Dental Management Coalition Poco Diablo, Sedona, AZ July 28, 2013 Maggie Maule, DMD, MBA Huong Le, DDS,MA, FACD MEANINGFUL USE UPDATE

Dental Management Coalition Poco Diablo, Sedona, AZ July 28, 2013 Maggie Maule, DMD, MBA Huong Le, DDS,MA, FACD MEANINGFUL USE UPDATE

EHR AND MEANINGFUL USE INCENTIVE PROGRAM OVERVIEW The American Recovery and Reinvestment Act of 2009 authorizes CMS to provide incentive payments to eligible professionals (EPs) and hospitals who adopt, implement, upgrade or demonstrate meaningful use of certified electronic health record (EHR) technology. Providers have to meet specific requirements in order to receive incentive payments: Meaningful Use Objectives

HISTORY OF EHR INITIATIVE IN 2004 President Bush began the EHR Initiative April 2004, emphasizing innovations in electronic health records and the secure exchange of medical information will help transform healthcare in America. Bush appointed the head of National Health Information Infrastructure within DHHS (Dr Tommy Thompson) that will speed up the adoption of technology HL7 EHR was adopted 10-year plan, $50M in 2004 in grants to local and regional organizations to create system to share healthcare information; $100 M for demonstration projects to test effectiveness of HIT and best practices and also create incentives and opportunities for providers to use the EMR technology

WHAT IS ELECTRONIC HEALTH RECORD? EHR

ELECTRONIC MEDICAL/DENTAL RECORD (EMR/EDR) An electronic record of health-related information on an individual within one health care organization, such as a Health Center A computerized record of a patient's clinical, demographic, and administrative data Real-time data access and evaluation in medical / dental care Provides the mechanism for longitudinal data storage and access A motivation for health care providers to implement this technology derives from the need for medical outcome studies, more efficient care, speedier communication among providers and management of health plans

EHR=EMR+EDR Provides a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting Includes information such as patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports Automates and streamlines the clinician's workflow Has the ability to generate a complete record of a clinical patient encounter - as well as supporting other care-related activities directly or indirectly via interface - including evidence-based decision support, quality management, and outcomes reporting Conforms to nationally recognized interoperability standards that can be created, managed, and consulted by authorized clinicians and staff, across more than one health care organization

INTEROPERABILITY EHR Flow Chart

BENEFITS OF AN INTEGRATED EDR/EHR Informed clinical practice Reduction in errors, increased availability of records and data, reminders and alerts, e-prescribing/refill automation Interconnection of clinicians Personalized care Improvements in population health

ARE WE READY TO PULL THE PLUG ON PAPER CHART AND READY TO BE PLUGGED INTO EHR? Do we have a choice? Not just any EHR. Certification required

GOALS OF USING CERTIFIED EHR PRODUCT TO ACHIEVE MEANINGFUL USE Improve quality, safety, efficiency, and reduce health disparities Engage patients and families in their health care Improve care coordination Improve population and public health All the while maintaining privacy and security CMS definition

GOALS OF MEANINGFUL USE Regional Extension Centers Medicaid EHR Program 1 st year incentive Workforce Training Medicare and Medicaid EHR Incentive Programs State Grants for Health Information Exchange Medicaid Administrative Funding for HIE Standards and Certification Framework Privacy and Security Framework Adoption Meaningful Use Exchange Improved Individual and Population Health Outcomes Increased Transparency and efficiency Improved ability to study and improve care delivery Health IT Practice Research

A CONCEPTUAL APPROACH TO MEANINGFUL USE Data Capture and Sharing Advanced clinical Processes Improved Outcomes

ACHIEVING MEANINGFUL USE 1. Use of certified EHR in a meaningful manner (e.g., e-prescribing) 2. Use of certified EHR technology for electronic exchange of health information to improve quality of health care 3. Use of certified EHR technology to submit clinical quality measures(cqm) and other such measures selected by the Secretary

WHO IS ELIGIBLE FOR MEANINGFUL USE INCENTIVE PAYMENTS?

ELIGIBILITY: PRACTICES PREDOMINANTLY & NEEDY INDIVIDUALS EP is also eligible when practicing predominantly in FQHC/RHC providing care to needy individuals Practicing predominantly is when FQHC/RHC is the clinical location for over 50% of total encounters over a period of 6 months in the most recent calendar year Needy individuals (specified in statute) include: Medicaid or CHIP enrollees; Patients furnished uncompensated care by the provider; or Furnished services at either no cost or on a sliding scale

ELIGIBILITY FOR INCENTIVE PAYMENTS CMS original rule is the providers have to demonstrate that they have adopted, implemented or upgraded certified EHR technology, for the first year of payment, and that they are meaningful users of certified EHR technology for the 90-day EHR reporting period. The above ruling was changed. At this time, you do not need to have a certified EHR in order to register for the Medicaid EHR Incentive Program (AIU). As an alternatively accepting AIU attestations from Medicaid providers, not meaningful use, as this is the minimum necessary for a Year 1 incentive payment. IN NOVEMBER 2011, ONC MADE ANNOUCEMENT THAT AIU IS NOT REQUIRED FOR FIRST ATTESTATION TO RECEIVE FIRST PAYMENTS.

NNOHA s HIT White Paper VERSION 2.0, AUGUST 2012

HIT White Paper Version 2.0 Helps oral health providers select and EDR/EHR and participate in Meaningful Use (MU) incentive programs through an EDR/EHR Selection Tool Provides review of MU and requirements applicable to oral health providers Identifies 6 Clinical Quality Measures (CQMs) that would be more applicable to Health Center oral health programs than current CQMs included in MU incentive programs

HIT White Paper Version 2.0 (cont.) Interviews four vendors to determine: interoperability between EDR and EHR ability to meet MU objectives capability of reporting NNOHA s proposed CQMs for oral health

EDR/EHR Selection Tool: Vendors Four vendors included in process: QSI/NextGen: QSI EDR and NextGen EHR. Open Dental/eClinicalWorks: Open Dental EDR and eclinicalworks EHR. Please note eclinicalworks is a separate corporation. Henry Schein/Vitera (formerly Sage): Dentrix Enterprise and Sage Intergy EHR. Please note Vitera is a separate corporation and has a HL7 interface to Dentrix Enterprise. Mediadent/SuccessEHS: Mediadent EDR and Success EHS EHR.

EDR/EHR Selection Tool: The Process Step Description of Steps 1 Eligible Professional Assessment 2 Vendor Background Information - Request For Information (RFI) 3 Review of Meaningful Use Core & Menu Set Objectives 4 Review of Meaningful Use Clinical Quality Measures (CQMs) 5 Vendor Response to Meaningful Use Certification and Reporting Measures 6 Vendor Response to NNOHA's Proposed Clinical Quality Measures (CQMs) for Oral Health 7 Vendor Response to EDR-EHR Practice-Specific Requirements 8 9 10 Vendor Response to Qualitative Requirements Vendor Response to Vendor Solution Cost Vendor Selection Criteria and Summary Ratings

Vendor Questions beyond MU Clinical Care management Treatment planning requirements Dental specific charting (tooth and perio) Dental Lab case tracking Productivity Measurement Admin functions (form letters, alerts, appt tracking, short list, billing, fee schedules, statements) Technical requirements Integration ability Dental imaging JC standards

RECOMMENDATIONS FOR HEALTH CENTER DENTAL PROGRAMS Before embarking on Meaningful Use, Health Centers should consider the following strategic roadmap questions: What are the implications of participating in Meaningful Use? Are the dentists eligible for Meaningful Use incentives? What external organizations can assist in the early planning, implementation and achievement of Meaningful Use of EDR/EHR systems? What features and capabilities should be included beyond suggested requirements? What is the Center s capital and operating budget for an EDR/EHR solution? What EDR/EHR selection process and deployment model should be used?

WHAT TO REPORT TO RECEIVE PAYMENTS Core Objectives: mandatory Menu Objectives Clinical Quality measures

REQUIREMENTS FOR MU REPORTING

MEANINGFUL USE CALCULATIONS Denominator (bottom) is describes the eligible cases for a measure or the eligible patient population. This includes all patients seen or admitted during the EHR reporting period. The denominator is all patients regardless of whether their records are kept using certified EHR technology. Numerator (top) describes the specific clinical action required by the measure for performance. This includes actions or subsets of patients seen or admitted during the EHR reporting period or actions taken on behalf of those patients, whose records are kept using certified EHR technology Reporting rate (dividing the numerator by the denominator) identifies the percentage of a defined patient population that was reported for the measure Exclusions: some patients may be excluded from the denominator based on medical, patient or system exclusions allowed by the measure.

PAYMENT SCHEDULE Medicaid: Payments began in 2011, as determined by each state and continue to pay on a diminishing scale over six years, through 2021. Stage I Year 1: Under the Medicaid EHR Incentive Program, incentives can also be paid for the adoption, implementation, or upgrade of certified EHR technology which can qualify your practice for the first year. Stage I Year 2: meaningful use must be maintained for 90 days and for year 3, the eligible providers must be meaningfully using their certified EHR technology for the entire 12 month period (calendar year for EPs, federal fiscal year for hospitals) (stage II).

STAGES OF PAYMENTS

PAYMENTS: EP ADOPTION TIMELINE 2011 2012 2013 2014 2015 2016 2011 $21,250 2012 $8,500 $21,250 2013 $8,500 $8,500 $21,250 2014 $8,500 $8,500 $8,500 $21,250 2015 $8,500 $8,500 $8,500 $8,500 $21,250 2016 $8,500 $8,500 $8,500 $8,500 $8,500 $21,250 2017 $8,500 $8,500 $8,500 $8,500 $8,500 2018 $8,500 $8,500 $8,500 $8,500 2019 $8,500 $8,500 $8,500 2020 $8,500 $8,500 2021 $8,500 TOT AL $63,750 $63,750 $63,750 $63,750 $63,750 $63,750

STAGES OF PAYMENTS Providers who were early demonstrators of meaningful use (2011) will meet three consecutive years of meaningful use under the Stage 1 criteria before advancing to the Stage 2 criteria in 2014. All other providers would meet 2 years of meaningful use under the Stage 1 criteria before advancing to the Stage 2 criteria in their 3rd year. In the first year of participation after AIU, providers must demonstrate meaningful use.

STAGE I PAYMENTS (CONT D) The following states have had the highest Medicare and Medicaid provider payments since the program began: 1. Texas 2. Florida 3. California 4. Pennsylvania 5. New York

COMBINED MEDICARE AND MEDICAID PAYMENTS JAN 2011-APRIL 2012

CMS MU REGISTRATION AND PAYMENTS MAY 2013

PROVIDER TYPE MAY 2013

PAYMENT SUMMARY AS OF MAY 2013

STAGE I PAYMENTS FROM DECEMBER 2012 TO FEBRUARY 2013 DECEMBER 2012 More than 350,000 eligible health care professionals and more than 4,200 hospitals have registered for the program. Over 106,000 EPs have received Medicare payments and over 69,000 have received Medicaid payments since it began in January 2011. 9,404 Dentists registered as of December 2012 4,912 Dentists have been paid under Medicare and Medicaid FEBRUARY 2013 More than 384,294 eligible health care professionals and more than 4299 hospitals have registered for the program. Over 264,292 EPs have received Medicare payments and over 120,002 have received Medicaid payments since it began in January 2011. 319 dentists have received Medicare payments and 10,577 dentists received Medicaid payments

IMPORTANT DATES TO REMEMBER FOR ATTESTATION FOR MU October 3, 2012: Medicare EP. Last date to start the 90-day reporting period to earn an $18,000 EHR incentive payment for 2012, and to be eligible for the maximum total of $44,000. (The potential total drops to $39,000 in 2013.) Physicians do not have to be registered by this date they can register at any time before they attest. January 1, 2013: First day of the 365-day, 2013 reporting period for any provider who earned first incentive payment in 2011 or 2012. February 28, 2013: Last date to register and to attest for the 2012 EHR incentive. Note: The entire reporting period has to have occurred within 2012. October 1, 2013: For eligible providers (EPs) whose first EHR payment year will be 2013, last day to start the 90-day reporting period and earn a $8,500. 2013: EPs who successfully demonstrate meaningful use in 2013 will not be subject to the 2015 payment adjustment. October 1, 2014: For EPs whose first incentive year is 2014, this is the last date to submit a successful meaningful use attestation and avoid the 2015 payment adjustment. Source: Health Security Solutions

STATE FLEXIBILITY TO REVISE MU States can seek CMS prior approval to require 4 MU objectives be core for their Medicaid providers Generate lists of patients by specific conditions for quality improvement, reduction of disparities, research, or outreach (can specify particular conditions) Reporting to immunization registries, reportable lab results, and syndromic surveillance (can specify for their providers how to test the data submission and to which specific destination)

PAYMENT METHODOLOGY How will the EHR incentive payments actually be distributed to the eligible professionals? They are distributed and taxed as income to the Tax ID number that the eligible providers uses when they register at the CMS registration system for both Medicare and Medicaid s EHR Incentive Programs, which went live on January 3, 2011. Taxable income unless signing over to health centers.

WHAT TO REPORT TO RECEIVE PAYMENTS Quality measures: Core Objectives: mandatory Menu Objectives: optional

REQUIREMENTS FOR MU REPORTING

MEANINGFUL USE CALCULATIONS Denominator is describes the eligible cases for a measure or the eligible patient population. This includes all patients seen or admitted during the EHR reporting period. The denominator is all patients regardless of whether their records are kept using certified EHR technology. Numerator describes the specific clinical action required by the measure for performance. This includes actions or subsets of patients seen or admitted during the EHR reporting period or actions taken on behalf of those patients, whose records are kept using certified EHR technology Reporting rate (dividing the numerator by the denominator) identifies the percentage of a defined patient population that was reported for the measure Exclusions: some patients may be excluded from the denominator based on medical, patient or system exclusions allowed by the measure.

STAGE I COMPONENTS

STAGE I-AIU/UPGRADE MEDICAID Only for first participation year Adopt/have purchase agreement Implement Acquire and Install, Commence Utilization of EHR Eg: Staff training, data entry of patient demographic information into EHR Upgrade Expand Upgrade to certified EHR technology or added new functionality to meet the definition of certified EHR technology Must be certified EHR technology capable of meeting meaningful use Meaningful use (MU) Successive participation year; and Some dually-eligible hospitals in year 1 Medicaid Providers AIU/MU does not have to be over six consecutive years No EHR reporting period

STAGE I REQUIREMENTS CONTINUED Stage 1 Objectives and Measures Reporting Eligible Professionals must complete: 15 core objectives 5 objectives out of 10 from menu set 6 total Clinical Quality Measures (3 core or alternate core, and 3 out of 38 from additional set)

STAGE I (CONT) Some MU objectives not applicable to every provider s clinical practice, thus they would not have any eligible patients or actions for the measure denominator. Exclusions do not count against the 5 deferred measures In these cases, the eligible professional, eligible hospital or CAH would be excluded from having to meet that measure Examples: Dentists who do not perform immunizations; Chiropractors do not e-prescribe

15 CORE OBJECTIVES Objective Measure Exclusion Dentist Routine Record patient demographics (sex, More than 50% of patients demographic None Yes race, ethnicity, date of birth, preferred data recorded as structured data language) Record vital signs and chart changes (height, weight, blood pressure, bodymass index, growth charts for children) More than 50% of patients 2 years of age or older have height, weight, and blood pressure recorded as structured data An EP who either sees no patients 2 years or older, or who believes that all three vital signs of height, weight, and blood pressure of their patients have no relevance to their scope of practice Yes: Blood pressure No: Other vitals Maintain up-to-date problem list of current and active diagnoses More than 80% of patients have at least one entry recorded as structured data Maintain active medication list More than 80% of patients have at least one entry recorded as structured data Maintain active medication allergy list More than 80% of patients have at least one entry recorded as structured data Record smoking status for patients 13 More than 50% of patients 13 years of age years of age or older or older have smoking status recorded as Provide patients with clinical summaries for each office visit On request, provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies) structured data Clinical summaries provided to patients for more than 50% of all office visits within 3 business days More than 50% of requesting patients receive electronic copy within 3 business days None None None An EP who sees no patients 13 years or older An EP who has no office visits during the EHR reporting period An EP that has no requests from patients or their agents for an electronic copy of patient health information during the EHR reporting period Yes Yes Yes Potential Potential Potential

15 CORE OBJECTIVES CONTINUED Objective Measure Exclusion Dentist Routine Generate and transmit permissible prescriptions electronically Computer provider order entry (CPOE) for medication orders More than 40% are transmitted electronically using certified EHR technology More than 30% of patients with at least one medication in their medication list have at least one medication ordered through CPOE Implement drug-drug and drug-allergy Functionality is enabled for these checks for interaction checks the entire reporting period Implement capability to electronically Perform at least one test of EHR s capacity exchange key clinical information to electronically exchange information among providers and patientauthorized entities Implement one clinical decision One clinical decision support rule support rule and ability to track implemented compliance with this rule Implement systems to protect privacy Conduct or review a security risk analysis, and security of patient data in the implement security updates as necessary, EHR and correct identified security deficiencies An EP who writes fewer than 100 prescriptions during the EHR reporting period An EP who writes fewer than 100 prescriptions during the EHR reporting period None None None None Potential Potential Yes Yes Yes Yes Report clinical quality measures (CQMs) to CMS or states For 2011, provide aggregate numerator and denominator through attestation; for 2012, electronically submit measures. Note: NNOHA has proposed additional CQMs for consideration that are relevant to oral health. None Potential

SELECT 5 OUT OF 10 MENU OBJECTIVE Objective Measure Exclusion Dentist Routine Implement drug formulary checks Drug formulary check system is implemented and has access to at least one internal or external drug formulary for the entire reporting period None Yes Incorporate clinical laboratory test results into EHRs as structured data Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach Use EHR technology to identify patient-specific education resources and provide those to the patient as appropriate Perform medication reconciliation between care settings Provide summary of care record for patients referred or transitioned to another provider or setting More than 40% of clinical laboratory test results whose results are in positive/negative or numerical format are incorporated into EHRs as structured data Generate at least one listing of patients with a specific condition More than 10% of patients are provided patient-specific education resources Medication reconciliation is performed for more than 50% of transitions of care Summary of care record is provided for more than 50% of patient transitions or referrals An EP who orders no lab tests whose results are either in a positive/negative or numeric format during the EHR reporting period None None An EP who was not the recipient of any transitions of care during the EHR reporting period An EP who neither transfers a patient to another setting nor refers a patient to another provider during the EHR reporting period Potential Yes Yes Potential Potential

SELECT 5 OUT OF 10 MENU OBJECTIVES CONTINUED Objective Measure Exclusion Dentist Routine Send reminders to patients (per patient preference) for preventive and follow-up care More than 20% of patients 65 years of age or older or 5 years of age or younger are sent appropriate reminders An EP who has no patients 65 years old or older or 5 years old or younger with records maintained using certified EHR technology Potential Provide patients with timely electronic access to their health information (including laboratory results, problem list, medication lists, medication allergies) More than 10% of patients are provided electronic access to information within 4 days of its being updated in the EHR An EP that neither orders nor creates any of the information listed at 45 CFR 170.304(g) during the EHR reporting period Potential *PH* Submit electronic immunization data to immunization registries or immunization information systems Perform at least one test of data submission and follow-up submission (where registries can accept electronic submissions) An EP who administers no immunizations during the EHR reporting period or where no immunization registry has the capacity to receive the information electronically No *PH* Submit electronic syndromic surveillance data to public health agencies Perform at least one test of data submission and follow-up submission (where public health agencies can accept electronic data) An EP who does not collect any reportable syndromic information on their patients during the EHR reporting period or does not submit such information to any public health agency that has the capacity to receive the information electronically Potential

NNOHA S PROPOSED CQMS Proposed Top Three Alternate Core Set Measures for Dentists (substitute when any of the current CQMs do not apply) Annual Oral Health Visit Topical Fluoride or Fluoride Varnish Treatment Periodontal Disease Assessment Proposed Other Alternate Core Set Measures for Dentists Dental Sealant Oral Cancer Risk Assessment & Counseling Completed Comprehensive Treatments Plan Dentist Routine Yes Yes Yes Dentist Routine Yes Yes Yes

STAGE 2 COMPONENTS

2. STAGE II MENU OBJECTIVES (OPTIONAL) Access imaging results through EHR (more than 10%) Record patient family health histories (more than 20%) Record electronic notes (more than 30%) Submit electronic syndromic surveillance data to public health registries (ongoing submissions) Identify and report cancer cases to a public health registry (ongoing submissions) Identify and report non-cancer cases to a specialized registry (ongoing submissions)

APPROVED STAGE II CQM: ORAL HEALTH Measure 1: Children who have dental decay or cavities Description: Percentage of children ages 0-20, who have had tooth decay or cavities during the measurement period. Measure 2: Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists Description: Percentage of children, age 0-20 years, who received a fluoride varnish application during the measurement period.

3. CERTIFIED EHR REQUIRED To meet meaningful use, providers must attest to the use of EHR technology that is certified by the Office of the National Coordinator Authorized Testing and Certification Body (ONC- ATCB) A list of the latest certified technology can be found on the ONC website http://onc-chpl.force.com/ehrcert

ANOTHER REQUIREMENT: CERTIFIED EHR

HOW TO REPORT

EXAMPLES Measure Information and Measure Values 1. Objective: Use computerized provider order entry (CPOE) for medication orders directly entered by a licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines Measure: More than 30 percent of all unique patients with at least one medication in their medication list seen by the EP have at least one medication order entered using CPOE Exclusion: Any EP who writes fewer than 100 prescriptions during the EHR reporting period would be excluded from this requirement Does this exclusion apply to you? Numerator: The number of patients in the denominator that have at least one medication order entered using CPOE Denominator: Number of unique patients with at least one medication in their medication list seen by the EP during the EHR reporting period 2. Objective: Implement drug-drug and drug-allergy interaction checks Measure: The EP has enabled this functionality for the entire EHR reporting period Note: This measure only requires a yes/no answer Numerator: N/A Denominator: N/A

OTHER REQUIREMENTS: CLINICAL QUALITY MEASURES (CQM) AND PAYOR MIX There are also Clinical Quality Measures that must be met such as BP measurements Medicaid: There is no minimum billing amount required for Medicaid. To qualify for the incentive program, 30% of your encounters within any 90-day consecutive period from the prior calendar year must be Medicaid patients (20% if you are a pediatrician). The exception is for EPs who have more than 50% of their encounters at an FQHC or RHC, who then can meet the patient volume requirement with 30% needy individuals (Medicaid, CHIP, sliding fee scale and uncompensated care).

STAGE I YEAR 1-2 The final rule from the Centers for Medicare and Medicaid (CMS) Services state that eligible providers must use certified EHR technology product for at least 90-days in the payment year and for a full twelve months in subsequent years. Eligible providers will register at the CMS website. Medicare providers will continue on the same website to attest that they have meaningful used certified EHR technology. Medicaid providers will complete their attestations with the State Medicaid agencies.

EP WORKING AT MULTIPLE SITES An Eligible Professional who works at multiple locations, but does not have certified EHR technology available at all of them would: Have to have 50% of their total patient encounters at locations where certified EHR technology is available Would base all meaningful use measures only on encounters that occurred at locations where certified EHR technology is available

STAGE I REPORTING CHANGES Reporting periods for meaningful use will be three months long regardless of what stage an eligible professional is following ( Rob Anthony, a health specialist with the CMS Office of E-Health Standards and Services) Also beginning in 2014, a physician group can submit a meaningful use attestation for all of its eligible professionals in one file, saving the practice from entering each individual s information separately.

FROM THE CMS FINAL RULE Dentists must report on 6 clinical measures; 3 core measures and 3 additional measures. ***Please refer to NNOHA Guide to the Future or CMS website If any of the core measures have a 0 as the denominator because it is not within the dentists scope of practice to capture that information then (s)he must choose from the alternates list. If the alternates don t apply he/she must verify that the alternates are not applicable to his/her scope of practice. **It is possible that the EP because of his/her specialty will not report on 3 of the core/alternate measures. If a dentist cannot find three measures within the menu set of 38 quality measures on which to report because it falls outside of his/her scope of practice, dentist has the option of sending a statement attesting to that fact. **It is possible that the dentist will not report on 3 menu clinical measures.

STAGE I CHALLENGES The most commonly deferred menu objective, at 84% had trouble providing a summary of care to patients at transitions to other physicians or hospitals. Next, 80% had trouble using the EHR to send reminders to specific groups of patients about preventive care. 68% of doctors deferred on syndromic surveillance sending information to public health agencies. And 66% deferred on being able to give patients electronic access to their records. The least-deferred items involved tasks that did not require outside transfers of information: checking drug formularies (15% deferral rate) and generating patient lists (25%).

FROM STAGE I TO STAGE II Stage I: 70% of physicians who achieved stage 1 requested an exclusion to the requirement that practices needed to provide, to 50% of patients who requested them, an electronic copy of their records within three days, according to CMS data. They qualified for exemptions because no patients asked for the records Stage II: require at least 5% of patients to download their records with few exceptions.

FROM STAGE I TO STAGE II Stages 1 and 2 each require meeting 20 total objectives, but stage 2 makes mandatory some EHR measures that are optional for stage 1, such as whether the electronic systems can incorporate clinical laboratory test results. Other measures stay the same but have higher thresholds, such as a requirement that EHRs send more than 50% of applicable prescriptions electronically, up from more than 40%. The number of required core set measures goes up to 17 in stage 2 from 15 in stage 1. Physicians also must choose and comply with three out of six additional menu set measures, as well as report at least nine clinical quality measures.

STAGE II Begins 2014 About 251,000 physicians and other eligible professionals already have received more than $2.6 billion in payments for the first stage of the Centers for Medicare & Medicaid Services electronic health records incentive program. Collecting for stage 2 will rely on two things: getting patients to look at their paperless records and exchanging data with others.

STAGE II The biggest hurdles with all of the electronic initiatives is interoperability To meet stage 2 requirements by 2014, practices over the next year will need to focus on getting vendors to perform necessary upgrades, improving patient engagement, and getting other organizations to adopt systems capable of receiving and sending data to and from their EHR systems

STAGE II In addition to meeting the core and menu objectives, eligible professionals, eligible hospitals and CAHs are also required to report clinical quality measures. Eligible professionals must report on 6 total clinical quality measures: 3 required core measures (or 3 alternate core measures) and 3 additional measures (selected from a set of 38 clinical quality measures). Eligible hospitals and CAHs must report on all 15 of their clinical quality measures.

STAGE II MANDATES Physicians who earned EHR bonuses in 2011 and 2012 would be required to meet stage 2 requirements starting in 2014. Doctors who start achieving meaningful use in 2013 or later would report under stage 1 rules for two years before moving onto stage 2, regardless of whether they incur any noncompliance penalties for being late adopters Please note, however, that you would not meet these Stage 2 requirements until you have met the Stage 1 requirements of the EHR Incentive Programs for a 90-day period in your first year of participation and a full year in your second year of participation.

STAGE I VS. STAGE II STAGE I 15 core objectives 5 objectives out of 10 from menu set 6 total Clinical Quality Measures (3 core or alternate core, and 3 out of 38 from additional set) Complete set for Stage II can be found on www.cms.gov STAGE II 2014 and beyond 17 core objectives 3 of 6 menu objectives 9 out of 64 CQMs 3 of the 6 key health care policy domains 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

STAGE II MU CORE SET o Use computerized physician order entry (>60% medication, 30% lab and 30% radiology orders) o Prescribe permissible drugs electronically (>50%) o Record patient demographics (>80%) o Record and chart changes in vital signs (>80%) o Record smoking status (>80%) o Use clinical decision support (at least five interventions) o Incorporate clinical lab results into EHR (more than 55%) o Generate lists of patients by specific conditions (at least one list) o Identify patients who need reminders for preventive or follow-up care (>10%) o Provide at least half of patients with access to health information (>5% use access) o Provide clinical summaries for patients within one business day (>50%) o Identify patient-specific education resources (>10%) o Communicate with patients on relevant health information (>5%) o Perform medication reconciliation during care transitions (>50%) o Send summaries of care during referrals (more than 50%) o o Submit electronic data to immunization registries (ongoing submissions during reporting period) Protect EHR information

STAGE II BEGINS 2014 Stage two of the program will begin in 2014. No providers will be required to follow the Stage 2 requirements outlined today before 2014. Outline the certification criteria for the certification of EHR technology, so eligible professionals and hospitals may be assured that the systems they use will work, help them meaningfully use health information technology, and qualify for incentive payments. Modify the certification program to cut red tape and make the certification process more efficient. Allow current 2011 Edition Certified EHR Technology to be used through 2013. Providers have the option of using 2014 certification in 2013 but they MUST use the 2014 certification starting in 2014. The CMS final rule also provides a flexible reporting period for 2014 to give providers sufficient time to adopt or upgrade to the latest EHR technology certified for 2014

DENTAL PROVIDERS: HOW ARE WE AFFECTED?

DENTAL PROVIDERS Medicaid Voluntary for States to implement (may not be an option in every State) No Medicaid payment reductions A/I/U option for 1 st participation year Maximum incentive is $63,750 for EPs States can adopt certain additional requirements for MU Last year a provider may initiate program is 2016; Last year to register is 2016 5 types of EPs, acute care hospitals (including CAHs) and children s hospitals

FROM THE CMS FINAL RULE Dentists must report on 6 clinical measures; 3 core measures and 3 additional measures. ***Please refer to NNOHA Guide to the Future or CMS website If any of the core measures have a 0 as the denominator because it is not within the dentists scope of practice to capture that information then (s)he must choose from the alternates list. If the alternates don t apply he/she must verify that the alternates are not applicable to his/her scope of practice. **It is possible that the EP because of his/her specialty will not report on 3 of the core/alternate measures. If a dentist cannot find three measures within the menu set of 38 quality measures on which to report because it falls outside of his/her scope of practice, dentist has the option of sending a statement attesting to that fact. **It is possible that the dentist will not report on 3 menu clinical measures.

STAGE 2 CQM: ORAL HEALTH Measure 1: Children who have dental decay or cavities Description: Percentage of children ages 0-20, who have had tooth decay or cavities during the measurement period. Measure 2: Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists Description: Percentage of children, age 0-20 years, who received a fluoride varnish application during the measurement period.

ACCEPTED ORAL HEALTH MEASURES I. Oral Evaluation Measure Concept: Children who received a comprehensive or periodic oral evaluation Aligned Administrative Measure: Percentage of enrolled children who accessed [dental/ oral health] care (received at least one service) who received a comprehensive or periodic oral evaluation within the reporting year. II. Prevention: Fluoride or sealants Measure Concept: Children who received topical fluoride or sealants Aligned Administrative Measure: Percentage of enrolled children at elevated risk who accessed [dental/ oral health] care (received at least one service) who received topical fluoride or sealants within the reporting year.

ADDITIONAL ORAL HEALTH MEASURES BEING PROPOSED III. Prevention: Sealants for 6 9 years-to be tested Measure Concept: Children aged 6-9 years who receive sealants in the first molar Aligned Administrative Measure: Percentage of enrolled children aged 6-9 years at elevated risk who accessed [dental/ oral health] care (received at least one service) who received a sealant in the first molar within the reporting year. IV. Prevention: Sealants for 10 14 years Measure Concept: Children aged 10-14 years who receive sealants in the second molar Aligned Administrative Measure: Percentage of enrolled children at elevated risk aged 10-14 years who accessed [dental/ oral] health care (received at least one service) who received a sealant in the second molar within the reporting year

ADDITIONAL ORAL HEALTH MEASURES BEING PROPOSED V. Prevention: Topical Fluoride Already tested Measure Concept: Children who receive topical fluoride Aligned Administrative Measure: Percentage of enrolled children at elevated risk who accessed [dental/ oral] health care (received at least one service) who received topical fluoride within the reporting year. VI.Care Continuity-Ready to be tested Measure Concept: Children who received a comprehensive or periodic oral evaluation in two consecutive years Aligned Administrative Measure: Percentage of enrolled children who accessed [dental/ oral health] services (received at least one service) who received a comprehensive or periodic oral evaluation in the year prior to the measurement, who also received a comprehensive or periodic oral evaluation within the reporting year. VII. Dental caries-already Tested Measure Concept: Children who have new caries or untreated caries Aligned administrative measure: NA.

STAGE III Public comment period opened in January 2013 Mystery as only a handful of proposed measures AMA is asking to delay No date has been set Likely to follow the same format with a divide core (mandatory) and menu (optional) requirements, with continuation of stage I and II and some new ones

RECAP: THREE STAGES Stage 1: The basic functionalities electronic health records must include such as capturing data electronically and providing patients with electronic copies of health information. Stage 2: (Will begin in 2014) Increases health information exchange between providers and promotes patient engagement by giving patients secure online access to their health information. Stage 3: (Rule will be released in 2014) Will continue to expand meaningful use objectives to improve health care outcomes.

RECAP: (CONT D) Stage 2 of the program will begin in 2014. No providers will be required to follow the Stage 2 requirements outlined today before 2014. Outline the certification criteria for the certification of EHR technology, so eligible professionals and hospitals may be assured that the systems they use will work, help them meaningfully use health information technology, and qualify for incentive payments. Modify the certification program to cut red tape and make the certification process more efficient.

RECAP: (CONT D) Allow current 2011 Edition Certified EHR Technology to be used through 2013. Providers have the option of using 2014 certification in 2013 but they MUST use the 2014 certification starting in 2014. The CMS final rule also provides a flexible reporting period for 2014 to give providers sufficient time to adopt or upgrade to the latest EHR technology certified for 2014

ADDITIONAL RESOURCES Get information, tip sheets and more at CMS official website for the EHR incentive programs: http://www.cms.gov/ehrincentiveprograms Follow the latest information about the EHR Incentive Programs on Twitter at http://www.twitter.com/cmsgov Learn about certification and certified EHRs, as well as other ONC programs designed to support providers as they make the transition http://healthit.hhs.gov www.nnoha.org

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