AMERICAN HEALTH LAWYERS ASSOCIATION MEDICARE AND MEDICAID INSTITUTE BALTIMORE MARCH, 2014

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1 I. Background AMERICAN HEALTH LAWYERS ASSOCIATION MEDICARE AND MEDICAID INSTITUTE BALTIMORE MARCH, 2014 MEANINGFUL USE ATTESTATIONS, AUDITS AND APPEALS James F. Flynn, Esq. Bricker & Eckler, LLP 100 South Third Street Columbus, Ohio (614) The Health Information Technology for Economic and Clinical Health ( HITECH ) Act (Pub. L ), which was enacted as a part of the American Recovery and Reinvestment Act of 2009 (commonly referred to as the Economic Stimulus Bill ), authorized payments to health care providers to incentivize their adoption and meaningful use of electronic health records ( EHRs ) in the care of patients. With more than $12 billion in Medicare incentive payments that have been made to date and an estimated total of $30 billion in incentive payments projected through 2019 for Medicare and Medicaid combined, providers have been heavily incentivized and reimbursed for their use of EHRs. These payments are premised upon provider self attestations of adoption and meaningful use of EHRs. The Centers for Medicare and Medicaid Services ( CMS ) and its contractors are in the process of auditing the support for these attestations. A. Adoption of Certified EHR Technology The first step in attaining eligibility for meaningful use incentive payments is utilizing certified EHR technology. 1 Certified EHR technology is defined as a qualified EHR that is certified as meeting standards adopted by the Office of National Coordinator of HIT ( ONC ) as applicable to the type of EHR system involved (either an ambulatory electronic health record 1 42 U.S.C. 1395ww(n) (for hospitals); 42 U.S.C. 1395w-4(o) (for physicians). 1

2 for office based physicians or an inpatient hospital electronic health record for hospitals). 2 Following an initial temporary certification program, ONC rolled out its current certification program on October 4, Certification of EHR systems is performed by ONC Authorized Certification Bodies and testing of EHR systems is performed by Accredited Testing Laboratories. EHR developers and vendors first test their products with an Authorized Testing Laboratory and then move to certification processes through an ONC Authorized Certification Body. The list of certified EHR products is posted on the ONC website at Certification criteria were first developed in 2011 (known as the 2011 Edition Certification Criteria) and new criteria were developed again in 2013 (known as the 2014 Edition Certification Criteria ). Effective as of federal fiscal year 2014 for hospitals and calendar year 2014 for physicians, providers must use EHR technology that is certified to the 2014 Edition Certification Criteria. B. Meaningful Use The second step in eligibility to receive meaningful use incentive payments is to meaningfully use the EHR technology in the care of patients. Statutorily, this is defined as demonstrating that certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of health care, such as promoting care coordination. 3 This exchange of information could occur between providers or between providers and patients. Meaningful use is demonstrated through the reporting of measures, as discussed below. To qualify as a meaningful user, the provider must demonstrate continuous meaningful use of EHR for 90 consecutive days in the first year of meaningful use and continuous meaningful use throughout each subsequent year U.S.C. 1395w-4(o)(4) U.S.C. 1395ww(n)(3)(A)(ii); 42 U.S.C. 1395w-4(o)(2)(A)(ii). 2

3 C. Reporting Meaningful Use The third and final step in eligibility to receive meaningful use incentive payments is to submit reports to CMS of required measures that demonstrate the meaningful use of EHR technology in the care of patients. 4 These reports are in the form of provider attestations. Attestations for the first year of meaningful use can be based on any 90 day period during the applicable year (federal fiscal year for hospitals, calendar for professionals). Attestations are typically due within 60 days following the completion of the federal fiscal year, although CMS recently extended the deadline for 2013 attestations for eligible professionals by one month to March 31, Attestations for subsequent years of meaningful use must be based on the entire year (except for a special exception for 2014, discussed below). D. Eligible hospitals and eligible professionals Meaningful use incentive payments are not available to all health care providers. Rather, such payments are available to eligible hospitals, defined as acute care hospitals, critical access hospitals, children s hospitals and cancer hospitals (also referenced as subsection (d) hospitals ). 5 Eligible professionals (or EPs ) are also entitled to meaningful use payments, with EPs defined as including medical and osteopathic physicians, dentists, chiropractors, podiatrists and optometrists, and for purposes of the Medicaid incentive payment program, also includes nurse practitioners, certified nurse midwives and physician assistants who work for federally qualified health centers or rural health clinics. Note that hospital based eligible professionals, such as pathologists, anesthesiologists or emergency room physicians, are not eligible to receive incentive payments. Medicare advantage organizations may also receive meaningful use incentive payments on behalf of certain affiliated hospitals and EPs. Meaningful use attestations and payments are based on federal fiscal years for hospitals (i.e., beginning October 1 and ending September 30) and calendar years for eligible professionals U.S.C. 1395ww(n)(3)(A)(iii), (B); 42 U.S.C. 1395w-4(o)(2)(A)(iii); (B) U.S.C. 1395ww(n)(6)(B). 3

4 E. Medicare versus Medicaid Meaningful use incentive payments are available under both the Medicare and Medicaid programs. Hospitals may be eligible to receive BOTH Medicare and Medicaid incentive payments if they participate in both programs and, for purposes of Medicaid payments, at least ten percent (10%) of their inpatient hospital volume consists of Medicaid patients. Eligible professionals must choose whether to receive Medicare or Medicaid incentive payments; they cannot receive both. To be eligible for Medicaid payments, Medicaid beneficiaries must comprise at least thirty percent (30%) of their patient volume, except for pediatricians where the threshold is twenty percent (20%). Prior to 2015, an eligible professional may change his or her election to the other program once but no more often than once. Of note, if an eligible professional elects to receive an EHR incentive payment from the Medicare program, he or she may not also receive an electronic prescribing incentive payment available only through the Medicare program; but if he or she elects EHR incentive payment participation under Medicaid, then he or she may receive BOTH a Medicaid EHR incentive and a Medicare electronic prescribing incentive payment. 6 F. Incentive Payment Amounts Meaningful use incentive payments are calculated differently depending on whether the meaningful user is an eligible professional, a critical access hospital, or any other type of hospital. Eligible professionals can receive up to a total of $44,000 over five years of meaningful use through the Medicare EHR incentive program and up to $63,750 over six years of meaningful use through the Medicaid EHR incentive program. For each eligible professional who predominantly provides more than fifty percent (50%) of his or her services in a health professional shortage area during any one year reporting period, the incentive payment for that year will be increased by an additional ten percent (10%). 7 Critical access hospitals are reimbursed for their services to Medicare beneficiaries on the basis of reasonable costs. Thus, meaningful use incentive payments for critical access 6 42 C.F.R (c)(1)(iii) U.S.C. 1395w 4(o)(1)(B). 4

5 hospitals are in the form of allowing critical access hospitals to claims reasonable cost reimbursement for the purchase of depreciable assets (e.g., computer hardware and software) associated with administering certified EHR technology in a single payment year rather than depreciating the assets over the respective useful lives of such assets. The costs reimbursed are proportionate to the percentage of Medicare beneficiaries treated by such hospital. For all other hospitals, the meaningful use incentive payment is calculated based on the following formula: (Initial amount = $2,000,000) + ($200 per discharge for the 1,150 th 23,000 th discharges) x (# of Medicare and MA inpatient days) (Total inpatient days x [(Total charges charity care charges) Total charges]) [this is referenced as the Medicare share ] 8 x [Transition Factor of 100% in year 1, 75% in year 2, 50% in year 3 and 25% in year 4] However, if the first year of meaningful use for a hospital is federal fiscal year 2014, then the transition factor starts at 75% and reduces to 50% in year two, 25% in year 3 and 0% the fourth and subsequent years. And, if the first year of meaningful use for a hospital is federal fiscal year 2015, then the transition factor starts at 50% and reduces to 25% the second year and 0% the third and subsequent years. G. Penalties for Failure To Meaningfully Use EHR For eligible hospitals and eligible professionals that have not begun meaningful use of EHR by federal fiscal year 2015 (for hospitals) or calendar year 2015 (for professionals), penalties in the form of negative payment adjustments commence. For hospitals, the annual market basket increase for inpatient prospective payments is reduced by 25% for the first year, 8 Based on most recently filed Medicare cost report at the time of the calculation of the payment, subject to adjustment upon settlement of the first 12-month cost report that begins after the beginning of the incentive payment year. For example, for a hospital with a calendar fiscal year and for incentive payment year 2013 (October 1, 2012 through September 30, 2013), CMS would most likely use the hospital s cost report for calendar year 2011 (which would be due by May 31, 2012) for a preliminary calculation and then use the hospital s calendar year 2013 Medicare cost report, once it is settled, to adjust the calculation, because that would be the fiscal year that begins (January 1, 2013) after the beginning of the incentive payment year (October 1, 2012). 5

6 50% for the second year and 75% for each year thereafter until meaningful use is achieved. Critical access hospitals receive a reduction in the percentage of costs reimbursed for failure to meaningfully use EHR from 101% to % in 2015, to % in 2016 to 100% in 2017 and beyond. For eligible professionals that have not begun meaningful use of EHR by calendar year 2015, fee schedule payments for professional charges are reduced by 1% in 2015 (2% if the professional is also not meeting electronic prescribing standards), 2% in 2016 and 3% in 2017 and beyond. II. Meaningful Use Standards Stage 1 and Stage 2 As providers have gradually incorporated the use of EHR into their health care services, CMS has developed criteria and measures to assess how much use is occurring. To date, CMS has promulgated both Stage 1 and Stage 2 criteria. The criteria are divided into core objectives, all of which must be satisfied, and menu objectives, of which a certain minimum number must be satisfied. With each objective, there is a measure to determine whether the objective is satisfied. A. Stage 1 Meaningful Use CMS issued Stage 1 meaningful use core criteria objectives and measures and menu criteria objectives and measures in a July 28, 2010 Final Rule 9 with the meaningful use criteria effective as of October 1, 2010 for hospitals and January 1, 2011 for professionals. Under these rules, Stage 1 meaningful use is demonstrated as follows: Eligible Hospitals and Critical Access Hospitals Eligible Professionals Core criteria must meet 14 objectives and measures Menu criteria must meet at least 5 of 10 objectives and measures Core criteria must meet 15 objectives and measures Menu criteria must meet at least 5 of Fed. Reg ; 42 C.F.R (a) (g). 6

7 objectives and measures The Stage 1 core criteria and menu criteria objectives and measures are summarized in the Appendix to this outline. B. Stage 2 Meaningful Use On September 4, 2012, CMS issued Stage 2 meaningful use core criteria objectives and measures and menu criteria objectives and measures 10 with the meaningful use criteria effective as of October 1, 2013 for hospitals and January 1, 2014 for professionals. Under these rules, Stage 2 meaningful use is demonstrated as follows: Eligible Hospitals and Critical Access Hospitals Eligible Professionals Core criteria must meet 16 objectives and measures Menu criteria must meet at least 3 of 6 objectives and measures Core criteria must meet 17 objectives and measures Menu criteria must meet at least 3 of 6 objectives and measures The Stage 2 core criteria and menu criteria objectives and measures are summarized in the Appendix to this outline. C. Stage 3 Meaningful Use Rules for Stage 3 meaningful use criteria have not yet been issued. Proposed rules are expected to be issued in the Fall of Depending on the pace of achievement through Stage 1 and Stage 2, as discussed below, some providers faced compliance with Stage 3 criteria beginning in 2016 (October, 2015 for hospitals). Because of the delay in issuing Stage 3 criteria, in December, 2013, CMS delayed the effective date of Stage 3 criteria from 2016 to 2017, as discussed below Fed. Reg ; 42 C.F.R (h) (m). 7

8 D. Duration of and Transition to Stages A provider is considered to have achieved Stage 1 meaningful use in a particular year if it satisfies the requisite criteria for a period of 90 consecutive days in that year. For the year following the first year of Stage 1 meaningful use, the provider must satisfy the requisite criteria for Stage 1 meaningful use for the entire year. Once a provider achieves meaningful use for two years (the first of which may only be for 90 days), the provider must then meet Stage 2 meaningful use criteria. Similar to the Stage 1 requirement, a provider is considered to have achieved Stage 2 meaningful use in the first year if it satisfies the requisite criteria for a period of 90 consecutive days in that year. Then, the next year, the provider must satisfy the requisite Stage 2 meaningful use criteria for the entire year. For various reasons, a couple of special rules and variations to the foregoing have been issued by CMS. First, for early adopters that first demonstrated Stage 1 meaningful use in 2011, they are allowed to remain at Stage 1 meaningful use criteria for a total of three years (with the first year being the 90 day period). Second, CMS issued a special rule for No matter what stage a provider may be in, a provider need only demonstrate 90 consecutive days of satisfaction of the applicable criteria to achieve meaningful use for This exception is applicable to 2014 only. Finally, in December, 2013, CMS delayed the effective date of yet tobe issued Stage 3 meaningful use criteria such that a provider that has achieved two years of Stage 2 meaningful use as of 2015 will be allowed to continue at Stage 2 for a third year in E. Unique Patients and Percentage Calculations To assess compliance with various measures under the meaningful use criteria, there are some nuances to keep in mind. First, the objectives and measures use the word unique frequently in describing patients, but the word has different meanings in different places. Many measures contain language similar to the following: More than 80% of all unique patients seen Many other measures contain a qualification that precedes such language that reads: Subject to paragraph (c) of this section, more than 80% of all unique patients seen Paragraph (c) is therefore important to understand, as follows: 8

9 (c)(1) If a measure (or associated objective) in paragraphs (d) through (m) of this section references paragraph (c) of this section, then the measure may be calculated by reviewing only the actions for patients whose records are maintained using certified EHR technology. A patient s record is maintained using certified EHR technology if sufficient data was entered in the certified EHR technology to allow the record to be saved, and not rejected due to incomplete data. (c)(2) If the objective and measure does not reference this paragraph (c) of this section, then the measure must be calculated by reviewing all patient records, not just those maintained using certified EHR technology. Presumably, in the latter case, the term unique is used in its everyday definition to describe individual encounters so that they are not counted more than once. These definitions affect the denominators in those measures that use a percentage. When measures are subject to paragraph (c), the denominator only includes patients, or actions taken on behalf of those patients, whose records are kept using certified EHR technology. When measures are not subject to paragraph (c), the denominator is all patients admitted or seen regardless of whether their records are kept using certified EHR technology. F. Exclusions and Exceptions The meaningful use rules and criteria contain a number of exceptions and exclusions under defined circumstances. Most of these are designed to address EPs whose practice does not include that practice being measured or does not include patient populations covered by the objective. For instance, the electronic prescribing objective is not applicable to EPs that write fewer than 100 prescriptions during an EHR reporting period. sometimes address situations where the denominator is 0 (but not always). These exclusions Providers may also apply for exceptions from the negative payment adjustments for the failure to achieve meaningful use requirements under the following circumstances: The hospital or EP is located in an area without sufficient internet access this is assessed based on any 90 day period between the start of the year that is two years prior to the payment adjustment year through the date of application; 9

10 applications must be filed at least six months prior to the beginning of the payment adjustment year (April 1 for hospitals, July 1 for EPs). New hospitals and new EPs for hospitals, exception applicable for at least one full cost reporting period following the acceptance of the first Medicare patient; for EPs, exception applicable for two years (including the year of beginning practice) after begin practicing Hardship or extreme circumstances each application is assessed on a caseby case and a year by year basis for reasons why meaningful use cannot be achieved; examples could include loss of EHR certification, severe financial distress, etc. Applications for exemption based on hardship are due six months prior to the beginning of the payment adjustment year (April 1 for hospitals, July 1 for EPs). EPs who lack face to face or telemedicine interactions (i.e., functionally equivalent to hospital based EPs, such as pathologists or anesthesiologists). Applications due by July 1 and determined on a case by case and year by year basis. EPs who practice at multiple locations and lack control over the use of certified EHR technology for 50% or more of their patient encounters (e.g., physicians using ASCs or treating nursing home patients). Again, applications are due by July 1 and are determined on a case by case and year by year basis. G. Medicaid States may adopt their own meaningful use requirements for purposes of Medicaid meaningful use incentive payments but, in the absence of state specific requirements, providers must follow the Medicare requirements to receive Medicaid meaningful use payments. For purposes of Medicaid meaningful use incentive payments, providers who adopt, implement or upgrade (sometimes referred to as AIU ) their certified EHR technology in their 10

11 first payment year do not need to satisfy the Stage 1 meaningful use criteria in order to receive payment. Adopt, implement or upgrade is defined as: (1) Acquire, purchase, or secure access to certified EHR technology capable of meeting meaningful use requirements; (2) Install or commence utilization of certified EHR technology capable of meeting meaningful use requirements; or (3) Expand the available functionality of certified EHR technology capable of meeting meaningful use requirements at the practice site, including staffing, maintenance, and training, or upgrade from existing EHR technology to certified EHR technology per the ONC EHR certification criteria. 11 III. Audits Given the amount of money paid through meaningful use incentive payments and some Congressional attention and scrutiny accompanying the level of oversight, CMS has significantly increased its audit activity in the past two years. In 2012, CMS engaged a private contractor, Figloiozzi and Company (the Contractor ), to conduct audits of meaningful use incentive payment recipients. It has been widely speculated (and attributed to CMS sources) that CMS intends to audit approximately 5% to 10% of all attesting providers. Post payment audit activity began in July, 2012 and pre payment audits began in January, Audits are both random and targeted around discrepancies. Audited providers that attested to Stage 1 meaningful use began receiving letters from the Contractor requesting information related to their attestation. requested information relating to the following: The letters typically Documentation demonstrating that the providers EHR technology meets the ONC certification requirements as certified EHR technology ; How emergency department admissions were determined; and Basis for the attestation as to meaningful use objectives and measures C.F.R

12 The letters required responses within a matter of weeks and left open the possibility of additional requests to follow based on the information submitted. Though the purpose of the meaningful use incentive payment program is to move health care providers to electronic record keeping, the most important audit activity is the documentation that supports each element of the provider s attestation. Recommended audit preparation steps include: Documentation of Electronic Activities Several aspects of the audited activity occur electronically and may not typically be maintained in paper form. Electronic records of activity may not be easily retained either. Each organization, no matter its size, should give careful thought to how it can and will maintain electronic or paper documentation of activities that relate to the use of electronic health records and the requirements for each element of the core and menu criteria to which the provider attested. This includes documentation that supports information supplied as a part of CMS clinical quality measures. 12 Record Retention Records must be maintained for six years following the submission of the attestation. Key Personnel Electronic health records and meaningful use payments involve individuals working in multiple areas of an organization, no matter its size: financial, technological, clinical, and record keeping being the primary areas. Rarely is one individual capable of covering all of those areas. Ideally before any audit activity occurs, each organization should identify the team of individuals necessary to describe, and answer questions concerning (1) the provider s use of electronic health records, both technologically and clinically in the care of patients; (2) the attestation and related requirements for receipt of meaningful use incentive payments; and (3) the documentation to support all of it. This team should agree on protocols for communicating with each other in the event of responding to any audit or inquiry and developing and implementing audit preparation steps. {Note that this team could easily 12 See CMS resource on audit documentation at Guidance/Legislation/EHRIncentivePrograms/Downloads/EHR_SupportingDocumentation_Audits.pdf. 12

13 be expanded to include the organization s privacy officer and expand its scope to include HIPAA compliance and responding to HIPAA audits.} EHR Technology It is imperative that each organization maintain documentation of ONC requirements for certified EHR technology and match that documentation with evidence that the provider s EHR technology meets the requirements. Providers should consider obtaining certification or assurance letters from the EHR vendor for this purpose. Meaningful Use Criteria, and The organization must have a thorough and complete understanding of the Stage 1 and Stage 2 meaningful use criteria applicable in a reporting period. This must include a process for updating criteria as they are further developed and expanded with subsequent stages and refinements. With this knowledge, the organization must be able to measure and document compliance with the criteria and objectives. Again, this requires knowledge of technological systems, how and to what extent those systems are being utilized by patient caregivers, and how to document and retain records of such activities. Attestation Compliance Each attestation submitted for purposes of meaningful use incentive payments operates as a claim to the federal government, subjecting the organization submitting the claim to potential liability under the False Claims Act. Thus, attestations should not be submitted without sufficient diligence. Further, subsequent discoveries that an attestation may have been completed inaccurately should be treated similar to discoveries of overpayments with prompt remediation. 13 Evolutionary Process The scope and magnitude of EHR use is fast moving and everchanging. All of the audit preparation processes must be capable of updating and keeping up with increased and expanded utilization of EHR. Mock Audits As is sometimes done with billing compliance, HIPAA compliance and other areas subject to potential governmental audits, it is always a good practice to 13 See e.g., Health Management Associates (Florida) voluntary self-disclosure and refund of approximately $31 million in meaningful use incentive payments based on its own internal review, in November,

14 periodically conduct a simulated or mock audit exercise. This can be done both internally or through an externally engaged consultant. Attorney Client Privilege To the extent any of the foregoing steps are conducted by an organization s legal counsel, certain audit preparation steps may be protected by attorney client privilege. This could include engaging an outside consultant to assist in the process or to conduct mock audits. IV. Appeals To date, there has been very little appeal activity and even less information about appeals processes and activity. The statute does preclude administrative or judicial review for certain activities related to meaningful use incentive payments, including: The methodology and standards for determining incentive payment amounts or negative payment adjustments. The methodology and standards for determining a meaningful EHR user, including: o The selection of quality measures; o The means for demonstrating meaningful use; o The case by case exceptions (e.g., hardship) The methodology and standards for determining hospital based eligible professionals. The specification of reporting periods and the selection of the form of payment. For hospitals, making estimates or using proxies of discharges and inpatient bed days, hospital charges, charity charges or the Medicare share. Critical access and IPPS hospitals should be able to appeal determinations reflected on their Medicare cost reports in the same way they may appeal other cost report determinations (i.e., through the Provider Reimbursement Review Board). This would include reimbursement and payment adjustments made to critical access hospitals paid on a percentage of costs and 14

15 the settlement of payment amount calculations made to IPPS hospitals preliminarily based on the most recently filed cost report at the time of payment. To date, no appeal regulations exist specific to meaningful use incentive payments. CMS declined to promulgate such regulations in September, 2012 at the time of issuing the final Stage 2 meaningful use rules, the last most significant rule making in this area. CMS stated rationale for declining specific appeal regulations was that appeal activity was primarily procedural and did not need to be specified in regulation: We recognize that there is a procedural appeals process currently in effect, and in all cases, we will require that requests for appeals, all filings, and all supporting documentation and data be submitted through a mechanism and in a manner specified by us. We expect all providers to exhaust this administrative review process prior to seeking review in Federal Court. 14 The CMS EHR Incentive Program website has guidance about its appeals process at: and Guidance/Legislation/EHRIncentivePrograms/Appeals.html. This guidance provides: If you have been denied an EHR incentive payment, have been determined to be ineligible for the program, or have received an audit decision that you believe to be in error, you can appeal the decision. Medicare eligible professionals (EPs) should file appeals with CMS, while Medicaid eligible professionals should contact their State Medicaid Agency for information about filing an appeal. Medicare eligible hospitals and critical access hospitals (CAHs) should also file appeals with CMS, whereas Medicaid eligible hospitals or any hospital that wants to appeal its Medicaid eligibility should contact their State Medicaid Agency for information about filing an appeal. Because CMS will conduct audits for both Medicare and Medicaid eligible hospitals, all appeals of eligible hospital audits should be filed with CMS. In order to begin the appeals process EPs, hospitals, or CAHs must complete the appropriate filing request below. It is important to follow the instructions specific to your appeal type on the filing request. Please note that the appeals submission process is time sensitive with a 30 day window for submission period. The filing request and supporting documentation must be submitted electronically to ehrappeals@provider resources.com. The appeal 14 See 77 Fed. Reg. at (Sept. 4, 2012). 15

16 will only be processed if all documentation is provided at the time of submission. (emphasis added) The website guidance then provides for five categories of appeals: Failed audit meaningful use appeal (prepayment or post payment) must be filed within 30 days from the date of the adverse determination. Failed reporting meaningful use appeal (regarding certified EHR technology) must be filed by December 31 for hospitals and March 31 for EPs Clinical Quality e Reporting meaningful use appeal must be filed by December 31 for hospitals and March 31 for EPs Eligibility appeal (i.e., requirements met but unable to register for reasons outside of the provider s control) must be filed by December 31 for hospitals and March 31 for EPs Other appeals (which must be explained) must be filed by December 31 for hospitals and March 31 for EPs Submitted: March 14,

17 APPENDIX SUMMARY OF STAGE 1 AND STAGE 2 MEANINGFUL USE CRITERIA, OBJECTIVES AND MEASURES There are 15 core criteria for eligible professionals ( EPs ) and 14 core criteria for eligible hospitals for Stage 1 Meaningful Use. All of the hospital core criteria are similar if not identical to 14 of the 15 core criteria for EPs. The core criteria objectives and measures for Stage 1 Meaningful Use for both eligible professionals and eligible hospitals are as follows: Stage 1 Core Criteria and for BOTH Hospital and Eligible Professionals 15 (14 objectives in common) Computerized provider order entry (CPOE) Use CPOE for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local, and professional guidelines More than 30% of Unique 16 patients with at least one medication in their medication list seen by the EP or admitted to the eligible hospital or CAH have at least one medication entered using CPOE Implement drug to drug and drug allergy interaction checks Maintain an up to date problem list of current and active diagnoses Maintain active medication list Maintain active medication allergy list Enable this functionality More than 80% of all unique patients have at least one entry or an indication that nor problems are known for the patient. More than 80% of all Unique patients have at least one entry or an indication that patient is not currently prescribed any medications. More than 80% of all unique patients have at C.F.R (d) for EPs and 495.6(f) for hospitals. 16 In certain circumstances, unique has specialized regulatory meaning. When capitalized, bolded and italicized, Unique is defined as limited to those patients whose records are maintained using certified EHR technology. (42 CFR 495.6(c).) When not capitalized, bolded and italicized, unique has its normal meaning. A-1

18 Stage 1 Core Criteria and for BOTH Hospital and Eligible Professionals 15 (14 objectives in common) Record demographics (preferred language, gender, race, ethnicity and date of birth) Record and chart changes in vital signs (height, weight, blood pressure, BMI, growth for children) Record smoking status for patients 13 years or older Report clinical quality measures to CMS (or States for Medicaid) (as applicable to EPs and hospitals) Implement one clinical decision support rule relevant to specialty or high clinical priority and the ability to track compliance with the rule Provide patients with an electronic copy of their health information (including diagnostic test results, problem lists, medication lists, medication allergies and, for hospitals, discharge summary and procedures), upon patient request. Beginning in 2014, provide patients ability to view information online, download and transmit within 4 business days. For EPs, provide clinical summaries for each office visit. For hospitals, provide discharge instructions at the time of discharge for patients who request it; beginning 2014, provide patients ability to view online, least one entry or an indication that patient has no known medication allergies. More than 50% of all Unique patients have demographics recorded. More than 50% of all Unique patients have vital signs changes recorded. More than 50% of all Unique patients 13 years or older have smoking status recorded. For 2011, provide aggregate numerator, denominator, and exclusions through attestation; For 2012, electronically submit clinical quality measures; For 2013, no longer applicable as it is included in other requirements (see 42 CFR 495.4) Implement one clinical decision support rule More than 50% of all Unique patients who request electronic copy receive it within 3 business days. Beginning in 2014, online access available. For EPs, more than 50% of all Unique patients receive clinical summaries within 3 business days. For hospitals, more than 50% of patients discharged from inpatient or ED receive discharge instructions if they request it; A-2

19 Stage 1 Core Criteria and for BOTH Hospital and Eligible Professionals 15 (14 objectives in common) download and transmit information about a hospital admission. Capability to exchange key clinical information among providers of care and patientauthorized entities electronically. Note: beginning in 2013, no longer required. Protect electronic health information beginning 2014, information available online within 36 hours of discharge. Performed at least one test of certified EHR s technology to electronically exchange key information. Note: beginning in 2013, no longer required. Conduct or review a security risk analysis and implement security updates as necessary. The additional core criterion applicable to EPs is as follows: Stage 1 Core Criterion Objective and Measure UNIQUE to Eligible Professionals 17 Generate and transmit permissible prescriptions electronically (erx) More than 40% of all permissible prescriptions written (i.e. of those whose records are maintained on EHR) are transmitted electronically C.F.R (d)(4). A-3

20 There are 10 menu criteria for Stage 1 Meaningful Use for both EPs and hospitals, of which each group must meet at least five. Of the 10 menu criteria, 8 are similar if not identical as between EPs and hospitals. The menu criteria for Stage 1 Meaningful Use for both eligible professionals and eligible hospitals are as follows: Stage 1 Menu Criteria and for BOTH Hospital and Eligible Professionals 18 (8 of 10 objectives in common) Implement drug formulary checks Enable this functionality Incorporate clinical lab test results into EHR Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach Use certified EHR to identify patient specific education resources and provide those resources to the patient if appropriate. Patients received from another setting of care or provider of care have medication reconciliation performed. Patients referred to another setting of care or provider of care have summary care records for each transition of care or referral. Capability to submit electronic data to immunization registries and actual submission according to applicable law and practice. More than 40% of all clinical lab results ordered for Unique patients whose results are either in a positive negative or numerical format are incorporated into the patient s EHR. Generate at least one report listing Unique patients with a specific condition. More than 10% of all Unique patients are provided patient specific education resources. More than 50% of all Unique patients who transition from another setting or provider have medication reconciliation performed. More than 50% of all Unique patients who transition to another setting or provider have summary care records prepared for each transition. Performed at least one test of certified EHR technology s capacity to submit electronic data and follow up submission if the test is C.F.R (e) for EPs and 495.6(g) for hospitals. A-4

21 Stage 1 Menu Criteria and for BOTH Hospital and Eligible Professionals 18 (8 of 10 objectives in common) successful. Capability to submit electronic syndromic surveillance data to public health agencies and actual submission according to applicable law and practice Performed at least one test of certified EHR technology s capacity to submit electronic data and follow up submission if the test is successful. The two additional menu criteria for Stage 1 Meaningful Use that are only applicable to EPs are as follows: Stage 1 Menu Criteria and UNIQUE to Eligible Professionals 19 (2 objectives) Send reminders to patients per patient preference for preventive/follow up care. Provide patients with timely electronic access to health information (including lab results, problem list, medication lists an dallergies) within 4 business days. Note: no longer included beginning in More than 20% of all Unique patients 65 years or older or 5 years or younger were sent an appropriate reminder. At least 10% of all unique patients seen are provided timely (within 4 business days) electronic access to their health information. Note: no longer included beginning in C.F.R (e)(4), (5). A-5

22 Similarly, the two additional menu criteria for Stage 1 Meaningful Use that are only applicable to hospitals are as follows: Stage 1 Menu Criteria and UNIQUE to Hospitals 20 (2 objectives) Record advance directives for patients 65 years old or older. Capability to submit electronic data on reportable lab results to public health agencies and actual submission according to applicable law and practice. More than 50% of all Unique patients 65 years old or older have an indication of an advance directive status recorded. Performed at least one test of certified EHR technology s capacity to provide electronic submission of reportable lab results to public health agencies and follow up submission if the test is successful. STAGE 2 MEANINGFUL USE There are 17 core criteria for EPs and 16 core criteria for eligible hospitals for Stage 2 Meaningful Use. Of the 17 criteria applicable to EPs, 13 are in common with hospital core criteria. The core criteria objectives and measures for Stage 2 Meaningful Use for both eligible professionals and eligible hospitals are as follows: Stage 2 Core Criteria and for BOTH Eligible Professionals and Hospitals 21 (13 of 17 objectives in common) (differences between Stage 1 and 2 noted) Use CPOE for medication, laboratory and radiology orders directly entered by any (difference between Stage 1 and 2 noted) More than 60% (30%) of Unique patients with at least one medication in their C.F.R (g)(2), (9) C.F.R (j) for EPs and (l) for hospitals. A-6

23 Stage 2 Core Criteria and for BOTH Eligible Professionals and Hospitals 21 (13 of 17 objectives in common) (differences between Stage 1 and 2 noted) licensed healthcare professional who can enter orders into the medical record per state, local, and professional guidelines Record demographics (preferred language, gender, race, ethnicity and date of birth), except hospitals also have to record date and preliminary cause of death for deaths occurring in the hospital. Record and chart changes in vital signs (height, weight, blood pressure, BMI, growth for children) Record smoking status for patients 13 years or older Implement one Use clinical decision support to improve performance on high priority health conditions rule relevant to specialty or high clinical priority and the ability to track compliance with the rule Incorporate clinical lab test results into EHR [Note: this was menu criteria for Stage 1] Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach. (difference between Stage 1 and 2 noted) medication list seen by the EP or admitted to the eligible hospital or CAH have at least one medication entered using CPOE; more than 30% of laboratory orders recorded by CPOE; and more than 30% of radiology orders recorded by CPOE. More than 80% (50%) of all Unique patients have demographics recorded. More than 80% (50%) of all Unique patients have vital signs changes recorded. More than 80% (50%) of all Unique patients 13 years or older have smoking status recorded. Implement five one clinical decision support rule interventions related to four or more clinical quality measures at a relevant point in patient care AND enable functionality for drug drug and drug allergy interaction checks. More than 55% (40%) of all clinical lab results ordered for Unique patients whose results are either in a positive negative or numerical format are incorporated into the patient s EHR. [Note: this was menu criteria for Stage 1] Generate at least one report listing Unique patients with a specific condition. [Note: this was menu criteria for Stage 1] A-7

24 Stage 2 Core Criteria and for BOTH Eligible Professionals and Hospitals 21 (13 of 17 objectives in common) (differences between Stage 1 and 2 noted) [Note: this was menu criteria for Stage 1] Provide patients with an electronic copy of their health information (including diagnostic test results, problem lists, medication lists, medication allergies and, for hospitals, discharge summary and procedures), upon patient request. Beginning in 2014, Provide patients ability to view information online, download and transmit within 4 business days. Use certified EHR to identify patient specific education resources and provide those resources to the patient if appropriate. [Note: this was menu criteria for Stage 1] Patients received from another setting of care or provider of care have medication reconciliation performed. [Note: this was menu criteria for Stage 1] Patients referred to another setting of care or provider of care have summary care records for each transition of care or referral. [Note: this was menu criteria for Stage 1] Capability to submit electronic data to immunization registries and actual submission (difference between Stage 1 and 2 noted) For EPs, more than 50% of all unique patients are provided timely (within 4 business days) online who request electronic copy receive it within 3 business days. Beginning in 2014, online access to their health information available. For hospitals, more than 50% of all patients discharged from inpatient or E.D. have information available online within 36 hours of discharge AND more than 5% of all unique patients who are discharged actually view, download or transmit to a third party. More than 10% of all unique patients are provided patient specific education resources. [Note: this was menu criteria for Stage 1] More than 50% of all Unique patients who transition from another setting or provider have medication reconciliation performed. [Note: this was menu criteria for Stage 1] More than 50% of all Unique patients who transition to another setting or provider have summary care records prepared for each transition; AND such summary care records are transmitted electronically through an HIE for 10% or more of UNIQUE patient transitions and referrals; AND conducts one or more successful electronic exchanges of a summary of car record with a recipient using technology from a different EHR vendor. [Note: this was menu criteria for Stage 1] Performed at least one test of certified EHR technology s capacity to submit electronic A-8

25 Stage 2 Core Criteria and for BOTH Eligible Professionals and Hospitals 21 (13 of 17 objectives in common) (differences between Stage 1 and 2 noted) according to applicable law and practice. [Note: this was menu criteria for Stage 1] Protect electronic health information (difference between Stage 1 and 2 noted) data and follow up submission if the test is successful. Successful ongoing submission of electronic immunization data from certified EHR technology to an immunization registry or immunization information system for the entire reporting period. [Note: this was menu criteria for Stage 1] Conduct or review a security risk analysis, including addressing the encryption/security of data stored, and implement security updates as necessary. Of note, the Stage 2 Meaningful Use Criteria no longer includes the following core criteria objectives and measures from Stage 1 Meaningful Use: Implement drug to drug and drug allergy interaction checks (however, this was added to the core criterion objective for clinical decision support; see above) Maintain an up to date problem list of current and active diagnoses Maintain active medication list Maintain active medication allergy list Report clinical quality measures to CMS (or States for Medicaid) Capability to exchange key clinical information among providers of care and patientauthorized entities electronically. (Note: this was removed as of 2013 under Stage 1 criteria anyway.) There are four Stage 2 Meaningful Use core criteria, objectives and measures applicable only to EPs, as follows: A-9

26 Stage 2 Core Criteria Objective and Measure UNIQUE to Eligible Professionals 22 (4 objectives) (differences between Stage 1 and 2 noted) Generate and transmit permissible prescriptions electronically (erx) Use clinically relevant information to identify patients who should receive Send reminders to patients per patient preference for preventive/follow up care and send these patients the reminder, per patient preference. [Note: this was a menu criteria for Stage 1.] (difference between Stage 1 and 2 noted) More than 50% (40%) of all permissible prescriptions written (i.e. of those whose records are maintained on EHR) are queried for a drug formulary and transmitted electronically. More than 10% (20%) of all Unique patients 65 years or older or 5 years or younger who have had 2 or more office visits within the prior 24 months were sent an appropriate reminder. [Note: this was a menu criteria for Stage 1.] Provide patients with timely electronic access to health information (including lab results, problem list, medication lists an dallergies) within 4 business days. Note: no longer included beginning in Provide clinical summaries for each office visit. [Note: this was a menu criteria for Stage 1.] Use secure electronic messaging to communicate with patients on relevant health information. At least 10% of all unique patients seen are provided timely (within 4 business days) electronic access to their health information. Note: no longer included beginning in More than 50% of all Unique patients receive clinical summaries within 1 3 business day for more than 50% of office visits. [Note: this was a menu criteria for Stage 1.] A secure message was sent using the electronic messaging function more than 5% of unique patients (or their authorized representatives) seen by the EP during the reporting period C.F.R (j)(2), (9), (11), and (17). A-10

27 Similarly, there are three Stage 2 Meaningful Use core criteria applicable only to hospitals, as follows: Stage 2 Core Criteria Objective and Measure UNIQUE to Hospitals 23 (3 objectives) (differences between Stage 1 and 2 noted) Capability to submit electronic data on reportable lab results to public health agencies and actual submission according to applicable law and practice. [Note: this was menu criteria for Stage 1] Capability to submit electronic syndromic surveillance data to public health agencies and actual submission according to applicable law and practice. [Note: this was menu criteria for Stage 1] Automatically track medications from order to administration using assistive technologies in conjunction with an electronic medication administration record (emar). (difference between Stage 1 and 2 noted) Performed at least one test of certified EHR technology s capacity to provide electronic submission of reportable lab results to public health agencies and follow up submission if the test is successful. Successful ongoing submission of electronic lab results from certified EHR technology to a public health agency for the entire reporting period. [Note: this was menu criteria for Stage 1] Performed at least one test of certified EHR technology s capacity to submit electronic data and follow up submission if the test is successful. Successful ongoing submission of electronic syndromic surveillance data to public health agencies for the entire reporting period. [Note: this was menu criteria for Stage 1] More than 10% of medication orders created by authorized providers of the inpatient or E.D. are tracked using emar (for patients whose records are electronic). There are 6 menu criteria for Stage 2 Meaningful Use for both EPs and hospitals, of which each group must meet at least three. Of the 6 menu criteria, 3 are similar if not identical as between EPs and hospitals. The menu criteria for Stage 2 Meaningful Use for both eligible professionals and eligible hospitals are as follows: C.F.R (l)(13), (14), and (16). A-11