OrHIMA Meaningful Use Stage 2 Presentation
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  • As the ability to integrate and manage grows, so does the data reporting requirements and expanded use of the data. Will support new payment models
  • Delay of Stage 2 timing
  • EMAR tracking of med orders is a new objective Also new is the online access objective
  • All public health reporting requirements moved to core
  • eRx is 10%
  • Radiology orders are added They are now proposing 65% eRx for stage 2 (up from 40%) Problem list, medication list, allergy list collapsed into summary of care objectives after transition (still need to maintain lists to meet new objective) Moved from 1 to 5 CDS, and now CDS interventions based on CQM on which you report
  • Medication reconciliation moves from menu to care HIE objective (includes lists & other fields – demographic, care plans etc.) 10% different organizational affiliation Public health objectives moved from menu to core, however, for EPs syndromic surveillance is still in core
  • 1,2, 4, and 5 are new menu objectives No longer will you be able to select a menu objective that will be excluded from, unless there are no other menu objectives available
  • Aligning the CQM requirements with the National Quality Strategy
  • CMS is soliciting public comment on two mechanisms of electronic CQM reporting: aggregate-level electronic reporting as a group, or through existing quality reporting systems (for Medicare providers). Within these and States’ mechanisms of reporting, CMS has proposed different approaches to CQM reporting that offer flexibility 
  • Medicare payment adjustments are required by statute to take effect in 2015. In this NPRM, CMS proposes that any Medicare EP or hospital that demonstrates meaningful use in 2013 would avoid payment adjustment in 2015. Also, any Medicare provider that first demonstrates meaningful use in 2014 would avoid the penalty if they meet the attestation requirement by July 3, 2014 (eligible hospitals)
  • CMS is also soliciting comment on additional criteria for exceptions.
  • CMS is also soliciting comment on additional criteria for exceptions.
  • While the final rule on Stage 1 required states to establish an appeals process for the Medicaid program, CMS had yet to establish a formal appeals process for the Medicare program. In the Stage 2 NPRM, CMS outlines three types of appeals as illustrated. Note, CMS has proposed some relatively aggressive appeal timeframes.

OrHIMA Meaningful Use Stage 2 Presentation OrHIMA Meaningful Use Stage 2 Presentation Presentation Transcript

  • Oregon Health Information Management AssociationMay 19th2013Brian Ahier
  • IOM Quality Chasm Report“If we want safer, higher-quality care, we will need tohave redesigned systems of care, including the use ofinformation technology to support clinical andadministrative processes.”IOM, Quality Chasm report, 2001
  • What is Meaningful Use?Meaningful Use is using certified EHR technology toImprove quality, safety, efficiency, and reduce healthdisparitiesEngage patients and families in their health careImprove care coordinationImprove population and public healthAll the while maintaining privacy and securityMeaningful Use mandated in law to receive incentives
  • Stage 2 MUACOsStage 3 MUPCMHs3-Part AimRegistries tomanage patientpopulationsTeam based care,case managementEnhanced accessand continuityPrivacy & securityprotectionsCare coordinationPrivacy & securityprotectionsPatient centeredcare coordinationImprovedpopulation healthRegistries fordiseasemanagementEvidenced basedmedicinePatient selfmanagementPrivacy & securityprotectionsCare coordinationStructured datautilizedData utilized toimprove deliveryand outcomesData utilized toimprove deliveryand outcomesPatient informedPatient engaged,communityresourcesStage 1 MUPrivacy & securityprotectionsBasic EHRfunctionality,structured dataImprove accessto informationUse informationto transformMeaningful Use as Building BlocksUtilizetechnology togatherinformation
  • Standards and Certification CriteriaStage 2 Meaningful Use
  • Here’s what it looks like today…Certified EHR Technology
  • Here’s the future…Certified EHR Technology
  • 2014 Edition CEHRT
  • Base EHR
  • 2014 Edition CEHRT EP/EH/CAH would only need tohave EHR technology withcapabilities certified for the MUmenu set objectives & measuresfor the stage of MU they seek toachieve.EP/EH/CAH would need to haveEHR technology with capabilitiescertified for the MU core setobjectives & measures for thestage of MU they seek to achieveunless the EP/EH/CAH can meetan exclusion.EP/EH/CAH must have EHRtechnology with capabilitiescertified to meet the definition ofBase EHR.
  • 2014 Certification Criteria associated with aBase EHR:• Demographics (170.314(a)(3))• Vital signs, BMI, & growth charts(170.314(a)(4))• Problem list (170.314(a)(5))• Medication list (170.314(a)(6))• Medication allergy list (170.314(a)(7))• Drug-drug, drug-allergy interactionchecks (170.314(a)(2))• CPOE (170.314(a)(1))• Clinical decision support (170.314(a)(8))• Clinical quality measures (170.314(c)(1)-(2))• Transition of Care – incorporatesummary care record (170.314(b)(1))• Transition of Care – create andtransmit summary care record(170.314(b)(2))• View, download, and transmit to 3rdParty (170.314(e)(1))• Privacy and Security CC:o Authentication, Access Control, &Authorization (170.314(d)(1))o Auditable events & tamper resistance(170.314(d)(2))o Audit report(s) (170.314(d)(3))o Amendments ( 70.314(d)(4))o Automatic log-off ( 170.314(d)(5))o Emergency access (170.314(d)(6))o Encryption of data at rest (170.314(d)(7))o Integrity (170.314(d)(8))o Accounting of disclosures (optional)(170.314(d)(9))• Automated numerator recording (170.314(g)(1))• Automated measure calculation (170.314(g)(2))• Non-%-based measure use report (170.314(g)(3))• Safety -enhanced design (170.314(g)(4))2014 Certification Criteria associated with MU MenuStage 2:• Imaging (170.314(a)(12))• Transmission to cancer registries (170.314(f)(8))• Cancer case information (170.314(f)(7))• Public health surveillance (170.314(f)(3))• Transmission to public health agencies (170.314(f)(4))• Family health history (170.314(a)(13))• Smoking status (170.314(a)(11))• eRx (170.314(b)(3))• Drug formulary checks (170.314(a)(10))• Patient lists (170.314(a)(14))• Patient reminders (170.314(a)(15))• Patient-specific education resources(170.314(a)(16))• Clinical information reconciliation(170.314(b)(4))• Clinical summaries (170.314(e)(2))• Secure messaging (170.314(e)(3))• Incorporate lab test andresults/values (170.314(b)(5))• Immunization information (170.314(f)(1))• Transmission to immunizationregistries (170.314(f)(2))2014 Certification Criteriaassociated with MU Core Stage 2:1 2 3
  • 3 ways to meetCEHRT definitionComplete EHREHR Module(s) that do just enough:Combination of EHR ModulesSingle EHR Module
  • What’s in the RuleMinor changes to Stage 1 of meaningful useStage 2 of meaningful useNew clinical quality measuresNew clinical quality measure reporting mechanismsAppealsDetails on the Medicare payment adjustmentsMinor Medicare Advantage program changesMinor Medicaid program changes
  • Medicaid EHR Incentive Program - Updates
  • Medicaid encounter definition changes:* A program year for hospitals is the federal fiscalyear and is the calendar year for eligibleprofessionals
  • Patient volume measurementtimeframes
  • Patient volume measurement examples
  • Practices Predominantly
  • Meaningful Use
  • 1099 Changes from the IRSCurrent Process (through Tax Year 2012)1099s are issued to recipients of incentive payments, or the Payee.Revised Process (effective Tax Year 2013)Starting with the 2013 tax year (1099s issued in early 2014), the 1099will be issued to the attesting provider, even if that providerdesignates another entity as the Payee. If the provider has assignedhis/her payment to a third party, it is that provider’s responsibility toissue a 1099 to the third party, and offset the 1099 he/she receives.
  • HospitalsStage 1 to Stage 2 Meaningful Use
  • Stage 2 Hospital Core Objectives1) Use CPOE for more than 60%of medication,laboratory and 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 supportinterventions + drug/drug and drug/allergy6) Incorporate lab results for more than 40%
  • Stage 2 Hospital Core Objectives7) Generate patient list by specific condition8) More than 10% of medication orders are trackedusing EMAR9) Provide online access to health information formore than 50% with more than 10% actuallyaccessing10) Use EHR to identify and provide educationresources more than 10%11) Medication reconciliation at more than 50% oftransitions of care
  • Stage 2 Hospital Core Objectives12) Provide summary of care document for more than50% of transitions of care and referrals with 10%sent electronically13) Successful ongoing transmission ofimmunization data14) Successful ongoing submission of reportablelaboratory results15) Successful ongoing submission of electronicsyndromic surveillance data16) Conduct or review security analysis and incorporatein risk management process
  • Stage 2 Hospital Menu Objectives1) Record indication of advanced directive for morethan 50%2) Incorporate more than 40% of imaging results3) Record family health history for more than 20%4) E-Rx for more than 10% of dischargeprescriptions
  • Stage 2 Transitions of CareEliminated Stage 1 objective of “Exchange of key clinicalinformation”More robust health information exchange for Stage 2“Transition of care” objective
  • Stage 2 Transitions of CareWhat a summary of care must include:Patient name.Procedures.Relevant past diagnoses.Laboratory test results.Vital signs (height, weight, blood pressure, BMI, growth charts).Smoking status.Demographic information (preferred language, gender, race,ethnicity, date of birth).Care plan field, including goals and instructions, andAny additional known care team members beyond the referringor transitioning provider and the receiving provider.Discharge instructions
  • Stage 2 Transitions of CareAND:An up-to-date problem list of current and active diagnosesAn active medication listAn active medication allergy listThe Transitions of Care objective combines elements ofprevious Stage 1 objectives that are no longer beingmeasured individually:Maintain an up-to-date problem listMaintain an active medication listMaintain an active medication allergy listIf there are no problems, meds, or med allergies = Indication in record
  • Transitions of Care – EPs Transitions of Care – EH/CAHsPatient name Patient nameSex SexDate of birth Date of birthRace (OMB Race and Ethnicity) Race (OMB Race and Ethnicity)Ethnicity (OMB Race and Ethnicity) Ethnicity (OMB Race and Ethnicity)Preferred language Preferred languageSmoking status (SNOMED-CT value set) Smoking status (SNOMED-CT value set)Problems (SNOMED-CT value set) Problems (SNOMED-CT value set)Medications (RxNorm) Medications (RxNorm)Medication allergies (RxNorm) Medication allergies (RxNorm)Laboratory test(s) (LOINC) Laboratory test(s) (LOINC)Laboratory value(s)/result(s) Laboratory value(s)/result(s)Vital signs (height, weight, blood pressure, BMI) Vital signs (height, weight, blood pressure, BMI)Care plan field(s), including goals and instructions Care plan field(s), including goals and instructionsProcedures (SNOMED-CT or HCPCS/CPT-4), optional CDT, optional ICD-10-PCS Procedures (SNOMED-CT or HCPCS/CPT-4), optional CDT, optional ICD-10-PCSCare Team Member(s), including the primary care provider of record and any additionalknown care team members beyond the referring or transitioning provider and thereceiving providerCare Team Member(s), including the primary care provider of record and any additionalknown care team members beyond the referring or transitioning provider and thereceiving providerEncounter diagnosis (ICD-10-CM or SNOMED-CT) Encounter diagnosis (ICD-10-CM or SNOMED-CT)Immunizations (HL7 Standard Code Set CVX) Immunizations (HL7 Standard Code Set CVX)Functional status, including activities of daily living and cognitive and disability status Functional status, including activities of daily living and cognitive and disability statusThe following are Elements that are different between EP and EH/CAHReason for referralDischarge instructionsReferring or transitioning providers name and office contact informationCommon MU Data SetData Elements in Common Between EP and EH/CAH in Addition to CommonMU Data SetElements that are different between EP and EH/CAHAll summary of care documentsmust include these data elements
  • Stage 2 Transitions of CareTwo measures, both must be met:1) The EP, eligible hospital or CAH that transitions or referstheir patient to another setting of care or provider of careprovides a summary of care record for more than 50percent of transitions of care and referrals.2) The EP, eligible hospital or CAH that transitions or referstheir patient to another setting of care or provider of careelectronically transmits a summary of care record usingCertified EHR Technology to a recipient with noorganizational affiliation and using a different CertifiedEHR Technology vendor than the sender for more than10 percent of transitions of care and referrals.
  • Stage 2 Transitions of CareWhat this means:Different providers, different organizationsDifferent EHRs, different vendors10%
  • Eligible ProfessionalsStage 1 to Stage 2 Meaningful Use
  • Meaningful Use ConceptsChangesExclusions no longer count to meeting one of the menuobjectivesAll denominators include all patient encounters atoutpatient locations equipped with certified EHRtechnologyNo ChangesNo change in 50% of EP outpatient encounters mustoccur at locations equipped with certified EHRtechnologyMeasure compliance = objective compliance
  • Stage 2 EP Core Objectives1) Use CPOE for more than 60% of medication,laboratory and radiology orders2) E-Rx for more than 65%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 supportinterventions + drug/drug and drug/allergy7) Incorporate lab results for more than 55%
  • Stage 2 EP Core Objectives8) Generate patient list by specific condition9) Use EHR to identify and provide more than 10%with reminders for preventive/follow-up10) Provide online access to health information formore than 50% with more than 10% actuallyaccessing11) Provide office visit summaries in 24 hours12) Use EHR to identify and provide educationresources more than 10%
  • Stage 2 EP Core Objectives13) More than 10% of patients send secure messagesto their EP14) Medication reconciliation at more than 50% oftransitions of care15) Provide summary of care document for more than50% of transitions of care and referrals with 10%sent electronically16) Successful ongoing transmission ofimmunization data17) Conduct or review security analysis and incorporatein risk management process
  • Stage 2 EP Menu Objectives1) More than 40% of imaging results are accessiblethrough Certified EHR Technology2) Record family health history for more than 20%3) Successful ongoing transmission of syndromicsurveillance data4) Successful ongoing transmission of cancer caseinformation5) Successful ongoing transmission of data to aspecialized registry
  • Changes to Stage 1CPOEOptional in 2013 Required in 2014+Vital SignsOptional in 2013 Required in 2014+
  • Changes to Stage 1Effective in 2013Vital SignsOptional in 2013 Required in 2014+
  • Changes to Stage 1PublicHealthEffective in 2013E-Copy and Online AccessRequired in 2014+
  • Clinical Quality MeasuresChange from Stage 1 to Stage 2:CQMs are no longer a meaningful use core objective,but reporting CQMs is still a requirement formeaningful use.Time periods for reporting CQMs – NO CHANGE fromStage 1 to Stage 2
  • Alignment Among ProgramsCMS is committed to aligning qualitymeasurement and reporting among programsAlignment efforts on several fronts: Choosing thesame measures for different program measure setsCoordinating quality measurement stakeholderinvolvement efforts and opportunities for publicinputIdentifying ways to minimize multiplesubmission requirements and mechanisms
  • Alignment Among ProgramsLessen provider burdenHarmonize with data exchange prioritiesSupport primary goal of all CMS qualitymeasurement programsTransforming our health care system to provide:Higher quality care Better health outcomes Lower cost through improvement
  • CQM - DomainsPatient and Family EngagementPatient SafetyCare CoordinationPopulation and Public HealthEfficient Use of Healthcare ResourcesClinical Processes/Effectiveness
  • CQM - Stage 1 to Stage 2HospitalsEligible Professionals
  • CQM Reporting Beginning in FY201424 CQMs, ≥1 from each domainIncludes 15 CQMs from July 28, 2010 Final RuleConsidering instituting a case numberthreshold exemption for some hospitalsReporting MethodsAggregate XML-based format specified by CMSManner similar to 2012 Medicare EHR IncentiveProgram Electronic Reporting Pilot
  • Payment AdjustmentsThe HITECH Act stipulates that for Medicare EP,subsection (d) hospitals and CAHs a paymentadjustment applies if they are not a meaningful EHRuser.An EP, subsection (d) hospital or CAH becomes ameaningful EHR user when they successfully attest tomeaningful use under either the Medicare orMedicaid EHR incentive programAs adopt, implement and upgrade does not constitutemeaningful use, a provider receiving a Medicaidincentive for AIU would still be subject to theMedicare payment adjustment.
  • Eligible Professional Payment Adjustments% Adjustment assuming less than 75 percent of EPs aremeaningful EHR users for CY 2018 and subsequent yearsPayment Adjustment Year 2015 2016 2017 2018 2019 2020+EP is not subject to thepayment adjustment for e-Rx in201499% 98% 97% 96% 95% 95%EP is subject to the paymentadjustment for e-Rx in 201498% 98% 97% 96% 95% 95%% Adjustment assuming more than 75 percent of EPsare meaningful EHR users for CY 2018 and subsequentyearsPayment Adjustment Year 2015 2016 2017 2018 2019 2020+EP is not subject to thepayment adjustment for e-Rx in201499% 98% 97% 97% 97% 97%EP is subject to the paymentadjustment for e-Rx in 201498% 98% 97% 97% 97% 97%
  • Eligible Professional EHR Reporting PeriodEP who has demonstrated meaningful use in 2011 or 2012Payment Adjustment Year 2015 2016 2017 2018 2019 2020Full Year EHR Reporting Period 2013 2014 2015 2016 2017 2018Payment Adjustment Year 2015 2016 2017 2018 2019 202090 Day Reporting Period 2013Full Year EHR Reporting Period 2014 2015 2016 2017 2018EP who has demonstrated meaningful use in 2013 forthe first time
  • Eligible Professional EHR Reporting PeriodPayment Adjustment Year 2015 2016 2017 2018 2019 202090 Day Reporting Period 2014* 2014Full Year EHR Reporting Period 2015 2016 2017 2018EP who has demonstrated meaningful use in 2014 forthe first time*In order to avoid the 2015 payment adjustment theEP must attest no later than Oct 1, 2014 whichmeans they must begin their 90 day EHR reportingperiod no later than July 2, 2014
  • EP Hardship ExemptionExemptions on an application basisInsufficient internet access two years prior to thepayment adjustment yearNewly practicing EPs for two yearsExtreme circumstances such as unexpected closures,natural disaster, EHR vendor going out of business,etc.Applications need to be submitted no later than July 1 ofyear before the payment adjustment year; however,we encourage earlier submission
  • EP Hardship ExemptionOther Possible Exemption Discussed in the ruleConcerned that the combination of 3 barrierswould constitute 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Any one of these barriers taken independentlydoes not constitute a significant hardshipDiscussion considers whether any specialty maynearly uniformly face all 3 barriers
  • Subsection (d) Hospital PaymentAdjustments% Decrease in the Percentage Increase to the IPPSPayment Rate that the hospital would otherwise receivefor that yearFor example if the increase to IPPS for 2015 was 2% thena hospital subject to the payment adjustment wouldonly receive a 1.5% increase2015 2016 2017 2018 2019 2020+% Decrease 25% 50% 75% 75% 75% 75%
  • Subsection (d) Hospital EHR Reporting PeriodHospital who has demonstrated meaningful use in 2011or 2012 (fiscal years)Hospital who demonstrates meaningful use in 2013 forthe first timePayment Adjustment Year 2015 2016 2017 2018 2019 2020Full Year EHR Reporting Period 2013 2014 2015 2016 2017 2019Payment Adjustment Year 2015 2016 2017 2018 2019 202090 Day Reporting Period 2013Full Year EHR Reporting Period 2013 2014 2015 2016 2017 2019
  • Subsection (d) Hospital EHR Reporting PeriodHospital who demonstrates meaningful use in 2014 forthe first time*In order to avoid the 2015 payment adjustment thehospital must attest no later than July 1, 2014 whichmeans they must begin their 90 day EHR reportingperiod no later than April 1, 2014Payment Adjustment Year 2015 2016 2017 2018 2019 202090 Day Reporting Period 2014* 2014Full Year EHR Reporting Period 2015 2016 2017 2019
  • Subsection (d) Hospital Hardship ExemptionExemptions on an application basis• Insufficient internet access two years prior to thepayment adjustment year• New hospitals for at least 1 full year cost reportingperiod• Extreme circumstances such as unexpected closures,natural disaster, EHR vendor going out of business,etc.Applications need to be submitted no later than April 1of year before the payment adjustment year; however,earlier submission is encouraged
  • Critical Access Hospital (CAH) Payment AdjustmentsApplicable % of reasonable costs reimbursementwhich absent payment adjustments is 101%2015 2016 2017 2018 2019 2020+% of reasonablecosts100.66% 100.33% 100% 100% 100% 100%
  • CAH Hardship ExemptionExemptions 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 unexpected closures,natural disaster, EHR vendor going out of business,etc.
  • AppealsTypesEligibility Appeals: Provider has met all the programrequirements and should have received an incentive butcould not because of a circumstance outside theprovider’s controlMeaningful Use Appeals: Provider has shown that he orshe used certified EHR technology and met themeaningful use objectives and associated measures aftera successful attestation.Incentive Payment Appeals: (Medicare EPs only)Provider has shown that he or she provided claims datanot used in determining the incentive payment amount
  • AppealsDeadlinesEligibility – 30 days after the 2 month period followingthe payment yearMeaningful Use - 30 days from the date of the demandletter or other finding that could result in therecoupment of an EHR incentive paymentIncentive Payment - 60 days from the date theincentive payment was issued or 60 days from anyFederal determination that the incentive paymentcalculation was incorrect
  • AppealsProcessProvider must present all relevant issues at the time of the initialfiling of an appealAn appeal in considered inchoate or premature if CMS still has anopportunity to resolve the issue. A provider is still permitted to filethe same appeal again if the issue is not resolved by the programdeadlinesAppeals have two levels: (1) an informal review that is completedwithin 90 days from the date of filing, and (2) a reconsiderationreview that can be requested if the provider does not prevail in theinformal review.Providers dissatisfied can file a request for reconsideration withcomments and documentation supporting the reconsiderationwithin 15 days of the initial determination
  • Appeals Process
  • Medicaid- Specific ChangesAn expanded definition of a Medicaid encounter:To include any encounter with an individual receivingmedical assistance under 1905(b), including Medicaidexpansion populationsTo permit inclusion of patients on panels seen within 24months instead of just 12To permit patient volume to be calculated from the mostrecent 12 months, instead of on the CYTo include zero-pay Medicaid claims