EHR Incentive Program Stage 3 Objectives & Measures Crosswalk of Stage 3 Proposed Objectives, Measures & Corresponding Stage 2 Measures Objective 1: Protect Patient Health Information Measures: 1 (Complete 1 Measure) Proposed Objective: Protect electronic protected health information (ephi) created or maintained by the certified EHR technology (CEHRT) through the implementation of appropriate technical, administrative, and physical safeguards. Objective 2: Electronic Prescribing (erx) Hospitals / CAHs, Eligible Professionals or Both (Stage 2 only) **For Stage 3 EPs, EHs & CAHs would have the same measure set** Stage 3 Objectives Stage 3 Measures Corresponding Stage 2 Conduct a security risk analysis in accordance to the requirements under 45 CFR 164.308(a)(1), including the encryption of data stored, implement security updates, and correct identified security deficiencies. Measures: 1 (Complete 1 Measure) Proposed Objective: EPs must generate and transmit permissible prescriptions electronically, and eligible hospitals and CAHs must generate and transmit permissible Risk analysis must be conducted or reviewed for each reporting period. EPs and EHs must conduct the security risk analysis upon installation of CEHRT or upon upgrade of a new Edition of certified EHR technology. Need to review the certification criteria to learn more about the audit log and tamper-resistance provisions. EP Measure: More than 80 percent of all permissible prescriptions written by an EP are queried for a drug formulary and transmitted electronically using CEHRT. EH Measure: More than 25 percent of hospital discharge medication orders for permissible prescriptions are queried for a drug formulary and transmitted electronically using CEHRT. 1 Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308(a)(1), including addressing the encryption/security of data stored in CEHRT in accordance with requirements under 45 CFR 164.312 (a)(2)(iv) and 45 CFR 164.306(d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the provider's risk management process More than 50 percent of all permissible prescriptions, or all prescriptions written by the EP and queried for a drug formulary and transmitted electronically using CEHRT
discharge prescriptions electronically Objective 3: Clinical Decision Support (CDS) Measures: 2 (Complete 2 Measures) Proposed Objective: Implement clinical decision support (CDS) interventions focused on improving performance on high-priority health conditions. Measure 1: EP and EH must implement five (5) clinical decision support interventions related to four (4) or more CQMs at a relevant point in patient care for the entire EHR reporting period. Measure 2: EP and EH has enabled and implemented the functionality for drug-drug and drug-allergy interactions checks for the entire EHR reporting period. 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. Absent four clinical quality measures related to an EP, eligible hospital or CAH's scope of practice or patient population, the clinical decision support interventions must be related to high-priority health conditions. Objective 4: Computerized Provider Order Entry (CPOE) Measures: 3 (Complete all 3 measures) Proposed Objective: Use computerized provider order entry (CPOE) for medication, laboratory, and diagnostic imaging orders directly entered by any licensed healthcare professional, credentialed medical assistant, or a medical staff member credentialed to and performing the equivalent duties of a credentialed medical assistant; who can enter orders into the medical Measure 1: More than 80 percent of medication orders created by the EP or authorized providers of the EH during the EHR reporting period are recorded using CPOE. Measure 2: More than 60 percent of laboratory orders created by the EP or authorized providers of the EH during the EHR reporting period are recorded using CPOE. Measure 3: More than 60 percent of diagnostic imaging orders created by the EP or authorized providers of the EH during the EHR reporting period are recorded using CPOE. 2. The EP, eligible hospital, or CAH has enabled and implemented the functionality for drug-drug and drug allergy interaction checks for the entire EHR reporting period. More than 60 percent of medication, 30 percent of laboratory, and 30 percent of radiology orders created by the EP or authorized providers of the eligible hospital's or CAH's inpatient or emergency department during the EHR reporting period are recorded using CPOE. 2
record per state, local, and professional guidelines. Objective 5: Patient Electronic Access to Health Information Measures: 2 (Complete both Measures) Proposed Objective: Use computerized provider order entry (CPOE) for medication, laboratory, and diagnostic imaging orders directly entered by any licensed healthcare professional, credentialed medical assistant, or a medical staff member credentialed to and performing the equivalent duties of a credentialed medical assistant; who can enter orders into the medical record per state, local, and professional guidelines. Objective 6: Coordination of Care through Patient Engagement Measures: 3, (Complete 2 of 3 Measures, submit data for all 3) Within 24 hours: Measure 1: For more than 80 percent of all unique patients seen by the EP or discharged from the EH: The patient (or patient-authorized representative) is provided access to view online, download, and transmit their health information within 24 hours of its availability to the provider, or The patient (or patient-authorized representative) is provided an OCN-certified API that can be used by third-party applications or devices to provide patients (or patient authorized representatives) access to their health information, within 24 hours of its availability to the provider. There are three proposed alternatives. All three would require the API to be available. Measure 2: The EP and EH must use clinically relevant information from CEHRT to identify patient-specific educational resources and provide electronic access to those materials to more than 35 percent of unique patients seen by the EP or discharged from the EH during the EHR reporting period. (This is increased from the Stage 2 threshold of 10 percent) The patient must be able to access this information on demand, such as through a patient portal, personal health record, or API and have everything necessary to access the information even if they opt out. Proposed Measures: Providers must attest to the numerator and denominator for all three measures, but would only be required to successfully meet the threshold for two of the three proposed measures. 3 Visit Summary/ Clinical Summary Clinical summaries provided to patients or patient-authorized representatives within 1 business day for more than 50 percent of office visits. Patient Education 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. More than 10 percent of all unique patients admitted to the eligible hospital are provided patient- specific education resources identified by Certified EHR Technology. View, Download, Transmit (VDT) 1. More than 50 percent of all unique patients seen by the EP during the EHR reporting period are provided timely
Measure 1: More than 25 percent of all unique patient seen by the EP or discharged from the EH actively engage with the electronic health record made accessible by the provider. EP and EH may meet the measure by either: Proposed Objective: Use communication function of certified EHR technology to engage with patients or their authorized representatives about the patient s care. or More than 25 percent of all unique patients seen by the EP or EH IP or ED during the EHR reporting period view, download, or transmit to a third party their health information More than 25 percent of all unique patients seen by the EP or EH IP or ED during the EHR reporting period access their health information through the use of an ONC-certified API that can be used by third party applications or devices. Measure 2: More than 35 percent of all unique patients seen by the EP or EH during the EHR reporting period, a secure message was sent using the electronic messaging function of CEHRT to the patient, or in response to a secure message sent by the patient. The secure message sent should contain relevant health information specific to the patient in order to the meet the measure. The provider is deemed to be the best judge of what should be considered relevant in this context. (within 4 business days after the information is available to the EP) online access to their health information subject to the EP's discretion to withhold certain information. 1. More than 50 percent of all patients who are discharged by an eligible hospital or CAH have their information available online within 36 hours of discharge 2. More than 5 percent 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 2. More than 5 percent of all patients (or their authorized representatives) who are discharged by an eligible hospital or CAH view, download or transmit to a third party their information during the reporting period. Secure Messaging Measure 3: Patient-generated health data from a nonclinical setting is incorporated into the certified EHR technology for more than 15percent of all unique patients seen by the EP or discharged from the EH during the EHR reporting period. A secure message was sent using the electronic messaging function of Certified EHR Technology by more than 5 percent of unique patients (or their authorized representatives) seen by the EP during the EHR reporting period Patient Generated Health Data 4
**New to MU** Was not an option under Stage 2 Objective 7: Health Information Exchange (HIE) Measures: 3 (Complete 2 of 3 Measures, submit data for all 3) Proposed Objective: The EP, EH provides a summary of care record when transitioning or referring their patient to another setting of care, retrieves a summary of care record upon the first patient encounter with a new patient, and incorporates summary of care information from other providers into their EHR using the functions of certified EHR technology. Providers must attest to the numerator and denominator for all three measures, but would only be required to successfully meet the threshold for two of the three proposed measures to meet the objective Measure 1: For more than 50 percent of transitions of care and referrals, the EP, EH that transition or refers their patient to another setting of care or provider of care: (1) creates a summary care record using CEHRT and (2) electronically exchanges the summary of care records. (The SOC documents must include the requirements and specifications included in the Common Clinical Data Set, CCDS specified by the 2015 ONC certification edition) Measure 2: For more than 40 percent of transitions or referrals received and patient encounters in with the provider has never before encountered the patient, the EP or EH incorporates into the patients EHR an electronic summary of care document from a source other than the provider s EHR system. Measure 3: For more than 80 percent of transitions or referrals received and patient encounters in which the provider has never before encountered the patient, the EP, EH performs a clinical information reconciliation. Medication Medication Allergy Current Problem List Measure: 1. The EP, eligible hospital, or CAH that transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 50 percent of transitions of care and referrals. Measure 2. The EP, eligible hospital or CAH that transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 10 percent of such transitions and referrals either (a) electronically transmitted using CEHRT to a recipient or (b) where the recipient receives the summary of care record via exchange facilitated by an organization that is a NwHIN Exchange participant or in a manner that is consistent with the governance mechanism ONC establishes for the nationwide health information network. Medication Reconciliation The EP, eligible hospital or CAH performs medication reconciliation for more than 50 percent of transitions of care in which the patient is transitioned into the care of the EP or admitted to the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23). 5
(Active engagement means that the provider is in the Labs to Public Health process of moving toward sending production data to a PHA or CDR, or is sending production data to a PHA or CDR.) Objective 8: Public Health and Clinical Data Registry Reporting Measures: 6 (EPs complete 3 of 5, EHs complete 4 of 6) Proposed Objective: The EP, eligible hospital, or CAH is in active engagement with a PHA or CDR to submit electronic public health data in a meaningful way using certified EHR technology, except where prohibited, and in accordance with applicable law and practice. Active Engagement Option 1 Completed Registration to Submit Data: The EP, EH registered to submit data with the PHA or CDR to which the information is being submitted; registration was completed within 60 days of the start of the EHR reporting period. Active Engagement Option 2 Testing and Validation: The EP, EH is in the process of testing and validation of the electronic submission of data. Providers must respond to request from the PHA or CDR within 30 days, failure to respond twice within the EHR reporting period would result in that provider not meeting the measure. Successful ongoing submission of electronic reportable laboratory results from Certified EHR Technology to public health agencies for the entire EHR reporting period. Syndromic Surveillance Successful ongoing submission of electronic syndromic surveillance data from Certified EHR Technology to a public health agency for the entire EHR reporting period Immunization History Active Engagement Option 3 Production: The EP, EH has completed testing and validation for the electronic submission and is electronically submitting production data to the PHR or CDR. Measure 1: Immunization Registry Reporting: The EP, eligible hospital, or CAH is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS). **NEW to MU** Registries **NEW to MU** Capability to identify and report specific cases to a specialized registry (other than a cancer registry), except where prohibited, and in accordance with applicable law and practice. Measure 2: Syndromic Surveillance Reporting: The EP, eligible hospital, or CAH is in active engagement with a public health agency to submit syndromic surveillance data from a non-urgent care ambulatory setting for EPs, or an 6
emergency or urgent care department for eligible hospitals and CAHs (POS 23). Measure 3: Case Reporting: The EP, eligible hospital, or CAH is in active engagement with a public health agency to submit case reporting of reportable conditions. Measure 4: Public Health Registry Reporting: The EP, eligible hospital, or CAH is in active engagement with a public health agency to submit data to public health registries. Measure 5: Clinical Data Registry Reporting: The EP, eligible hospital, or CAH is in active engagement to submit data to a clinical data registry. Measure 6: Electronic Reportable Laboratory Result Reporting: The eligible hospital or CAH is in active engagement with a public health agency to submit electronic reportable laboratory results. This measure is available to eligible hospitals and CAHs only. 7