Meaningful Use. Medicare and Medicaid EHR Incentive Programs

Meaningful Use Medicare and Medicaid

Table of Contents What is Meaningful Use?... 1 Table 1: Patient Benefits... 2 What is an EP?... 4 How are Registration and Attestation Being Handled?... 5 What are the Meaningful Use Requirements?... 5 Table 2: Stage 1 Core Requirements... 6 Table 3: Stage 1 Menu Requirements... 11 Table 4: Stage 2 Core Requirements... 15 Table 5: Stage 2 Menu Requirements... 27

What is Meaningful Use? The federal government established the Meaningful Use program to improve the quality of patient care through increased use of Electronic Health Records across the country. The program provides Medicare and Medicaid incentive payments to hospitals and eligible professionals (EPs) when they demonstrate "meaningful use" of a certified Electronic Health Record. Along with the requirements from other external regulatory and accrediting bodies, the goals of the Meaningful Use program are in alignment and will help you: Improve Quality, Safety, Efficiency Engage Patients and Families Improve Care Coordination Improve Population and Public Health Ensure Privacy and Security Protections Meaningful Use of an electronic health record (EHR) offers immediate, tangible MU Patient Benefits (Table 1), such as requiring ready access to personal health information, medication reconciliation completed at each transition of care, use of alerts to potential drug-drug or drug-allergy interactions, and electronic prescribing. For physicians, meaningful use will ultimately ensure the ability to exchange health information with other providers, streamlining collaboration for coordinated patient care. Quality reporting allows providers to compare quality measures against national standards to identify areas where improvements may be needed. Meaningful Use quality reporting requirements are the first step in shifting quality reporting away from abstracted, retrospective reports towards real-time quality monitoring through the use of decision support tools, and utilizing specified terminology standards to improve comparability, reliability, and reusability of data. Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 1

Table 1: Patient Benefits Meaningful Use helps to define a shift in viewing the health record from not only a place to document care (which it is), but also a repository for knowledge, which can be used to transform and improve the delivery of care. The stated goals of the Meaningful Use program have benefits for patients (see examples below). Meaningful Use Goals Model of Care Elements Benefits to Patients and Communities Engage patients and their families Respect MU requires that patients have ready access to their health information, such as access to electronic copies of their health records upon request, and summary of care documents within specified time frames. Patients must also be provided ready access to their care team, through the availability and use of secure electronic messaging. Improve quality, safety, efficiency Quality Providers must maintain an active medication list and a medication allergy list within the electronic record. This allows for alerts with drug-drug interactions and drug-allergy interactions, thereby helping improve patient safety. In addition, providers are required to perform medication reconciliation at each transition of care. Ultimately, meaningful use of electronic health records will increase the use of Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 2

real-time decision-support tools to avoid errors and recommend treatment. Improve quality, safety, efficiency Quality Requirement for electronic prescribing, thereby reducing errors due to illegible handwritten prescriptions. Improve care coordination Improve quality, safety, efficiency Improve quality Improve population and public health Improve population and public health Teamwork Efficiency Quality Teamwork Quality Exchange health information with another provider. As health information exchange (HIE) technology becomes more sophisticated, this will help improve care coordination. Better sharing of information between providers will help reduce duplication of services, thereby reducing health care costs, and will facilitate care coordination and treatment. Quality metrics must be reported out of the certified record, with specified terminology requirements. This will ultimately allow better comparability of data, and improve real-time quality monitoring versus retrospective quality reporting Report data to state or other public health agencies, such as immunization or syndromic surveillance data. Disease reporting to state or other agencies will help monitor and improve public health and will eventually offer real-time surveillance of public health Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 3

issues and disease outbreaks. Improve quality, safety, efficiency Innovation Greater adoption of electronic health technology will help pressure IT vendors to develop and improve IT solutions that are integrated with clinical care processes. Improve population and public health Efficiency Demonstration of Meaningful Use provides terminology specifications, thereby improving comparability, reliability and reusability of data. Ensure privacy, security protections Respect MU specifies electronic health information protection. What is an EP? Providers report to the Centers for Medicare and Medicaid Services (CMS) through Eligible Hospitals (EH) and Eligible Professionals (EP). Each EH reports data as a single entity, but each EP reports individually. EPs in the Medicare program are doctors (of medicine, osteopathy, oral surgery, dental medicine, optometry, podiatry or chiropractors) who bill the Medicare Physician Fee Schedule for patient services, and perform their services in an outpatient setting. EPs in the Medicaid program include the following outpatient providers*: o Physicians (primarily doctors of medicine and doctors of osteopathy) o Nurse practitioners o Certified nurse-midwives o Dentists Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 4

o Physician assistants who furnish services in a Federally qualified Health Center or Rural Health Clinic that is led by a physician assistant. *In certain states, optometrists are eligible for the Medicaid EHR Incentive Program. For an optometrist to be eligible, the state Medicaid program must cover adult optometrist services as physician services in the Medicaid State Plan. Please check with your state Medicaid agency for more information. How are Registration and Attestation Being Handled? As part of the process of meeting the CMS Meaningful Use incentive program that was initiated in 2009, eligible providers (EPs) and hospital representatives must complete a process of registering and attesting for the program. So, what is registration and attestation? Registration: In order to participate in the Medicare Electronic Health Record Incentive Program (also known as Meaningful Use program), an EP must first enroll in the program using the physician s National Plan and Provider Enumeration System (NPPES) user identification and password. Attestation: After a provider has met the Program requirements, the data must be submitted to CMS. Meaningful Use reports can be generated from certified Electronic Health Records. What are the Meaningful Use Requirements? There will be at least 3 stages of Meaningful Use. Each stage has different requirements. Each EH and EP will report data for 2 years within each stage. There are several core measures that must be met, along with a few selection of measures selected from a menu. Some of the measures have exclusions, if an EH or EP meets that exclusion, they do not need to report that measure. Table 2: Stage 1 Core Requirements Table 3: Stage 1 Menu Requirements (select 5 for each EH / EP) Table 4: Stage 2 Core Requirements Table 5: Stage 2 Menu Requirements (select 3 for each EH / EP) Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 5

Table 2: Stage 1 Core Requirements Objectives Measures Exclusion Eligible Professionals Hospitals Record demographics preferred language gender Record demographics preferred language gender More than 50% of all unique patients seen by the EP or admitted to the eligible hospital s inpatient or emergency department have demographics recorded as structured data race race ethnicity ethnicity date of birth date of birth date and preliminary cause of death in the event of mortality in the eligible hospital Record and chart changes in vital signs: Height Weight Blood pressure Calculate and display BMI Plot and display Record and chart changes in vital signs: Height Weight Blood pressure Calculate and display BMI Plot and display growth charts for children 2-20 For more than 50% of all unique patients age 2 and over seen by the EP or admitted to eligible hospital s inpatient or emergency department, height, weight and blood pressure are recorded as structured data Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 6

growth charts for children 2-20 years, including BMI years, including BMI Maintain an up-to date problem list of current and active diagnoses Maintain an up-to date problem list of current and active diagnoses More than 80% of all unique patients seen by the EP or admitted to the eligible hospital s inpatient or emergency department have at least 1 entry or an indication that no problems are known for the patient recorded as structured data Maintain active medication list Maintain active medication list More than 80% of all unique patients seen by the EP or admitted to the eligible hospital s inpatient or emergency department have at least 1 entry (or an indication that the patient is not currently prescribed any medication) recorded as structured data Maintain active medication allergy list Maintain active medication allergy list More than 80% of all unique patients seen by the EP or admitted to the eligible hospital s inpatient or emergency department have at least 1 entry (or an indication that the patient has no known medication allergies) recorded as structured data Record smoking status for patients 13 years old or older Record smoking status for patients 13 years old or older More than 50% of all unique patients 13 years old or older seen by the EP or admitted to the eligible hospital s inpatient or emergency department have smoking status recorded as structured data Any EP who sees no patient 13 years or older Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 7

Use computerized provider order entry (CPOE) for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines Use CPOE for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines More than 30% of unique patients with at least 1 medication in their medication list seen by the EP or admitted to the eligible hospital s inpatient or emergency department have at least 1 medication order entered using CPOE Any EP who writes fewer than 100 prescriptions during the EHR reporting period Implement drug-drug and drug-allergy interaction checks Implement drug-drug and drug-allergy interaction checks The EP/eligible hospital has enabled this functionality for the entire EHR reporting period (Y/N attestation) Implement 1 clinical decision support rule relevant to specialty or high clinical priority along with the ability to track compliance that rule Implement 1 clinical decision support rule related to a high priority hospital condition along with the ability to track compliance with that rule Implement 1 clinical decision support rule (Y/N attestation) Generate and transmit permissible prescriptions electronically (erx) More than 40% of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology Any EP who writes fewer than 100 prescriptions during the EHR reporting period Provide clinical summaries for patients for each office visit Provide patients with an electronic copy of their discharge instructions at time of discharge, upon More than 50% of all patients who are discharged from an eligible hospital inpatient department or emergency department and who request an electronic copy of their Any EP that neither orders nor creates lab tests or information that Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 8

Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies), upon request request Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies, discharge summary, procedures), upon request discharge instructions are provided it Clinical summaries provided to patients for more than 50% of all office visits within 3 business days More than 50% of all patients of the EP or the inpatient or emergency departments of the eligible hospital who request an electronic copy of their health information are provided it within 3 business days would be contained in the problem list, medication list, medication allergy list (or other information as listed at 45 CFR 170.304(g)) during the EHR reporting period Capability to exchange key clinical information (for example, problem list, medication list, medication allergies, diagnostic test results), among providers of care and patient authorized entities electronically Capability to exchange key clinical information (for example, discharge summary, procedures, problem list, medication list, medication allergies, diagnostic test results), among providers of care and patient authorized entities electronically Performed at least 1 test of certified EHR technology's capacity to electronically exchange key clinical information (Y/N attestation) Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities Conduct or review a security risk analysis per 45 CFR 164.308 (a)(1) and implement security updates as necessary and correct identified security deficiencies as part of its risk management process Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 9

capabilities Report ambulatory clinical quality measures to CMS or the States Report hospital clinical quality measures to CMS or the States For 2011, provide aggregate numerator, denominator, and exclusions through attestation as discussed in section II(A)(3) of [the Medicare and Medicaid EHR Incentive Programs final rule] For 2012, electronically submit the clinical quality measures as discussed in section II(A)(3) of [the Medicare and Medicaid EHR Incentive Programs final rule] Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 10

Table 3: Stage 1 Menu Requirements Objectives Measures Exclusions Eligible Professionals Hospitals Incorporate clinical lab-test results into certified EHR technology as structured data Incorporate clinical lab-test results into certified EHR technology as structured data More than 40% of all clinical lab tests results ordered by the EP or by an authorized provider of the eligible hospital for patients admitted to its inpatient or emergency department during the EHR reporting period whose results are either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data An EP who orders no lab tests whose results are either in a positive/negative or numeric format during the EHR reporting period qualifies for an exclusion from this objective/measure The EP who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation The eligible hospital or CAH who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation The EP, eligible hospital performs medication reconciliation for more than 50% of transitions of care in which the patient is transitioned into the care of the EP or admitted to the eligible hospital s inpatient or emergency department An EP who was not the recipient of any transitions of care during the EHR reporting period qualifies for an exclusion from this objective/measure Capability to submit electronic data to immunization registries or Immunization Information Systems and actual submission in accordance Capability to submit electronic data to immunization registries or Immunization Information Systems and actual submission in accordance with applicable Performed at least 1 test of certified EHR technology's capacity to submit electronic data to immunization registries and follow up submission if the test is successful (unless none of the An EP who administers no immunizations during the HER reporting period or where no immunization registry has the capacity to receive Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 11

with applicable law and practice law and practice immunization registries to which the EP, eligible hospital submits such information have the capacity to receive the information electronically) (Y/N attestation) the information electronically qualifies for an exclusion from this objective/measure Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach Generate at least 1 report listing patients of the EP, eligible hospital with a specific condition (Y/N attestation) Record advance directives for patients 65 years old or older More than 50% of all unique patients 65 years old or older admitted to the eligible hospital s inpatient department have an indication of an advance directive status recorded An eligible hospital or CAH that admits no patients age 65 old or older during the EHR reporting period Capability to submit electronic data on reportable (as required by state or local law) lab results to public health agencies and actual submission in accordance with applicable law and practice Performed at least 1 test of certified EHR technology s capacity to provide electronic submission of reportable lab results to public health agencies and follow-up submission if the test is successful (unless none of the public health agencies to which eligible hospital or CAH submits such information have the capacity to receive the information electronically) (Y/N attestation) Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 12

Capability to submit electronic syndromic surveillance data to public health agencies and actual submission in accordance with applicable law and practice Capability to submit electronic syndromic surveillance data to public health agencies and actual submission in accordance with applicable law and practice Performed at least 1 test of certified EHR technology's capacity to provide electronic syndromic surveillance data to public health agencies and follow-up submission if the test is successful (unless none of the public health agencies to which an EP, eligible hospital or CAH submits such information have the capacity to receive the information electronically) (Y/N attestation) 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. Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate More than 10% of all unique patients seen by the EP or admitted to the eligible hospital s or CAH s inpatient or emergency department (POS 21 or 23) are provided patient-specific education resources Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, medication allergies) within four business days of the information being available to the EP More than 10% of all unique patients seen by the EP are provided timely (available to the patient within 4 business days of being updated in the certified EHR technology) electronic access to their health information subject to the EP s discretion to withhold certain information Any EP that neither orders nor creates any of the information listed at 45 CFR 170.304(g) (e.g., lab test results, problem list, medication list, medication allergy list, immunizations, and procedures) during the EHR reporting period Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 13

qualifies for an exclusion from this objective/measure The EP who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary of care record for each transition of care or referral The eligible hospital or CAH who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary of care record for each transition of care or referral The EP, eligible hospital or CAH who transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 50% of transitions of care and referrals An EP who neither transfers a patient to another setting nor refers a patient to another provider during the EHR reporting period qualifies for an exclusion from this objective/measure Send reminders to patients per patient preference for preventive/ follow up care More than 20% of all unique patients 65 years or older or 5 years old or younger were sent an appropriate reminder during the EHR reporting period An EP who has no patients 65 years old or older or 5 years old or younger with records maintained using certified her technology qualifies for an exclusion from this objective/measure Implement drugformulary checks Implement drug-formulary checks The EP/eligible hospital/cah has enabled this functionality and has access to at least 1 internal or external drug formulary for the entire EHR reporting period (Y/N attestation) Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 14

Table 4: Stage 2 Core Requirements Stage 2 Objective Stage 2 Measures Exclusions Eligible Professional Eligible Hospital Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines More than 60% of medication, 30% of laboratory, and 30% of radiology orders created by the EP or authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using CPOE. Any EP who writes fewer than 100 medication, radiology, or laboratory orders during the EHR reporting period. Generate and transmit permissible prescriptions electronically (erx) More than 50% of all permissible prescriptions, or all prescriptions written by the EP and queried for a drug formulary and transmitted electronically using CEHRT. Any EP who: (1) Writes fewer than 100 permissible prescriptions during the EHR reporting period. (2) Does not have a pharmacy within their organization and there are no pharmacies that accept electronic prescriptions within 10 miles of the EP's practice location at the start of his/her EHR reporting period. Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 15

Record the following demographics Preferred language Sex Race Ethnicity Date of birth Record the following demographics Preferred language Sex Race Ethnicity Date of birth Date and preliminary cause of death in the event of mortality in the eligible hospital or CAH More than 80% of all unique patients seen by the EP or admitted to the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period have demographics recorded as structured data. Record and chart changes in vital signs: Height/length Weight Blood pressure (age 3and over) Calculate and display BMI Plot and display growth charts for patients 0-20 Record and chart changes in vital signs: Height/length Weight Blood pressure (age 3 and over) Calculate and display BMI Plot and display growth charts for patients 0-20 years, More than 80% of all unique patients seen by the EP or admitted to the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period have blood pressure (for patients age 3 and over only) and height/length and weight (for all ages) recorded as structured data Any EP who: (1) Sees no patients 3 years or older is excluded from recording blood pressure. (2) Believes that all 3 vital signs of height/length, weight, and blood pressure have no relevance to their scope of practice is excluded from recording them. (3) Believes that height/length and weight are relevant to their scope of practice, but blood Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 16

years, including BMI including BMI pressure is not, is excluded from recording blood pressure. (4) Believes that blood pressure is relevant to their scope of practice, but height/length and weight are not, is excluded from recording height/length and weight. Record smoking status for patients 13 years old or older Record smoking status for patients 13 years old or older More than 80% of all unique patients 13 years old or older seen by the EP or admitted to the eligible hospital's or CAH's inpatient or emergency departments (POS 21 or 23) during the EHR reporting period have smoking status recorded as structured data Any EP or EH that neither sees nor admits any patients 13 years old or older. Use clinical decision support to improve performance on high priority health conditions Use clinical decision support to improve performance on high priority health conditions 1. Implement 5 clinical decision support interventions related to 4 or more clinical quality measures at a relevant point in patient care for the entire EHR reporting period. Absent 4 clinical quality measures related to an EP, eligible hospital or CAH's scope of practice or patient population, the clinical decision support interventions must be related to high-priority Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 17

health conditions. It is suggested that 1 of the 5 clinical decision support interventions be related to improving healthcare efficiency. 2. The EP, eligible hospital, or CAH has enabled and implemented the functionality for drug drug and drug allergy interaction checks for the entire EHR reporting period. Incorporate clinical labtest results into Certified EHR Technology as structured data. Incorporate clinical lab-test results into Certified EHR Technology as structured data More than 55% of all clinical lab tests results ordered by the EP or by authorized providers of the eligible hospital or CAH for patients admitted to its inpatient or emergency department (POS 21 or 23) during the EHR reporting period whose results are either in a positive/negative affirmation or numerical format are incorporated in Certified EHR Technology as structured data. Any EP who orders no lab tests where results are either in a positive/negative affirmation or numeric format during the EHR reporting period. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach. Generate at least 1 report listing patients of the EP, eligible hospital or CAH with a specific condition. Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 18

or outreach. Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care and send these patients the reminder, per patient preference. Any EP who has had no office visits in the 24 months before the EHR reporting period. Automatically track medications from order to administration using assistive technologies in conjunction with an electronic medication administration record (emar). More than 10% of medication orders created by authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period for which all doses are tracked using emar. Any eligible hospital or CAH with an average daily inpatient census of fewer than 10 patients. Provide patients the ability to view online, download, and transmit their health information within 4 business days of the information being available to the EP. 1. More than 50% of all unique patients seen by the EP during the EHR reporting period are provided timely (within 4 business days after the information is available to the EP) online access to their health information subject to the EP's discretion to withhold certain information. 2. More than 5% of all unique patients seen by the EP during Any EP who: (1) Neither orders nor creates any of the information listed for inclusion as part of both measures, except for "Patient name" and "Provider's name and office contact information, may exclude both measures. (2) Conducts 50% or more of his or her patient encounters in a county that does not have 50% Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 19

Provide patients the ability to view online, download, and transmit information about a hospital admission. the EHR reporting period (or their authorized representatives) view, download, or transmit to a third party their health information. 1. More than 50% of all patients who are discharged from the inpatient or emergency department (POS 21 or 23) of an eligible hospital or CAH have their information available online within 36 hours of discharge 2. More than 5% of all patients (or their authorized representatives) who are discharged from the inpatient or emergency department (POS 21 or 23) of an eligible hospital or CAH view, download or transmit to a third party their information during the reporting period. 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 may exclude only the second measure. Any eligible hospital or CAH that is located 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 is excluded from the second measure. Provide clinical summaries for patients for each office visit. Clinical summaries provided to patients or patient-authorized representatives within 1 business day for more than 50% Any EP who has no office visits during the EHR reporting period. Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 20

of office visits. Use Certified EHR Technology to identify patient-specific education resources and provide those resources to the patient Use Certified EHR Technology to identify patient-specific education resources and provide those resources to the patient Patient-specific education resources identified by CEHRT are provided to patients for more than 10% of all unique patients with office visits seen by the EP during the EHR reporting period. Any EP who has no office visits during the EHR reporting period. More than 10% of all unique patients admitted to the eligible hospital's or CAH's inpatient or emergency departments (POS 21 or 23) are provided patientspecific education resources identified by Certified EHR Technology. Use secure electronic messaging to communicate with patients on relevant health information A secure message was sent using the electronic messaging function of Certified EHR Technology by more than 5% of unique patients (or their authorized representatives) seen by the EP during the EHR reporting period. Any EP who has no office visits during the EHR reporting period, or any EP who conducts 50% or more of his or 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. The EP who receives a The eligible hospital or CAH The EP, eligible hospital or CAH Any EP who was not the Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 21

patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation. who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation performs medication reconciliation for more than 50% of transitions of care in which the patient is transitioned into the care of the EP or admitted to the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23). recipient of any transitions of care during the EHR reporting period. The EP who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care provides a summary care record for each transition of care or referral. The eligible hospital or CAH who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care provides a summary care record for each transition of care or referral. 1. The EP, eligible hospital, or CAH that transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 50% of transitions of care and referrals. 2. The EP, eligible hospital or CAH that transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 10% of such transitions and referrals either-- (a) electronically transmitted using CEHRT to a recipient or (b) where the recipient receives the summary of care record via exchange facilitated by an organization that is a NwHIN Exchange participant or in a manner that 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 three measures. Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 22

Capability to submit electronic data to immunization registries or immunization information systems Capability to submit electronic data to immunization registries or immunization information systems except where is consistent with the governance mechanism ONC establishes for the nationwide health information network. 3. An EP, eligible hospital or CAH must satisfy 1 of the 2 following criteria: (A) Conducts 1 or more successful electronic exchanges of a summary of care document, as part of which is counted in "measure 2" (for EPs the measure at 495.6(j)(14)(ii)(B) and for eligible hospitals and CAHs the measure at 495.6(l)(11)(ii)(B)) with a recipient who has EHR technology that was developed designed by a different EHR technology developer than the sender's EHR technology certified to 45 CFR 170.314(b)(2); or (B) Conducts 1 or more successful tests with the CMS designated test EHR during the EHR reporting period. Successful ongoing submission of electronic immunization data from Certified EHR Technology to an immunization registry or immunization information Any EP or EH that meets 1 or more of the following criteria may be excluded from this objective: (1) the EP or EH does not Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 23

except where prohibited, and in accordance with applicable law and practice prohibited, and in accordance with applicable law and practice system for the entire EHR reporting period. 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) the EP or EH operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required for CEHRT at the start of their EHR reporting period; (3) the EP or EH operates in a jurisdiction where no immunization registry or immunization information system provides information timely on capability to receive immunization data; or (4) the EP or EH 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 Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 24

Capability to submit electronic reportable laboratory results to public health agencies, except where prohibited, and in accordance with applicable law and practice Capability to submit electronic syndromic Successful ongoing submission of electronic reportable laboratory results from Certified EHR Technology to public health agencies for the entire EHR reporting period. Successful ongoing submission of electronic syndromic of their EHR reporting period can enroll additional EPs. Any eligible hospital or CAH that meets 1 or more of the following criteria: (A) Operates in a jurisdiction for which no public health agency is capable of receiving electronic reportable laboratory results in the specific standards required for Certified EHR Technology at the start of their EHR reporting period. (B) Operates in a jurisdiction for which no public health agency provides information timely on capability to receive electronic reportable laboratory results. (C) Operates in a jurisdiction for which no public health agency that is capable of accepting the specific standards required by Certified EHR Technology at the start of their EHR reporting period can enroll additional eligible hospitals or CAHs. Any eligible hospital or CAH that meets 1 or more of the Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 25

surveillance data to public health agencies, except where prohibited, and in accordance with applicable law and practice surveillance data from Certified EHR Technology to a public health agency for the entire EHR reporting period. following criteria may be excluded from this objective: (1) Does not have an emergency or urgent care department; (2) Operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data in the specific standards required by Certified EHR Technology at the start of their EHR reporting period; (3) Operates in a jurisdiction where no public health agency provides information timely on capability to receive syndromic surveillance data; or (4) Operates in a jurisdiction for which no public health agency that is capable of accepting the specific standards required by Certified EHR Technology at the start of their EHR reporting period can enroll additional eligible hospitals or CAHs. Protect electronic health information created or maintained by the Protect electronic health information created or maintained by the Certified Conduct or review a security risk analysis in accordance with the requirements under 45 CFR Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 26

Certified EHR Technology through the implementation of appropriate technical capabilities EHR Technology through the implementation of appropriate technical capabilities 164.308(a)(1), including addressing the encryption/security of data stored in CEHRT in accordance with requirements under 45 CFR 164.312 (a)(2)(iv) and 45 CFR 164.306(d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the provider's risk management process. Table 5: Stage 2 Menu Requirements Stage 2 Objective Stage 2 Measures Exclusions Eligible Professional Eligible Hospital Record whether a patient 65 years old or older has an advance directive More than 50% of all unique patients 65 years old or older admitted to the eligible hospital's or CAH's inpatient department (POS 21) during the EHR reporting period have an indication of an advance directive status recorded as structured data. An eligible hospital or CAH that admits no patients age 65 years old or older during the EHR reporting period. Imaging results consisting of the image itself and any Imaging results consisting of the image itself and any More than 10% of all tests whose result is 1 or more images ordered by the EP or by an authorized provider of the Any EP who orders less than 100 tests whose result is an image during the EHR reporting period; or any EP who Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 27

explanation or other accompanying information are accessible through Certified EHR Technology. explanation or other accompanying information are accessible through Certified EHR Technology. eligible hospital or CAH for patients admitted to its inpatient or emergency department (POS 21 and 23) during the EHR reporting period are accessible through Certified EHR Technology. has no access to electronic imaging results at the start of the EHR reporting period. Record patient family health history as structured data Record patient family health history as structured data More than 20% of all unique patients seen by the EP or admitted to the eligible hospital or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period have a structured data entry for 1 or more first-degree relatives. Any EP who has no office visits during the EHR reporting period. Generate and transmit permissible discharge prescriptions electronically (erx) More than 10% of hospital discharge medication orders for permissible prescriptions (for new, changed, and refilled prescriptions) are queried for a drug formulary and transmitted electronically using Certified EHR Technology. Does not have an internal pharmacy that can accept electronic prescriptions and is not located within 10 miles of any pharmacy that accepts electronic prescriptions at the start of their EHR reporting period. Record electronic notes in patient records Record electronic notes in patient records Enter at least 1 electronic progress note created, edited and signed by an eligible professional for more than 30% of unique patients with at least 1 office visit during the EHR reporting period. Enter at least 1 electronic progress note created, edited and signed by an authorized provider of the eligible hospital's or CAH's Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 28

Provide structured electronic lab results to ambulatory providers inpatient or emergency department (POS 21 or 23) for more than 30% of unique patients admitted to the eligible hospital or CAH's inpatient or emergency department during the EHR reporting period. Electronic progress notes must be text-searchable. Nonsearchable notes do not qualify, but this does not mean that all of the content has to be character text. Drawings and other content can be included with searchable text notes under this measure. Hospital labs send structured electronic clinical lab results to the ordering provider for more than 20% of electronic lab orders received Capability to submit electronic syndromic surveillance data to public health agencies, except where prohibited, and in accordance with applicable law and practice Successful ongoing submission of electronic syndromic surveillance data from Certified EHR Technology to a public health agency for the entire EHR reporting period Any EP that meets 1 or more of the following criteria may be excluded from this objective: (1) the EP is not in a category of providers that collect ambulatory syndromic surveillance information on their patients during the EHR reporting period; (2) the EP operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data in the Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 29

specific standards required by CEHRT at the start of their EHR reporting period; (3) the EP operates in a jurisdiction where no public health agency provides information timely on capability to receive syndromic surveillance data; or (4) the EP operates in a jurisdiction for which no public health agency that is capable of accepting the specific standards required by CEHRT at the start of their EHR reporting period can enroll additional EPs. Capability to identify and report cancer cases to a public health central cancer registry, except where prohibited, and in accordance with applicable law and practice. Successful ongoing submission of cancer case information from CEHRT to a public health central cancer registry for the entire EHR reporting period Any EP that meets at least 1 of the following criteria may be excluded from this objective: (1) The EP does not diagnose or directly treat cancer; (2) The EP operates in a jurisdiction for which no public health agency is capable of receiving electronic cancer case information in the specific standards required for CEHRT at the beginning of their EHR reporting Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 30

Capability to identify and report specific cases to a specialized registry (other than a cancer registry), except where prohibited, and in accordance with applicable law and practice. Successful ongoing submission of specific case information from Certified EHR Technology to a specialized registry for the entire EHR reporting period. period; (3) The EP operates in a jurisdiction where no PHA provides information timely on capability to receive electronic cancer case information; or (4) The EP operates in a jurisdiction for which no public health agency that is capable of receiving electronic cancer case information in the specific standards required for CEHRT at the beginning of their EHR reporting period can enroll additional EPs. Any EP that meets at least 1 of the following criteria may be excluded from this objective: (1) The EP does not diagnose or directly treat any disease associated with a specialized registry sponsored by a national specialty society for which the EP is eligible, or the public health agencies in their jurisdiction; (2) The EP operates in a jurisdiction for which no specialized registry sponsored by a public health agency or by a national specialty society for which the EP is eligible is capable of receiving electronic specific case information in the specific standards Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 31

required by CEHRT at the beginning of their EHR reporting period; (3) The EP operates in a jurisdiction where no public health agency or national specialty society for which the EP is eligible provides information timely on capability to receive information into their specialized registries; or (4) The EP operates in a jurisdiction for which no specialized registry sponsored by a public health agency or by a national specialty society for which the EP is eligible that is capable of receiving electronic specific case information in the specific standards required by CEHRT at the beginning of their EHR reporting period can enroll additional EPs. Meaningful Use: Medicare and Medicaid Updated: June 27, 2014 Page 32