Stage 2 Meaningful Use: A Deep Dive James R. Christina, DPM FPMA 2014 Annual Meeting Naples, FL Latest CMS Data April 2014 Provider Summary 1
Payment Summary What Stage Am I In? 2 2 CMS Proposed Rule On May 20, 2014 CMS and Office of the National Coordinator (ONC) released a notice of proposed rulemaking (NPRM) that would allow providers participating in the EHR Incentive Programs to use the 2011 Edition of certified electronic health record technology (CEHRT) for calendar and fiscal year 2014. The NPRM will grant flexibility to providers who are experiencing difficulties fully implementing 2014 Edition CEHRT to attest this year. The proposed rule would allow providers to use EHRs that have been certified under the 2011 Edition, a combination of the 2011 and 2014 Editions, or the 2014 Edition. Beginning in 2015, all eligible providers would be required to report using 2014 Edition CEHRT. 2
If you can attest to not being able to fully implement 2014 CEHRT then you have the following options You would be able to attest for MU: If you Using 2011 Using 2011 & Using 2014 were Edition 2014 Edition Edition scheduled CEHRT to CEHRT to CEHRT to to do: do: do: demonstra te: 2013 Stage 1 objectives and 2013 Stage 1 measures 2014 Stage 1 Stage 1 in objectives -or- objectives 2014 and measures 2014 Stage 1 and measures objectives and measures 2013 Stage 1 objectives and measures 2014 Stage 1 -OR- objectives 2013 Stage 1 2014 Stage 1 and measures Stage 2 in objectives objectives and -OR- 2014 and measures measures Stage 2 -OR- objectives Stage 2 and measures objectives and measures FACTS ABOUT PROPOSED RULE: This is a proposed rule meaning that there is a 60 day comment period. APMA will comment on the proposed rule, particularly stating that there should not be the need to attest to inability to fully implement but all providers should have the option of choosing what CEHRT they want to use to attest. The comment period will end on July 21, 2014. CMS will probably not issue the final rule on this until around September 1, 2014. That will mean when the final rule comes out there will be only one calendar quarter (Oct-Dec) left to meet the requirements for MU for 2014. CMS has indicated that if you feel that you will attest to not being able to fully implement 2014 CEHRT and you are able to meet the MU requirements in the proposed rule during one of the calendar quarters prior to the final rule, you will be able to attest to that calendar quarter once the rule is finalized. So for example, if you were scheduled to demonstrate Stage 1 or Stage 2 of MU in 2014 and during one of the calendar quarters you were still using your 2011 CEHRT, if you met the 2013 Stage 1 objectives and measures, you would be able to attest to that quarter once the final rule was published. Note that the options in the table listed depend on whether you were scheduled to report on Stage 1 or Stage 2 in 2014. Note that it will still only require a 90 day attestation linked to one of the calendar quarters for 2014. Reporting of clinical quality measures will depend on whether you are meeting 2013 or 2014 objectives and measures If you have upgraded to a 2014 CEHRT but are not able to fully implement all of the features you can attest to 2014 Stage 1 objectives and measures. As stated in the proposed rule: A provider s ability to fully implement all of the functionality of 2014 Edition CEHRT may be limited by the availability and timing of product installation, deployment of new processes and workflows, and employee training. This effect is compounded for providers in Stage 2 as some providers may not be able to fully implement all of thefunctions included in 2014 Edition CEHRT that are necessary to meet the Stage 2 objectives and measures in time to complete their EHR reporting period in 2014. Therefore, under our proposal, providers who are scheduled to begin Stage 2 for the 2014 EHR reporting period but are unable to fully implement all the functions of their 2014 Edition CEHRT required for Stage 2 objectives and measures due to delays in 2014 Edition CEHRT availability would have the option of using 2014 Edition CEHRT to attest to the 2014 Stage 1 objectives and measures for the 2014 EHR reporting period. Providers who are scheduled to begin Stage 2 in 2014 who choose this option must attest that they are unable to fully implement 2014 Edition CEHRT because of issues related to 2014 Edition CEHRT availability delays when they attest to the meaningful use objectives and measures. 3
Reporting Period for 2014 (remains unchanged even with proposed rule) EHR Must Have 2014 ONC Certification (Unless you attest to being unable to fully implement 2014 CEHRT) Stage 2 Requirements 4
Core Objectives Computerized Provider Order Entry (CPOE) 5
Do I have to enter orders for x-rays taken in my office? I asked this question of CMS: For Stage 2 Core Measure 1 CPOE--if a eligible provider has ability to take x-rays in their office, do they need to put an order for an x-ray as a CPOE even though the x-ray is taken on site in their office and if so then they need to make that available under the menu set measure as structured data in the patient's record--correct? To expand on this most podiatrists i t have x-ray capability in their offices to take foot and ankle x-ray films. They bill for both components taking the x-rays and reading and interpreting the x-rays, so no other health care provider is involved. It seems tedious for them to enter an order for the x-rays in the patient record to take these on site. Also, for the menu set measure, they would then have to somehow get the films from their office into a digital form (probably a digital photograph of the x-ray) and scan it into the patient record as structured data. I appreciate clarification of this measure. This was the CMS response: The CMS Stage 2 Final Rule states that the CPOE function should be used the first time the order becomes part of the patient s medical record and before any action can be taken on the order... The provider must make the determination as to what constitutes the patient s medical record and what does not based on their existing policies and applicable state and Federal e law. Our only requirements in this regard are that the determination be made by the provider prior to the start of the EHR reporting period and be uniformly applied. You are correct that if an x-ray is entered via CPOE then Menu Measure 3 objective is that the imaging results and any explanation accompanying the image result need to be accessible through CEHRT for more than 10% of all tests ordered by the EP during the reporting period. There is an exclusion for any EP who orders less than 100 imaging tests during the reporting period. 6
E-Prescribing (erx) 7
Record Demographics 8
Record Vital Signs 9
Record Smoking Status 10
Use Clinical Decision Support 11
Potential CQMs for Podiatrists Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (Population and Public Health) Preventive Care and Screening: Influenza Immunization (Population and Public Health) Pneumonia Vaccination Status for Older Adults (Clinical Processes/Effectiveness) Diabetes: Eye Exam (Clinical Processes/Effectiveness) Diabetes: Foot Exam (Clinical Processes/Effectiveness) Diabetes: Hemoglobin A1c Poor Control (Clinical Processes/Effectiveness) Hemoglobin A1c Test for Pediatric Patients (Clinical Processes/Effectiveness) Diabetes: Urine Protein Screening (Clinical Processes/Effectiveness) Diabetes: Low Density Lipoprotein (LDL) Management (Clinical Processes/Effectiveness) Falls: Screening for Future Fall Risk (Patient Safety) Documentation of Current Medications in the Medical Record (Patient Safety) Closing the referral loop: receipt of specialist report (Care Coordination) Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow Up (Population and Public Health) Preventive Care and Screening: Screening for High Blood Pressure and Follow Up Documented (Population and Public Health) 12
Provide Patients the Ability to View Online, Download and Transmit Their Health Information 13
Provide Clinical Summaries 14
Security Risk Analysis 15
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http://www.healthit.gov/providers-professionals/security-risk-assessment Incorporate Clinical Lab Test Results 17
Generate Lists of Patients by Specific Conditions 18
Reminders for Preventive/Follow- Up Care 19
Patient Education Resources 20
Medication Reconciliation 21
Summary of Care Record 22
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Submit to Immunization Registries 25
Use Secure Electronic Messaging with Patients 26
MENU OBJECTIVES Menu Objectives 27
Submit electronic syndromic surveillance data to public health agencies 28
Record electronic notes in patient records 29
Imaging results accessible through CEHRT 30
Record patient family health history Report cancer cases to a public health central cancer registry 31
Report specific cases to a specialized registry 32
Qualified Clinical Data Registry (QCDR) For 2014, these registries are CMS- approved entities that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients. 33
U S Wound Registry (USWR) The U.S. Wound Registry (USWR) is one of many specialty registries developed and operated by the non-profit Chronic Disease Registry. It became a PQRS registry at the outset of the registry process in 2008 and is one of most experienced PQRS registries. As a non-profit organization focused on quality of care for patients with chronic wounds, the USWR began to shed light on gaps in practice such as why off-loading is so poorly implemented td for dibti diabetic foot ulcers. 1 USWR worked with the Institute for Clinical Outcomes Research (ICOR) to develop the Wound Healing Index (WHI) to stratify patients by severity in order to provide a more equitable way to report healing outcomes. 2 In conjunction with the Alliance of Wound Care Stakeholders (AWCS) USWR submitted new wound care quality measures to CMS in 2009 and 2011 and started the Do the Right Thing TM project to pilot test these quality measures in outpatient wound centers (e.g. DFU off-loading, venous ulcer compression, vascular assessment of patients with leg ulcers). 3 For many years the USWR has lead the way in PQRS reporting for wound care clinicians. APMA relationship with USWR Complete the survey TODAY: http://uswoundregistry.com/apmasurvey Beginning on March 31, 2014 when specifications are posted online, select the APMA recommended measures and ask you EHR vendor to program the specifications into your EHR. You may want to have to contact your EHR vendor beforehand to discuss any integration issues. Download the Business Associate Agreement (BAA) from the USWR website (http://www.uswoundregistry.com), sign it, and return it by fax to the USWR at 832-550-2941 or to enrollment@uswoundregistry.com. Once your vendor has completed the programming to allow you to submit your measures, you are ready to create an account for payment. Work with your assigned USWR representative to finish your set up and begin reporting! APMA members receive a $50 discount What If None of the Menu Objectives Are Relevant? It s rare, but it s possible that none of the menu objectives are applicable to your scope of practice. If that is the case for you and you qualify for all of the exclusions for each of the menu objectives, then you can select 3 menu objectives and claim the exclusion for each. However, if you do not qualify for all of the exclusions to the menu objectives, you must go back and select menu objectives on which you can report. 34
CLINICAL QUALITY MEASURES (CQMs) Clinical Quality Measures (CQMs) Changes to CQMs in 2014 Beginning in 2014, the reporting of clinical quality measures (CQMs) will change for all providers. EHR technology that has been certified to the 2014 standards d and capabilities i will contain new CQM criteria, and eligible professionals will report using the new 2014 criteria regardless of whether they are participating in Stage 1 or Stage 2 of the EHR Incentive Programs. 35
How to Submit CQM Data in 2014 All Medicare eligible professionals have the option of submitting three months of CQM data online through the CMS Registration & Attestation System. Medicare eligible professionals also have the option to submit a full year of data electronically using the QRDA format to receive credit for the EHR Incentive Program and the Physician Quality Reporting System. Please note that your attestation for the Medicare EHR Incentive Program is not complete until you submit clinical quality measure data, so your EHR incentive payment will be held until your electronic submission is processed. How to Select CQMs in 2014 Beginning in 2014, eligible professionals must select and report on 9 of a possible list of 64 approved CQMs for the EHR Incentive Programs. There is also a new requirement in 2014 that the quality measures selected must cover at least 3 of the 6 available National Quality Strategy (NQS) domains, which represent the Department of Health and Human Services NQS priorities for health care quality improvement. The 6 domains are: Patient and Family Engagement Patient Safety Care Coordination Population and Public Health Efficient Use of Health Care Resources Clinical Processes/Effectiveness You can find a complete list of the 2014 CQMs for the EHR Incentive Programs and their associated National Quality Strategy domains at: Clinical Quality Measure webpage at http://www.cms.gov/regulations-and- Guidance/Legislation/ EHRIncentivePrograms/ClinicalQualityMeasures.html Potential CQMs for Podiatrists Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (Population and Public Health) Preventive Care and Screening: Influenza Immunization (Population and Public Health) Pneumonia Vaccination Status for Older Adults (Clinical Processes/Effectiveness) Diabetes: Eye Exam (Clinical Processes/Effectiveness) Diabetes: Foot Exam (Clinical Processes/Effectiveness) Diabetes: Hemoglobin A1c Poor Control (Clinical Processes/Effectiveness) Hemoglobin A1c Test for Pediatric Patients (Clinical Processes/Effectiveness) Diabetes: Urine Protein Screening (Clinical Processes/Effectiveness) Diabetes: Low Density Lipoprotein (LDL) Management (Clinical Processes/Effectiveness) Falls: Screening for Future Fall Risk (Patient Safety) Documentation of Current Medications in the Medical Record (Patient Safety) Closing the referral loop: receipt of specialist report (Care Coordination) Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow Up (Population and Public Health) Preventive Care and Screening: Screening for High Blood Pressure and Follow Up Documented (Population and Public Health) 36
CQMs are a reporting requirement Unlike the Physician Quality Reporting System (PQRS), reporting CQMs for Meaningful Use is a reporting requirement only you y do not have to meet a threshold for performance. It is acceptable to report CQMs in which you have patients in the denominator but zero in the numerator (you did not perform the quality measure) RESOURCES CMS Attestation Calculator http://www.cms.gov/apps/stage-2-meaningful-use-attestation-calculator/ 37
Questions James R. Christina, DPM jrchristina@apma.org 301-581-9265 38