Meaningful Use Stage 2: Important Implications for Pediatrics

Meaningful Use Stage 2: Important Implications for Pediatrics

Glossary of Acronyms MU CQM EHR CEHRT EPs CAHs e-rx CPOE emar ONC CMS HHS Meaningful Use Clinical quality measure Electronic health record Certified electronic health record technology Eligible professionals Critical access hospitals Electronic prescribing Computerized Provider Order Entry Electronic medication administration record Office of the National Coordinator Centers for Medicare and Medicaid Services U.S. Department of Health and Human Services

Meaningful Use (MU) Defined Promotes the spread of electronic health records to improve health care and seeks to: Improve quality, safety, efficiency, and reduce health disparities Engage patients and family Improve care coordination, population health, and public health Maintain privacy and security of patient health information Stages move from building a foundation for data capturing and sharing to the use of data to improve health outcomes. Stage 1 : Data Capturing and Sharing o Final Rule Released: July 2010 Incentive program: 2011 Stage 2: Advance Clinical Processes o Final Rule Released: August 2012 Incentive program: 2014 Stage 3: Improved Health Outcomes o Timeline to be determined

Summary of Final Rule for Stage 2 Amends Stage 1 Defines new criteria for Stage 2 Changes the definition of what constitutes a Medicaid encounter Extends eligibility to hospital based providers Greater emphasis on patient engagement and electronic exchange of information New pediatric specific clinical quality measures (CQMs) and reporting mechanisms

Changes from Stage 1 to Stage 2 Stage 1 Stage 2 Eligible Professionals (EPs) 15 Core Objectives 5 of 10 menu objectives 20 total objectives EPs 17 Core Objectives 3 of 6 menu objectives 20 total objectives Eligible Hospitals and Critical Access Hospitals (CAHs) 14 Core Objectives 5 of 10 menu objectives 19 total objectives Eligible Hospitals and CAHs 16 Core Objectives 3 of 6 menu objectives 19 total objectives

Stage 2 Core Objectives for EPs Core Objective Measure Use Computerized Provider Order Entry (CPOE) for medication orders Generate and transmit permissible prescriptions electronically (e-rx) Record demographics: Preferred language, gender, race, ethnicity and date of birth. Record and chart changes in vital signs: Height, weight, blood pressure, calculate and display BMI, plot and display growth charts for children 2-20 years, including BMI. Record smoking status for patients 13 years old and older More than 60 percent of medication, 30% laboratory, and 30% radiology orders created during the EHR reporting period are recorded using CPOE. More than 50 percent of all permissible prescriptions written are compared to at least one drug formulary and transmitted electronically using CEHRT. More than 80 percent of all unique patients seen have demographics recorded as structured data. More than 80 percent of all unique patients have blood pressure (for patients age 3 and over only) and height/length and weight (for all ages) recorded as structured data. More than 80 percent of all unique patients 13 years or older have smoking status recorded as structured data.

EP Core Objectives (continued) Core Objective Measure Interventions: Implement one clinical decision support rule relevant to specialty or high clinical priority along with the ability to track compliance that rule. Patient Access: Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies), upon request. Implement 5 clinical decision support interventions related to 4 or more clinical quality measures at a relevant point in patient care for the entire EHR reporting period. Enabled and implemented the functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period. More than 50% of all unique patients seen during the EHR reporting period are provided timely (available to the patient within 4 business days after the information is available to the EP) online access to their health information. More than 5% of all unique patients seen by the EP during the EHR reporting period (or their authorized representatives) view, download, or transmit to a third party their health information. Provide clinical summaries for patients for each office visit Incorporate clinical lab-test results into certified EHR technology as structured data Clinical summaries provided to patients within one business day for more than 50% of office visits. More than 55% of all clinical lab tests results ordered during the EHR reporting period whose results are either in a positive/negative or numerical format are incorporated in CEHRT as structured data.

EP Core Objectives (continued) Core Objective Measure Patient Lists: Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach. Patient Reminders: Send reminders to patients per patient preference for preventive/ follow up care. Generate at least one report listing patients of the EP with a specific condition. 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. Patient Education: Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate Patient-specific education resources identified by CEHRT are provided to patients for more than 10% of all unique patients with office visits seen by the EP during the EHR reporting period. The EP who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation The EP performs medication reconciliation for more than 50% of transitions of care in which the patient is transitioned into the care of the EP.

EP Core Objectives (continued) Core Objective 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 summary of care record for each transition of care or referral Capability to submit electronic data to Immunization Registries or Immunization Information Systems and actual submission except where prohibited and in accordance with applicable law and practice Security Analysis: Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities Secure Messaging Measure 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. Successful ongoing submission of electronic immunization data from Certified EHR Technology to an immunization registry or immunization information system for the entire EHR reporting period. Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308(a)(1). A secure message was sent using the electronic messaging function of CEHRT by more than 5% of unique patients seen during the EHR reporting period.

Stage 2 Menu Objectives for EPs Must meet 3 of 6 Menu Objective Measure Imaging Results Family History Submission of syndromic surveillance data More than 10% of all scans and tests whose result is an image ordered for patients seen during the EHR reporting period are incorporated into or accessible through CEHRT More than 20% of all unique patients seen during the EHR reporting period have a structured data entry for one or more first-degree relatives or an indication that family health history has been reviewed Successful ongoing submission of electronic syndromic surveillance data from CEHRT to a public health agency for the entire EHR reporting period Cancer Successful ongoing submission of cancer case information from CEHRT to a cancer registry for the entire EHR reporting period Specialized Registry Successful ongoing submission of specific case information from CEHRT to a specialized registry for the entire EHR reporting period Record electronic notes in patient records Enter at least one electronic progress note created, edited and signed by an EP for more than 30% of unique patients

Stage 2 Core Objectives for Hospitals and CAHs Core Objective Use Computerized Provider Order Entry (CPOE) for medication orders Measure More than 60% of medication, 30% of laboratory, and 30% of radiology orders created by authorized providers during the EHR reporting period are recorded using CPOE. Record demographics: Preferred language, gender, race, ethnicity, date of birth., and date and preliminary cause of death More than 80% of all unique patients admitted to the inpatient or emergency department have demographics recorded as structured data Record and chart changes in vital signs: Height, weight, blood pressure, calculate and display BMI, plot and display growth charts for children 2-20 years, including BMI More than 80% of all unique patients admitted to the inpatient or emergency department have blood pressure (for patients age 3 and over only) and height and weight (for all ages) recorded as structured data. Record smoking status for patients 13 years old and older More than 80% of all unique patients 13 years old or older admitted to the inpatient or emergency department have smoking status recorded as structured data

Hospitals and CAHs Core Objectives (continued) Core Objective Interventions: Implement one clinical decision support rule relevant to specialty or high clinical priority along with the ability to track compliance that rule Patient Access: Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies), upon request Incorporate clinical lab-test results into certified EHR technology as structured data Measure Implement 5 clinical decision support interventions related to 4 or more clinical quality measures at a relevant point in patient care for the entire EHR reporting period. Enabled and implemented the functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period. More than 50% of all unique patients discharged from the inpatient or emergency departments during the EHR reporting period are provided timely (available to the patient within 36 hours after discharge from the hospital.) online access to their health information More than 5% of all unique patients discharged from the inpatient or emergency departments during the EHR reporting period (or their authorized representatives) view, download, or transmit to a third party their health information More than 55% of all clinical lab tests results ordered by authorized providers for patients admitted to its inpatient or emergency department during the EHR reporting period whose results are either in a positive/negative or numerical format are incorporated in CEHRT as structured data

Hospitals and CAHs Core Objectives (continued) Core Objective Measure Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach Generate at least one report listing patients with a specific condition Patient education: Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate Incorporate clinical lab-test results into certified EHR technology as structured data The eligible hospital or CAH that receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation More than 10% of all unique patients admitted to the inpatient and emergency departments are provided patient- specific education resources identified by CEHRT. More than 55% of all clinical lab tests results ordered by authorized providers for patients admitted to its inpatient or emergency department during the EHR reporting period whose results are either in a positive/negative or numerical format are incorporated in CEHRT as structured data The eligible hospital or CAH performs medication reconciliation for more than 50% of transitions of care in which the patient is transitioned into the care of the eligible hospital or CAH.

Hospitals and CAHs Core Objectives (continued) Core Objective Measure The eligible hospital or CAH that transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary of care record for each transition of care or referral 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 an organization that is a NwHIN Exchange participant or is validated through an ONC-established governance mechanism. Capability to submit electronic data to Immunization Registries or Immunization Information Systems and actual submission except where prohibited and in accordance with applicable law and practice Successful ongoing submission of electronic immunization data from Certified EHR Technology to an immunization registry or immunization information system for the entire EHR reporting period. Capability to submit electronic data on reportable (as required by state or local law) lab results to public health agencies and actual submission except where prohibited and in accordance with applicable law and practice Successful ongoing submission of electronic reportable laboratory results from CEHRT to public health agencies for the entire EHR reporting period as authorized, and in accordance with applicable State law and practice.

Hospitals and CAHs Core Objectives (continued) Core Objective Measure Security Analysis: Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308(a)(1). Capability to submit electronic syndromic surveillance data to public health agencies and actual submission except where prohibited and in accordance with applicable law and practice Successful ongoing submission of electronic syndromic surveillance data from CEHRT to a public health agency for the entire EHR reporting period. Automatically track medications from order to administration using assistive technologies in conjunction with an emar More than 10% of medication orders created by authorized providers during the EHR reporting period for which all doses are tracked are tracked using emar.

Stage 2 Menu Objectives for Hospitals and CAHs Must meet 3 of 6 Menu Objective Record advance directives for patients 65 years old or older Imaging Results Family History Generate and transmit permissible discharge prescriptions electronically (e- Rx) Record electronic notes in patient records Provide structured electronic lab results to ambulatory providers Measure More than 50% of all unique patients 65 years old or older admitted inpatient department during the EHR reporting period have an indication of an advance directive status recorded as structured data More than 10% of all scans and tests whose result is an image ordered by an authorized provider for patients admitted to its inpatient or emergency department during the EHR reporting period are incorporated into or accessible through CEHRT. More than 20% of all unique patients admitted to the inpatient or emergency department during the EHR reporting period have a structured data entry for one or more first-degree relatives or an indication that family health history has been reviewed. More than 10% of hospital discharge medication orders for permissible prescriptions (for new or changed prescriptions) are compared to at least one drug formulary and transmitted electronically using CEHRT. Enter at least one electronic progress note created, edited and signed by an EP for more than 30% of unique patients admitted to the inpatient or emergency department during the EHR reporting period. Send structured electronic clinical lab results to the ordering provider for more than 20% of electronic lab orders received.

Stage 2 Changes Beginning in 2014 EHRs Meeting ONC 2014 Standards all EHR Incentive Programs participants will have to adopt CEHRT that meets ONC s Standards & Certification Criteria 2014 Final Rule Reporting Period Reduced to Three Months to allow providers time to adopt 2014 CEHRT and prepare for Stage 2, all participants will have a threemonth reporting period in 2014 Batch Reporting groups will be allowed to submit attestation information for all of their individual EPs in one file for upload to the Attestation System, rather than having each EP individually enter data.

Medicaid Changes Stage 2 changes the definition of what constitutes a Medicaid encounter, allowing patients covered by the Children's Health Insurance Program (CHIP) to be eligible for inclusion in most states. In Stage 1: 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 Medicaid patient volume for providers calculated across 90-day period in last calendar year (for EPs) or Federal fiscal year (for hospitals)

Medicaid Changes In Stage 2: Service rendered on any one day to a Medicaidenrolled individual, regardless of payment liability Includes zero-pay claims and encounters with patients in CHIP programs in States that have Medicaid expansion programs or in States with a combined Medicaid and CHIP program. Services can be included provider s Medicaid patient volume calculation as long as the services were provided to a beneficiary who is enrolled in Medicaid States have the option to allow providers to calculate Medicaid patient volume across 90-day period in last 12 months preceding provider s attestation

States with stand-alone CHIP programs Alabama Arizona Colorado Connecticut Georgia Kansas Mississippi New York Nevada Oregon Pennsylvania Utah Vermont Washington West Virginia Wyoming Texas

Definition of Hospital Based Providers 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

Patient Engagement 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 CMS is introducing exclusions based on broadband availability in the provider s county.

Electronic Information Exchange Providers must: Send a summary of care record for more than 50% of transitions of care and referrals Electronically transmit a summary of care for more than 10% of transitions of care and referrals Additionally, at least one summary of care document must be sent electronically to a recipient with different EHR vendor or to CMS test EHR.

Clinical Quality Measures CQM reporting will remain the same through 2013 44 EP CQMs 15 Eligible Hospital and CAH CQMs In 2012 and continued in 2013, there are two reporting methods available for reporting the Stage 1 measures: Attestation ereporting pilots In 2014, EPs must report on 9 of the 64 approved CQMs 9 specific to pediatrics Medicaid providers submit CQMs according to their statebased submission requirements.

Clinical Quality Measures 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

Pediatric Specific CQMs Title Measure Appropriate Testing for Children with Pharyngitis Percentage of children 2-18 years of age, who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode. Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents Chlamydia Screening for Women Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported. Percentage of patients with height, weight, and body mass index (BMI) percentile documentation. Percentage of patients with counseling for nutrition. Percentage of patients with counseling for physical activity. Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for Chlamydia during the measurement period. Use of Appropriate Medications for Asthma Percentage of patients 5-64 years of age who were identified as having persistent asthma and were appropriately prescribed medication during the measurement period.

Pediatric Specific CQMs (continued) Title Childhood Immunization Status Measure Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. Appropriate Treatment for Children with Upper Respiratory Infection (URI) Percentage of children 3 months-18 years of age who were diagnosed with URI and were not dispensed an antibiotic prescription on or three days after the episode. ADHD: Follow-Up Care for Children Prescribed Attention Deficit/Hyperactivity Disorder (ADHD) Medication Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.

Pediatric Specific CQMs (continued) Title Measure Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan Children who have dental decay or cavities Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen. Percentage of children ages 0-20, who have had tooth decay or cavities during the measurement period.

MU Resources ONC Meaningful Use Stage 2 Homepage (Includes links to the text of the final rules, HHS and CMS press releases, and FAQs at the bottom of the page.) CMS Stage 2 Webpage ONC Fact Sheet: 2014 Edition Standards & Certification Criteria (S&CC) Final Rule CMS Stage 2 Overview Tipsheet Stage 1 vs. Stage 2 Comparison Table for Eligible Professionals (EPs) CMS Stage 2 Fact Sheets Understanding the HIPAA Privacy Rule AAP Child Health Informatics Center, Meaningful Use Resources