eligible hospital or CAH in lieu of using the hospital s CEHRT can be determined non-hospital-based and potentially receive an incentive payment. Determination will be made through an application process. 12

13 Stage 2 Meaningful Use 13

14 What is Your Meaningful Use Path? For Medicare EPs: 14

15 What is Your Meaningful Use Path? For Medicare Hospitals: 15

16 Meaningful Use: Changes from Stage 1 to Stage 2 Stage 1 Eligible Professionals 15 core objectives 5 of 10 menu objectives 20 total objectives Stage 2 Eligible Professionals 17 core objectives 3 of 6 menu objectives 20 total objectives Eligible Hospitals & CAHs 14 core objectives 5 of 10 menu objectives 19 total objectives Eligible Hospitals & CAHs 16 core objectives 3 of 6 menu objectives 19 total objectives 16

17 Changes to Meaningful Use Changes Menu Objective Exclusion While you can continue to claim exclusions if applicable for menu objectives, starting in 2014 these exclusions will no longer count towards the number of menu objectives needed. No Changes Half of Outpatient Encounters at least 50% of EP outpatient encounters must occur at locations equipped with certified EHR technology. Measure compliance = objective compliance Denominators based on outpatient locations equipped with CEHRT and include all such encounters or only those for patients whose records are in CEHRT depending on the measure. 17

18 2014 Changes 1. EHRs Meeting ONC 2014 Standards starting in 2014, all EHR Incentive Programs participants will have to adopt certified EHR technology that meets ONC s Standards & Certification Criteria 2014 Final Rule 2. Reporting Period Reduced to Three Months to allow providers time to adopt 2014 certified EHR technology and prepare for Stage 2, all participants will have a threemonth reporting period in

19 Stage 2: Batch Reporting Stage 2 rule allows for batch reporting. What does that mean? Starting in 2014, groups will be allowed to submit attestation information for all of their individual EPs in one file for upload to the Attestation System, rather than having each EP individually enter data. 19

20 EPs must meet all 17 core objectives: Core Objective 1. CPOE Stage 2 EP Core Objectives 2. E-Rx E-Rx for more than 50% Measure Use CPOE for more than 60% of medication, 30% of laboratory, and 30% of radiology 3. Demographics Record demographics for more than 80% 4. Vital Signs Record vital signs for more than 80% 5. Smoking Status Record smoking status for more than 80% 6. Interventions Implement 5 clinical decision support interventions + drug/drug and drug/allergy 7. Labs Incorporate lab results for more than 55% 8. Patient List Generate patient list by specific condition 9. Preventive Reminders Use EHR to identify and provide reminders for preventive/follow-up care for more than 10% of patients with two or more office visits in the last 2 years 20

21 Stage 2 EP Core Objectives EPs must meet all 17 core objectives: Core Objective 10. Patient Access 11. Visit Summaries 12. Education Resources Measure Provide online access to health information for more than 50% with more than 5% actually accessing Provide office visit summaries for more than 50% of office visits Use EHR to identify and provide education resources more than 10% 13. Secure Messages More than 5% of patients send secure messages to their EP 14. Rx Reconciliation 15. Summary of Care Medication reconciliation at more than 50% of transitions of care Provide summary of care document for more than 50% of transitions of care and referrals with 10% sent electronically and at least one sent to a recipient with a different EHR vendor or successfully testing with CMS test EHR 16. Immunizations Successful ongoing transmission of immunization data 17. Security Analysis Conduct or review security analysis and incorporate in risk management process 21

22 Stage 2 EP Menu Objectives EPs must select 3 out of the 6: Menu Objective 1. Imaging Results Measure More than 20% of imaging results are accessible through Certified EHR Technology 2. Family History Record family health history for more than 20% 3. Syndromic Surveillance 4. Cancer 5. Specialized Registry 6. Progress Notes Successful ongoing transmission of syndromic surveillance data Successful ongoing transmission of cancer case information Successful ongoing transmission of data to a specialized registry Enter an electronic progress note for more than 30% of unique patients 22

23 Stage 2 Hospital Core Objectives Eligible hospitals must meet all 16 core objectives: Core Objective 1. CPOE Measure Use CPOE for more than 60% of medication, 30% of laboratory, and 30% of radiology 2. Demographics Record demographics for more than 80% 3. Vital Signs Record vital signs for more than 80% 4. Smoking Status Record smoking status for more than 80% 5. Interventions Implement 5 clinical decision support interventions + drug/drug and drug/allergy 6. Labs Incorporate lab results for more than 55% 7. Patient List Generate patient list by specific condition 8. emar emar is implemented and used for more than 10% of medication orders 23

24 Stage 2 Hospital Core Objectives Eligible hospitals must meet all 16 core objectives: Core Objective 9. Patient Access 10. Education Resources 11. Rx Reconciliation 12. Summary of Care 24 Measure Provide online access to health information for more than 50% with more than 5% actually accessing Use EHR to identify and provide education resources more than 10% Medication reconciliation at more than 50% of transitions of care Provide summary of care document for more than 50% of transitions of care and referrals with 10% sent electronically and at least one sent to a recipient with a different EHR vendor or successfully testing with CMS test EHR 13. Immunizations Successful ongoing transmission of immunization data 14. Labs 15. Syndromic Surveillance 16. Security Analysis Successful ongoing submission of reportable laboratory results Successful ongoing submission of electronic syndromic surveillance data Conduct or review security analysis and incorporate in risk management process

25 Stage 2 Hospital Menu Objectives Eligible Hospitals must select 3 out of the 6: Menu Objective 1. Progress Notes 2. E-Rx 3. Imaging Results Measure Enter an electronic progress note for more than 30% of unique patients More than 10% electronic prescribing (erx) of discharge medication orders More than 20% of imaging results are accessible through Certified EHR Technology 4. Family History Record family health history for more than 20% 5. Advanced Directives 6. Labs Record advanced directives for more than 50% of patients 65 years or older Provide structured electronic lab results to EPs for more than 20% 25

26 Closer Look at Stage 2: Patient Engagement Patient engagement engagement is an important focus of Stage 2. Requirements for Patient Action: More than 5% of patients must send secure messages to their EP More than 5% of patients must access their health information online EXCULSIONS CMS is introducing exclusions based on broadband availability in the provider s county. 26

27 Closer Look at Stage 2: Electronic Exchange Stage 2 focuses on actual use cases of electronic information exchange: Stage 2 requires that a provider send a summary of care record for more than 50% of transitions of care and referrals. The rule also requires that a provider electronically transmit a summary of care for more than 10% of transitions of care and referrals. At least one summary of care document sent electronically to recipient with different EHR vendor or to CMS test EHR. 27

28 Changes to Stage 1: CPOE Current Stage 1 Measure New Stage 1 Option Denominator= Unique patient with at least one medication in their medication list Denominator= Number of orders during the EHR Reporting Period This optional CPOE denominator is available in 2013 and beyond for Stage 1 28

29 Changes to Stage 1: Vital Signs Current Stage 1 Measure New Stage 1 Measure Age Limits= Age 2 for Blood Pressure & Height/ Weight Age Limits= Age 3 for Blood Pressure, No age limit for Height/ Weight Exclusion= All three elements not relevant to scope of practice Exclusion= Blood pressure to be separated from height /weight The vital signs changes are optional in 2013, but required starting in

30 Changes to Stage 1: Testing of HIE Current Stage 1 Measure Stage 1 Measure Removed One test of electronic transmission of key clinical information Requirement removed effective 2013 The removal of this measure is effective starting in

31 Changes to Stage 1: E-Copy & Online Access Current Stage 1 Objective New Stage 1 Objective Objective= Provide patients with e-copy of health information upon request Provide electronic access to health information Objective= Provide patients the ability to view online, download and transmit their health information The measure of the new objective is 50% of patients have accessed their information; there is no requirement that 5% of patients do access their information for Stage 1. The change in objective takes effect in 2014 to coincide with the 2014 certification and standards criteria 31 31

32 Changes to Stage 1: Public Health Objectives Current Stage 1 Objectives New Stage 1 Addition Immunizations Reportable Labs Addition of except where prohibited to all three objectives Syndromic Surveillance This addition is for clarity purposes and does not change the Stage 1 measure for these objectives. 32

33 Clinical Quality Measures 33

34 How do CQMs relate to the CMS Incentive Programs? Although reporting CQMs is no longer a core objective of the EHR Incentive Programs, all providers are required to report on CQMs in order to demonstrate meaningful use. In 2014 and beyond, reporting programs (i.e., PQRS, erx reporting) will be streamlined in order to reduce provider burden. 34

35 Alignment Among Programs 2014 represents CMS s commitment to aligning quality measurement and reporting among programs, including Hospital Inpatient Quality Reporting Program, PQRS, CHIPRA, and ACO Programs Hospital Inpatient Quality Reporting Program PQRS CHIPRA ACO 35

36 Alignment Among Programs Alignment includes: Choosing the same measures for different program measure sets Coordinating quality measurement stakeholder involvement efforts and opportunities for public input Identifying ways to minimize multiple submission requirements and mechanisms 36

37 Alignment Among Programs Lessen provider burden Harmonize with data exchange priorities Support primary goal of all CMS quality measurement programs Transforming our health care system to provide: Higher quality care Better health outcomes Lower cost through improvement 37

38 CQM Alignment with HHS Priorities All providers must select CQMs from at least 3 of the 6 HHS National Quality Strategy domains: Patient and Family Engagement Patient Safety Care Coordination Population and Public Health Efficient Use of Healthcare Resources Clinical Processes/Effectiveness 38

39 CQMs in 2014 and Beyond A complete list of 2014 CQMs and their associated National Quality Strategy domains will be posted on the CMS EHR Incentive Programs website ( in the future. CMS will also post a recommended core set of CQMs for EPs that focus on highpriority health conditions. 39

40 Reporting CQMs in 2014 Beginning in 2014, all Medicare-eligible providers in their second year and beyond of demonstrating meaningful use must electronically report their CQM data to CMS. Medicaid providers will electronically report their CQM data to their state. and Beyond 40

41 CQMs in 2014 and Beyond CQMs change in 2014: Provider Prior to and Beyond* EPs Complete 6 out of 44 3 core or 3 alt. core 3 menu Complete 9 out of 64 Choose at least 1 measure in 3 NQS domains Recommended core CQMs include: 9 CQMs for the adult population 9 CQMs for the pediatric population Prioritize NQS domains Eligible Hospitals and CAHs Complete 15 out of 15 Complete 16 out of 29 Choose at least 1 measure in 3 NQS domains *Regardless of the stage of meaningful use, all providers will complete this number of CQMs in

42 Reporting CQMs in 2014 and Beyond Eligible Professionals reporting for the Medicare EHR Incentive Program Category Data Level Payer Level Submission Type Reporting Schema EPs in 1 st Year of Demonstrating MU* Aggregate All payer Attestation Submit 9 CQMs from EP measures table (includes adult and pediatric recommended core CQMs), covering at least 3 domains EPs Beyond the 1 st Year of Demonstrating Meaningful Use Option 1 Aggregate All payer Electronic Submit 9 CQMs from EP measures table (includes adult and pediatric recommended core CQMs), covering at least 3 domains Option 2 Patient Medicare Only Electronic Satisfy requirements of PQRS EHR Reporting Option using CEHRT Group Reporting (only EPs Beyond the 1 st Year of Demonstrating Meaningful Use)** EPs in an ACO (Medicare Shared Savings Program or Pioneer ACOs) Patient Medicare Only Electronic Satisfy requirements of Medicare Shared Savings Program of Pioneer ACOs using CEHRT EPs satisfactorily reporting via PQRS group reporting options Patient Medicare Only Electronic Satisfy requirements of PQRS group reporting options using CEHRT *Attestation is required for EPs in their 1 st year of demonstrating MU because it is the only reporting method that would allow them to meet the submission deadline of October 1 to avoid a payment adjustment. **Groups with EPs in their 1 st year of demonstrating MU can report as a group, however the individual EP(s) who are in their 1 st year must attest to their CQM results by October 1 to avoid a payment adjustment. 42

43 Reporting CQMs in 2014 and Beyond Eligible Hospitals reporting for the Medicare EHR Incentive Program Category Data Level Payer Level Submission Type Reporting Schema Eligible Hospitals in 1 st Year of Demonstrating MU* Aggregate All payer Attestation Submit 16 CQMs from Eligible Hospital/CAH measures table, covering at least 3 domains Eligible Hospitals/CAHs Beyond the 1 st Year of Demonstrating Meaningful Use Option 1 Aggregate All payer Electronic Submit 16 CQMs from Eligible Hospital/CAH measures table, covering at least 3 domains Option 2 Patient All payer (sample) Electronic Submit 16 CQMs from Eligible Hospital/CAH measures table, covering at least 3 domains Manner similar to the 2012 Medicare EHR Incentive Program Electronic Reporting Pilot 43

44 CQM Timing Time periods for reporting CQMs NO CHANGE from Stage 1 to Stage 2 Provider Type Reporting Period for 1 st year of MU (Stage 1) Submission Period for 1 st year of MU (Stage 1) Reporting Period for Subsequent years of MU (2 nd year and beyond) Submission Period for Subsequent years of MU (2 nd year and beyond) EP 90 consecutive days within the calendar year Anytime immediately following the end of the 90-day reporting period, but no later than February 28 of the following calendar year 1 calendar year (January 1 December 31) 2 months following the end of the EHR reporting period (January 1 February 28) Eligible Hospital/ CAH 90 consecutive days within the fiscal year Anytime immediately following the end of the 90-day reporting period, but no later than November 30 of the following fiscal year 1 fiscal year (October 1 September 30) 2 months following the end of the EHR reporting period (October 1 November 30) 44

45 2014 CQM Quarterly Reporting For Medicare providers, the month reporting period is fixed to the quarter of either the fiscal (for eligible hospitals and CAHs) or calendar (for EPs) year in order to align with existing CMS quality measurement programs. In subsequent years, the reporting period for CQMs would be the entire calendar year (for EPs) or fiscal year (for eligible hospitals and CAHs). Provider Type EP Eligible Hospital/CAH Optional Reporting Period in 2014* Calendar year quarter: January 1 March 31 April 1 June 30 July 1 September 30 October 1 December 31 Fiscal year quarter: October 1 December 31 January 1 March 31 April 1 June 30 July 1 September 30 Reporting Period for Subsequent Years of Meaningful Use (Stage 1 and Subsequent Stages) 1 calendar year (January 1 - December 31) 1 fiscal year (October 1 - September 30) Submission Period for Subsequent Years of Meaningful Use (Stage 1 and Subsequent Stages) 2 months following the end of the reporting period (January 1 - February 28) 2 months following the end of the reporting period (October 1 - November 30) 45

46 Core CQMs for EPs CMS selected the CQMs for the proposed core set 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/ population health priorities Conditions that are common to health disparities 46

47 Core CQMs for EPs (cont d) 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 47

48 CQM Reporting in 2013 CQMs will remain the same through Electronic specifications for the CQMs will be updated. In 2012 and continued in 2013, there are two reporting methods available for reporting the Stage 1 measures: Attestation ereporting pilots Physician Quality Reporting System EHR Incentive Program Pilot for EPs ereporting Pilot for eligible hospitals and CAHs Medicaid providers submit CQMs through their state-based attestation submissions. 48

49 Payment Adjustments & Hardship Exceptions Medicare Only EPs, Subsection (d) Hospitals and CAHs 49

50 Payment Adjustments The HITECH Act stipulates that for Medicare EP, subsection (d) hospitals and CAHs a payment adjustment applies if they are not a meaningful EHR user. An EP, subsection (d) hospital or CAH becomes a meaningful EHR user when they successfully attest to meaningful use under either the Medicare or Medicaid EHR Incentive Program Adopt, implement and upgrade meaningful use A provider receiving a Medicaid incentive for AIU would still be subject to the Medicare payment adjustment. 50

51 EP Payment Adjustments % Adjustment shown below assumes less than 75% of EPs are meaningful users for CY 2018 and subsequent years EP is not subject to the payment adjustment for e-rx in 2014 EP is subject to the payment adjustment for e-rx in % 98% 97% 96% 95% 95% 98% 98% 97% 96% 95% 95% % Adjustment shown below assumes more than 75% of EPs are meaningful users for CY 2018 and subsequent years EP is not subject to the payment adjustment for e-rx in % 98% 97% 97% 97% 97% EP is subject to the payment adjustment for e-rx in % 98% 97% 97% 97% 97% 51

52 EP EHR Reporting Period Payment adjustments are based on prior years reporting periods. The length of the reporting period depends upon the first year of participation. For an EP who has demonstrated meaningful use in 2011 or 2012: Payment Adjustment Year Based on Full Year EHR Reporting Period To Avoid Payment Adjustments: EPs must continue to demonstrate meaningful use every year to avoid payment adjustments in subsequent years. 52

53 EP EHR Reporting Period For an EP who demonstrates meaningful use in 2013 for the first time: Payment Adjustment Year Based on 90 day EHR Reporting Period 2013 Based on Full Year EHR Reporting Period To Avoid Payment Adjustments: EPs must continue to demonstrate meaningful use every year to avoid payment adjustments in subsequent years. 53

54 EP EHR Reporting Period EP who demonstrates meaningful use in 2014 for the first time: Payment Adjustment Year Based on 90 day EHR Reporting Period 2014* 2014 Based on Full Year EHR Reporting Period *In order to avoid the 2015 payment adjustment the EP must attest no later than October 1, 2014, which means they must begin their 90 day EHR reporting period no later than July 1,

55 Payment Adjustments for Providers Eligible for Both Programs Eligible for both programs? If you are eligible to participate in both the Medicare and Medicaid EHR Incentive Programs, you MUST demonstrate meaningful use according to the timelines in the previous slides to avoid the payment adjustments. You may demonstrate meaningful use under either Medicare or Medicaid. Note: Congress mandated that an EP must be a meaningful user in order to avoid the payment adjustment; therefore receiving a Medicaid EHR incentive payment for adopting, implementing, or upgrading your certified EHR Technology would not exempt you from the payment adjustments. 55

56 Subsection (d) Hospital Payment Adjustments % Decrease in the Percentage Increase to the IPPS* Payment Rate that the hospital would otherwise receive for that year: % Decrease 25% 50% 75% 75% 75% 75% Example: If the increase to IPPS for 2015 was 2%, than a hospital subject to the payment adjustment would only receive a 1.5% increase 2% increase X 25% =.5% payment adjustment OR 1.5% increase total *Inpatient Prospective Payment System (IPPS) 56

57 Subsection (d) Hospital EHR Reporting Period Payment adjustments are based on prior years reporting periods. The length of the reporting period depends upon the first year of participation. For a hospital that has demonstrated meaningful use in 2011 or 2012 (fiscal years): Payment Adjustment Year Based on Full Year EHR Reporting Period For a hospital that demonstrates meaningful use in 2013 for the first time: Payment Adjustment Year Based on 90 day EHR Reporting Period 2013 Based on Full Year EHR Reporting Period To Avoid Payment Adjustments: Eligible hospitals must continue to demonstrate meaningful use every year to avoid payment adjustments in subsequent years. 57

58 Subsection (d) Hospital EHR Reporting Period For a hospital that demonstrates meaningful use in 2014 for the first time: Payment Adjustment Year Based on 90 day EHR Reporting Period 2014* 2014 Based on Full Year EHR Reporting Period *In order to avoid the 2015 payment adjustment the hospital must attest no later than July 1, 2014 which means they must begin their 90 day EHR reporting period no later than April 1,

59 Critical Access Hospital (CAH) Payment Adjustments Applicable % of reasonable costs reimbursement which absent payment adjustments is 101%: % of reasonable costs % % 100% 100% 100% 100% Example: If a CAH has not demonstrated meaningful use for an applicable reporting period, then for a cost reporting period that begins in FY 2015, its reimbursement would be reduced from 101 percent of its reasonable costs to percent. 59

60 CAH EHR Reporting Period Payment adjustments for CAHs are also based on prior years reporting periods. The length of the reporting period depends upon the first year of participation. For a CAH who has demonstrated meaningful use prior to 2015 (fiscal years): Payment Adjustment Year Based on Full Year EHR Reporting Period For a CAH who demonstrates meaningful use in 2015 for the first time: Payment Adjustment Year Based on 90 day EHR Reporting Period 2015 Based on Full Year EHR Reporting Period To Avoid Payment Adjustments: CAHs must continue to demonstrate meaningful use every year to avoid payment adjustments in subsequent years. 60

61 EP Hardship Exceptions EPs can apply for hardship exceptions in the following categories: 1. Infrastructure EPs must demonstrate that they are in an area without sufficient internet access or face insurmountable barriers to obtaining infrastructure (e.g., lack of broadband). 2. New EPs Newly practicing EPs who would not have had time to become meaningful users can apply for a 2-year limited exception to payment adjustments. 4. EPs must demonstrate that they meet the following criteria: Lack of face-to-face or telemedicine interaction with patients Lack of follow-up need with patients 5. EPs who practice at multiple locations must demonstrate that they: Lack of control over availability of CEHRT for more than 50% of patient encounters 3. Unforeseen Circumstances Examples may include a natural disaster or other unforeseeable barrier. 61

62 EP Hardship Exceptions EPs whose primary specialties are anesthesiology, radiology or pathology: As of July 1 st of the year preceding the payment adjustment year, EPs in these specialties will receive a hardship exception based on the 4 th criteria for EPs EPs must demonstrate that they meet the following criteria: o Lack of face-to-face or telemedicine interaction with patients o Lack of follow-up need with patients 62

63 Eligible Hospital and CAH Hardship Exceptions Eligible hospitals and CAHs can apply for hardship exceptions in the following categories 1. Infrastructure Eligible hospitals and CAHs must demonstrate that they are in an area without sufficient internet access or face insurmountable barriers to obtaining infrastructure (e.g., lack of broadband). 2. New Eligible Hospitals or CAHs New eligible hospitals and CAHs with new CMS Certification Numbers (CCNs) that would not have had time to become meaningful users can apply for a limited exception to payment adjustments. limited to one full year after the CAH accepts its first patient. For eligible hospitals the hardship exception is limited to one full-year cost reporting period. 3. Unforeseen Circumstances Examples may include a natural disaster or other unforeseeable barrier. For CAHs the hardship exception is 63

64 Applying for Hardship Exceptions Applying: EPs, eligible hospitals, and CAHs must apply for hardship exceptions to avoid the payment adjustments. Granting Exceptions: Hardship exceptions will be granted only if CMS determines that providers have demonstrated that those circumstances pose a significant barrier to their achieving meaningful use. Deadlines: Applications need to be submitted no later than April 1 for hospitals, and July 1 for EPs of the year before the payment adjustment year; however, CMS encourages earlier submission For More Info: Details on how to apply for a hardship exception will be posted on the CMS EHR Incentive Programs website in the future: 64

65 Medicaid-Specific Changes 65

66 Medicaid Eligibility Expansion Patient Encounters: The definition of what constitutes a Medicaid patient encounter has changed. The rule includes encounters for anyone enrolled in a Medicaid program, including Medicaid expansion encounters (except stand-alone Title 21), and those with zero-pay claims. The rule adds flexibility in the look-back period for overall patient volume. 66

67 Provider Eligibility: Patient Medicaid Encounters: Volume Calculation Previously under Stage 1 rule: o Service rendered on any one day where Medicaid paid for all or part of the service or Medicaid paid the copays, cost-sharing, or premiums Changed in Stage 2 rule (applicable to all stages): o Service rendered on any one day to a Medicaid-enrolled individual, regardless of payment liability o Includes zero-pay claims and encounters with patients in Title 21-funded Medicaid expansions (but not separate CHIPs) 67

68 Provider Eligibility: Patient Volume Calculation Zero-pay claims include: Claim denied because the Medicaid beneficiary has maxed out the service limit Claim denied because the service wasn t covered under the State s Medicaid program Claim paid at $0 because another payer s payment exceeded the Medicaid payment Claim denied because claim wasn t submitted timely Such services can be included in provider s Medicaid patient volume calculation as long as the services were provided to a beneficiary who is enrolled in Medicaid 68

69 Provider Eligibility: Patient Volume Calculation CHIP encounters to include in patient volume calculation: Previously under Stage 1 rule: o Only CHIP encounters for patients in Title 19 Medicaid expansion programs Under Stage 2 rule (applicable to all stages): o CHIP encounters for patients in Title 19 and Title 21 Medicaid expansion programs As before, encounters with patients in stand-alone CHIP programs cannot be included in Medicaid patient volume calculation 69

70 Provider Eligibility: Patient Volume Calculation 90-day period for Medicaid patient volume calculation: Under Stage 1 rule, Medicaid patient volume for providers calculated across 90-day period in last calendar year (for EPs) or Federal fiscal year (for hospitals) Under Stage 2 rule (applicable to all stages), States also have option to allow providers to calculate Medicaid patient volume across 90-day period in last 12 months preceding provider s attestation Also applies to needy individual patient volume Applies to patient panel methodology, too o With at least one Medicaid encounter taking place in the 24 months prior to 90-day period (expanded from 12 months prior) 70

71 Children s Hospitals Medicaid made approximately 12 additional children s hospitals eligible that have not been able to participate to date, despite meeting all other eligibility criteria, because they do not have a CMS Certification Number since they do not bill Medicare. 71

72 Hospital Incentive Calculation Changes under Stage 2 rule for determining discharge-related amount: Hospitals that begin participating in FFY 2013 or later use discharge data from most recent continuous 12-month period for which data are available prior to payment year Hospitals that began participating before FFY 2013 use discharge data from hospital fiscal year that ends during FFY prior to hospital fiscal year that services as the first payment year 72

73 Stage 2 Resources CMS Stage 2 Webpage: Guidance/Legislation/EHRIncentivePrograms/Stage_2.html Links to the Federal Register Tipsheets: Stage 2 Overview 2014 Clinical Quality Measures Payment Adjustments & Hardship Exceptions (EPs & Hospitals) Stage 1 Changes Stage 1 vs. Stage 2 Tables (EPs & Hospitals) 73

74 2014 Edition Standards & Certification Criteria Final Rule Steve Posnack, MHS, MS, CISSP Director, Federal Policy Division

75 S&CC 2014 Edition Final Rule Major Themes Enhancing standards-based exchange Promoting EHR technology safety and security Enabling greater patient engagement Introducing greater transparency Reducing regulatory burden 75

76 S&CC and Meaningful Use Complementary but Different Scopes S&CC scope = technical Specifies the capabilities EHR technology must include and how they need to perform in order to be certified It does not specify how the EHR technology needs to be used Meaningful use scope = behavioral Specifies how eligible providers need to use Certified EHR Technology in order to receive incentives 76

77 NPRM versus Final Rule S&CC February (a) Clinical (n=18) (b) Care Coordination (n=6) (c) CQMs (n=3) (d) Privacy and Security (n=9*) (e) Patient Engagement (n=3) (f) Public Health (n=8) (g) Utilization (n=4) S&CC August (a) Clinical (n=17) (b) Care Coordination (n=7) (c) CQMs (n=3) (d) Privacy and Security (n=9*) (e) Patient Engagement (n=3) (f) Public Health (n=6*) (g) Utilization (n=4) * = includes optional certification criteria 77

78 New Certification Criteria Ambulatory & Inpatient Inpatient Only Ambulatory Only Electronic Notes Image results Family Health History Amendments View, Download, & Transmit to 3 rd party Auto numerator recording Non-%-based measure use report Safety-enhanced design Quality management system Electronic medication administration record erx (for discharge) Transmission of electronic lab tests and values/results to ambulatory providers Secure messaging Cancer case information Transmission to cancer registries Data Portability 78

79 Revised Certification Criteria Drug-drug, drug-allergy interaction checks Ambulatory & Inpatient Vital signs, body mass index, and growth charts Ambulatory Only Demographics CQMs (3 criteria) Clinical summaries Clinical information reconciliation Problem list Clinical decision support Incorporate lab tests and values/results End-user device encryption Auditable events and tamper-resistance erx Inpatient Only Drug-formulary checks TOC receive, display, and incorporate toc/referral summaries Patient list creation Smoking status Transmission to Immunization Registries Audit report(s) TOC create and transmit toc/referral summaries Patient-specific education resources Automated measure calculation Transmission to public health agencies syndromic surveillance Transmission of reportable lab tests and values/results 79

80 Unchanged Certification Criteria CPOE Medication list Ambulatory & Inpatient Advance directives Immunization information Medication allergy list Authentication, access control, & authorization Integrity Incorporate lab test results (inpatient only) Vital signs, body mass index, and growth charts Patient lists Public health surveillance Automatic log-off Emergency access Accounting of disclosures Smoking status Drug-formulary checks Patient reminders Reportable laboratory tests and values/results These certification criteria would be eligible for gap certification 80

81 Revised Certified EHR Technology (CEHRT) Definition July 2010 Final Rule Policy Static Definition Driven by Certification Criteria August 2012 Final Rule Policy Dynamic Definition Driven by Meaningful Use Still available option and effective through 2013 in addition to other flexibilities Would be available as soon as final rule is effective and once EHR technology certified to the 2014 Edition EHR certification criteria is available 81

82 Revised CEHRT Definition Most important point: Quantity Quantity Quantity It is all about the quantity of EHR technology certified to the 2014 Edition EHR certification criteria for MU stage you seek to meet. EHR technology developers have the opportunity to rethink EHR software package(s) to offer right size certifications to their customers. 82

83 2014 Edition CEHRT Easy as 1, 2, 3 + C* What varies is the quantity of EHR technology certified to the 2014 Edition EHR certification criteria that would be necessary EP/EH/CAH would only need to have EHR technology with capabilities certified for the MU menu set objectives & measures for the stage of MU they seek to achieve. EP/EH/CAH would need to have EHR technology with capabilities certified for the MU core set objectives & measures for the stage of MU they seek to achieve unless the EP/EH/CAH can meet an exclusion. Base EHR 1 EP/EH/CAH must have EHR technology with capabilities certified to meet the Base EHR definition. *C = CQMs 83

84 Certification Criteria Assigned to Final Base EHR Definition It is a definition. It is meant to be used like a checklist to meet the CEHRT definition. It is not a Base EHR or a singular type of EHR technology that has these capabilities. The Base EHR definition includes CQM requirements not specified in this table Edition EHR Certification Criteria Required to Satisfy the Base EHR Definition EHR technology that: Certification Criteria Demographics (a)(3) Includes patient demographic and Vital Signs (a)(4) clinical health information, such as Problem List (a)(5) medical history and problem lists Medication List (a)(6) Medication Allergy List (a)(7) Has the capacity to provide clinical decision support Has the capacity to support physician order entry Has the capacity to capture and query information relevant to health care quality Has the capacity to exchange electronic health information with, and integrate such information from other sources Drug-Drug and Drug-Allergy Interaction Checks (a)(2) Clinical Decision Support (a)(8) Computerized Provider Order Entry (a)(1) Clinical Quality Measures (c)(1) through (3) Transitions of Care (b)(1) and (2) Data Portability (b)(7) View, Download, and Transmit to 3rd Party (e)(1) N/A N/A N/A Has the capacity to protect the confidentiality, integrity, and availability of health information stored and exchanged Privacy and Security (d)(1) through (8) 84

85 Understanding the CEHRT Definition Quantity Spectrum Vendor A Vendor B Vendor X Vendor A Vendor B Vendor C MU Edition Complete EHR 2014 Edition EHR Module Approaches MU1 Base EHR MU2 Menu MU1 Menu MU1 Core Base EHR MU2 Menu MU1 Core Base EHR MU1 Menu MU1 Core Base EHR Vendor A Vendor B MU1 Menu MU1 Core Base EHR MU2 Menu MU1 Core Base EHR MU2 Menu MU1 Core Base EHR Vendor A Vendor B Stage 1 EP/EH Stage 2 EP/EH Stage 1 EP/EH Stage 1 EP/EH w/exclusions Stage 2 EP/EH Stage 2 EP/EH w/exclusions

86 Now 3 ways to meet CEHRT definition Complete EHR (ultimate assurance) EHR Module(s): Combination of EHR Modules Single EHR Module In the case of EHR Modules, it is now possible for an eligible provider to have just enough EHR technology certified to the 2014 Edition EHR certification criteria to meet the CEHRT definition. 86

87 Revised Definition of CEHRT Effective Dates EHR Reporting Period FY/CY 2011 FY/CY 2012 FY/CY 2013 FY/CY2014 MU Stage 1 MU Stage 1 MU Stage 1 MU Stage 1 or MU Stage 2 All EPs, EHs, and CAHs must have: 1) EHR technology that has been certified to all applicable 2011 Edition EHR certification criteria or equivalent 2014 Edition EHR certification criteria adopted by the Secretary; or 2) EHR technology that has been certified to the 2014 Edition EHR certification criteria that meets the Base EHR definition and would support the objectives, measures, and their ability to successfully report CQMs, for MU Stage 1. All EPs, EHs, and CAHs must have EHR technology certified to the 2014 Edition EHR certification criteria that meets the Base EHR definition and would support the objectives, measures, and their ability to successfully report the CQMs, for the MU stage that they seek to achieve. There is no such thing as being Stage 1 Certified or Stage 2 Certified 2014 Edition EHR technology would be able to support the achievement of either meaningful use Stage. 87

88 2014 Certification Criteria associated with MU Core Stage 2: Drug-drug, drug-allergy interaction checks ( (a)(2)) Vital signs, BMI, & growth charts ( (a)(4)) Smoking status ( (a)(11)) Patient list creation ( (a)(14)) Patient-specific education resources ( (a)(15)) emar ( (a)(16)) Clinical information reconciliation ( (b)(4)) Incorporate lab tests & values/results ( (b)(5)) View, download, & transmit to 3 rd Party ( (e)(1)) Immunization information ( (f)(1)) Transmission to immunization registries ( (f)(2)) Transmission to PH agencies syndromic surveillance ( (f)(3)) Transmission of reportable lab tests & values/results ( (f)(4)) *= optional MU Menu MU Core Base EHR 2014 ed. certification criteria for which certification may be required: Automated numerator recording ( (g)(1)) Automated measure calculation ( (g)(2)) Safety-enhanced design ( (g)(3)) Quality management system ( (g)(4)) 2014 Certification Criteria associated with a Base EHR: CPOE ( (a)(1)) Demographics ( (a)(3)) Problem list ( (a)(5)) Medication list ( (a)(6)) Medication allergy list ( (a)(7)) Clinical decision support ( (a)(8)) Transitions of care ( (b)(1) & (2)) Data portability ( (b)(7)) Clinical quality measures ( (c)(1) - (3)) Privacy and Security CC: o Authentication, access control, & authorization ( (d)(1)) o Auditable events & tamper resistance ( (d)(2)) o Audit report(s) ( (d)(3)) o Amendments ( (d)(4)) o Automatic log-off ( (d)(5)) o Emergency access ( (d)(6)) o End-user device encryption ( (d)(7)) o Integrity ( (d)(8)) o Accounting of disclosures* ( (d)(9)) 2014 Certification Criteria associated with MU Menu Stage 2: Electronic notes ( (a)(9)) Drug-formulary checks ( (a)(10)) Image results ( (a)(12)) Family health history ( (a)(13)) Advance directives ( (a)(17)) erx ( (b)(3)) Transmission of e-lab tests & values/results to providers ( (b)(6))

89 Do you have EHR Technology that meets the new Certified EHR Technology definition for Meaningful Use Stage 1? START HERE Do you have a 2014 Edition Complete EHR for the Ambulatory (EPs) or Inpatient (EHs/CAHs) Setting? No Yes Yes Yes Is your EHR technology certified to the following certification criteria required to meet the Base EHR definition? : (a)(1),(3)&(5-8) CPOE/Demogfrx/ProbList/ MedList/MedAllergyList/CDS (b)(1),(2)&(7) TOC/Data Port (c)(1)-(3) CQMS (d)(1)-(8) P&S Yes Do you have EHR technology that has been: Certified to 9 CQMs 6 from CMS recommended core set Address 3 domains from the set selected by CMS for EPs? EP No No No Do you have EHR technology that has been: Certified to 16 CQMs from CMS selected set for EH/CAHs Address 3 domains from the set selected by CMS for EH/CAHs? Yes Is your EHR technology certified to the Yes Is your EHR technology certified to the Yes following certification criteria to support following certification criteria to support the MU1 EP Core Objectives you seek to the MU1 EP Menu Objectives you seek to achieve and for which you cannot meet a meet? : MU exclusion? : (a)(10) RxFormulary (b)(5) Incorp Lab (a)(2) DD/DA (b)(3) erx (a)(14) Pt List (f)(1) Immz Info (a)(4) Vitals (e)(1) VDTx3 (a)(15) Pt Edu (f)(2) Immz Tx (a)(11) Smoking (e)(2) Clinical Sum (b)(4) ClinInfoRec (f)(3) Syn Surv No No Is your EHR technology certified to the Is your EHR technology certified to the following certification criteria to support following certification criteria to support the MU1 EH/CAH Menu Objectives you the MU1 EH/CAH Core Objectives you seek seek to meet? : to achieve and for which you cannot meet (a)(10) RxFormulary (b)(5) Incorp Lab a MU exclusion? : (a)(14) Pt List (f)(1) Immz Info Yes (a)(2) DD/DA (a)(11) Smoking Yes (a)(15) Pt Edu (f)(2) Immz Tx Yes (a)(4) Vitals (e)(1) VDTx3 (a)(17) AD (f)(3) Syn Surv (b)(4) ClinInfoRec (f)(4) ELR No No Note: To meet the CEHRT definition, EHR technology will need to have been certified to: Automated numerator recording ( (g)(1)) or Automated measure calculation ( (g)(2)); Safety-enhanced design ( (g)(3)); and Quality management system ( (g)(4))

90 EPs: Do you have EHR Technology that meets the new Certified EHR Technology definition for Meaningful Use Stage 1? START HERE Do you have a 2014 Edition Complete EHR for the Ambulatory Setting? Yes Yes No Is your EHR technology certified to the following certification criteria required to meet the Base EHR definition? : (a)(1),(3)&(5-8) CPOE/Demogfrx/ProbList/ MedList/MedAllergyList/CDS (b)(1),(2)&(7) TOC/Data Port (c)(1)-(3) CQMS (d)(1)-(8) P&S Yes No No No No Do you have EHR technology that has been: Certified to 9 CQMs 6 from CMS recommended core set Address 3 domains from the set selected by CMS for EPs? Is your EHR technology certified to the Is your EHR technology certified to the following certification criteria to support the following certification criteria to support Yes MU1 EP Core Objectives you seek to achieve Yes the MU1 EP Menu Objectives you seek to and for which you cannot meet a MU meet? : Yes exclusion? : (a)(10) RxFormulary (b)(5) Incorp Lab (a)(2) DD/DA (b)(3) erx (a)(14) Pt List (f)(1) Immz Info (a)(4) Vitals (e)(1) VDTx3 (a)(15) Pt Edu (f)(2) Immz Tx (a)(11) Smoking (e)(2) Clinical Sum (b)(4) ClinInfoRec (f)(3) Syn Surv Note: To meet the CEHRT definition, EHR technology will need to have been certified to: Automated numerator recording ( (g)(1)) or Automated measure calculation ( (g)(2)); Safety-enhanced design ( (g)(3)); and Quality management system ( (g)(4))

91 ONC HIT Certification Program Final Changes Temporary Certification Program Sunsets Upon 2014 Edition final rule effective date Program Name Change ONC HIT Certification Program Revisions to EHR Module Certification Requirements Privacy and Security Certification Policy Will not require upfront certification to P&S for the 2014 Edition CC Policy outcome now reflected in Base EHR definition (which includes all P&S CC) Other tweaks to make certification more efficient 91

92 ONC HIT Certification Program Final Changes (cont.) Application of certain new certification criteria to EHR technology (g)(1): Automated numerator recording (g)(3): Safety-enhanced design 8 Medication related certification criteria: CPOE; Drug-drug, drug-allergy interaction checks; Medication list; Medication allergy list; Clinical decision support; emar; e-prescribing; and Clinical information reconciliation (g)(4): Quality management system Price Transparency: ONC-ACBs are required to ensure that EHR technology developers notify eligible providers about additional types of costs (i.e., one-time, ongoing, or both) that affect a certified Complete EHR or certified EHR Module s total cost of ownership for the purposes of achieving meaningful use. Test Result Transparency: The final rule requires that ONC-ACBs submit a hyperlink of the test results used to issue a certification to a Complete EHR or EHR Module. 92

93 Standards Applicability Purpose Demographics Vocabulary & Code Sets OMB Race/Ethnicity ISO (constrained) Content Exchange / Utilization Transport Problems SNOMED CT + US ext CDS HL7 Infobutton + IGs Smoking Status SNOMED CT + US ext Family Health History SNOMED CT + US ext HL7 Pedigree Patient Ed Resources HL7 Infobutton + IGs ToC receive, display, & incorporate SNOMED CT + US ext RxNorm CCD/C32 CCR Applicability Statement for Secure Health Transport AppState + XDR/XDM Consolidated CDA SOAP RTM + XDR/XDM 93

94 Standards Applicability (cont.) Purpose ToC Create & Transmit Vocabulary & Code Sets [Common MU Data Set] ICD-10-CM CVX Content Exchange / Utilization Consolidated CDA e-rx RxNorm NCPDP SCRIPT 10.6 Transport Applicability Statement for Secure Health Transport AppState + XDR/XDM SOAP RTM + XDR/XDM Incorporate Labs (ambulatory) LOINC HL7 S&I LRI Spec Data Portability [Common MU Data Set] ICD-10-CM CVX Consolidated CDA Applicability Statement for Secure Health Transport AppState + XDR/XDM SOAP RTM + XDR/XDM 94

95 Standards Applicability Purpose CQM Export CQM Import CQM e-submit View, download, transmit to 3 rd party Clinical Summary [Common MU Data Set] [Common MU Data Set] Content Exchange / Utilization QRDA Category I QRDA Category I QRDA Category I & III Consolidated CDA WCAG Level A Consolidated CDA Immz Reporting CVX HL IGs Syndromic Surveillance ELR Cancer Registry Vocabulary & Code Sets SNOMED CT + US ext LOINC SNOMED CT + US ext LOINC HL IG (inpatient only) HL IG CDA R2 + IG Transport Applicability Statement for Secure Health Transport 95