Medicare and Medicaid EHR Incentive Programs: Stage 2

Transcription

1 Medicare and Medicaid EHR Incentive Programs: Stage 2 DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

2 Conflict of Interest Disclosure Elizabeth Holland Robert Anthony Jason McNamara Steven Posnack Have no real or apparent conflicts of interest to report HIMSS

3 Learning Objectives 1.Understand requirements for Stage 2 objectives 2.Understand changes to 2014 certification 3.Understand changes to 2014 clinical quality measurement

4 Who We Are Elizabeth Holland, Director, HIT Initiatives Group, Office of E-Health Standards & Services, CMS Robert Anthony, Deputy Director, HIT Initiatives Group, Office of E-Health Standards & Services, CMS Jason McNamara, Technical Director for Health IT, CMCS Steven Posnack, Director, Federal Policy Division, ONC

5 What Is in the Stage 2 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 Medicare Advantage program changes Medicaid program changes

6 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.

7 Stage 2 Eligibility 7

8 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.

9 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.

10 Stage 2 Meaningful Use

11 Stages of Meaningful Use Advanced clinical processes Improved outcomes Data capturing and sharing Stage 3 Stage 2 Stage 1

12 When Do I Start Stage 2?

13 When Do I Start Stage 2?

14 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. 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.

15 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 2014.

16 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

17 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 EXCLUSIONS CMS is introducing exclusions based on broadband availability in the provider s county.

18 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.

19 Secure Messaging Family Health History Imaging Results Registry Reporting Progress Notes Online Patient Information Family Health History Imaging Results Registry Reporting Progress Notes E Prescribing emar Electronic lab results EP Hospital

20 Lab Results Patient Lists Patient Education Summary of Care Records Medication Reconciliation Immunizations Patient Reminders Online Patient Information EP Lab Results Patient Lists Patient Education Summary of Care Records Medication Reconciliation Immunizations Public health lab results Syndromic surveillance Hospital

21 Stage 2 EP Core Objectives Core Objective 1. CPOE Measure Use CPOE for more than 60% of medication, 30% of laboratory, and 30% of radiology 2. E-Rx E-Rx for more than 50% 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

22 Stage 2 EP Core Objectives Core Objective 10. Patient Access 11. Visit Summaries 12. Education Resources 13. Secure Messages 14. Rx Reconciliation 15. Summary of Care 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% More than 5% of patients send secure messages to their EP 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

23 Stage 2 EP Menu Objectives Menu Objective 1. Imaging Results Measure More than 10% 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

24 Stage 2 Hospital 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

25 Core Objective 9. Patient Access 10. Education Resources 11. Rx Reconciliation 12. Summary of Care 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

26 Stage 2 Hospital Menu Objectives 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 10% 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%

27 Clinical Quality Measures 27

28 Aligning CQMs Across Programs CMS s commitment to alignment includes finalizing the same CQMs used in multiple quality reporting programs for reporting beginning in 2014 Other programs include Hospital IQR Program, PQRS, CHIPRA, and Medicare SSP and Pioneer ACOs Hospital Inpatient Quality Reporting Program Physician Quality Reporting System Children s Health Insurance Program Reauthorization Act Medicare Shared Savings Program and Pioneer ACOs 28

29 Aligning Reporting Mechanisms Identifying ways to minimize multiple submission requirements and mechanisms Provider Requirements Mechanisms EPs Eligible Hospitals and CAHs CY 2013 Medicare Physician Fee Schedule (MPFS) NPRM includes proposals for aligning reporting requirements FY 2012 and FY 2013 Inpatient Prospective Payment Schedule (IPPS) final rules include target for electronic reporting in Hospital IQR Program Option to submit once and get credit for the CQM requirement in two programs Individual EPs PQRS EHR reporting option Group Practices PQRS GPRO options Medicare SSP or Pioneer ACOs ereporting pilot will be the possible basis for the electronic reporting mechanism in hospital reporting programs, beginning with the Hospital IQR Program

30 Electronic Submission of CQMs Beginning 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 report their CQM data to their state, which may include electronic reporting.

31 CQM Selection and 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

32 Changes to CQMs Reporting Prior to 2014 Beginning in 2014 EPs Report 6 out of 44 CQMs 3 core or alt. core 3 menu EPs Report 9 out of 64 CQMs Selected CQMs must cover at least 3 of the 6 NQS domains Recommended core CQMs: 9 for adult populations 9 for pediatric populations Eligible Hospitals and CAHs Report 15 out of 15 CQMs Eligible Hospitals and CAHs Report 16 out of 29 CQMs Selected CQMs must cover at least 3 of the 6 NQS domains

33 Medicaid Program Changes

34 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

35 Patient Volume Medicaid Encounters: Previously under Stage 1 rule: Service rendered on any one day where Medicaid paid for all or part of the service or Medicaid paid the co pays, cost sharing, or premiums Changed in Stage 2 rule (applicable to all stages): Service rendered on any one day to a Medicaid enrolled individual, regardless of payment liability Includes zero pay claims and encounters with patients in Title 21 funded Medicaid expansions (but not separate CHIPs) 35

36 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 36

37 CHIP encounters in patient volume calculation Previously under Stage 1 rule: Only CHIP encounters for patients in Title 19 Medicaid expansion programs Under Stage 2 rule (applicable to all stages): 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 37

38 90 day Reporting Period for Patient Volume 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 With at least one Medicaid encounter taking place in the 24 months prior to 90 day period (expanded from 12 months prior) 38

39 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. 39

40 Hospital Incentive Calculation discharge related amount: 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 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 40

41 Adopt, Implement, or Upgrade (AIU) starting in 2014: To align our polices with ONC EHR Certification Standards we modified our definition of Adopt, Implement or Upgrade. Providers can no longer attest to AIU with any Certified EHR Technology. Providers who attest to AIU in 2014 are required to secure Certified EHR Technology that can bring them to Meaningful Use in the subsequent years. 41

42 2014 EHR Certification Changes

43 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

44 General Points to Remember Two types of certifications can be issued: Complete EHR (i.e., EHR tech certified to all mandatory cert. criteria) EHR Module (i.e., EHR tech certified to less than all mandatory cert. criteria) The scope of a certification issued to EHR technology represents only the capabilities for which the certification was sought/granted. EHR technology developers get to choose the type of certification sought for EHR technology and its scope (i.e., for EHR Modules, the number of cert. criteria to which it would be certified). Additional capabilities beyond those for which certification criteria have been adopted are not within the scope of ONC s regulatory framework and reflect a business decision made by the EHR technology developer if they are included with an EHR technology to which a certification is issued.

45 So what? What s to be excited about? Now 3 ways to meet CEHRT definition Complete EHR Generally provides overall assurance. EPs would still need EHR technology certified to cancer registry certification criteria if they seek to meet that MU objective. 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.

46 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 EPs, EHs, and CAHs have 3 options: 1) EHR technology that has been certified to all applicable 2011 Edition EHR certification criteria. 2) EHR technology that has been certified to all applicable 2011 Edition or equivalent 2014 Edition EHR certification criteria 3) EHR technology certified to the 2014 Edition EHR certification criteria that meets the Base EHR definition and would support ability to achieve MU stage 1 and successfully report the CQMs. 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. Same Policy 2014 Edition EHR technology supports the achievement of either meaningful use stage. Certification is not tied to MU stages. No Stage 1 Certified or Stage 2 Certified in perpetuity. 46

47 Illustrated: Two Types of Certifications Issued Complete EHR or EHR Module

48 1 Universe of EHR technology capabilities (e.g., all of what XYZ s EHR technology includes) 2014Ed Complete EHR definition 2 Generally supports MUS1 or MUS2 achievement Certified to all mandatory 2014Ed CC for setting MUS2 EHR Module certified to number of 2014Ed 3 necessary to support MUS1 4 MUS1 Inner square = EHR Module certified to number of 2014Ed CC less than MUS1 (or MUS2) Outer square = EHR Module certified to number of 2014Ed CC necessary to support MUS2 5 Base EHR definition = certified EHR Module 6 EHR Module certified to less than Base EHR definition 48 Point to remember: Certification s scope does NOT address all capabilities included in EHR technology 2014 Edition Scope Stops Here

49 A Different Look: Understanding the CEHRT Definition and the Minimum Number of Certification Criteria to which EHR Technology would need to be certified

50 2014 Edition Complete EHR 2014 Edition EHR Module Approaches MU2 MU1 Base EHR Vendor A MU2 Menu MU1 Menu MU1 Core Base EHR Stage 1 EP/EH Vendor B MU2 Menu MU2 Core Base EHR Stage 2 EP/EH Vendor A Vendor B MU1 Menu MU1 Core Base EHR Stage 1 EP/EH Vendor A Vendor B MU1 Menu MU1 Core Base EHR Stage 1 EP/EH w/exclusions Vendor X MU2 Menu MU2 Core Base EHR Stage 2 EP/EH Vendor A Vendor B Vendor C MU2 Menu MU2 Core Base EHR Stage 50 2 EP/EH w/exclusions

51 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))

52 Do you have EHR Technology that meets the new Certified EHR Technology definition for Meaningful Use Stage 1?

53 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) IncorpLab (a)(2) DD/DA (b)(3) erx (a)(4) Vitals (e)(1) VDTx3 (a)(11) Smoking (e)(2) Clinical Sum No No (a)(14) Pt List (f)(1) Immz Info (a)(15) Pt Edu (f)(2) Immz Tx (b)(4) ClinInfoRec (f)(3) SynSurv 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) IncorpLab 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) SynSurv (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))

54 Stage 2 Resources CMS Stage 2 Webpage: and Guidance/Legislation/EHRIncentivePrograms/Stage_2.html Links to the Federal Register Stage 2 Meaningful Use Specification Sheets 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)

55 CMS Program Sessions TITLE SESSION # DATE TIME ROOM SPEAKERS Stage 1: CMS EHR Incentive Programs Stage 2: CMS EHR Incentive Programs CMS Town Hall: CMS and ehealth: Building the Future ICD-10 and Administrative Simplification 23 Monday, March 4 11:00 AM - 12:00 PM New Orleans Theater C 62 Tuesday, March 5 9:45 AM - 10:45 AM New Orleans Theater C 81 Tuesday, March 5 1:00 PM - 2:00 PM New Orleans Theater C 131 Wednesday, March 6 8:30 AM - 9:30 AM Room 294 Elizabeth Holland, CMS Travis Broome, CMS Jason McNamara, CMS Elizabeth Holland, CMS Robert Anthony, CMS Jason McNamara, CMS Steven Posnack, ONC Robert Tagalicod, CMS Kate Goodrich, CMS Elizabeth Holland, CMS Christine Stahlecker, CMS Maribel Franey, CMS Christine Stahlecker, CMS Matthew Albright, CMS Kari Gaare, CMS Denesecia Green, CMS Views from the CMS Administrator 138 Wednesday, March 6 9:45 AM - 10:45 AM New Orleans Theater C Marilyn Tavenner, CMS CMS Quality Measurement 178 Thursday, March 7 11:15 AM - 12:15 PM New Orleans Theater C Maria Michaels, CMS Deborah Kraus, CMS Maria Harr, CMS

56 Talk to CMS about ehealth at Booth #2868 To learn more about CMS ehealth programs, visit