2015 Modified Stage 2 Requirements

Executive Summary The Medicare and Medicaid EHR Incentive Programs began providing incentive payments to eligible professionals, eligible hospitals and critical access hospitals (CAHs) as they adopted, implemented, upgraded or demonstrated meaningful use of certified EHR technology. Eligible professionals could have received up to $44,000 through the Medicare EHR Incentive Program. EPs successful participation now allows them to avoid payment adjustments to the Physician Fee Schedule (PFS). An electronic health record (EHR) sometimes called an electronic medical record (EMR) allows healthcare providers to record patient information electronically instead of using paper records. However, EHRs are often capable of doing much more than just recording information. The EHR Incentive Program asks providers to use the capabilities of their EHRs to achieve benchmarks that can lead to improved patient care. This document covers how to best use PayDC & Advanced Provider Solutions Software to capture and calculate the Meaningful Use data you need to successfully satisfy the Meaningful Use requirements.

Disclaimer: Though PayDC (Advanced Provider Solutions, LLC) believes reasonable efforts have been made to ensure the accuracy of the information contained in the Document, it may include inaccuracies or typographical errors and may be changed or updated without notice. Information is based on documentation obtained through the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs as of October 2, 2015. It is intended for discussion and educational purposes only and is provided "AS IS" WITHOUT WARRANTY OF ANY KIND AND RELIANCE ON ANY INFORMATION PRESENTED IS AT YOUR OWN RISK. PAYDC AND ITS CONTRIBUTORS HEREBY DISCLAIM ALL WARRANTIES AND CONDITIONS WITH REGARD TO THIS INFORMATION, AND ANY AND ALL PRODUCTS, SERVICES AND RELATED GRAPHICS, INCLUDING ALL IMPLIED WARRANTIES AND CONDITIONS. In no event shall PAYDC be liable for any direct, indirect, punitive, incidental, special, or consequential damages or damages for loss of profits, revenue, data, down time, or use, arising out of or in any way connected with the use of the Document or performance of any services, whether based on contract, tort, negligence, strict liability or otherwise. If you are dissatisfied with any portion of the Document, or with any of these terms of use, your sole and exclusive remedy is to discontinue using the Document. Furthermore, please be advised that (i) PayDC (Advanced Provider Solutions, LLC) does not warrant or guarantee, or make any representation or any promise with respect to, any result, output or outcome arising or resulting from the use of any software, including but not limited to the Meaningful Use module, or any service provided or made available by PayDC, including but not limited to compliance with any governmental law, rule or regulation, meeting any standard or any qualification requirement, or qualifying to receive any payment, including but not limited to any incentive payment under the applicable provisions (as may be amended from time to time) of the American Recovery and Reinvestment Act of 2009 (the Act ), including but not limited to the applicable provisions of Title XIII of Division A of the Act (the Health Information Technology for Economic and Clinical Health Act, also known as HITECH) and Title IV of Division B of the Act (Medicare and Medicaid Health Information Technology; Miscellaneous Medicare Provisions) and regulations related thereto, (ii) PayDC shall have no responsibility or liability with respect to the use of any software or service provided or made available by PayDC or any result, output or outcome arising or resulting from the use of any software or any service provided or made available by PayDC, including but not limited to the failure to qualify to receive any incentive payment under the applicable provisions (as may be amended from time to time) of the Act, including but not limited to the applicable provisions of Title XIII of Division A of the Act (the Health Information Technology for Economic and Clinical Health Act, also known as HITECH), and Title IV of Division B of the Act (Medicare and Medicaid Health Information Technology; Miscellaneous Medicare Provisions) and regulations related thereto, and (iii) the entire risk arising out of the operation, use or performance of any software or any service provided or made available by PayDC remains with the client company/user.

Table of Contents Topic Page # What is Modified Stage 2? 5 When is my reporting period? 6 What do I need to do to successfully demonstrate MU? (overview) 7-8 2015 Modified Stage 2 Objectives Protect Patient Health Information Clinical Decision Support (CDS) Computerized Provider Order Entry (CPOE) Electronic Prescribing Health Information Exchange Patient Specific Education Medication Reconciliation Patient Electronic Access Secure Electronic Messaging Public Health Reporting 9-49 9 13 18 24 27 31 36 39 43 49 Meaningful Use Dashboard 53-55 When can I attest? 56 Payment adjustments & exceptions 57-59 References 60

What is Modified Stage 2? The EHR Incentive Programs in 2015 through 2017 (Modified Stage 2) reflect changes to the objectives and measures of Stages 1 and 2 to align with Stage 3, which focuses on the advanced use of EHRs. The changes also aim to reduce the complexity of the program and work toward a shift to a single set of sustainable objectives and measures in 2018. Redundant, duplicative, or topped out measures have been removed.

When is my reporting period? Starting in 2015, the EHR reporting period for all providers will be based on the calendar year. In 2015 only, the EHR reporting period for all providers will be any continuous 90-day period. EPs may select an EHR reporting period of any continuous 90 day period from January 1, 2015 through December 31, 2015.

What do I need to do to successfully demonstrate Meaningful Use? All providers are required to attest to a single set of objectives and measures (Modified Stage 2).

What do I need to do to successfully demonstrate Meaningful Use? For EPs, there are 10 objectives, including one consolidated public health reporting objective. This replaces the core and menu objectives structure of previous stages. In 2015, all providers must attest to objectives and measures using EHR technology certified to the 2014 Edition. To assist providers who may have already started working on meaningful use in 2015, there are alternate exclusions and specifications within individual objectives for providers who were previously scheduled to be in Stage 1 of meaningful use. These include: Allowing providers who were previously scheduled to be in a Stage 1 EHR reporting period for 2015 to use a lower threshold for certain measures. Allowing providers to exclude for Stage 2 measures in 2015 for which there is no Stage 1 equivalent.

Objective 1: Protect Patient Health Information Measure & Exclusions Alternate Exclusions Measure: Conduct or review a security risk analysis, including addressing the security (to include encryption) of ephi created or maintained in CEHRT, and implement security updates as necessary and correct identified security deficiencies as part of the EP s risk management process. NONE Exclusion: None

Objective 1: Protect Patient Health Information Independently conduct or review a security risk analysis including office practices, addressing the encryption/security of data stored in CEHRT, implement security updates as necessary, and correct identified security deficiencies as part of the provider's risk management process. A Security Risk Analysis requires you to perform all of the following steps. Conduct a Risk Analysis Complete a Risk Management Assessment & Plan of Action Implement an Employee Sanction Policy Perform a periodic system activity review Here is an example of the types of questions you will be required to answer for your risk analysis: Answer all questions to the best of your ability. Do not leave any answers blank. Sign and date each section. Include the Employee Sanction Policy in your employment policy documents. Audits may take time complete. It is recommended that periodic audits (monthly or weekly) are performed throughout the reporting period.

Objective 1: Protect Patient Health Information The following sites can be used as resources when conducting the risk assessment: http://www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/smallprovider.pdf http://www.healthit.gov/providers-professionals/ehr-implementation-steps/step-2- plan-your-approach#resource_table http://www.healthit.gov/sites/default/files/pdf/privacy/privacy-and-security-guidechapter-2.pdf http://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/Downloads/SecurityRiskAssessment_Fact Sheet_Updated20131122.pdf http://paydc.com/support/frequently-asked-questions/ Scroll to What does PayDC do to protect my information and maintain security? Rather than performing this assessment on your own, you may employ a professional to perform this for you. Our recommended vendor for the risk analysis is HIPAA Secure Now. PayDC/APS clients get a 10% discount, so be sure to let them know you are a client! Our contact there is Art Gross. http://www.hipaasecurenow.com/index.php/store/store-smb/

Objective 1: Protect Patient Health Information This is a YES/NO question during your attestation, and therefore there are no calculations listed on the dashboard for this measure. It is critical that you retain documentation that this measure was completed during your reporting year. Dated & signed documents, forms, screenshots, reports from your EHR & risk assessment vendor, etc.

Objective 2: Clinical Decision Support Measure & Exclusions Measure 1: Implement five clinical decision support interventions related to four or more clinical quality measures at a relevant point in patient care for the entire EHR reporting period. The clinical decision support interventions must be related to high priority health conditions. Measure 2: The EP has enabled and implemented the functionality for drug-drug and drug allergy interaction checks for the entire EHR reporting period. ***EPs must meet both measures to satisfy the requirement*** Exclusion: For the second measure, any EP who writes fewer than 100 medication orders during the EHR reporting period. Alternate Exclusions For an EHR reporting period in 2015 only, an EP who was scheduled to participate in Stage 1 in 2015 may satisfy the following in place of measure 1: Implement one clinical decision support rule relevant to specialty or high clinical priority along with the ability to track compliance with that rule.

Objective 2: Clinical Decision Support Implement Clinical Decision Alerts 1. Go to View>>Manage CDS Alerts 2. Click Add New

Objective 2: Clinical Decision Support Name your alert Click Add Criteria to enter the rules of your alert. This is what will identify which patients this alert appears for You can combine multiple rules to create more specific target groups Ex: Demographics/Sex/Female AND Demographics/Age/>/50 AND Vitals/BMI/>/25 will combine to identify women over 50 whose BMI is greater than 25. Fill in the Citation/Research/Guidelines - Why are you targeting this group? What are you providing them with? Clinical Resource/Reference Where did you gather the information you re supplying to the patients?

Objective 2: Clinical Decision Support Enable drug-drug and drug allergy interactions checks This is an automatically enabled feature of the Dr First application There are no additional steps needed for this portion of the measure to be satisfied

Objective 2: Clinical Decision Support This is a YES/NO question during your attestation, and therefore there are no calculations listed on the dashboard for this measure. It is critical that you retain documentation that this measure was completed during your reporting period. Dated documents, screenshots, reports from your EHR, etc.

Objective 3: Computerized Provider Order Entry Measure & Exclusions Measure 1: More than 60 percent of medication orders created by the EP during the EHR reporting period are recorded using computerized provider order entry. Exclusion: Any EP who writes fewer than 100 medication orders during the EHR reporting period. Measure 1 of 3 ***EPs must meet all 3 measures to satisfy the requirement*** Alternate Exclusions For Stage 1 providers in 2015, more than 30 percent of all unique patients with at least one medication in their medication list seen by the EP during the EHR reporting period have at least one medication order entered using CPOE; or more than 30 percent of medication orders created by the EP during the EHR reporting period are recorded using computerized provider order entry.

Objective 3: Computerized Provider Order Entry Measure & Exclusions Alternate Exclusions Measure 2: More than 30 percent of laboratory orders created by the EP during the EHR reporting period are recorded using computerized provider order entry. Providers scheduled to be in Stage 1 in 2015 may claim an exclusion for measure 2 (laboratory orders) of the Stage 2 CPOE objective for an EHR reporting period in 2015. Exclusion: Any EP who writes fewer than 100 laboratory orders during the EHR reporting period. Measure 2 of 3 ***EPs must meet all 3 measures to satisfy the requirement***

Objective 3: Computerized Provider Order Entry Measure 2: Lab Orders Click on Meaningful Use: Meds/Labs/Reports from the patient account screen Go to the Lab Orders tab and click Add New Fill in all fields Click SAVE

Objective 3: Computerized Provider Order Entry Measure & Exclusions Alternate Exclusions Measure 3: More than 30 percent of radiology orders created by the EP during the EHR reporting period are recorded using computerized provider order entry. Providers scheduled to be in Stage 1 in 2015 may claim an exclusion for measure 3 (radiology orders) of the Stage 2 CPOE objective for an EHR reporting period in 2015. Exclusion: Any EP who writes fewer than 100 radiology orders during the EHR reporting period. Measure 3 of 3 ***EPs must meet all 3 measures to satisfy the requirement***

Objective 3: Computerized Provider Order Entry Measure 3: Radiology Click on Meaningful Use: Meds/Labs/Reports from the patient account screen Go to the Radiology/Imaging tab and click Add New Fill in all fields Click SAVE

Objective 3: Computerized Provider Order Entry CPOE is measured here on the MU Dashboard

Objective 4: Electronic Prescribing Measure & Exclusions Measure: More than 50 percent of permissible prescriptions written by the EP are queried for a drug formulary and transmitted electronically using CEHRT. Exclusions: Any EP who: Alternate Exclusions For Stage 1 providers in 2015, more than 40 percent of all permissible prescriptions written by the EP are transmitted electronically using CEHRT. Writes fewer than 100 permissible prescriptions during the EHR reporting period; or Does not have a pharmacy within his or her organization and there are no pharmacies that accept electronic prescriptions within 10 miles of the EP's practice location

Objective 4: Electronic Prescribing Electronic prescriptions are generated & sent using the Dr First application. In Dr First, click Prescribe and type the medication you wish to prescribe. Click on the dosage. You ll see this screen next Fill in Pharmacy, Sig, Duration, Quantity, Refills, Directions to Pharmacist/Patient, then click Continue Review the prescription and click OK

Objective 4: Electronic Prescribing erx is measured here on the MU Dashboard

Objective 5: Health Information Exchange Measure & Exclusions Measure: The EP that transitions or refers their patient to another setting of care or provider of care must (1) use CEHRT to create a summary of care record; and (2) electronically transmit such summary to a receiving provider for more than 10 percent of transitions of care and referrals. Exclusions: Any EP who transfers a patient to another setting or refers a patient to another provider less than 100 times during the EHR reporting period. Alternate Exclusions Provider may claim an exclusion for the Stage 2 measure that requires the electronic transmission of a summary of care document if for an EHR reporting period in 2015, they were scheduled to demonstrate Stage 1, which does not have an equivalent measure.

Objective 5: Health Information Exchange A summary of care can be generated and sent through the patient s SOAP note screen. At the bottom of the SOAP note, click Other Functions then Send Summary of Care This summary can be sent to any patient or provider who has a secure electronic email address.

Objective 5: Health Information Exchange Once the care summary is generated and sent, you ll need to record that it was done in the Meaningful Use: Meds/Labs/Reports section. In this window you ll click Patient Transfer Out then click to add a line item. Next, you ll enter the provider who transferred the patient, the date the patient was transferred, and check the box to show that the summary record was provided. Click SAVE

Objective 5: Health Information Exchange Health Information Exchange is measured here on the MU Dashboard

Objective 6: Patient Specific Education Measure & Exclusions Alternate Exclusions Measure: : Patient specific education resources identified by CEHRT are provided to patients for more than 10 percent of all unique patients with office visits seen by the EP during the EHR reporting period. Exclusions: Any EP who has no office visits during the EHR reporting period. Provider may claim an exclusion for the measure of the Stage 2 Patient Specific Education objective if for an EHR reporting period in 2015 they were scheduled to demonstrate Stage 1 but did not intend to select the Stage 1 Patient Specific Education menu objective.

Objective 6: Patient Specific Education Patient educational resources can include traditional print materials as well as multimedia materials and interactive tools. Some examples of patient education resources are Informational materials about health conditions, medical procedures, medications, and other health topics Patient instructions that explain what patients need to do, including self-care instructions, when to come for follow-up appointments, tests and procedures Decision-support tools that help patients to understand the scientific evidence as well as the risks and benefits of different healthcare choices, and to make informed decisions based on the evidence and their personal values and preferences Self-management tools that help patients manage their health conditions, such as tracking blood sugar levels or asthma symptoms.

Objective 6: Patient Specific Education Looking for materials for your patients? Right-click on the patient name in the alphabetical list on the account screen and click Patient-Specific Education Resources You ll be routed to https://www.nlm.nih.gov/medlin eplus/ where you can find materials for your patients.

Objective 6: Patient Specific Education Once your patients have been provided with their materials, mark in their SOAP note that this information was provided. In the Objective section, click Clinical Quality Measures and check the box for Patient Specific Educational Resource Provided

Objective 6: Patient Specific Education Pt. Specific Education is measured here on the MU Dashboard

Objective 7: Medication Reconciliation Measure & Exclusions Alternate Exclusions Measure: : The EP performs medication reconciliation for more than 50 percent of transitions of care in which the patient is transitioned into the care of the EP. Exclusions: Any EP who was not the recipient of any transitions of care during the EHR reporting period. Alternate Exclusion: Provider may claim an exclusion for the measure of the Stage 2 Medication Reconciliation objective if for an EHR reporting period in 2015 they were scheduled to demonstrate Stage 1 but did not intend to select the Stage 1 Medication Reconciliation menu objective.

Objective 7: Medication Reconciliation The goal of this measure is to create the most accurate list possible of all medications a patient is taking and compare that list against the transferring physician s orders. You ll record the patient transfer in the Meaningful Use: Meds/Labs/Reports section. In this window you ll click Patient Transfer In then click to add a line item. Next, you ll enter the provider who received the patient transfer, the date the patient was transferred, and check the box to show that the medication reconciliation was completed. Click SAVE

Objective 7: Medication Reconciliation Medication Reconciliation is measured here on the MU Dashboard

Objective 8: Patient Electronic Access (VDT) Measure & Exclusions Measure 1: More than 50 percent of all unique patients seen by the EP during the EHR reporting period are provided timely access to view online, download, and transmit to a third party their health information Exclusions: Any EP who: Neither orders nor creates any of the information listed for inclusion as part of the measures Conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period. Alternate Exclusions Providers may claim an exclusion for the second measure if for an EHR reporting period in 2015 they were scheduled to demonstrate Stage 1, which does not have an equivalent measure. Measure 1of 2 ***EPs scheduled to report on Stage 2 requirements this year must meet both measures to satisfy the requirement***

Objective 8: Patient Electronic Access (VDT) 1. Go to View>>Initiate Patient Health Vault Account 2. Select patient, enter their email, have them choose a secret question and answer, then click Create Account 3. In the objective section of the SOAP note, check Provided Electronic Access

Objective 8: Patient Electronic Access (VDT) Measure & Exclusions Measure 2: At least one patient seen by the EP during the EHR reporting period (or patient-authorized representative) views, downloads or transmits to a third party his or her health information during the EHR reporting period. Exclusions: Any EP who: Neither orders nor creates any of the information listed for inclusion as part of the measures Conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period. Alternate Exclusions Providers may claim an exclusion for the second measure if for an EHR reporting period in 2015 they were scheduled to demonstrate Stage 1, which does not have an equivalent measure. Measure 2 of 2 ***EPs scheduled to report on Stage 2 requirements this year must meet both measures to satisfy the requirement***

Objective 8: Patient Electronic Access (VDT) At least one patient must follow the instructions in their email to complete their HealthVault registration.

Objective 8: Patient Electronic Access (VDT) Pt. Electronic Access is measured here on the MU Dashboard

Objective 9: Secure Messaging Measure & Exclusions Measure 1: For an EHR reporting period in 2015, the capability for patients to send and receive a secure electronic message with the EP was fully enabled during the EHR reporting period. Exclusions: Any EP who: Any EP who has no office visits during the EHR reporting period Conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period. Alternate Exclusions An EP may claim an exclusion for the measure if for an EHR reporting period in 2015 they were scheduled to demonstrate Stage 1, which does not have an equivalent measure.

Objective 9: Secure Messaging Providers must first register with our secure service, EMR Direct. After completing registration, you will have the inbox enabled in your account. This inbox is accessible through the Inbox button at the top of your application. You can only send messages to and receive messages from other secure addresses. The recipient (or authorized representative) must be authenticated and the message content must be encrypted and integrity-protected in accordance with the standard for encryption and hashing algorithms. Your patients secure address can be stored in their demographics under Patient Data>>Phone Email Fax

Objective 9: Secure Messaging Refresh mailbox Create new message/ Reply to existing message Inbox displays messages received Selected message displays here Sent messages Attachments display here

Objective 9: Secure Messaging You can send a message by clicking New Mail or Reply Your secure address automatically appears in the from field. Enter the recipient s secure email in the to section, or click on the search button to see a list of patient s addresses. Next, enter the subject and message. If you d like to add an attachment, it must be an.xml file SEND when complete

Objective 9: Secure Messaging This is a YES/NO question during your attestation, and therefore there are no calculations listed on the dashboard for this measure. It is critical that you retain documentation that this measure was completed during your reporting period. Dated documents, screenshots, reports from your EHR, etc.

Objective 10: Public Health Reporting Measure & Exclusions Measure 1: Immunization Registry Reporting- The EP is in active engagement with a public health agency to submit immunization data. Exclusion: Any EP meeting one or more of the following criteria may be excluded from the immunization registry reporting measure if the EP: Alternate Exclusions An EP scheduled to be in Stage 1 in 2015 may meet 1 measure. Does not administer any immunizations to any of the populations for which data is collected by its jurisdiction's immunization registry or immunization information system during the EHR reporting period Operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required to meet the CEHRT definition at the start of the EHR reporting period Operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data from the EP at the start of the EHR reporting period. Measure 1 of 3 ***EPs must meet 2 of the 3 measures to satisfy the requirement, unless exclusions apply***

Objective 10: Public Health Reporting Measure & Exclusions Alternate Exclusions Measure 2: Syndromic Surveillance Reporting: The EP is in active engagement with a public health agency to submit syndromic surveillance data. An EP scheduled to be in Stage 1 in 2015 may meet 1 measure. Exclusion: Any EP meeting one or more of the following criteria may be excluded from the syndromic surveillance reporting measure if the EP: Is not in a category of providers from which ambulatory syndromic surveillance data is collected by their jurisdiction's syndromic surveillance system Operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data from EPs in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period Operates in a jurisdiction where no public health agency has declared readiness to receive syndromic surveillance data from EPs at the start of the EHR reporting period. Measure 2 of 3 ***EPs must meet 2 of the 3 measures to satisfy the requirement, unless exclusions apply***

Objective 10: Public Health Reporting Measure & Exclusions Alternate Exclusions Measure 3: Specialized Registry Reporting: The EP is in active engagement to submit data to a specialized registry. An EP scheduled to be in Stage 1 in 2015 may meet 1 measure. Exclusion: Any EP meeting at least one of the following criteria may be excluded from the specialized registry reporting measure if the EP: Does not diagnose or treat any disease or condition associated with, or collect relevant data that is collected by, a specialized registry in their jurisdiction during the EHR reporting period Operates in a jurisdiction for which no specialized registry is capable of accepting electronic registry transactions in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period Operates in a jurisdiction where no specialized registry for which the EP is eligible has declared readiness to receive electronic registry transactions at the beginning of the EHR reporting period. Measure 3 of 3 ***EPs must meet 2 of the 3 measures to satisfy the requirement, unless exclusions apply***

Objective 10: Public Health Reporting These 3 measures will be YES/NO questions during your attestation, and therefore there are no calculations listed on the dashboard for these measures. It is critical that you retain documentation that these measures were completed during your reporting period or have documentation prepared to justify an exclusion in the event of an audit.

Meaningful Use Dashboard The Meaningful Use Dashboard helps you track your Meaningful Use Progress through out your reporting period. You must first REFRESH your data before viewing the dashboard to ensure the calculations are accurate and up-to-date. 1. Go to File>>Refresh Dr First Subscription Patients 2. Click Yes to begin the refresh. This window will disappear and the process will run in the background while you do other things in the application. 3. You will see this window when the refresh is complete.

Meaningful Use Dashboard 4. Go to View>>Measure Calculation Automated 5. Select Stage 1 or Stage 2, enter Provider s name and reporting period start and end date. Click GENERATE REPORT

Meaningful Use Dashboard Patients missing the required data Requirement name Patients who have the required data present # of patients meeting the requirement Total patients seen during reporting period (based on SOAP notes recorded) Numerator Denominator

When can I attest? Despite the change to a 90-day EHR reporting period in 2015, providers will not be able to attest to meaningful use for an EHR reporting period in 2015 prior to January 4, 2016. For an EHR reporting period in 2015, all Medicare providers must attest by February 29, 2016.

Payment Adjustments & Exceptions In 2015, participants who successfully demonstrate meaningful use for this period and satisfy all other program requirements will avoid the payment adjustment in CY 2017 if the EP successfully attests by February 29, 2016. You must demonstrate meaningful use every year in order to avoid Medicare payment adjustments. For example, an eligible professional who demonstrates meaningful use for the first time in 2013 will avoid the payment adjustment in 2015, but will need to demonstrate meaningful use again in 2014 in order to avoid the payment adjustment in 2016. Medicare eligible professionals who are not meaningful users will be subject to a payment adjustment.

Payment Adjustments & Exceptions This payment adjustment will be applied to the Medicare physician fee schedule (PFS) amount for covered professional services furnished by the eligible professional during the year. Eligible professionals receive the payment adjustment amount that is tied to the year that they did not demonstrate meaningful use (e.g., A health care professional who is eligible for a payment adjustment in 2018 will receive a 4% PFS reduction regardless if this is their first or fourth year not demonstrating meaningful use). The table below illustrates the potential application of payment adjustments to covered professional services for a Medicare eligible professional.

Payment Adjustments & Exceptions Providers may apply for hardship exceptions to avoid the payment adjustments. Eligible professionals can apply for hardship exceptions in the following categories: Infrastructure: Eligible professionals must demonstrate that they are in an area without sufficient internet access or face insurmountable barriers to obtaining infrastructure (e.g., lack of broadband). New Eligible Professionals: Newly practicing eligible professionals who would not have had time to become meaningful users can apply for a 2-year limited exception to payment adjustments. Unforeseen Circumstances: Examples may include a natural disaster or other unforeseeable barrier. 2014 EHR Vendor Issues: The eligible professional s EHR vendor was unable to obtain 2014 certification or the eligible professional was unable to implement meaningful use due to 2014 EHR certification delays. Patient Interaction: Lack of face-to-face or telemedicine interaction with patient. Lack of follow-up need with patients Practice at Multiple Locations: Lack of control over availability of CEHRT for more than 50% of patient encounters. PECOS Specialties: An EP that has a primary specialty listed in PECOS as anesthesiology, radiology or pathology 6 months prior to the first day of the payment adjustments that would otherwise apply. The specialty codes include diagnostic radiology (30), nuclear medicine (36), interventional radiology (94), anesthesiology (05), and pathology (22) Hardship exceptions are granted on a case-by-case basis. Information on how to apply for a hardship exception is posted on the CMS EHR Incentive Programs website.

References What you need to know for 2015: https://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage3_EP.pdf Overview Sheet for 2015-2017: https://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage3Overview2015 _2017.pdf Registration and Attestation https://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/RegistrationandAttestation.html Payment Adjustments & Hardship Exceptions Tipsheet for Eligible Professionals https://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/Downloads/PaymentAdj_Hardshi pexceptipsheetforep.pdf 2014 Definition Stage 1 Objectives https://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/Downloads/EP_MU_TableOfCont ents.pdf Stage 2 Objectives https://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2_MeaningfulUs especsheet_tablecontents_eps.pdf