Benefiting from Meaningful Use and Quality Reporting THE GREENWAY GUIDE

Benefiting from Meaningful Use and Quality Reporting THE GREENWAY GUIDE

Contents TABLE OF FIGURES...4 WELCOME TO GREENWAY S GUIDE TO BENEFITING FROM MEANINGFUL USE AND QUALITY REPORTING...5 GETTING STARTED...6 Staging the vision and goals...6 The numbers...7 Eligibility and applicable timelines...8 EPs in the Medicare pathway...8 EPs in the Medicaid pathway...8 Meaningful use reporting by stage...9 WHY PARTICIPATE?...10 Incentive fund capture...10 Medicare pathway...10 Medicaid pathway...11 Avoid payment adjustments...12 How to avoid the 2015 payment adjustment...12 Ongoing hardship exceptions...13 Alignment with quality incentive programs...13 Patient-centered medical home (PCMH)...13 Physician Quality Reporting System (PQRS)...16 Comprehensive Primary Care (CPC) Initiative...16 Patient care...17 Care coordination, safety and outcomes...17 Benefits of patient portals...18 Portals and MU requirements...19 HOW TO PARTICIPATE...20 Implement a meaningful use-certified EHR...20 Understanding 2011 and 2014 certification editions...20 Registering per-provider for meaningful use incentives...21 ASSESSING AND SELECTING MEANINGFUL USE MEASURES...22 Core objectives and menu sets...22 Stage 1...22 Stage 2...23 Exclusions...26 Selecting menu items...26 Clinical summary and summary of care...28 Clinical quality measures...29 What they gauge...29 Where the data comes from...29 How CMS uses the data...29 Recommended core sets...30 Why these specific measures?...31 Choosing appropriate CQMs for your practice...32 Reporting CQMs...32 What CQMs are your colleagues reporting?...34 2

UPDATED CAPTURING AND REPORTING (ATTESTING) DATA...36 Finalizing 2014 reporting and requirements for 2015...36 A note about dashboard technology...39 Reporting timelines by stage...39 Attestation...39 Attestation and CQMs...40 Amending submitted attestations...41 Receiving your payment...41 Meaningful use audits...41 Appeals process...41 WHAT S NEXT?...41 Meaningful use Stage 3...41 NOW WHAT?...44 Tools to demonstrate meaningful use of HIT...44 Nothing to lose...44 IT S HEALTHCARE, SO YOU NEED THIS: GLOSSARY OF ACRONYMS...45 CHOOSE GREENWAY...46 3

Table of Figures Figure 1: Stages of Meaningful Use...9 Figure 2: Medicare EHR Incentive Payment Schedule for Eligible Professionals...10 Figure 3: Medicaid EHR Incentive Payment Schedule for Eligible Professionals...11 Figure 4: Examples of MU and PCMH Alignment...15 Figure 5: Stage 1 Meaningful Use Objectives for Eligible Professionals...22 Figure 6: Stage 2 Meaningful Use Objectives for Eligible Professionals...23 Figure 7: EP 2011, 2012, and 2013 90 Days Menu Objective Performance...27 Figure 8: EPs Plans to Attest for Stage 2...34 Figure 9: Top-Ranked CQM Groups...34 Figure 10: Preventive Care and Screening...35 Figure 11: Top-Reported Pediatric Measures...35 Figure 12: CEHRT Edition...36 Figure 13: Stages of Meaningful Use...37 4

Welcome Welcome to Greenway s Guide to Benefiting from Meaningful Use and Quality Reporting The Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs, commonly known as meaningful use (MU), reward providers for delivering high-quality care shifting American healthcare away from fee-forservice and toward pay-for-performance models to improve care and manage costs. Various quality programs including accountable care organizations (ACOs), patient-centered medical homes (PCMHs) and the Physician Quality Reporting System (PQRS) share the pay-for-performance goals of meaningful use and continue to adopt its quality reporting objectives. Public and private payer alignment will only increase as these quality initiatives evolve from adoption and functionality incentive programs into foundational elements of physicians reimbursements for care. Already, meaningful use and related quality programs have sharpened their focus on patient outcomes and population health management. Multi-program performance initiatives in the 2015 Medicare physician fee schedule reflect this, as do proposals pending in Congress that would employ meaningful use, PQRS and patient engagement strategies to help restructure the existing fee-for-service system. To help ensure that you have the information you need to avoid financial penalties and plan for MU and its impact on other reimbursement programs, Greenway Health is delighted to present this guide to benefiting from meaningful use and quality reporting. The guide: Walks you through registration, reporting choices, timelines, and attestation and payment cycles. Details opportunities for bundling meaningful use with other incentive programs offering many benefits to practices, with little additional effort. Includes insights and experiences shared by your peers, because one of the best ways to succeed in a program like meaningful use is to familiarize yourself with what has worked for others like you. For your convenience, we ve included at-a-glance charts and visual information, links to relevant Centers for Medicare & Medicaid Services (CMS) and Office of the National Coordinator for Health Information Technology (ONC) materials, and data examples to show the impact meaningful use has on patient care and care coordination. 5

Getting Started Staging the vision and goals Understanding that EHR adoption has financial, workflow, installation and staffing implications, Congress supported funding the meaningful use incentive program as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 to encourage widespread and accelerated adoption. The HITECH Act charged CMS with determining program requirements in two categories: Objectives Types of data to be captured Measures Patient population levels, thresholds or percentages at which the data should be collected The Act also required CMS to create a set of Clinical Quality Measures (CQMs). Provider groups and health information technology (HIT) organizations provided input used to shape the data capture requirements. The vision for meaningful use is twofold: 1. To advance the functionality of EHRs and the corresponding documentation of clinical data over time. 2. To use that data to advance evidence-based medicine by analyzing the impact of technology-driven or automated physician support tools on patient care, patient adherence to care plans and patient outcomes. MU intends to improve outcomes for at-risk elderly and low-income populations who represent the most clinically and financially challenging cases with respect to chronic disease management and access to care. On a larger scale, MU and related quality programs such as PQRS and PCMH aim to improve clinical documentation and preventive care for better patient outcomes, improved population health and lower costs for all in the United States, regardless of age or income. 1 To meet these goals, meaningful use is organized into three stages, each with a unique area of emphasis as prescribed by CMS and ONC: Stage 1 Data capture and reporting Stage 2 Information exchange and care coordination Stage 3 Improving outcomes Later sections in this guide describe each stage, its requirements and its goals in more detail. 1 Centers for Medicare & Medicaid Services. Quality Initiatives General Information. http://www.cms. gov/medicare/quality-initiatives-patient-assessment- Instruments/QualityInitiativesGenInfo/index.html?redirect=/ QualityInitiativesGenInfo/01_Overview.asp 6

The numbers To date, the program has proven successful in terms of adoption and incentive capture. According to the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics, U.S. office-based physician adoption of any type of EHR reached 78 percent in 2013, up from 18 percent in 2001. EHR adoption has increased by 21 percent since the beginning of the meaningful use program in 2011. 2 Industry-wide, CMS reports that as of April 2014, more than $15 billion has been paid to Eligible Professionals (EPs) in the Medicare pathway, and more than $8 billion to EPs in the Medicaid pathway. Meaningful Use by the Numbers GREENWAY Medicare EPs 10,000+ have received $244+ million NATIONALLY providers and clinicians 537,600 identified as eligible for MU EPs have registered for 316,303 Medicare incentives EPS have registered for 156,640 Medicaid incentives $15.8 billion Medicare payout 3 $8.1 billion Medicaid payout All figures as of April, 2014 2 Centers for Disease Control and Prevention. NCHS Data Brief 143: Use and Characteristics of Electronic Health Record Systems Among Office-based Physician Practice: United States, 2001 2013. January 2014. http://www.cdc.gov/nchs/data/ databriefs/db143.pdf 3 Centers for Medicare & Medicaid Services Medicare and Medicaid EHR Incentive Programs HIT Policy Committee June 10, 2014 update. www.healthit.gov/facas/sites/faca/files/ HITPC_CMSUpdate_2014-06-10.pptx. 7

Eligibility and applicable timelines You are eligible to benefit from the meaningful use program if you practice within the following categories, which include both primary care and specialty medicine. EPS IN THE MEDICARE PATHWAY Doctor of medicine or osteopathy Doctor of dental surgery or dental medicine Doctor of podiatry Doctor of optometry Chiropractor EPS IN THE MEDICAID PATHWAY Physicians (primarily doctors of medicine and doctors of osteopathy) Nurse practitioner Certified nurse-midwife Dentist Physician assistant who furnishes services in a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) that is led by a physician assistant. Meaningful use timelines remain flexible as to when an EP can enter either program, which then determines how many payment years and maximum incentive funds can be pursued. NOTE Those eligible for both pathways must choose only one upon first registering for the program. Before 2015, EPs can switch but only once after the first incentive payment is initiated within the originally chosen pathway. 8

MEDICAID ELIGIBILITY THRESHOLD REQUIREMENTS In addition to qualifying by clinician category, Medicaid EPs must: Have a 30% minimum Medicaid patient volume (20% for pediatricians), or Practice predominantly in an FQHC or RHC with a minimum 30% of patients meeting the definition of needing assistance. CMS defines individuals needing assistance as those meeting any of the following three criteria: 1. Receiving medical assistance from Medicaid or the Children s Health Insurance Program (CHIP) 2. Furnished uncompensated care by the provider 3. Furnished services at either no cost or reduced cost based on a sliding scale determined by the individual s ability to pay CHIP patients do not count toward patient volume criteria. Meaningful use reporting by stage Overall, MU reporting (meaning the ongoing compilation and submission of required data to CMS) is accomplished by stage, and each stage extends over calendar years. How many calendar years depends on when an EP began reporting Stage 1. As a general rule, the program requires that EPs report at least two years of a given stage before advancing to the next. Currently, subsequent reporting is required throughout an entire calendar year after 2014. It is expected that Stage 3 will also allow the 90-day or fixed quarter reporting for year one, as the other stages have historically done. NOTE In recent rulings, CMS has elected to extend the timelines of both Stage 1 and Stage 2 beyond the fixed two years of reporting for each stage that was originally envisioned. Figure 1 details the current reporting timeline, based on first payment year or start date. 4 Figure 1: Stages of Meaningful Use First Payment Year 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2011 1 1 1 1 or 2* 2 2 3 3 TBD TBD TBD 2012 1 1 1 or 2* 2 2 3 3 TBD TBD TBD 2013 1 1* 2 2 3 3 TBD TBD TBD 2014 1* 1 2 2 3 3 TBD TBD 2015 1 1 2 2 3 3 TBD 2016 1 1 2 2 3 3 4 U.S. Dept. of Health and Human Services and the Centers for Medicare & Medicaid Services. Notice of Proposed Rulemaking. Medicare and Medicaid Programs; Modifications to the Medicare and Medicaid Electronic Health Record Incentive Programs for 2014; and Health Information Technology: Revisions to the Certified EHR Technology Definition. 79 FR 29732. May 23, 2014. https://federalregister.gov/a/2014-11944. 2017 1 1 2 2 3 * 3-month quarter EHR reporting period for Medicare and continuous 90-day EHR reporting period (or 3 mouths at State option) for Medicaid EPs. All providers in their first year in 2014 use any continuous 90-day EHR reporting period 9

Why Participate? Incentive fund capture The meaningful use program rewards EHR adoption and continuous reporting through incentive funds granted per EP, no matter the size of a practice s clinical staff. This holds true whether EPs are pursuing the Medicare or Medicaid pathway, but there are fundamental differences between the two that have implications for: Total incentives received When an EP must begin a pathway to receive any funds When the funds run out Avoiding payment penalties, also known as adjustments MEDICARE PATHWAY In the Medicare pathway, incentive payments depend on when an EP enters the program. Payment amounts decrease over time, as detailed in Figure 2. Figure 2: Medicare EHR Incentive Payment Schedule for Eligible Professionals* First Payment Received in 2011 First Payment Received in 2012 First Payment Received in 2013 First Payment Received in 2014 Payment Amount in 2011 Payment Amount in 2012 $18,000 $12,000 $18,000 Payment Amount in 2013 $7,840 Reduction ($160) $11,760 Reduction ($240) $14,700 Reduction ($300) Payment Amount in 2014 $3,920 Reduction ($80) $7,840 Reduction ($160) $11,760 Reduction ($240) $11,760 Reduction ($240) Payment Amount in 2015 $1,960 Reduction ($40) $3,920 Reduction ($80) $7,840 Reduction ($160) $7,840 Reduction ($160) Payment Amount in 2016 TOTAL Incentive Payments $1,960 Reduction ($40) $3,920 Reduction ($80) $3,920 Reduction ($80) $43,720 $43,480 $38,220 $23,520 *As required by law, President Obama issued a sequestration order on March 1, 2013. Under mandatory reductions, Medicare EHR incentive payments made to eligible professionals and eligible hospitals will be reduced by 2%. This 2% reduction has been applied to any Medicare EHR incentive payment for a reporting period that ended on or after April 1, 2013. This reduction does not apply to Medicaid EHR incentive payments. Important deadlines and incentive caps 2016 is the last year EPs are scheduled to receive a payment (despite the overall program lasting through 2021 for Medicare or Medicaid EPs). Throughout a given EP s Medicare timeline, an EP can miss an entire attestation year and then re-enter the program. For example, missing year two would mean then receiving the payment for year three. (A missed year s payment cannot be made up, and missing a year would count against a maximum five-year cycle and payment.) 10

MEDICAID PATHWAY The Medicaid pathway is a maximum six-year funding program allowing a total, per-ep incentive payment of $63,750, as shown in Figure 3. Incentive payments in the Medicaid pathway remain the same over time, and allow more flexible start dates to receive the maximum amount through 2021. Figure 3: Medicaid EHR Incentive Payment Schedule for Eligible Professionals First Payment Received in 2011 First Payment Received in 2012 First Payment Received in 2013 First Payment Received in 2014 First Payment Received in 2015 First Payment Received in 2016 Payment Amount in 2011 Payment Amount in 2012 Payment Amount in 2013 Payment Amount in 2014 Payment Amount in 2015 Payment Amount in 2016 Payment Amount in 2017 Payment Amount in 2018 Payment Amount in 2019 Payment Amount in 2020 Payment Amount in 2021 TOTAL Incentive Payments $21,250 $0 $0 $0 $0 $0 $8,500 $21,250 $0 $0 $0 $0 $8,500 $8,500 $21,250 $0 $0 $0 $8,500 $8,500 $8,500 $21,250 $0 $0 $8,500 $8,500 $8,500 $8,500 $21,250 $0 $8,500 $8,500 $8,500 $8,500 $8,500 $21,250 $0 $8,500 $8,500 $8,500 $8,500 $8,500 $0 $0 $8,500 $8,500 $8,500 $8,500 $0 $0 $0 $8,500 $8,500 $8,500 $0 $0 $0 $0 $8,500 $8,500 $0 $0 $0 $0 $0 $8,500 $63,750 $63,750 $63,750 $63,750 $63,750 $63,750 Important deadlines and notes 2016 is the last year a Medicaid EP can enter the program and receive maximum funds. The maximum participation of six years does not have to be completed during consecutive years, depending on start date. Funding is administered voluntarily by states and territories, and can be subject to the participating state s changes in funding or funding levels. The $21,250 one-time payment is for EPs who adopt, implement or upgrade (AIU) an EHR to one that is certified by ONC to satisfy meaningful use functionality. This initial payment does not count as the first actual year of reporting and attestation. GREAT RESOURCE You can plan or estimate current and future payment cycles by using the charts in this guide. For more help planning your course of action, take advantage of CMS s interactive online tool, My EHR Participation Timeline. 11

Avoid payment adjustments Like incentive payments, payment adjustments in the MU program were meant to motivate the adoption and meaningful use of EHRs. Adjustments primarily affect EPs in the Medicare pathway. Beginning on Jan. 1, 2015, payment adjustments will start at 1 percent of the EP s annual Medicare Part B claims of the Medicare Physician Fee Schedule. They then accumulate over time to a currently projected 5 percent by 2019, depending on national attestation rates. Generally, the adjustments are structured on an every-other-year basis: If you did not attest in 2013, you will incur the 1 percent adjustment in 2015, and so on through the life of the meaningful use program. CMS is currently projecting payment adjustments to occur through 2020. Despite incentive payments in the Medicare pathway scheduled to end in 2016, Medicare EPs should continue with annual meaningful use reporting and stage progression to avoid mounting payment adjustments. NOTE Medicaid EPs in the meaningful use program who do not bill Medicare are not subject to payment adjustments. But be careful to note that if you are in the Medicaid pathway, and bill Medicare for patients who are Medicare beneficiaries, you will be subject to payment adjustments if you are not actively participating in meaningful use or happen to skip a reporting year. HOW TO AVOID THE 2015 PAYMENT ADJUSTMENT EPs who attested for either 90 days or a full calendar year of Stage 1 in 2013 are not subject to the 2015 payment adjustment. New practicing providers or clinicians who can be defined as an EP enrolling for the first time to treat Medicare patients and receive Medicare payments can avoid the 2015 payment adjustment. Specialist exceptions via specialty codes as defined by the Medicare Provider Enrollment, Chain and Ownership System (PECOS) also avoid the 2015 adjustment. Exceptions are available for the following specialties: Diagnostic radiology (30) Nuclear medicine (36) Interventional radiology (94) Anesthesiology (05) Pathology (22) 12

ONGOING HARDSHIP EXCEPTIONS Because payment adjustments can continue through the life of the meaningful use program, hardship exceptions to the Medicare payment adjustments can likewise continue past the first payment adjustment in 2015. Hardship categories providing exceptions from payment adjustments, according to CMS language, include: Lack of infrastructure Insufficient Internet access to comply with related objectives, and insurmountable barriers to obtaining connectivity. Unforeseen/uncontrollable circumstances Natural disaster, practice closure, financial reasons, EHR certification/vendor issues. Lack of control over availability of certified EHR technology EPs who practice at multiple locations and are unable to control availability at one or more locations accounting for more than 50 percent of patient encounters. Lack of face-to-face interaction with patients When face-to-face interaction and follow-up with patients are outside of practice scope, or when follow-up is extremely rare. Alignment with quality incentive programs MU Meaningful use provides a foundation for the workflows, clinical functionality, documentation and reporting not only to lower barriers for entering other quality programs, but also to align your practice s quality reporting with other programs offering incentive capture. EHR REPORTING OBJECTIVES The CMS Physician Quality Reporting System (PQRS) which predates meaningful use has increasingly aligned its electronic clinical quality measures (CQMs) and EHR reporting requirements with those of meaningful use, to the point that in 2014, EPs in both programs select from the same CQM list and reporting functions. PQRS MEASURES PCMH This alignment of quality reporting requirements across programs will continue to expand with the development of advanced payment models (APMs) formed by CMS in collaboration with private payers (as detailed in the following sections). PATIENT-CENTERED MEDICAL HOME (PCMH) If you have an EHR certified for meaningful use, you also have data capture abilities mapping to PCMH recognition scoring. Overall, the meaningful use and PCMH programs have like-minded goals for patient care, patient engagement and care coordination, which lead to crossover functionality such as electronic prescribing, using clinical decision support, maintaining medication lists, providing summaries of care during care transitions and more. As private payers embrace the quality reporting elements of medical homes, the ability to report to CMS for public payer incentives, bundled with that of private payer incentives through a PCMH program, offers an excellent opportunity to capitalize on multiple programs. 13

After publication of the meaningful use Stage 1 final rule in 2010, the National Committee for Quality Assurance (NCQA) launched its 2011 patient-centered medical home (PCMH) recognition program that matched a range of its data capture standards with nearly 30 available meaningful use objectives and CQMs. The NCQA recognition program recently released its 2014 standards for PCMH level I, II and III recognition, which align with core and menu objectives from Stage 2 of meaningful use in several key ways. Examples of this alignment include: Element 3B: Clinical Data contains several MU Stage 2 core and menu requirements such as height/length and weight recordings for more than 80 percent of all patients, blood pressure and date of update for more than 80 percent of patients three years of age and older, and BMI calculation and display by the EHR. Element 3D: Use Data for Population Management contains several MU Stage 2 core requirements related to identifying patients who need certain preventive care, immunizations, and chronic or acute care services and reminding them or their caregivers of the need at least once per year. Element 5B: Referral Tracking requires, among other things, that practices have the capacity for electronic exchange of key clinical information and provide electronic summaries of care upon referral for more than 50 percent of referrals both of which are MU Stage 2 core requirements. GREAT RESOURCE This chart shows the alignment of meaningful use Stage 2 core and menu item objectives with 2014 PCMH recognition standards. Scroll through the 2014 PCMH standards to find designations of Stage 2 alignment. TIP Generally, the higher the recognition level achieved, the higher the per-patient or per-visit incentive payments, which in PCMH come from contractual agreements with private payers such as state Blue Cross Blue Shield programs. PCMH data is also submitted directly to the private payer, not to CMS as in the meaningful use or PQRS programs. Keep in mind, however, that PCMH standards outnumber the combined meaningful use core and menu objectives and CQMs, so not all of the recognition standards are met by meaningful use elements. Must-pass 2014 PCMH standards including Element 1A: patient-centered appointment access, Element 2D: the practice team, and Element 4B: care planning and self-care support, among others, have no direct analogues in meaningful use requirements. 14

Multiple PCMH standards (or clinical data factors) can, however, be found within one meaningful use objective. For example, one core meaningful use objective to record and chart five patient vital signs incorporates five separate PCMH clinical data factors. TIP When choosing meaningful use menu items, align them with diagnostic conditions selected for PCMH uniform data system clinical measures. DID YOU KNOW? Greenway s MU-certified PrimeSUITE EHR enables providers to receive auto credits toward the scores required for recognition as NCQA patient-centered medical homes. To learn more, visit Greenway s PCMH Solutions page. Threshold and measure alignment Meaningful use and PCMH data standards are so similar that even the specific thresholds or percentages cross over, enabling providers to use the same quality reporting for incentive capture across both programs Electronic prescribing Figure 4: Examples of MU and PCMH Alignment Meaningful Use More than 40 percent of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology. Patient-Centered Medical Home Generates and transmits at least 40 percent of eligible prescriptions to pharmacies. Providing patients with electronic access to health information (patient engagement) More than 50 percent of all patients who request an electronic copy of their health information are provided it within three business days. More than 50 percent of patients who request an electronic copy of their health information (such as problem list, diagnoses, diagnostic test results, medication lists, allergies) receive it within three business days. Providing patients with clinical summaries (electronic or manual patient engagement) Clinical summaries provided to patients for more than 50 percent of all office visits within three business days. Clinical summaries are provided to patients for more than 50 percent of office visits within three business days. Provider exchange of clinical information/ referral tracking (care coordination) Capability to exchange key clinical information (for example, problem list, medication list, medication allergies and diagnostic test results), among providers of care and patient-authorized entities electronically. Demonstrating the capability for electronic exchange of key clinical information (such as problem list, medication list, allergies, diagnostic test results) between clinicians. 15

PHYSICIAN QUALITY REPORTING SYSTEM (PQRS) There are also many similarities between the meaningful use and PQRS programs, in part because both are administered by CMS. In PQRS, as in meaningful use, providers and clinicians must meet eligibility criteria to participate. PQRS eligibility requirements can be found here. In 2014, for example, EPs in both programs can select the same CQMs to satisfy both program requirements, provided that the measures are reported to CMS through EHRs certified to the meaningful use program. Payment penalties (adjustments) are part of the PQRS process. Adjustment rules differ depending on whether the reporting entity is an individual EP or a group practice: Overall, EPs who do not participate or report in 2014 are subject to a 2016 payment adjustment. Group reporting includes a requirement to register within the Group Practice Reporting Option (GPRO). Registering and then reporting nine CQMs through a certified EHR means avoiding a 2016 Medicare payment adjustment. PQRS EPs must report on the nine CQMs for the entire year, not the flexible 90-day reporting period permitted in the Medicare pathway for 2014. GREAT RESOURCES! The CMS website maintains a wealth of information on the PQRS program and its alignment with meaningful use. An example of how the three programs have historically aligned can be found here. When selecting quality reporting measures that fit your patient population and clinical goals, consider choosing meaningful use, PQRS and PCMH overlap criteria this can maximize your incentive data capture and streamline reporting. COMPREHENSIVE PRIMARY CARE (CPC) INITIATIVE Referred to in the healthcare sector as an advanced payment model, the Comprehensive Primary Care (CPC) Initiative is a four-year pilot program begun in 2013 by CMS in conjunction with 44 private insurance and health plan payers. Expected to expand beyond the nearly 500 primary care practices already participating, it is one of the growing number of quality reporting incentive programs grounded in meaningful use. 16

As a care coordination and value-based medicine program, the CPC Initiative incorporates a subset of meaningful use data measures into its clinical goals. Participants complete their reporting for the initiative via EHRs certified under the meaningful use program. The program also allows providers to share healthcare cost savings, similar to the CMS accountable care structures, and targets all patients of a participating practice, not just Medicare beneficiaries as in PQRS or meaningful use. DID YOU KNOW? Multi-payer programs with expanded patient populations outside of Medicare are good examples of opportunities for providers and clinicians grounded in meaningful use functionality. GREAT RESOURCES! Much more on the CPC program can be found here. Patient care CARE COORDINATION, SAFETY AND OUTCOMES Better documentation of patient care, improved tracking of outcomes and greater patient engagement represent major goals of meaningful use. By following meaningful use criteria, practices can advance patients access to their own health information, decrease adverse drug interactions and clinical errors, automate preventive and follow-up care processes, and streamline referrals for improved care coordination. Progress toward those goals has already been made through several MU core objectives: 5 Electronic prescribing: More than 190 million electronic prescriptions have been transmitted since MU began. This, coupled with a separate required objective to use Computerized Physician Order Entry (CPOE) for medication orders, has been credited with reducing prescription and medication errors. Patient reminders: More than 13 million reminders have been sent for patients ages 65 and older or 5 and younger which is driving adherence to care plans. Patient electronic access: More than 33 million patients have received electronic access to health information via patient portals. TIP When your practice becomes adept at meeting meaningful use objectives, examine ways to expand select required processes beyond your Medicare or Medicaid patients to your entire patient population. Meaningful use data capture and analysis is also a good way to assess internal quality goals and patient care trends. 5 Tagalicod, Robert, Director, Office of E-Health Standards and Services, Centers for Medicare and Medicaid Services. The Real World Impact of Meaningful Use. http://www.cms.gov/ ehealth/listserv_realworldimpact_meaningfuluse.html. 17

BENEFITS OF PATIENT PORTALS Every day, millions of people in the U.S. transact with banks, book airfare and reserve tables at restaurants using Internet and mobile applications, or apps. They ve grown to appreciate the convenience, access and speed with which apps enable them to accomplish these everyday tasks. It s no wonder, then, that people have started to demand the same convenient access to their health information. When you couple that demand with the healthcare sector s increased focus on patient engagement as a means to improve patient outcomes and population health, a spotlight falls on patient portals and the benefits they offer practices and patients. Meeting meaningful use reporting requirements for patient engagement presents a win-win situation: Through a patient portal on a practice s website, patients can take an active role in their own healthcare, and practices acquire tools to boost office efficiency. Through a portal, patients should be able to: Schedule appointments Request prescription refills Access financial tools such as online statements and bill pay Review care and office visit summaries Access integrated personal health records (PHRs) Review test and lab results Access appointment reminders Contact the office through secure messaging Update insurance or contact information Making these features available to patients can improve office efficiency by: Decreasing phone calls and mail Reducing time spent updating records and completing administrative tasks Minimizing waiting room paperwork 18

PORTALS AND MU REQUIREMENTS Online patient portals can aid in meeting the following MU core requirements and menu items: STAGE 1 CORE REQUIREMENTS Provide electronic copy of health information upon request (test results, problem list, medication list, allergy list) to more than 50 percent of patients requesting, within three business days. Provide clinical summaries following an office visit to more than 50 percent of all patients within three business days. STAGE 1 MENU ITEMS Provide patient-specific educational resources to more than 10 percent of patients Provide timely access to health information within four days to at least 10 percent of patients STAGE 2 CORE REQUIREMENTS Provide the ability for patients to view, download and transmit (VDT) health information within four business days of becoming available to the EP. More than 50 percent of unique patients are provided access to information within four days after information is available to EP More than 5 percent shown to transmit data to a third party Provide clinical summaries following an office visit, to more than 50 percent of patients within one business day Provide educational resources to more than 10 percent of patients PROMOTE YOUR PORTAL Simply having a portal is no guarantee patients will use it, but you can maximize adoption rates and eventually, results with promotions including: Posters and pamphlets in waiting and exam rooms Promotion on paper billing statements Promotion during telephone conversations Take-home cards with login instructions Incentives such as preferred appointment times if requested through the portal Registration assistance during office visits Clear icons and prompts on practice website Regular external information flow to patient population Awareness campaigns Office hours Special events Physician buy-in and promotion directly to patients DID YOU KNOW? Greenway Health provides practices with posters, brochures and more to help encourage patients to use the portal. 19

How to Participate Implement a meaningful use-certified EHR The Office of the National Coordinator for Health Information Technology (ONC) oversees the certification process of EHRs to the specifications of meaningful use objectives and measures. ONC has designated three organizations to carry out the testing and certification of EHRs, the names of which you should be familiar with when assessing EHR capabilities: Drummond Group ICSA Labs InfoGard Laboratories, Inc GREAT RESOURCE! Additional information on the certification process can be found here. The ONC maintains a detailed website that includes a list of all complete or modular EHRs that have been certified for meaningful use. The site is searchable by vendor, product name or certification number. Understanding 2011 and 2014 certification editions You may notice that EHR software is branded with a 2011 or 2014 certification. These certification editions are matched to the stages of meaningful use: The 2011 certification edition reflects the objectives and measures of Stage 1, and the 2014 edition matches the objectives and measure of Stage 2. Each edition is usable throughout multiple years of reporting, as long as it is used within the appropriate stage. Keep in mind that refinements have been made to certain objectives on an annual basis since MU reporting began in 2011. As adjustments to objectives and measures within a given stage occur, EHR developers match those changes in the meaningful use software s capabilities. That s why you will encounter designations for 2013 Stage 1 or 2014 Stage 1 objectives and measures. For MU Stage 1, you would still use the Stage 1 or 2011 edition of your certified EHR software, as the 2011 edition matches Stage 1, no matter the reporting year adjustments. NOTE To ease the transition between reporting Stage 1 and Stage 2 objectives, CMS recently proposed that a combination of 2011- and 2014-certified editions could be used by EPs who are still in the certified software upgrade process but want or need to begin reporting Stage 2 in 2014. This proposal would allow Stage 1, 2013, Stage 1, 2014, or Stage 2 objectives to be reported using this combination edition. A final ruling on this proposal is expected prior to the last quarter of 2014. After identifying meaningful use certification and implementing a certified EHR, you are ready to register for the program. 20

Registering per-provider for meaningful use incentives To register for the Medicare or Medicaid incentive programs, there are a few basic things to know and elements to have ready: Registration is only required once during the life of the incentive program Registration is required for every individual EP within a practice Registration requires two types of identifying information: National Provider Identifier (NPI) National Plan and Provider Enumeration System (NPPES) Web user account The NPPES user ID and password begins registration Providers may apply for and obtain an NPPES login here DID YOU KNOW? CMS allows a third party such as a group practice staff member to register EPs for the program. Registering this way will create an Identity and Access Management System (I&A) Web user account (User ID/Password), which will be associated to the eligible professional s NPI. To pursue this option, get started here. Registration Preparatory Materials and Registration Web Portal GREAT RESOURCES! CMS provides detailed online guides for the registration process, as well an online registration portal: Registration Guide: Medicare Pathway: Registration User Guide for Medicare Eligible Professionals Registration Guide: Medicaid Pathway: Registration User Guide for Medicaid Eligible Professionals Registration Portal: https://ehrincentives.cms.gov 21

Assessing and selecting meaningful use measures Core objectives and menu sets Once you have implemented certified technology and registered for the meaningful use program, the next step is assessing the core objectives required for all EPs and selecting the optional menu items that best fit your care objectives, specialty and patient population. For Stage 1, EPs report all 13 core objectives and choose five of nine menu items. For Stage 2, EPs report all 17 core objectives and choose three of five menu items. STAGE 1 Figure 5: Stage 1 Meaningful Use Objectives for Eligible Professionals (EPs) - Core Set Measures Measure Threshold Requirements Exclusion 1 Use computerized provider order entry (CPOE) for medication orders. More than 30% of all unique patients medication lists have at least one medication order entered using CPOE. Any EP who writes fewer than 100 prescriptions during the EHR reporting period. 2 Implement drug-drug, drugallergy checks. Optional Alternative: More than 30% of medication orders created during the EHR reporting period are recorded using CPOE. Enable and have access to at least one internal or external formulary. 3 Maintain problem list. Maintain an up-to-date current diagnoses problem list. 4 Generate and transmit permissible prescriptions electronically (erx). 5 Maintain an active medication list. 6 Maintain an active allergy list. No exclusion. No exclusion. erx for at least 40% of permissible scripts. 1. Any EP who writes fewer than 100 prescriptions during the EHR reporting period. Maintain an active medication list for at least 80% of unique patient visits and at least one entry. Maintain an active allergy list for at least 80% of unique patient visits and at least one entry. 7 Record demographics. More than 50% of all unique patients have demographics recorded as structured data. 8 Record and chart changes in vital signs. Record vital signs and children growth charts of more than 50% of unique patient visits. Required age for blood pressure is 3 years or older. 2. Any EP who does not have a pharmacy within his or her organization and no pharmacies within 10 miles that accept erx at the start/end of EHR reporting period. No exclusion. No exclusion. No exclusion. 1. Any EP who sees no patients 3 years or older is excluded from recording blood pressure. 2. Any EP who believes that height, weight and blood pressure have no relevance to his or her scope of practice are excluded from recording them. 3. Any EP who believes that height and weight are relevant to his or her practice, but blood pressure is not, is excluded from recording blood pressure; or 4. Any EP who believes that blood pressure is relevant to his or her practice, but height and weight are not, is excluded from recording height and weight. 22

Figure 5 continued: Stage 1 Meaningful Use Objectives for Eligible Professionals (EPs) - Core Set Measures Measure Threshold Requirements Exclusion 9 Record smoking status. More than 50% of all unique patients 13 years and older have smoking status recorded as structured data. 10 Launch/track clinical decision support rule. 11 Provide patients the ability to view online, download and transmit their health information. Implement at least one clinical decision support rule. Provide 50% or more of all unique patients seen during the EHR reporting period, online access to their health information within four business days. 12 Provide clinical summaries. Provide clinical summaries (EPs) and discharge summary (hospitals) for at least 50% of all patients. 13 Protect electronic health information. Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308(a)(1) and implement security updates as necessary and correct identified security deficiencies as part of the provider s risk management process. Any EP who sees no patients 13 years or older. No exclusion. Any EP who has no requests from patients or their agents for an electronic copy of patient health information during the EHR reporting period. Any EP who has no office visits during the EHR reporting period. No exclusion. STAGE 2 Figure 6: Stage 2 Meaningful Use Objectives for Eligible Professionals (EPs) - Core Set Measures Measure Threshold Requirements Exclusion 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. More than 60% of medications, 30% of laboratory and 30% radiology orders created by the EP are recorded using CPOE. More than 50% of all permissible scripts written by the EP are compared to at least one drug formulary and transmitted electronically using certified EHR technology. More than 80% of all unique patients have demographics recorded as structured data. More than 80% of all unique patients have blood pressure (over 3 years) and height/weight recorded as structured data. Any EP who writes fewer than 100 medication, radiology or lab orders during the EHR reporting period. 1. Any EP who writes fewer than 100 prescriptions during the EHR reporting period. 2. Any EP who doesn t have a pharmacy within his or her organization and no pharmacies accept electronic prescriptions within 10 miles of the EPs practice location at the start of his/ her EHR reporting period. No exclusion. 1. Any EP who sees no patient 3 years orolder is excluded from recording blood pressure. 2. Any EP who believes that all three vital signs of height/length, weight and blood pressure have no relevance to his or her scope of practice is excluded from recording them. 3. Any EP who believes that height/weight are relevant to his or her scope of practice, but blood pressure is not, is excluded from recording blood pressure. 4. Any EP who believes that blood pressure is relevant to his or her scope of practice, but height/length and weight are not, is excluded from recording height/length and weight. 23

Figure 6 continued: Stage 2 Meaningful Use Objectives for Eligible Professionals (EPs) - Core Set Measures Measure Threshold Requirements Exclusion 5 Record smoking status for patients 13 years old or older. 6 Use of clinical decision support to improve performance on highpriority health conditions. 7 Provide patients the ability to view online, download, and transmit their health information. 8 Provide clinical summaries to patients for each office visit. 9 Protect electronic health information created or maintained by the Certified EHR Technology. 10 Incorporate clinical labtest 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. More than 80% of all unique patients 13 years or older have smoking status recorded as structured data. 1. Implement five clinical decision support interventions related to four or more clinical quality measures (CQMs). 2. The EP has enabled the functionality for drugdrug and drug-allergy interaction checks for entire reporting period. 1. More than 50% of all unique patients seen during the reporting period are provided timely online access to their health information. 2. More than 5% of these patients view, download, or transmit to a third party. Clinical summaries provided to patients within 24 hours for more than 50% of office visits. 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 at rest and implement security updates as necessary and correct identified security deficiencies as part of the provider s risk management process. More than 55% of all clinical lab results ordered by the EP with either positive/negative or numerical format are incorporated as structured data. Generate at least one report listing patients of the EP with a specific condition. More than 10% of unique patients who have had two or more office visits with the EP within 24 months prior to the beginning of the EHR reporting period were sent a reminder, per patient preference. More than 10% of patients with an office visit are provided patient-specific education resources identified by Certified EHR Technology. The EP must perform medication reconciliation for more than 50% of transitions of care in which the patient transitioned into the care of the EP. Any EP who writes fewer than 100 medication orders during the EHR reporting period is excluded from measure part two. Any EP who writes fewer than 100 medication orders during the EHR reporting period is excluded from measure part two. 1. Any EP who neither orders nor creates any of the information listed for inclusion as both parts of the measure, except for Patient s name and Provider s name and office contact information, may exclude both measures. 2. Any EP who conducts 50% or more of his/ her patient encounters in a county that doesn t have 50% or more of its housing units with 3 Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may be excluded from measure part two. Any EP who has no office visits during the EHR reporting period. No exclusion. Any EP who orders no lab tests where results are either positive/negative or numerical format during the EHR reporting period. No exclusion. Any EP who has had no office visits within the 24 months before the EHR reporting period. Any EP who has no office visits during the EHR reporting period. Any EP who was not the recipient of any transitions of care during the EHR reporting period. 24

Figure 6 continued: Stage 2 Meaningful Use Objectives for Eligible Professionals (EPs) - Core Set Measures Measure Threshold Requirements Exclusion 15 Provide summary of care record for each transition of care or referral. 1. The EP who transitions patients to other care settings must provide a summary of care record for more than 50% of transitions of care and referrals. Any EP who transfers a patient to another setting or refers a patient to another provider less than 100 times during the EHR reporting period is excluded from all parts of this measure. 2. The EP must electronically submit that transition of care using Certified EHR Technology to a recipient with no organizational affiliation or with a different EHR vendor more than 10% of the time. 16 Submit electronic data to immunization registries. 3. The EP must conduct one or more successful electronic exchanges of a summary of care document with a recipient using EHR technology or with a different EHR vendor. Or the EP must conduct one or more successful tests with test designed by CMS during the EHR reporting period. Successful ongoing submission of electronic immunization data from CEHRT to an immunization registry or immunization information system for the entire reporting period. Any EP who meets one or more of the following criteria may be excluded: 1. Doesn t administer any of the immunizations to any of the populations for which data is collected by their jurisdiction s immunization registry or immunization information system during the EHR reporting period. 2. Operates in a jurisdiction where no immunization registry or immunization information system is capable of accepting specific standards required for CERHT at the start of their EHR reporting period. 3. Operates in a jurisdiction where no immunization registry or immunization information system provides information timely on capability to receive immunization data. 17 Use secure electronic messaging to communicate with patients on relevant health information. More than 5% of unique patients were sent a secure message using the electronic messaging function of Certified EHR Technology. 4. Operates in a jurisdiction for which no immunization registry or immunization information system that is capable of accepting the specific standards required by CEHRT at the start of their EHR reporting period can enroll additional EPs. Any EP who has no office visits during the EHR reporting period or who conducts 50% or more of his/her patient encounters in a county that does not have 50% or more of its housing units with 3Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period. TIP To satisfy the secure messaging 5%+ threshold, CMS has ruled that if a patient sees multiple EPs and has received a message from one of them, all care plan EPs can count it toward the threshold. 25