Selecting Your Stage 1 Meaningful Use MENU Objectives

Selecting Your Stage 1 Meaningful Use MENU Objectives

Highlights The EHR Incentive Program Stage 1 Meaningful Use program requires each provider to choose 5 meaningful use objectives from a list of 10. Some of these objectives will be easier than others for most providers. Providers should identify the 5 Menu objectives they aim to achieve before they start their 90 days of Meaningful Use. In addition to the 5 Menu objectives selected as their goals, providers should choose 1-2 back- up items. All of the Stage 1 Menu objectives move to Core (required) in Stage 2 except the Submission of Electronic Syndromic Surveillance. However, some of the measures change with Stage 2. This White Paper by Sevocity should assist providers with selecting their Stage 1 Menu objectives that will be easiest for them to attain and position them better for Stage 2 Meaningful Use. Background on Meaningful Use Requirements The American Reinvestment and Recovery Act (ARRA) authorized the Centers for Medicare & Medicaid Services (CMS) to provide reimbursement incentives to eligible providers who are meaningful users of certified EHRs. There will be three stages of Meaningful Use (MU) with each stage requiring more advanced use of EHRs. Stage 1 requirements have been released and generally apply to 2011 through 2013. Stage 2 requirements have been released and apply to 2014 or 2015, depending upon when the provider completes their first Stage 1 MU period. CMS has not released stage 3 requirements. Stage 1 and Stage 2 Meaningful Use requirements may be found on the government s website: http://healthit.hhs.gov Stage 1 MENU Meaningful Use Requirements For Stage 1, providers must complete all 15 CORE Meaningful Use objectives and 5 selected MENU objectives from a list of 10 possible MENU objectives (unless they can attest to an exemption of a Core and/or Menu objective). One of the MENU objectives selected must be a Public Health Objective either electronic submission to the state immunization registry or electronic submission of syndromic surveillance. Because selection of one of the public health items is required, this White Paper does not address those objectives. Each practice will want to evaluate their state s immunization submission Page 2

process and the practice s immunization volume to determine if the immunization objective is the best one to select for Stage 1 or the electronic syndromic surveillance data. Note that while a provider must choose one of the public health objectives, they may choose both of them, leaving only 3 other menu objectives to satisfy the total of five. Stage 2 Meaningful Use Requirements For Stage 2, CMS moved all of the Stage 1 MENU objectives, except electronic submission of syndromic surveillance, into the REQUIRED/CORE objectives. Changes were made to some of the objectives for Stage 2. As a result, it would generally behoove providers completing Stage 1 to go ahead and make plans for ALL of the Stage 1 Menu objectives. The Impact of Your EHR on the MENU Items You Choose A Complete ONC- ATCB Certified EHR must be capable of achieving all Core and Menu objectives. However, it is important to note that some EHR vendors charge extra for functionality that may be needed. For example, use of a Patient Portal is needed for one of the Stage 1 MENU objectives and some EHR vendors charge extra for installation and /or use of their Patient Portal or require the purchase of a third party portal. Many EHR vendors also charge extra for all or some of their eprescribing capabilities. The possibility of extra charges for services was built into this analysis (see CONs where applicable). Some EHRs may not charge for these services and for those that do, the costs can vary dramatically. As such, every provider is encouraged to weigh any additional costs from their EHR vendor as part of their decision on the Menu items they select. In addition to cost considerations, some EHRs may perform a function in a manner that is cumbersome within normal workflow. As such, your workflow for an objective and how it is accomplished with your EHR should also be considered when selecting the menu objectives you will complete. Because of potential cost and workflow issues, ideally you will review these objectives with potential EHR vendors before selecting an EHR. If you already have an EHR, it is important that you review the MENU objectives you select with your EHR vendor PRIOR to the start of your selected Meaningful Use period to determine any potential extra cost or impacts on your workflow. Because of the variability in cost and functionality among various EHRs, those considerations have not been taken into account in the ranking for this White Paper. The ranking in this White Paper assumes that none of the MENU objectives will result in extra charges from your EHR vendor or in cumbersome functionality within the EHR. Page 3

Easiest to Most Difficult the MENU Meaningful Use Objectives in Order When selecting your non Public Health MENU objectives for Stage 1 which ones should you choose? The following recommendations are based on general ease within the normal practice workflow and take into consideration how the applicable Stage 1 MENU items are incorporated in Stage 2. For each objective the rationale for its order in the list is explained as well as PRO s and CON s of selecting the objective. #1 Generate Patient List by Condition (MENU Objective 3): For this objective you must generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach. While the purpose of the reporting is included in the requirement, in practice, you must only generate such a report at least once during your Meaningful Use period. Your EHR should include reporting by Assessment or Diagnosis Code(s) which should allow you to easily meet this Menu objective. Your EHR should allow you to quickly and easily run a report meeting this objective. This item moves to a Core objective for Stage 2. CON s: None According to CMS statistics*, as of December 2012, 74.4% of providers attesting to Meaningful Use selected this as one of their Menu objectives, making it the second most selected Menu objective. TIP: Print and save the printed report in a file during your MU reporting period. Make sure the report shows the date it was produced on the report. If not, take a screen shot of producing the report from the EHR. #2 Drug Formulary Enabled in the EHR (MENU Objective 1): This requires that the EP has enabled this functionality and has access to at least one internal or external formulary for the entire reporting period. As such, you should be able to simply turn this functionality on within your EHR, or it may already be provided/turned on by your vendor (this is what Sevocity does). Depending upon how this is done by your EHR vendor there may be little or no extra cost to turn on the formulary. Page 4

Depending upon how this function is done by your EHR, it may be no extra work, extra clicks, etc. it may simply present the formulary information where you can act on it if you choose. Query of the Drug Formulary was incorporated into the eprescribing Core objective for Stage 2. CON s: Your vendor may charge extra for formulary support, and/or the workflow may be cumbersome. According to CMS statistics*, as of December 2012, 84.9% of providers attesting to Meaningful Use selected this as one of their Menu objectives, making it the most selected Menu objective. TIP: Save documentation from your vendor proving that this feature was turned on and/or included in your EHR. #3 Patient Specific Education (MENU Objective 6): This requires that more than 10% of all unique patients seen by the EP are provided patient- specific education resources. Whether you are in family practice or a specialist, you most likely already provide written patient education to 10% or more of your patients. Your EHR should make it easy and inexpensive (or free) to produce your existing handouts from the EHR and/or access third party sources of patient education, such as links to external websites or content provided within the EHR. Depending upon how this is done by your EHR vendor, there may be little or no extra cost. Depending upon how this function is done by your EHR, it may be little extra work, extra clicks, etc. to print information for your patients and record the education provided within the EHR. At 10%, the required volume is low. This item moves to a Core objective for Stage 2. CON s: Your EHR vendor may charge extra to provide Patient Education and/or the workflow may be cumbersome. According to CMS statistics*, as of December 2012, 51.3% of providers attesting to Meaningful Use selected this as one of their Menu objectives, making it the fourth most selected Menu objective. TIP: Have available (and make sure your staff uses) patient education for your most common assessments, such as Diabetes and Obesity. This should help ensure you meet the 10% objective. Page 5

#4 Provide Patients with Electronic Timely Access (MENU Objective 5): This requires that more than 10% of the unique patients seen by the EP are provided timely (available within 4 days of being updated within the certified EHR technology) electronic access to their health information subject to the EP s discretion to withhold certain information. This objective essentially means providing a patient portal. This objective probably scares more providers than any other Menu requirement because there is a concern that patients will use a portal like an email system and inundate the practice with portal messages. There are also concerns that many patients are not ready or able to use a portal. This is a particularly common concern among practices serving older patients. However, many practices implementing a portal find their patients are receptive and welcome the portal. Also, instead of emails and phone calls for appointments, medication refills and other routine items, these are received in a manner that is more convenient and easier to manage. Frankly this is not the 4 th easiest Menu objective. However, it was ranked #4 because this item has the greatest growth in Stage 2. For Stage 2 not only does this become a Core objective, but providers will also be required to ensure that at least 5% of the unique patients seen during the period access (use) the portal. Implementing a portal now and getting patients in the habit of using the portal is the best way to ensure that this is not a barrier to achieving Stage 2 Meaningful Use. This item moves to a Core objective for Stage 2 and it will then require that at least 5% of patients access the portal. Many practices find receiving requests for items like appointments and medication refills is easier to manage through a portal connected with their EHR. Many patients like to use a portal. Once implemented, a portal can also be used for patient reminders and other items central to patient care. CON s: Some patients may not have Internet access and/or be ready to use a portal. Portals may occasionally be misused by patients. Many EHR vendors charge extra for portals. Some vendors charge per transaction and this could get very expensive as portal use grows. According to CMS statistics*, as of December 2012, 32.9% of providers attesting to Meaningful Use selected this as one of their Menu objectives, making it the sixth most selected Menu objective. TIP: Develop a patient agreement for the Portal to have patients sign acknowledging how to use (and not use) the portal. Include a link to the portal on your practice website. Page 6

#5 Medication Reconciliation (MENU Objective 7): This requires that the EP performs medication reconciliation for more than 50% of transactions of care in which the patient is transitioned into the care of the EP. In order to provide proper care for your patients you are probably doing this already. Your EHR should make it easy and inexpensive to perform a Pharmacy Benefits Manager History (PBMx) query for the patient s existing drugs as submitted by their insurance companies and/or pharmacies. However, even with PBMx, you may need to add medications that were cash pay or otherwise do not show up in the PBMx. Depending upon how PBMx is done by your EHR vendor, there may be little or no extra cost. Some EHRs may further assist by including Duplicate Therapy Warnings in the event you prescribe a new medication that includes ingredients that may cause it to duplicate existing medications. This item moves to a Core objective for Stage 2. CON s: If your EHR vendor charges extra to provide PBMx and/or the workflow is cumbersome, this may not be an easy Menu objective for Stage 1. According to CMS statistics*, as of December 2012, 46.3% of providers attesting to Meaningful Use selected this as one of their Menu objectives, making it the fifth most selected Menu objective. TIP: If your EHR does not have a PBMx function but has the ability to store your favorite medications, add the medications your patients commonly take (including those from other providers) on your favorite medications list to make them faster and easier to add to the patient s medication list. #6 Summary of Care for Transition of Care (MENU Objective 8): This requires that the EP who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide a summary of care record for each transition of care or referral for more than 50% of such transitions of care/referrals. In short, in order to meet this objective you will need to: Track each time a patient is transitioned to another setting of care and to whom Send a Summary of Care to the new provider Track that the Summary of Care was provided The way your EHR handles this and the additional tools it may provide (or you may have available) can make a vast difference in how easy or difficult and how expensive this objective is to perform and equally importantly, track correctly. Tools that may help with this Menu objective include secure Page 7

electronic faxing capabilities (the ability to send a fax without having to print and scan the document), a letters system within your EHR, a referral tracking system within your EHR and the ability of your EHR to maintain a complete contact list with applicable address, etc. for other providers with whom you frequently share patients. You are most likely already providing a summary of care to other providers. Some EHR tools can improve the ease of providing and documenting a summary of care through features such as system generated letters, referral tracking and exports. This item moves to a Core objective for Stage 2 and is enhanced to require minimum levels of electronic exchange. CON s: Secure electronic faxing can be expensive if not included with your EHR and/or the process within the EHR to create and/or document of the Summary of Care may be cumbersome. Proving this objective requires well- executed workflow and documentation. According to CMS statistics*, as of December 2012, only 15.7% of providers attesting to Meaningful Use selected this as one of their Menu objectives, making it the eighth most selected Menu objective. TIP: Find out if your EHR has the capability to maintain a clinics contacts list that can be used to retain the names, addresses, phone numbers and fax numbers of other providers of care that your patients commonly use. You (or your vendor) may also be able to upload this from an external data file. #7 Send Patient Reminders (MENU Objective 4): This requires that more than 20% of unique patients 65 years of age and older or 5 years old and younger were sent an appropriate reminder during the EHR reporting period. Reminders are a great tool for patient care and if your practice is already consistently performing reminders this Menu objective may move up in importance for your practice. However, for practices not currently doing reminders, this can be expensive and/or cumbersome. You must get the reminder to the patient or their guardian via mail, a phone call or sending the reminder through the patient portal. While the latter may be the most cost effective, a patient portal is probably the least appropriate communication means for patients 65 and older. In addition, some EHR systems may not be adept at segregating reminders by the applicable age ranges, requiring manual work from you to reach the designated patient populations. You may already be doing reminders and your EHR may effectively facilitate reminders. Reminders should improve patient care. This item moves to a Core objective for Stage 2 but changes to more than 10% of all (no longer based on age) unique patients seen by the EP in the 24 months prior to the EHR reporting period. Page 8

CON s: Mailing and calling patients can be expensive and time consuming. The EHR may not be adept at segregating the current age based patient population and/or at tracking this objective. Since the objective is changing considerably, it may make more sense to focus on use of the patient portal and wait to implement patient reminders in Stage 2. According to CMS statistics*, as of December 2012, 19.0% of providers attesting to Meaningful Use selected this as one of their Menu objectives, making it the seventh most selected Menu objective. TIP: Start collecting and entering patient email addressed into your EHR now. #8 Incorporate Clinical Lab Results (MENU Objective 2): This requires more than 40% of clinical lab test results ordered by the EP during the EHR reporting period whose results are either in a positive/negative or numerical format are incorporated in the certified EHR technology as structured data. On the surface, this would appear to be a fairly easy Menu objective to achieve. Electronic lab results are relatively common and easy to implement and they greatly improve workflow and chart accuracy. However, as they say, the devil is in the details. While the 40% may not be difficult to achieve, it may be difficult to track the numerator and denominator for this measure because there are so many variables, including: Lab orders can be placed as multiple orders but received as one set of results or visa versa. Because of this, there have been reports of EHRs producing a numerator number that is larger than the denominator and CMS will not allow this in the attestation. Results in any structured data count, so lab results manually entered into the EHR in a flowsheet or other structured format with numerical and positive/negative results can count. This is helpful for getting to the 40% threshold but makes it more difficult to count the numerator when the number/count may need to come from two different sources both results received via HL7 and those entered manually. During the initial 90 days of meaningful use, providers may be ramping up their use of EHR. However, typically when the lab results HL7 process is turned on, all lab results will be received electronically into the EHR including lab results for patients not seen in the EHR. This can also cause the numerator (lab results received electronically) to be higher than the denominator (lab results ordered) if the denominator is calculated by the EHR. HL7 (structured) lab results are available from all national labs and most regional and hospital labs. A solid process for electronic lab results is much more efficient and reliable than receipt of faxed or paper lab results. This item becomes a Core objective in Stage 2 of Meaningful Use and moves from 40% to 55%. Page 9

CON s: Correctly tracking and calculating the numerator and denominator for this measure can be very difficult. Lab interfaces typically cost extra. It may take time to get lab interfaces set up, potentially delaying the start of your MU period or reducing the counted results during the period. According to CMS statistics*, as of December 2012, 64.2% of providers attesting to Meaningful Use selected this as one of their Menu objectives, making it the third most selected Menu objective. TIP: Ask your lab(s) to pay for the EHR lab interface with them often the lab will pay all or a portion of the installation fee for the interface. #9 Choose Two of the Public Health Options (MENU Objectives 9 and 10): Providers are required to select at least one Public Health Menu objective (state immunization registry or electronic submission of syndromic surveillance), however you may select both. Doing so will satisfy 2 of your required 5 menu objectives, leaving only 3 additional items to select. According to CMS statistics*, as of December 2012, only 11.3% of providers attesting to Meaningful Use selected both of the public health options, making it the least selected avenue for achieving the Menu Items. This is not surprising because the immunization registry option will not apply to all practices and both of these options require a degree of interaction and support outside the practice. In addition, many EHRs charge extra for such interfaces. Page 10

Summary Ranking Recommendation Attestations as of 12/31/2012* #1 Generate Patient List by Condition (MENU 3) #2 Drug Formulary Enabled in the EHR (MENU 1) #3 Patient Specific Education (MENU 6) #4 Provide Patients with Electronic Timely Access (MENU 5) #5 Medication Reconciliation (MENU 7) #6 Summary of Care for Transition of Care (MENU 8) #7 Send Patient Reminders (MENU 4) #8 Incorporate Clinical Lab Results (MENU 2) #9 Choose Two of the Public Health Options (MENU 9 and 10) Drug Formulary Enabled in the EHR (MENU 1) Generate Patient List by Condition (MENU 3) Incorporate Clinical Lab Results (MENU 2) Patient Specific Education (MENU 6) Medication Reconciliation (MENU 7) Provide Patients with Electronic Timely Access (MENU 5) Send Patient Reminders (MENU 4) Summary of Care for Transition of Care (MENU 8) Choose Two of the Public Health Options (MENU 9 and 10) The Menu Meaningful Use objectives ultimately selected by a practice for Stage 1 can vary significantly based upon the practice s current processes, their EHR and their patient population. The recommendations in this White Paper assume typical practice conditions and EHR constraints, however every practice is different. Practices are encouraged to review the PROs and CONs of each Menu item and make the decision that is best for their practice and include a 6 th and 7 th Menu objective as a fallback provision. Since many of the Stage 1 Menu Items become Core objectives in Stage 2, practices may want to begin progress on all of the Stage 1 Menu objectives. Page 11

Resources * CMS Statistics: The Menu objectives selected by the 117,285 Eligible Providers attesting to Meaningful Use as of December 2012 per the CMS report EP Recipients of Medicare EHR Incentive Program Payments (available at https://www.cms.gov/regulations- and- Guidance/Legislation/EHRIncentivePrograms/DataAndReports.html) were analyzed to determine the frequency with which each of the Menu Meaningful Use objectives were selected by the providers in the report. Menu objetives were selected as follows: Menu 1: 99,608 (84.9%) Menu 2: 75,255 (64.2%) Menu 3: 87,223 (74.4%) Menu 4: 22,293 (19.0%) Menu 5: 38,625 (32.9%) Menu 6: 60,195 (51.3%) Menu 7: 54,339 (46.3%) Menu 8: 18,363 (15.7%) Menu 9 (Public Health req): 93,836 (80.0%) Menu 10 (Public Health req): 36,696 (31.9%) Menu 9 and 10: 13,247 (11.3%) About Sevocity Based in San Antonio, Texas, Sevocity empowers physician practices and health centers to embrace Electronic Health Records (EHRs) by providing an easy- to- use, affordable, Internet- based electronic health record system. Because Sevocity EHR is an ASP (application service provider) system that provides secure access to clinical information via the Internet, clinics and health centers avoid the expensive upfront capital expenditure and ongoing maintenance costs associated with client/server offerings. For more information about Sevocity, visit http://www.sevocity.com or call (877) 777-2298. Page 12