Meaningful Use Stage 1 and 2 Your Survival Guide!

Where to go for Help, Handouts, and Future Updates Meaningful Use Stage 1 and 2 Your Survival Guide! Dr. Henry and Dr. Gross are affiliated with www.ehrguru.net and have lectured for numerous companies including Topcon, First Insight, RevolutionEHR, FoxFire, VisionWeb, SolutionReach, and the AOA. Dr. Gross is on the Vision Expo Advisory Board. Jay W. Henry, O.D., M.S. Philip J. Gross, O.D. Game Plan This lecture is strictly about the Meaningful Use Objectives for Stage 1 and Stage 2 Meaningful Use Stage 1 and Stage 2: Objective requirements Clinical implications of each objective Objective exemptions Objective compliance How to navigate the different stages Meaningful Use Meaningful Use Meaningful use is the set of standards defined by the Centers for Medicare & Medicaid Services (CMS) Incentive Programs that governs the use of electronic health records and allows eligible providers and hospitals to earn incentive payments by meeting very specific criteria The overall goal of meaningful use is to promote the spread of electronic health records to improve health care in the United States Meaningful Use Specific Goals of Meaningful Use Improve quality of health care Improve safety, efficiency and reduce health disparities Engage patients and families in their care Improve Care Coordination Improve population and public health Ensure adequate privacy and security protections for personal health information 1

Meaningful Use: The Next Stages All providers will complete at least two years of Stage 1 Meaningful Use (MU) before advancing to the Stage 2 criteria in their 3 rd or 4 th year. Maximum Payment by Start Year Annual Incentive Payment by Stage of Meaningful Use 2011 2012 2013 2014 2015 2016 2011 1 1 1 2 2 2 $44,000 $18,000 $12,000 $8,000 $4,000 $2,000 2012 1 1 2 2 2 $44,000 $18,000 $12,000 $8,000 $4,000 $2,000 2013 1 1 2 2 $39,000 $15,000 $12,000 $8,000 $4,000 2014 1 1 2 $24,000 $12,000 $8,000 $4,000 Meaningful Use: Reporting Period First year of participation Providers must demonstrate meaningful use for any continuous 90-day reporting period All subsequent years of participation except 2014 Providers must demonstrate meaningful use for a full year EHR reporting period (entire calendar year) For 2014 only (unless it s your first year of participation) All providers regardless of their stage of meaningful use are only required to demonstrate meaningful use for a 3-month EHR reporting period For Medicare EHR incentive program it is fixed to a quarter of the calendar year (1/1 3/31, 4/1-6/30, 7/1 9/30, 10/1 12/31) For Medicaid EHR incentive program the reporting period is not fixed YEAR 1 All Other Years 2014 Unless it is your first year Reporting Periods Meaningful Use Objectives Meaningful use established a core and menu structure for objectives that providers must achieve Core objectives are objectives that all providers must meet Some have exclusions which could exempt you from having to complete that objective (If you exempt from an objective you get credit as if you did it) Menu objectives allow the providers to select from a list a certain number of objectives to meet Some have exclusions which could exempt you from having to complete that objective Stage 1 Changes CMS has announced changes to Stage 1 Meaningful Use objectives Some changes took effect Jan. 1 st, 2013 Some changes took effect Jan. 1 st, 2014 We will cover all of these changes in the following slides. Fasten your seatbelts! Remember Don t Shoot the Messenger!! Meaningful Use: Stage 1 vs. Stage 2 Original Stage 1 criteria 2014 Stage 1 criteria 15 core objectives 13 core objectives 5 of 10 menu objectives 5 of 9 menu objectives 20 total objectives 18 total objectives Stage 2 criteria for Eligible Professionals 17 core objectives 3 of 6 menu objectives 20 total objectives 2

Stage 1 Change on Exclusions to Menu Items Beginning in 2014 You will no longer be permitted to count an exclusion toward the minimum of 5 menu objectives if there are other menu objectives which you can achieve Stage 1 and Stage 2 Objectives In other words, a provider cannot select a menu objective and claim an exclusion for it if there are other menu objectives they can meet If you claim an exclusion for a menu objective you will then be required to report on all menu items and either attest or exclude from each of them For Stage 1 Information Follow 13 Stage 1 Core Objectives 9 Stage 1 Menu Objectives For Stage 2 Information Follow 17 Stage 2 Core Objectives 6 Stage 2 Menu Objectives Stage 1 Core Objectives Beginning of Stage 1 Core Objectives Beginning of Stage 2 Core Objectives 1. Computerized provider order entry (CPOE) 2. Drug-drug and drug-allergy checks 3. E-Prescribing (erx) 4. Record patient demographics 5. Maintain an up to date problem list of current and active diagnoses 6. Maintain active medication list 7. Maintain active medication allergy list 8. Record and chart changes in vital signs 9. Record smoking status for patients 13 years or older 10. Implement clinical decision support 11. Provide patients the ability to view online, download and transmit their health information within 4 business days of the information being available to the EP 12. Provide Clinical summaries for patients for each office visit 13. Protect electronic health information Stage 2 Core Objectives 1. Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders 2. Generate and transmit permissible prescriptions electronically (erx) 3. Record demographic information 4. Record and chart changes in vital signs 5. Record smoking status for patients 13 years old or older 6. Use clinical decision support to improve performance on high-priority health conditions 7. Provide patients the ability to view online, download and transmit their health information 8. Provide clinical summaries for patients for each office visit 9. Protect electronic health information created or maintained by the Certified EHR Technology 10. Incorporate clinical lab-test results into Certified EHR Technology 11. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach 12. Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care 13. Use certified EHR technology to identify patient-specific education resources 14. Perform medication reconciliation 15. Provide summary of care record for each transition of care or referral 16. Submit electronic data to immunization registries 17. Use secure electronic messaging to communicate with patients on relevant health information CPOE: Computerized Provider Order Entry More than 30% of all unique patients seen by the EP with at least one medication in their medication list must have at least one medication order entered using CPOE You can be excluded from meeting this objective if you write fewer than 100 prescriptions during the reporting period You must create using CPOE the following: Measure 1: More than 60% of medication orders Measure 2: More than 30% of laboratory orders Measure 3: More than 30% of radiology orders You can be excluded individually from meeting each of the above measures for the ones that you have fewer than 100 orders during the reporting period 3

CPOE Details Computerized Provider Order Entry (CPOE): A provider's use of computer assistance to directly enter medical orders from a computer or mobile device Laboratory Order: Order for any service provided by a laboratory that could not be provided by a nonlaboratory Radiology Order: Order for any imaging services that uses electronic product radiation. The EP can include orders for other types of imaging services that do not rely on electronic product radiation in this definition as long the policy is consistent across all patient and for the entire EHR reporting period CPOE Changes > 30% of unique patients with a medication order have at least one medication ordered using CPOE Based on total number of medication, lab, or radiology orders not unique patients with a medication order Increases % of medication orders: > 60% of medication orders Adds Lab and Radiology orders: > 30% You can exclude from each area individually if you have less than 100 orders for any of the areas (medication, lab, radiology) You will still be required to attest on the areas that you have > 100 orders For example if you have 200 medication orders but only 50 lab orders and 10 radiology orders you would be required to attest on the medication orders and take the exclusion on lab and radiology orders Stage 1 CPOE Alternate Measure Optional Change 2013 and beyond Beginning in 2013, CMS has added an optional alternate measure for Stage 1 CPOE EPs may select either the original CPOE or the alternate CPOE measure for Stage 1 Original Measure More than 30% of all unique patients seen by the EP with at least one medication in their medication list must have at least one medication order entered using CPOE Alternate Measure More than 30% of all medication orders, created by the EP, during the EHR reporting period are recorded using CPOE Computerized Provider Order Entry Directly entering orders into a computer has the benefit of reducing errors by minimizing the ambiguity of hand-written orders, but a much greater benefit is seen with the combination of CPOE and clinical decision support tools Implementation of CPOE is being increasingly encouraged as an important solution to the challenge of reducing medical errors, and improving health care quality and efficiency 4

Drug-Drug and Drug-Allergy Checks EP has enabled the functionality to automatically check for drug-drug or drugallergy interactions for the entire EHR reporting period There is no exclusion for this objective. No longer a separate objective for Stage 2 It has been incorporated into the Stage 2 Clinical Decision Support measure Drug-Drug and Drug-Allergy Changes EP has enabled the functionality to automatically check for drug-drug or drug-allergy interactions for the entire EHR reporting period No longer an objective has been incorporated and combined into Clinical Decision Support Measure Drug-Drug and Drug-Allergy Checks You are responsible for understanding the potential negative interaction a medication you prescribe may have when combined with another medication the patient is already taking Remember this goes back to the importance of keeping an active medication list up to date for each patient Lipitor and Biaxin is there a problem with this combination? Oral antibiotic and Oral contraceptive is there a problem? If we are using a certified EHR with eprescribing, this should occur as part of the ordering of the medications Be sure this feature is turned on and active for you entire reporting period This combination may increase statin levels, risk of myopathy, kidney and / or liver damage may result Electronic Prescribing More than 40% of all permissible prescriptions written are transmitted electronically using certified CEHRT You can be excluded from meeting this objective if you write fewer than 100 prescriptions during the reporting period or (New Starting 2013) Do not have a pharmacy within your organization and there are no pharmacies that accept electronic prescriptions within 10 miles of the EP's practice location at the start of your EHR reporting period More than 50% of prescriptions are compared to a drug formulary and transmitted electronically You can be excluded from meeting this objective if you write fewer than 100 prescriptions during the reporting period or Do not have a pharmacy within your organization and there are no pharmacies that accept electronic prescriptions within 10 miles of the EP's practice location at the start of your EHR reporting period 5

Electronic Prescribing Changes > 40% of permissible prescriptions transmitted electronically Increases % of prescriptions transmitted by erx to > 50% of permissible prescriptions Adds prescriptions are also queried for a drug formulary E-Prescribing (erx) Improves medication safety Better management of medication costs Improved prescribing accuracy and efficiency Increase practice efficiency Reducing health care costs Reduction of adverse drug events Patient Demographics More than 50% of all unique patients seen by the EP have demographics recorded Preferred language, Race, Ethnicity, Gender, Date of Birth No Exclusion More than 80% of all unique patients seen by the EP have demographics recorded. Preferred language, Race, Ethnicity, Gender, Date of Birth No Exclusion Patient Demographics Changes > 50% of unique patients have demographic data stored as structured data Increases percentage to > 80% of unique patients have demographic data stored as structured data Patient Demographics Details Preferred language Ask what is your preferred language and let patient select or write in Ethnicity (federal definition) Hispanic or Latino Not Hispanic or Latino Race (Federal definition, one or more that apply) American Indian or Alaska Native Asian Black or African American White Native Hawaiian or Other Pacific Islander For Race and Ethnicity refuse to specify may be recorded and is a valid response 6

Record demographics Many studies indicate that African Americans are 3x more likely to develop POAG, and have an increased risk of hypertensive retinopathy Latinos have an increased risk of diabetes Whites have an increased risk of AMD Patient with central distorted vision --- proper age, race, and gender for central serous? Maintain an Up-to-Date Problem List More than 80% of all unique patients seen by the EP have at least one entry or an indication that no problems are known for the patient recorded as structured data There is no exclusion for this objective No longer a separate objective for Stage 2 It has been incorporated into the Stage 2 Summary of Care Document at Transitions of Care and Referrals Maintain an up-to-date list of current and active diagnosis (problem list) This is an ongoing list of active problems or diagnosis Creating this list will allow you to immediately understand your patient's overall health The problem lists states the most important health problems facing a patient You will know they are diabetic and you need to do additional clinical testing for diabetic retinopathy, or that they have POAG and need additional clinical testing done We typically already record problems or diagnosis just be sure to list them in the proper fields in your EHR Maintain Active Medication List More than 80% of all unique patients seen by the EP have at least one medication recorded or an indication that the patient is not currently prescribed any medication recorded There is no exclusion for this objective. No longer a separate objective for Stage 2 It has been incorporated into the Stage 2 Summary of Care Document at Transitions of Care and Referrals 7

Maintain active medication list We should be checking all patients medication list at each visit because many of the meds have ocular side effects If they tell you they are on a diabetic medication that will alert you to the need for additional testing for retinopathy or macular edema as well We now need to indicate a negative if no prescribed medications exist In other words, we have to make sure that the record shows no prescribed medications Maintain Active Medication Allergy List More than 80% of all unique patients seen by the EP have at least one medication allergy recorded or an indication that the patient has no known medication allergies recorded. There is no exclusion for this objective No longer a separate objective for Stage 2 It has been incorporated into the Stage 2 Summary of Care Document at Transitions of Care and Referrals Maintain active medication allergy list We should be checking all patients allergy status at each visit so we don t prescribe a medication that could cause an allergic or anaphylactic reaction We now need to indicate a negative if no medication allergies exist In other words, we have to make sure that the record shows no active medication allergies 8

Record and Chart Changes in Vital Signs For more than 50% of all unique patients seen by the EP, blood pressure (for patients age 3 and over only) and height and weight (for all ages) are recorded as structured data. BMI should be calculated and displayed, Plot and display growth and BMI charts for 0-20 years. BMI should be calculated and displayed, Plot and display growth and BMI charts for 0-20 years You may be excluded if you: See no patients 3 years or older excluded from recording blood pressure Believe that all 3 vital signs of height/length, weight, and blood pressure have no relevance to your scope of practice You are excluded from recording blood pressure if you believe that height/length and weight are relevant to your scope of practice, but blood pressure is not You are excluded from recording height/length and weight if you believe that blood pressure is relevant to your scope of practice, but height/length and weight are not For more than 80% of all unique patients seen by the EP, blood pressure (for patients age 3 and over only) and height and weight (for all ages) are recorded as structured data. BMI should be calculated and displayed, Plot and display growth and BMI charts for 0-20 years You may be excluded if you: See no patients 3 years or older excluded from recording blood pressure Believe that all 3 vital signs of height/length, weight, and blood pressure have no relevance to your scope of practice You are excluded from recording blood pressure if you believe that height/length and weight are relevant to your scope of practice, but blood pressure is not You are excluded from recording height/length and weight if you believe that blood pressure is relevant to your scope of practice, but height/length and weight are not Vital Signs Changes Vital signs must be recorded for more than 50% of all unique patients age 3 and over Increases percentage to > 80% of unique patients Record and chart changes in vital signs Many clinical studies have shown an increased risk of AMD, glaucoma, and Cataracts in overweight patients BMI is calculated as weight (lbs) / height 2 (inches) x 703 BMI of 18.5-25 is normal, > 25 is overweight, >30 is Obese Height/weight/BMI: Can add height and weight to patient questionnaire Suggest starting with patient attestation for height and weight but move to actually measuring it The BMI is a function of the software Blood pressure: We should be doing this on all patients Helps in the diagnosis of hypertensive retinopathy You will be surprised how many patients have significantly elevated BP and you may be the one to prevent them from having a stroke Record and chart changes in vital signs Recent study found that after 6 years of age, the probability of obesity in adulthood exceeded 50% for obese children Recent study found that atherosclerosis starts in childhood and the presence of obesity is highly correlated Large prospective study found Obese men has 1.46 to 2.40 times the risk of death Obese women had 1.51 to 2.76 times the risk of death According to the World Health Organization 51% of cerebrovascular disease deaths are attributable to high systolic blood pressure, 45% of ischemic heart disease deaths are attributable to high systolic blood pressure, The leading cause of cardiovascular death worldwide is high blood pressure How do you read a Height-to-Age Chart 9

Record Smoking Status for Patients 13 Years or Older More than 50% of all unique patients 13 years old or older seen by the EP have smoking status recorded as structured data You can be excluded from this objective if you do not see any patients who are age 13 years or older More than 80% of all unique patients 13 years old or older seen by the EP have smoking status recorded as structured data You can be excluded from this objective if you do not see any patients who are age 13 years or older Smoking Status Changes > 50% of unique patients 13 years or older have smoking status recorded as structured data Increases % to > 80% of unique patients 13 years or older have smoking status recorded as structured data Record smoking status for patients 13 years or older We know and should advise any patients who are smoking that they have an increased risk for AMD as well as glaucoma, and cataracts Consider adding questions to the patient registration form to get the information on status Have this information recorded during history taking This must be recorded in the EHR as structured data and it will be tracked by the EHR for compliance Record smoking status for patients 13 years or older Tobacco is the single greatest cause of disease and premature death in America today and is responsible for: More than 435,000 deaths annually $96 billion annually in medical expenses $97 billion annually in lost productivity When compared with non-smokers, smoking is estimated to increase the risk of: Coronary heart disease by 2 to 4 times Stroke by 2 to 4 times Men developing lung cancer by 23 times Women developing lung cancer by 13 times Death from chronic obstructive lung diseases by 12 to 13 times 10

Clinical Decision Support Rule Implement one clinical decision support rule that will trigger alerts for providers when they have patients with certain diagnosis or conditions No exclusion Measure 1: Implement five clinical decision support interventions related to four or more clinical quality measures for the entire EHR reporting period Measure 2: The EP has enabled and implemented the functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period For Measure 2, you can be excluded if you write fewer than 100 medication orders during the reporting period Clinical Decision Support Changes One clinical decision support rule enabled related to your specialty 5 Rules are now required based on four clinical quality measures (to be covered next) plus drug-drug and drug-allergy interaction checks If there are not four clinical quality measures related to your scope of practice or patient population, the clinical decision support interventions must be related to high-priority health conditions Clinical Decision Support Details Clinical Decision Support: Functionality that builds upon the foundation of an EHR to provide persons involved in care processes with general and person-specific information, intelligently filtered and organized, at appropriate times, to enhance health and health care Implement clinical decision support These are rules designed to help us meet the standard of care in terms of testing and follow up care Examples: If a patient has an active medication of Plaquenil listed, has a macular visual field, color vision testing, and a SD OCT been ordered? When an IOP is above a specific level, a warning of possible glaucoma is triggered If a diagnosis of glaucoma is entered, is the patient scheduled or have they had a VF or a scanning laser within the last 6-12months 11

Report Clinical Quality Measures Beginning in 2013 no longer a separate objective Has been incorporated into the definition of a Meaningful EHR user Starting in 2014, all CQMs will be submitted electronically to CMS No longer a separate objective but providers must still submit CQM s to achieve meaningful use Starting in 2014, all CQMs will be submitted electronically to CMS Clinical Quality Measures Clinical quality measures, or CQMs, are tools that help us measure and track the quality of healthcare services provided by eligible professionals CQMs measure many aspects of patient care including: outcomes clinical processes, patient safety efficient use of healthcare resources, care coordination patient engagements, population and public health clinical guidelines Clinical Quality Measures Although clinical quality measure (CQM) reporting has been removed as a core objective for EPs, all providers are required to report on CQMs in order to demonstrate meaningful use Beginning in 2014, all providers regardless of their stage of meaningful use will report on CQMs in the same way Report ambulatory clinical quality measures to CMS for 2014 For 2014, CMS is not requiring the submission of a core set of CQMs Instead CMS has identified two recommended sets of CQMs, one for adults and one for children CMS encourages eligible professionals to report from the recommended set to the extent those CQMs are applicable to your scope of practice and patient population Report ambulatory clinical quality measures to CMS for 2014 CMS selected the recommended core set of CQMs for EPs based on analysis of several factors: Conditions that contribute to the morbidity and mortality of the most Medicare and Medicaid beneficiaries Conditions that represent national public health priorities Conditions that are common to health disparities Conditions that disproportionately drive healthcare costs and could improve with better quality measurement Measures that would enable CMS, States, and the provider community to measure quality of care in new dimensions, with a stronger focus on parsimonious measurement Measures that include patient and/or caregiver engagement Report ambulatory clinical quality measures to CMS for 2014 EPs must report on 9 out of 64 total CQMs Providers must select CQMs from at least 3 of the 6 key health care policy domains (listed below) recommended by the Department of Health and Human Services National Quality Strategy 1. Patient and Family Engagement 2. Patient Safety 3. Care Coordination 4. Population and Public Health 5. Efficient Use of Healthcare Resources 6. Clinical Processes/Effectiveness 12

Report ambulatory clinical quality measures to CMS for 2014 Adult Recommended Measures Controlling High Blood Pressure Use of High-Risk Medications in the Elderly Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Use of Imaging Studies for Low Back Pain Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan Documentation of Current Medications in the Medical Record Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Closing the referral loop: receipt of specialist report Functional status assessment for complex chronic conditions Report ambulatory clinical quality measures to CMS for 2014 Pediatric Recommended Measures Appropriate Testing for Children with Pharyngitis Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents Chlamydia Screening for Women Use of Appropriate Medications for Asthma Childhood Immunization Status Appropriate Treatment for Children with Upper Respiratory Infection (URI) ADHD: Follow-Up Care for Children Prescribed Attention- Deficit/Hyperactivity Disorder (ADHD) Medication Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan Children who have dental decay or cavities Report ambulatory clinical quality measures to CMS for 2014 Beginning in 2014, all Medicare-eligible providers beyond their first year of demonstrating meaningful use must electronically report their CQM data to CMS 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 Quality Reporting Document Architecture (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 Report ambulatory clinical quality measures to CMS for 2014 Need help understanding CQMs for 2014?? CQM webpage http://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/20 14_ClinicalQualityMeasures.html Medicaid eligible professionals must submit their clinical quality measurement data to their State Medicaid Agency Patient Electronic Copy and Access New for 2014 More than 50% of all unique patients are provided online access to their health information within 4 business days after the information is available to the EP You can be excluded if you neither order nor create any of the info listed for inclusion (see next slide) You can be excluded if you conduct 50% or more of encounters in a county that does not have 50% or more housing units with 3Mbps broadband availability Measure 1: More than 50% of all unique patients are provided timely (within 4 business days after the info is available to the EP) online access to their health information Measure 2: More than 5% of all unique patients view, download, or transmit to a 3rd party their health information You can be excluded if you neither order nor create any of the info listed for inclusion (see next slide) You can be excluded if you conduct 50% or more of encounters in a county that does not have 50% or more housing units with 3Mbps broadband availability 13

Patient Electronic Copy and Electronic Access Changes Must be done for > 50% of unique patients Must be done for > 50% of unique patients Now being held accountable for the patients to utilize the information: More than 5% of all unique patients (or authorized representative) view, download, or transmit to a 3rd party their health information You must provide: patient name, provider's name and office contact information, current and past problem list, procedures. laboratory test results, current medication list and medication history, current medication allergy list and medication allergy history, vital signs, smoking status, demographic information care plan field(s), including goals and instructions, and any known care team members including the primary care provider (PCP) of record You may be excluded if you don t create any of the above listed information (except patient name, provider name and office info) Patient Electronic Copy and Electronic Access Patient access will allow patients to understand what clinical testing was completed during an encounter as well as the results of those tests Online electronic access through either a patient portal or personal health record (PHR) will satisfy this objective The minimal information to be included is: Lab test results, problem list, medication list, and medication allergy list You may withhold information from the electronic copy in accordance with HIPAA Provide Clinical Summaries for Patients for Each Office Visit Clinical summaries must be provided to patients within 3 business days of visit for more than 50% of all office visits You may be excluded if you have no office visits Clinical summaries must be provided to patients or authorized representatives within 1 business days for more than 50% of all office visits You may be excluded if you have no office visits Provide Clinical Summaries Changes You have 3 business days to provide summary You have 1 business day to provide summary Provide clinical summaries for patients for each office visit At completion of the exam, the EHR would take the key clinical data elements from the electronic record and create a summary of the findings which can be given to the patient to help them better understand their overall health The clinical summary can be provided through a personal health record, patient portal on the web site, secure e-mail, electronic media such as CD or USB fob, or printed copy. If the EP chooses an electronic media, they would be required to provide the patient a paper copy upon request 14

Provide clinical summaries for patients for each office visit Enhances the ability of patients to remember and, if necessary, convey to family members, the content of interactions with their care team Supports greater patient engagement in making good choices about healthy behaviors Summaries should include items such as: updated medication list, vital signs, reason for visit, problem list, medications / immunizations, lab tests ordered / results, and follow up appointments An EP may choose to withhold particular information if they believe substantial harm may arise from disclosure Capability to Exchange Key Clinical Information This objective was eliminated from Stage 1 in 2013 and is no longer an objective Protect Electronic Health Information Conduct or review a security risk analysis and implement security updates as needed and correct identified security deficiencies as part of the process No exclusion This objective is not required for Stage 2 However this concept is covered under the Summary of Care Record for Transitions of Care Objective in Stage 2 Conduct or review a security risk analysis including addressing the encryption/security of data at rest and implement security updates as needed and correct identified security deficiencies as part of the process No exclusion 15

Protect electronic health information A major goal of the Security Rule is to protect the privacy of individuals health information while allowing covered entities to adopt new technologies to improve the quality and efficiency of patient care This is similar to the current HIPAA security rules You must conduct or review a security risk analysis and implement updates as necessary Should be done once prior to end of reporting period Your software vendor should be able to provide you with tools to complete the risk analysis Protect electronic health information HIPAA protects the privacy of individually identifiable health information, called protected health information (PHI) Security Rule protects a subset of information covered by the Privacy Rule, which is all individually identifiable health information a covered entity creates, receives, maintains or transmits in electronic form. The Security Rule calls this information electronic protected health information (e-phi) Protect electronic health information The Security Rule requires covered entities to maintain reasonable and appropriate administrative, technical, and physical safeguards for protecting e-phi Specifically, covered entities must: Ensure the confidentiality, integrity, and availability of all e- PHI they create, receive, maintain or transmit Identify and protect against reasonably anticipated threats to the security or integrity of the information Protect against reasonably anticipated, impermissible uses or disclosures Ensure compliance by their workforce Protect electronic health information The Security Rule requires covered entities to perform a risk analysis as part of their security management processes A risk analysis process includes, but is not limited to, the following activities: Evaluate the likelihood and impact of potential risks to e-phi Implement appropriate security measures to address the risks identified in the risk analysis Document the chosen security measures and, where required, the rationale for adopting those measures Maintain continuous, reasonable, and appropriate security protections Protect electronic health information Administrative Safeguards Are Required Security Management Process: Must identify and analyze potential risks to e-phi, and implement security measures that reduce risks and vulnerabilities to a reasonable and appropriate level Security Personnel: Must designate a security official who is responsible for developing and implementing its security policies and procedures Information Access Management: Implement policies and procedures for authorizing access to e-phi only when such access is appropriate based on the user or recipient's role (role-based access) Workforce Training and Management: Must provide for appropriate authorization and supervision of workforce members who work with e- PHI. You must train all workforce members regarding security policies and procedures, and you must have and apply appropriate sanctions against workforce members who violate policies and procedures Evaluation: Must perform a periodic assessment of how well your security policies and procedures meet the requirements of the Security Rule Protect electronic health information Physical Safeguards Are Required Facility Access and Control: Must limit physical access to facilities while ensuring that authorized access is allowed Workstation and Device Security: Must implement policies and procedures to specify proper use of and access to workstations and electronic media. Must have in place policies and procedures regarding the transfer, removal, disposal, and re-use of electronic media, to ensure appropriate protection of electronic protected health information (e-phi) 16

Protect electronic health information Technical Safeguards Are Required Access Control: Must implement technical policies and procedures that allow only authorized persons to access electronic protected health information (e-phi) Audit Controls: Must implement hardware, software, and/or procedural mechanisms to record and examine access and other activity in information systems that contain or use e-phi Integrity Controls: Must implement policies and procedures to ensure that e-phi is not improperly altered or destroyed. Electronic measures must be put in place to confirm that e-phi has not been improperly altered or destroyed Transmission Security: Must implement technical security measures that guard against unauthorized access to e-phi that is being transmitted over an electronic network Protect electronic health information Required and Addressable Implementation Specifications The "required" implementation specifications must be implemented. The "addressable" designation does not mean that an implementation specification is optional it permits covered entities to determine whether the addressable implementation specification is reasonable and appropriate for that covered entity If it is not, the Security Rule allows the covered entity to adopt an alternative measure that achieves the purpose of the standard, if the alternative measure is reasonable and appropriate Protect electronic health information Organizational Requirements Covered Entity Responsibilities: If a covered entity knows of an activity or practice of a business associate that constitutes a material breach or violation of the business associate s obligation, the covered entity must take reasonable steps to cure the breach or end the violation. Violations include the failure to implement safeguards that reasonably and appropriately protect e-phi Protect electronic health information Policies and Procedures and Documentation Requirements Must adopt reasonable and appropriate policies and procedures to comply with the provisions of the Security Rule. Must maintain, until six years after the later of the date of their creation or last effective date, written security policies and procedures and written records of required actions, activities or assessments Updates: Must periodically review and update your documentation in response to environmental or organizational changes that affect the security of electronic protected health information (e-phi) Protect electronic health information Enforcement and Penalties for Noncompliance Compliance: The Security Rule establishes a set of national standards for confidentiality, integrity and availability of e-phi. The Department of Health and Human Services (HHS), Office for Civil Rights (OCR) is responsible for administering and enforcing these standards, in concert with its enforcement of the Privacy Rule, and may conduct complaint investigations and compliance reviews End of Stage 1 Core Objectives Continued Stage 2 Core Objectives Beginning of Stage 1 Menu Objectives 17

Stage 1 Menu Objectives 1. Drug formulary checks 2. Incorporate clinical lab-test results 3. Generate lists of patients by specific conditions 4. Send reminders to patients for preventive / follow-up care 5. Patient specific education resources 6. Medication reconciliation 7. Summary of care record for transitions of care 8. Submit electronic data to immunization registries 9. Submit electronic syndromic surveillance data to public health agencies Drug Formulary Checks EP has enabled functionality for a drug formulary checks and has access to at least one internal or external formulary for the entire reporting period You can be excluded from meeting this objective if you write fewer than 100 prescriptions during the reporting period No longer a separate objective for Stage 2 It has been incorporated into the Stage 2 e-prescribing measure Menu Item Drug Formulary Changes Removed as an objective Incorporated into the e-prescribing measure for Stage 2 Drug Formulary Checks When you prescribe a medication you will now need to consider if that medication is the best choice both for the condition and for the patient s medication formulary For example would it be best to prescribe Vigamox if it is nonformulary or would it make more sense to utilize Zymar instead if it is on the formulary? For each clinical condition there may be multiple medications that work This is a function of your certified EHR software e- prescribing system Be sure the functionality is turned on and active for your entire reporting period 18

Incorporate Clinical Lab-Test Results More than 40% of all clinical lab test results ordered by the EP during the reporting period (whose results are in a +/- or numerical format) are incorporated in the EHR as structured data You can be excluded from this objective if you did not order any lab tests during the reporting period or if none of the lab tests ordered have results in a positive / negative or numerical format More than 55% of all clinical lab test results ordered by the EP during the reporting period (whose results are in a +/- or numerical format) are incorporated in the EHR as structured data You can be excluded from this objective if you did not order any lab tests during the reporting period or if none of the lab tests ordered have results in a positive / negative or numerical format Clinical Lab-Test Results Changes Menu objective Requires > 40% of discrete lab test results to be stored as structured data Core objective Increased the percentage to > 55% of discrete lab test results to be stored as structured data Clinical Lab-Test Results Details The lab test results must be recorded as structured data in your EHR It is important to understand that this data does not have to come back into your EHR directly from the lab in an electronic format You may enter the results as structured data through manual entry via typing, option selecting, scanning, or other means Incorporate clinical lab-test results Remember for those patients with Uveitis, DM, Graves disease or other conditions requiring lab tests that the results must ultimately be entered into the EHR as structured data This applies to lab results ordered by you during the reporting period whose results are either positive/negative or numerical format Typically blood, urine, path reports Some of us could take the exemption for not ordering any lab tests whose results are either in a positive/negative or numeric format during the EHR reporting period 19

Generate Lists of Patients by Specific Conditions Generate at least one report listing patients of the EP with a specific condition No exclusion Generate at least one report listing patients of the EP with a specific condition No exclusion Menu Objective Patient Lists Changes Core Objective No other changes Generate lists of patients by specific conditions There may be times when you need to know every patient in your office that has a certain condition to offer them a new best treatment that becomes available New glaucoma medication or treatment option New contact lens material or type of lens All certified EHRs can generate a list of patients based on certain conditions The objective does not dictate the reports which must be generated An EP can determine which reports are most useful to their care efforts Patient Reminders (Stage 1) Preventive Care (Stage 2) More than 20% of all patients 65 years or older or 5 years or younger were sent the appropriate reminder during the reporting period You can be excluded from this objective if you have no patients 65 years or older or 5 years old or younger More than 10% of all unique patients who have had 2 or more office visits within the 24 months before the beginning of the reporting period were sent a reminder, per pt. preference when available You can be excluded if you have no office visits in the 24 months before the EHR reporting period Patient Reminders / Preventive Care Changes Menu objective Required 20% of all patients 65 years or older or 5 years or younger to be sent reminder Core Measure Lowered the percentage to 10% but now includes all unique patients who have had 2 or more office visits within the 24 months before the beginning of the reporting period 20

Send Reminders to Patients for Preventive / Follow Up Care This allows us to properly follow up with our patients who need further care Do some of your patients with POAG need to follow up for an OCT or VF Do a group of your diabetic patients need to return for a DFE This is fairly easy to do in all certified EHR software There is no specific requirements for the reminders You have the discretion to determine the frequency, means of transmission and form of the reminder limited only by the requirements of HIPAA Electronic Access to Health Information for Patients This objective was replaced in 2014 with the core objective More than 50% of all unique patients seen by the EP during the EHR reporting period are provided timely (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 This objective is no longer a measure for Stage 2 However the concept is covered as part of Patient Electronic Access for Stage 2 (covered earlier) Patient Specific Education Resources More than 10% of all unique patients seen by the EP are provided patient specific education resources No exclusion Patient-specific education resources identified by the EHR are provided to patients for more than 10% of all unique patients with office visits You can be excluded if you have no office visits during the reporting period Patient Specific Educational Resources Changes Menu Objective Percentage required is 10% of all unique patients seen are given educational resources Core Objective Percentage remains at 10% but now is all unique patients with office visits Exclusion now available for EPs with no office visits Patient specific education resources It is our job as a doctor to properly educate our patients on all of their clinical findings and diagnosis as well as risks and benefits of each treatment option Certified EHRs have the ability to identify patient specific educational resources based on the problem list, medication list, or lab test results The EHR technology should be used to suggest the patient educational resources The resources do not have to be stored within or generated by the EHR. AMD or ERM = Amsler Grid AMD = AREDS information as well 21

Medication Reconciliation The EP performs medication reconciliation (including name, dosage, frequency, and route) for more than 50% of transitions of care in which the patient is transitioned into your care You can be excluded if you are not the recipient of any transitions of care during the EHR reporting period The EP performs medication reconciliation (including name, dosage, frequency, and route) for more than 50% of transitions of care in which the patient is transitioned into your care You can be excluded if you are not the recipient of any transitions of care during the EHR reporting period Medication Reconciliation Changes Menu Objective Required 50% of transitions of care or relevant encounters Core Objective Percentage remains at 50%, no other changes Medication Reconciliation This is very important to our patient care Unintended inconsistencies in medication regimens may occur at any point of transition in care The goal is to review all medications a patient it taking with them and provide them with a current updated list after each encounter This helps avoid negative drug interactions as well as drug duplication Medication reconciliation is the process of identifying the most accurate list of all medications the patient is taking by comparing the medical record to an external list of medications obtained from a patient, hospital or other provider This is a very difficult objective due to the requirements 22

Summary of Care Record for Transitions of Care EP who refers or transitions their patient to another provider or setting provides a summary of care record more than 50% of the time You can be excluded from meeting this objective if you don t refer or transfer any patients to another setting during the reporting period Measure 1: EP who refers or transitions their patient provides a summary of care record for more than 50% of transitions of care and referrals Measure 2: EP who refers or transitions their patient provides a summary of care record for more than 10% 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 Measure 3: An EP must satisfy one of the following criteria: Conducts one or more successful electronic exchanges of a summary of care document, with a recipient who has EHR technology that was developed by a different EHR developer than the sender's EHR technology Conducts one or more successful tests with the CMS designated test EHR during the EHR reporting period Summary of Care Record Changes Menu Item Summary given 50% of time when patient transitioned to another care provider Can be excluded if you have no patients transitioned or referred during the reporting period Core Objective This objective now requires 3 Measures to be met You can be excluded if you transfer or refer a patient to another provider less than 100 times during the reporting period Summary of Care Record for Transitions of Care You must provide a summary of care record to the provider you are referring the patient to This is important because it allows the next provider of care to understand your clinical findings which may impact the patients care You could use the clinical summary or your electronic copy For Stage 1 an electronic or paper copy of the summary care record can be sent Directly to the next provider Provided to the patient to deliver to the next provider For Stage 2 you must have 10% of the summaries transmitted electronically This is why secure (direct) messaging is so important! Submit Electronic Data to Immunization Registries Perform at least one test of certified EHRs capacity to submit electronic data to immunization registries and follow up submission if the test is successful except where prohibited You are excluded from meeting this objective if: You don t administer immunizations There s no immunization registry to which you can send information Successful ongoing submission of electronic immunization data from CEHRT to an immunization registry or immunization information system for the entire EHR reporting period You are excluded if: You don t administer immunizations No immunization registry in your jurisdiction is capable of accepting the required standards at the start of your reporting period No immunization registry in your jurisdiction provides information timely on capability to receive immunization data No immunization registry in your jurisdiction that is capable of accepting the standards is enrolling additional EPs at the start of your reporting period Immunization Registries Changes Menu Item We are excluded because we don t give immunizations however New for 2013 CMS has stated that it will require that providers perform at least one test of their Certified EHR Technology s capability to send data to public health agencies, except where prohibited The intent of this modification is to encourage all EPs to submit public health data, even when not required by State/local law Therefore, if providers are authorized to submit the data, they should do so even if it is not required by either law or practice For Stage 1 attestation: On the menu items, you must attest on either this public health measure or the syndromic surveillance measure Core Objective We are still excluded because we don t give immunizations but the same CMS requirement (shown as new for 2013 above) still applies 23

Use Secure Electronic Messaging New Objective for Stage 2 A secure message was sent using the electronic messaging function of CEHRT by more than 5 % of unique patients (or their authorized representatives) seen by the EP during the EHR reporting period You can be excluded if you have no office visits during the EHR reporting period OR You conduct 50% or more of your patient encounters in a county that does not have 50% or more of its housing units with 3Mbps (Megabits per second) broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period New Stage 2 Core Objective: Secure Messaging Details Secure Message: Any electronic communication between a provider and patient that ensures only those parties can access the communication This electronic message could be secure email or the electronic messaging function of a PHR, an online patient portal, or any other electronic means that is authenticated (both patient and EHR user) and encrypted The EP is not expected/required to personally respond to the electronic message from the patient End of Stage 2 Core Objectives Continue Stage 1 Menu Objectives Beginning of Stage 2 Menu Objectives Stage 2 Menu Objectives 1. Submit electronic syndromic surveillance data to public health agencies 2. Record electronic notes in patient records 3. Imaging results accessible through CEHRT 4. Record patient family health history 5. Identify and report cancer cases to a State cancer registry 6. Identify and report specific cases to a specialized registry (other than a cancer registry) Submit Electronic Syndromic Surveillance Data to Public Health Agencies Perform at least one test of certified EHRs capability to provide electronic syndromic surveillance data to public health agencies and follow up submission if the test is successful except where prohibited by law You are excluded from meeting this objective if: You don t collect any reportable syndromic data There s no registry to which you can send information Successful ongoing submission of electronic syndromic surveillance data from CEHRT to a public health agency for the entire EHR reporting period You are excluded if: You don t collect ambulatory syndromic surveillance information No public health agency in your jurisdiction is capable of accepting the required standards at the start of your reporting period No public health agency in your jurisdiction provides information timely on capability to receive syndromic surveillance data No public health agency in your jurisdiction that is capable of accepting the standards is enrolling additional EPs at the start of your reporting period 24

Syndromic Surveillance Changes Menu Item We are excluded because we don t collect any syndromic data. however New for 2013 CMS has stated that it will require that providers perform at least one test of their Certified EHR Technology s capability to send data to public health agencies, except where prohibited The intent of this modification is to encourage all EPs to submit public health data, even when not required by State/local law Therefore, if providers are authorized to submit the data, they should do so even if it is not required by either law or practice For Stage 1 attestation: On the menu items, you must attest on either this public health measure or the Immunization Registry measure Menu Objective We are still excluded because we don t collect any syndromic surveillance data but the same CMS requirement (shown as new for 2013 above) still applies Electronic Notes End of Stage 1 Menu Objectives Continued Stage 2 Menu Objectives Enter at least one electronic progress note created, edited and signed by an EP for more than 30% of unique patients with at least one office visit during the EHR reporting period The text of the electronic note must be text searchable and may contain drawings and other content No exclusion New Stage 2 Menu Item: Electronic Notes Details Electronic Notes: Defined as electronic progress notes CMS will rely on providers own determinations and guidelines defining when progress notes are necessary to communicate individual patient circumstances and for coordination with previous documentation of patient observations, treatments and/or results in the electronic health record This could be a as simple as creating an encounter: Must be electronic note that is text searchable Must be signed by EP Must be done for 30% of your unique patients with visits during the reporting period New Stage 2 Menu Item: Electronic Notes Research indicates that electronic searchable notes promote quality, safety and efficiency in the health care setting It is important to have all notes recorded in the electronic record 25

Imaging Results More than 10% of all tests whose result is one or more images ordered by the EP during the EHR reporting period are accessible through CEHRT You can be excluded if you order less than 100 tests whose result is an image during the EHR reporting period or You have no access to electronic imaging results at the start of the EHR reporting period New Stage 2 Menu Item: Imaging Results Details What is Meant by Imaging: The description of radiology services from the Stage 2 CPOE objective is the minimum description of imaging CMS describes radiologic services as any imaging service that uses electronic product radiation. Electronic product radiation is defined as: "any ionizing or nonionizing electromagnetic or particulate radiation, or [a]ny sonic, infrasonic, or ultrasonic wave that is emitted from an electronic product as the result of the operation of an electronic circuit in such product" If the provider desires to include other types of imaging services that do not rely on electronic product radiation they may do so as long as the policy is consistent across all patients and for the entire EHR reporting period New Stage 2 Menu Item: Imaging Results Details What is meant by Accessible through CEHRT: Either incorporation of the image and accompanying information into CEHRT An indication in CEHRT that the image and accompanying information are available for a giving patient in another technology and a link to that image and accompanying information New Stage 2 Menu Item: Imaging Results Details What is Meant by No Access: None of the imaging providers used by the EP provide electronic images and any explanation or other accompanying information that are accessible through their CEHRT at the start of the EHR reporting period Many of us will be excluded because we order less than 100 tests during the reporting period Family Health History More than 20% of all unique patients seen by the EP during the EHR reporting period must have a structured data entry for one or more first-degree relatives You can be excluded if you have no office visits New Stage 2 Menu Item: Family Health History Details What is Meant by First degree relative: A family member who shares about 50% of their genes with a particular individual in a family First degree relatives include parents, offspring, and siblings To meet this objective you must enter structured health history data for one or more first degree relatives A structured data entry of unknown meets reporting requirement 26

New Stage 2 Menu Item: Family Health History Numerous studies have shown that family health history consistently served as the superior tool for predicting an individual s risk of developing certain diseases How about patients with AMD, color vision deficiencies, early cataracts, corneal dystrophies Report Cancer Cases Successful ongoing submission of cancer case information from CEHRT to a public health central cancer registry for the entire EHR reporting period You may be excluded if you meet any of the following: Do not diagnose or directly treat cancer No public health agency in your jurisdiction is capable of accepting the required cancer case information at the start of your reporting period No public health agency in your jurisdiction provides information timely on capability to receive electronic cancer case information No public health agency in your jurisdiction that is capable of accepting electronic cancer case information can enroll additional EPs at the start of your reporting period New Stage 2 Menu Item: Report Cancer Cases Most, if not all of us, would be excluded since we don t diagnose or directly treat cancer If you don t meet the exclusion you must: Have ongoing submission to registry Register and initiate submission within 60 days of the start of your reporting period Register with intent to submit but are still engaged in testing and validating submission Report Specific Cases Successful ongoing submission of specific case information from CEHRT to a specialized registry for the entire EHR reporting period You may be excluded if you meet any of the following: Do not diagnose or treat any disease associated with a specialized registry sponsored by a national specialty society No specialized registry in your jurisdiction is capable of receiving electronic specific case information at the start of your reporting period No public health agency or national specialty society in your jurisdiction for which the EP is eligible provides information timely on capability to receive information into their specialized registries No specialized registry in your jurisdiction that is capable of receiving electronic specific case information can enroll additional EPs at the start of your reporting period New Stage 2 Menu Item: Report Specific Cases Details What is Meant by Specialized Registry: Sponsored by national specialty societies and specialized registries maintained by public health agencies Many of us would meet the exclusion for not diagnosing or directly treating any disease associated with a specialized registry but if one is created we would need to utilize it! 27