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Meaningful Use Stage 2:What’s Next?Stage 2 Proposed RuleLisa Hays, Program ManagerSue Shumate, Implementation SpecialistMO-12-02-RECApril 2012

Slides adapted fromRobert Anthony, CMSSteve PosnackDirector of Federal Policy Division

Proposed RuleEverything discussed in this presentation is part ofa notice of proposed rulemaking (NPRM).Full notices for the 2014 EHR-technology certificationare online:CMS Rule: http://www.ofr.gov/OFRUpload/OFRData/201204443 PI.pdfONC 0 PI.pdfComments period: through May 7. Visitwww.regulations.gov and search for “CMS 0044”.Content on this page is subject to the Notice on the title page of this presentation.

What is in the Proposed RuleMinor changes to Stage 1 of meaningful useStage 2 of meaningful useNew clinical quality measuresNew clinical quality measure reporting mechanismsAppealsDetails on the Medicare payment adjustmentsMinor Medicare Advantage program changesMinor Medicaid program changes3Content on this page is subject to the Notice on the title page of this presentation.

Stage 2 TimelineJune 2011: HITPC Recommendations on Stage 2February 2012: Stage 2 Proposed RuleSummer 2012: Stage 2 Final RuleOct. 1, 2013/Jan. 1, 2014: Proposed Stage 2 Start Dates5Content on this page is subject to the Notice on the title page of this presentation.

Stages of Meaningful 2014201520162017Content on this page is subject to the Notice on the title page of this presentation.

Stage 1 to Stage 2 Meaningful UseEligible Professionals15 core objectives5 of 10 menu objectives20 total objectivesEligible Professionals17 core objectives3 of 5 menu objectives20 total objectivesEligible Hospitals & CAHs14 core objectives5 of 10 menu objectives19 total objectivesEligible Hospitals & CAHs16 core objectives2 of 4 menu objectives18 total objectives7Content on this page is subject to the Notice on the title page of this presentation.

Meaningful Use ConceptsChangesExclusions no longer count to meeting one of the menuobjectivesAll denominators include all patient encounters atoutpatient locations equipped with certified EHRtechnologyNo ChangesNo change in 50% of EP outpatient encounters must occurat locations equipped with certified EHR technologyMeasure compliance objective compliance8Content on this page is subject to the Notice on the title page of this presentation.

Changes to Stage 1CPOEDenominator: UniquePatient with at least onemedication in their med listDenominator: Number ofOrders during the EHRReporting Period*Optional in 2013 Required in 2014 Vital SignsAge Limits: Age 2 forBlood Pressure &Height/WeightAge Limits: Age 3 forBlood Pressure, No agelimit for Height/Weight*Optional in 2013 Required in 2014 Content on this page is subject to the Notice on the title page of this presentation.

Changes to Stage 1Vital SignsExclusion: All threeelements not relevantto scope of practiceExclusion: Allows BP tobe separated fromheight/weight*Optional in 2013 Required in 2014 Test of Health Information ExchangeOne test of electronictransmission of keyclinical informationRequirement removedeffective 2013*Effective t on this page is subject to the Notice on the title page of this presentation.16

Changes to Stage 1 E-Copy and OnlineAccessReplacement Objective:Objective: Provide patients withe‐copy of health informationupon requestObjective: Provide electronicaccess to health informationProvide patients the ability toview online, download andtransmit their healthinformation*Required in 2014 Public Health ObjectivesImmunizationsAddition of “except whereprohibited” to all threeReportable LabsSyndromic Surveillance*Effective t on this page is subject to the Notice on the title page of this presentation.17

Stage 2 EP Core MU Objectives1. Use CPOE for more than 60% of medication,laboratory and radiology orders2. eRx for more than 50%3. Record demographics for more than 80%4. Record vital signs for more than 80%5. Record smoking status for more than 80%6. Implement 5 clinical decision support rules drugdrug and drug-allergyContent on this page is subject to the Notice on the title page of this presentation.

Stage 2 EP Core MU Objectives7. Incorporate lab results for more than 55%8. Generate patient list by specific condition9. Use EHR to identify and provide more than 10% withreminders for preventive/follow-up10.Provide online access to health information for morethan 50% with more than 10% actually accessing11.Provide office visit summaries in 24 hours12.Use EHR to identify and provide education resourcesmore than 10%Content on this page is subject to the Notice on the title page of this presentation.

Stage 2 EP Core MU Objectives13. More than 10% of patients send securemessages to their EP14. Medication reconciliation at more than 65% oftransitions of care15. Provide summary of care document for more than65% of transitions of care and referrals with 10%sent electronically16. Successful ongoing transmission ofimmunization data17. Conduct or review security analysis andincorporate into risk management tent on this page is subject to the Notice on the title page of this presentation.

Stage 2 EP Menu Objectives (3 of 5)1. More than 40% of imaging results are accessible throughCertified EHR Technology2. Record family health history for more than 20%3. Successful ongoing transmission of syndromic surveillancedata4. Successful ongoing transmission of cancer caseinformation5. Successful ongoing transmission of data to a Programs/Content on this page is subject to the Notice on the title page of this presentation.

Stage 2 Hospital Core Objectives1. Use CPOE for more than 60% of medication, laboratoryand radiology orders2. Record demographics for more than 80%3. Record vital signs for more than 80%4. Record smoking status for more than 80%5. Implement 5 clinical decision support rules drug-drugand drug-allergy6. Incorporate lab results for more than 55%Content on this page is subject to the Notice on the title page of this presentation.

Stage 2 Hospital Core Objectives7. Generate patient list by specific condition8. EMAR is implemented and used for more than 10% ofmedication orders9. Provide online access to health information for morethan 50% with more than 10% actually accessing10.Use EHR to identify and provide education resourcesmore than 10%11.Med. Rec. at more than 65% of transitions of care4Content on this page is subject to the Notice on the title page of this presentation.

Stage 2 Hospital Core Objectives12.Provide summary of care document for more than 65%of transitions of care and referrals with 10% sentelectronically13.Successful ongoing transmission of immunization data14.Successful ongoing submission of reportablelaboratory results15.Successful ongoing submission of electronic syndromicsurveillance data16.Conduct or review security analysis and incorporate inrisk management processContent on this page is subject to the Notice on the title page of this presentation.4

Stage 2 Hospital Menu Objectives(2 of 4)1. Record indication of advanced directive for morethan 50%2. More than 40% of imaging results are accessiblethrough Certified EHR Technology3. Record family health history for more than 20%4. eRx for more than 10% of discharge prescriptionsContent on this page is subject to the Notice on the title page of this presentation.

Clinical Quality MeasuresChange from Stage 1 to Stage 2:CQMs are no longer a meaningful usecore objective, but reporting CQMs isstill a requirement for meaningful t on this page is subject to the Notice on the title page of this presentation.18

CQM - TimingTime periods for reporting CQMs - NO CHANGEfrom Stage 1 to Stage 2ProviderTypeReportingPeriod for 1styear of MU(Stage 1)Submission Period for1st year of MU (Stage 1)EP90 consecutivedays within thecalendar yearAnytime immediately1 calendar yearfollowing the end of the 90‐ (January 1 day reporting period , but no December 31)later than February 28 of thefollowing calendar year2 months following theend of the EHR reportingperiod (January 1 February 28)EligibleHospital/CAH90 consecutivedays within thefiscal yearAnytime immediately1 fiscal year (Octoberfollowing the end of the 90‐ 1 - September 30)day reporting period , but nolater than November 30 ofthe following fiscal year2 months following theend of the EHR reportingperiod (October 1 November 30)http://www.cms.gov/EHRIncentivePrograms/Content on this page is subject to the Notice on the title page of this presentation.Reporting Periodfor Subsequentyears of MU (2ndyear and beyond)Submission Periodfor Subsequent yearsof MU (2nd year andbeyond)19

CQM - Stage 1 to Stage 2Eligible Professionals3 core OR 3 alt. core CQMsplus3 menu CQMs6 total CQMsEligible Hospitals & CAHs15 total t on this page is subject to the Notice on the title page of this presentation.Eligible Professionals1a) 12 CQMs ( 1 per domain)1b) 11 core 1 menu CQMs2) PQRSGroup Reporting12 total CQMsEligible Hospitals & CAHs24 CQMs ( 1 per domain)24 total CQMs20

CQM Reporting in 2013EPs & Hospitals CQMs will remain the same through 2013 As published in the July 28, 2010 Final Rule Electronic specifications for the CQMs will beupdated Reporting Methods: Attestation 2012 Electronic Reporting Pilots extended to 2013 Medicaid - State-based s/Content on this page is subject to the Notice on the title page of this presentation.21

CQM Reporting for EPs beginning inCY2014EHR Incentive Program OnlyOption 1a: 12 CQMs, 1 from each domainOption 1b: 11 “core” CQMs 1 “menu” CQMMedicaid - State based e-submissionAggregate XML-based format specified by CMSEHR Incentive Program PQRSOption 2: Submit and satisfactorily report CQMsunder PQRS EHR Reporting option using CEHRTRequirements for PQRS are in CY 2012 MedicarePhysician Fee Schedule final rule (76 FR ent on this page is subject to the Notice on the title page of this presentation.22

CQM Reporting for EPsBeginning in CY2014 Group Reporting (3 options):(1) 2 EPs, each with aunique NPI under oneTIN(2) EPs in an ACO(Medicare SharedSavings Program)Submit 12 CQMs from EPmeasures table, 1 from eachdomainSatisfy requirements of MedicareShared Savings Program usingCertified EHR Technology(3) EPs satisfactorilyreporting via PQRSGPRO optionSatisfy requirements of PQRSGPRO option using CertifiedEHR Content on this page is subject to the Notice on the title page of this presentation.23

CQM Reporting for HospitalsBeginning in FY2014 24 CQMs, 1 from each domain Includes 15 CQMs from July 28, 2010 FinalRule Considering instituting a case numberthreshold exemption for some hospitals Reporting Methods Aggregate XML-based format specified byCMS Manner similar to 2012 Medicare EHRIncentive Program Electronic Reporting nt on this page is subject to the Notice on the title page of this presentation.24

EP Payment Adjustments% ADJUSTMENT ASSUMING LESS THAN 75 PERCENT OF EPs AREMEANINGFUL EHR USERS FOR CY 2018 AND SUBSEQUENT YEARSEP is not subject to the paymentadjustment for e‐Rx in 2014EP is subject to the paymentadjustment for e‐Rx in 20142015 2016 2017 2018 2019 2020 99% 98% 97%96% 95%95%98% 98% 97%96% 95%95%% ADJUSTMENT ASSUMING MORE THAN 75 PERCENT OF EPs AREMEANINGFUL EHR USERS FOR CY 2018 AND SUBSEQUENT YEARS2015 2016 2017 2018 2019 2020 EP is not subject to the paymentadjustment for e‐Rx in 2014EP is subject to the paymentadjustment for e‐Rx in t on this page is subject to the Notice on the title page of this presentation.99% 98% 97%97% 97%97%98% 98% 97%97% 97%97%25

EP EHR Reporting PeriodEP who has demonstrated meaningful use in 2011or 2012Payment Adjustment YearFull Year EHR Reporting Period2015 2016 2017 2018 2019 20202013 2014 2015 2016 2017 2019EP who demonstrates meaningful use in 2013 forthe first timePayment Adjustment Year90 day EHR Reporting PeriodFull Year EHR Reporting ent on this page is subject to the Notice on the title page of this presentation.2015 2016 2017 2018 2019 202020132014 2015 2016 2017 201926

EP EHR Reporting PeriodEP who demonstrates meaningful use in 2014 forthe first timePayment Adjustment Year90 day EHR Reporting PeriodFull Year EHR Reporting Period2015 2016 2017 2018 2019 20202014* 20142015 2016 2017 2019*In order to avoid the 2015 payment adjustmentthe EP must attest no later than Oct 1, 2014which means they must begin their 90 day EHRreporting period no later than July 2, t on this page is subject to the Notice on the title page of this presentation.27

EP Hardship ExemptionProposed Exemptions on an application basis Insufficient internet access two years prior to thepayment adjustment year Newly practicing EPs for two years Extreme circumstances such as unexpectedclosures, natural disaster, EHR vendor going outof business, etc.Applications need to be submitted no later thanJuly 1 of year before the payment adjustmentyear; however, earlier submission is Content on this page is subject to the Notice on the title page of this presentation.28

EP Hardship ExemptionOther Possible Exemption Discussed in NPRM Concerned that the combination of 3 barriers wouldconstitute a significant hardship Lack of direct interaction with patients Lack of need for follow-up care for patients Lack of control over the availability of Certified EHRTechnology They do not believe any one of these barriers takenindependently constitutes a significant hardship In their discussions, it was considered whether any specialty maynearly uniformly face all 3 ntent on this page is subject to the Notice on the title page of this presentation.29

CAH Hardship ExemptionProposed Exemptions on an application basis Insufficient internet access for the paymentadjustment year New CAHs for one year after they accept their firstpatient Extreme circumstances such as unexpectedclosures, natural disaster, EHR vendor going out ofbusiness, t on this page is subject to the Notice on the title page of this presentation.36

Medicaid- SpecificChanges Proposed an expanded definition of a Medicaidencounter: To include any encounter with an individual receivingmedical assistance under 1905(b), including Medicaidexpansion populations To permit inclusion of patients on panels seen within24 months instead of just 12 To permit patient volume to be calculated from themost recent 12 months, instead of on the CY To include zero-pay Medicaid ent on this page is subject to the Notice on the title page of this presentation.37

Redefining Certified EHR TechnologyWhy they think it is important 1. Provides greater flexibility2. Clearer definition of CEHRT and its requirements3. Promotes continued progress towards increasedinteroperability requirements4. Reduces regulatory burden (EO 13563)46Content on this page is subject to the Notice on the title page of this presentation.

Certified EHR TechnologyHere’s what it lookslike today 2011-2013Here’s what we areproposing 201447Content on this page is subject to the Notice on the title page of this presentation.

2014 Edition CEHRTBase EHR48Content on this page is subject to the Notice on the title page of this presentation.

2014 Edition CEHRTMU MenuMU CoreBase EHRContent on this page is subject to the Notice on the title page of this presentation.EP/EH/CAH would only need to haveEHR technology with capabilitiescertified for the MU menu setobjectives & measures for the stage ofMU they seek to achieve.EP/EH/CAH would need to have EHRtechnology with capabilities certifiedfor the MU core set objectives &measures for the stage of MU theyseek to achieve unless the EP/EH/CAHcan meet an exclusion.EP/EH/CAH must have EHR technologywith capabilities certified to meet thedefinition of Base EHR.50

Questions and CommentsCMS 3 PI.pdfONC 0 PI.pdfComments period: through May 7 atwww.regulations.gov. Search for “CMS 0044”55Content on this page is subject to the Notice on the title page of this presentation.

Minor changes to Stage 1 of meaningful use Stage 2 of meaningful use New clinical quality measures New clinical quality measure reporting mechanisms . 15.Provide summary of care document for more than 65% of transitions of care and referrals with 10% sent electronically 16.Successful ongoing transmission of