orhima meaningful use stage 2 presentation

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Oregon Health Information Management Association May 19 th 2013 Brian Ahier

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Page 1: OrHIMA Meaningful Use Stage 2 Presentation

Oregon Health Information Management Association

May 19th 2013

Brian Ahier

Page 2: OrHIMA Meaningful Use Stage 2 Presentation

IOM Quality Chasm Report

“If we want safer, higher-quality care, we will need to have redesigned systems of care, including the use of information technology to support clinical and administrative processes.”IOM, Quality Chasm report, 2001

Page 3: OrHIMA Meaningful Use Stage 2 Presentation

What is Meaningful Use? Meaningful Use is using certified EHR

technology toImprove 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

Meaningful Use mandated in law to receive incentives

Page 4: OrHIMA Meaningful Use Stage 2 Presentation

Stage 2 MUACOs

Stage 3 MUPCMHs

3-Part Aim

Registries to manage patient

populations

Team based care, case management

Enhanced access and continuity

Privacy & security protections

Care coordination

Privacy & security protections

Patient centered care coordination

Improved population health

Registries for disease

management

Evidenced based medicine

Patient self management

Privacy & security protections

Care coordination

Structured data utilized

Data utilized to improve delivery

and outcomes

Data utilized to improve delivery

and outcomes

Patient informed

Patient engaged, community resources

Stage 1 MU

Privacy & security protections

Basic EHR functionality,

structured data

Improve access to information

Use information to transform

Meaningful Use as Building Blocks

Utilize technology to

gather information

Page 5: OrHIMA Meaningful Use Stage 2 Presentation

Standards and Certification Criteria

Stage 2 Meaningful Use

Page 6: OrHIMA Meaningful Use Stage 2 Presentation

Here’s what it looks like today…

Certified EHR Technology

Page 7: OrHIMA Meaningful Use Stage 2 Presentation

Here’s the future…

Certified EHR Technology

Page 8: OrHIMA Meaningful Use Stage 2 Presentation

2014 Edition CEHRT

Page 9: OrHIMA Meaningful Use Stage 2 Presentation

Base EHR

Page 10: OrHIMA Meaningful Use Stage 2 Presentation

2014 Edition CEHRTEP/EH/CAH would only need to have EHR technology with capabilities certified for the MU menu set objectives & measures for the stage of MU they seek to achieve.EP/EH/CAH would need to have EHR technology with capabilities certified for the MU core set objectives & measures for the stage of MU they seek to achieve unless the EP/EH/CAH can meet an exclusion.EP/EH/CAH must have EHR technology with capabilities certified to meet the definition of Base EHR.

Page 11: OrHIMA Meaningful Use Stage 2 Presentation

2014 Certification Criteria associated with a Base 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 interaction

checks (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 – incorporate

summary care record (170.314(b)(1))• Transition of Care – create and

transmit summary care record (170.314(b)(2))

• View, download, and transmit to 3rd Party (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 Menu Stage 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 and

results/values (170.314(b)(5))• Immunization information (170.314(f)

(1))• Transmission to immunization

registries (170.314(f)(2))

2014 Certification Criteria associated with MU Core Stage 2:

1 2 3

Page 12: OrHIMA Meaningful Use Stage 2 Presentation

3 ways to meet CEHRT definitionComplete EHREHR Module(s) that do just enough:Combination of EHR ModulesSingle EHR Module

Page 13: OrHIMA Meaningful Use Stage 2 Presentation

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

Page 14: OrHIMA Meaningful Use Stage 2 Presentation

Medicaid EHR Incentive Program - Updates

Page 15: OrHIMA Meaningful Use Stage 2 Presentation

Medicaid encounter definition changes:

* A program year for hospitals is the federal fiscal year and is the calendar year for eligible professionals

Page 16: OrHIMA Meaningful Use Stage 2 Presentation

Patient volume measurement timeframes

Page 17: OrHIMA Meaningful Use Stage 2 Presentation

Patient volume measurement examples

Page 18: OrHIMA Meaningful Use Stage 2 Presentation

Practices Predominantly

Page 19: OrHIMA Meaningful Use Stage 2 Presentation

Meaningful Use

Page 20: OrHIMA Meaningful Use Stage 2 Presentation

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 1099 will be issued to the attesting provider, even if that provider designates another entity as the Payee. If the provider has assigned his/her payment to a third party, it is that provider’s responsibility to issue a 1099 to the third party, and offset the 1099 he/she receives.

Page 21: OrHIMA Meaningful Use Stage 2 Presentation

HospitalsStage 1 to Stage 2 Meaningful Use

Page 22: OrHIMA Meaningful Use Stage 2 Presentation

Stage 2 Hospital Core Objectives1) Use CPOE for more than 60%of

medication, laboratory and radiology orders

2) 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

interventions + drug/drug and drug/allergy

6) Incorporate lab results for more than 40%

Page 23: OrHIMA Meaningful Use Stage 2 Presentation

Stage 2 Hospital Core Objectives7) Generate patient list by specific condition8) More than 10% of medication orders are

tracked using EMAR 9) Provide online access to health

information for more than 50% with more than 10% actually accessing

10)Use EHR to identify and provide education resources more than 10%

11)Medication reconciliation at more than 50% of transitions of care

Page 24: OrHIMA Meaningful Use Stage 2 Presentation

Stage 2 Hospital Core Objectives12)Provide summary of care document for

more than 50% of transitions of care and referrals with 10% sent electronically

13)Successful ongoing transmission of immunization data

14)Successful ongoing submission of reportable laboratory results

15)Successful ongoing submission of electronic syndromic surveillance data

16)Conduct or review security analysis and incorporate in risk management process

Page 25: OrHIMA Meaningful Use Stage 2 Presentation

Stage 2 Hospital Menu Objectives

1) Record indication of advanced directive for more than 50%

2) Incorporate more than 40% of imaging results

3) Record family health history for more than 20%

4) E-Rx for more than 10% of discharge prescriptions

Page 26: OrHIMA Meaningful Use Stage 2 Presentation

Stage 2 Transitions of CareEliminated Stage 1 objective of “Exchange of

key clinical information”

More robust health information exchange for Stage 2 “Transition of care” objective

Page 27: OrHIMA Meaningful Use Stage 2 Presentation

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, andAny additional known care team members beyond the

referring or transitioning provider and the receiving provider.

Discharge instructions

Page 28: OrHIMA Meaningful Use Stage 2 Presentation

Stage 2 Transitions of CareAND:An up-to-date problem list of current and active

diagnosesAn active medication listAn active medication allergy list

The Transitions of Care objective combines elements of previous Stage 1 objectives that are no longer being measured individually:

Maintain an up-to-date problem listMaintain an active medication listMaintain an active medication allergy list

If there are no problems, meds, or med allergies = Indication in record

Page 29: OrHIMA Meaningful Use Stage 2 Presentation

Transitions of Care – EPs Transitions of Care – EH/CAHsPatient name Patient name

Sex Sex

Date of birth Date of birth

Race (OMB Race and Ethnicity) Race (OMB Race and Ethnicity)

Ethnicity (OMB Race and Ethnicity) Ethnicity (OMB Race and Ethnicity)

Preferred language Preferred language

Smoking 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 instructions

Procedures (SNOMED-CT or HCPCS/CPT-4), optional CDT, optional ICD-10-PCS Procedures (SNOMED-CT or HCPCS/CPT-4), optional CDT, optional ICD-10-PCS

Care Team Member(s), including the primary care provider of record and any additional known care team members beyond the referring or transitioning provider and the receiving provider

Care Team Member(s), including the primary care provider of record and any additional known care team members beyond the referring or transitioning provider and the receiving provider

Encounter 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 status

The following are Elements that are different between EP and EH/CAHReason for referral Discharge instructions

Referring or transitioning provider's name and office contact information

Common MU Data Set

Data Elements in Common Between EP and EH/CAH in Addition to Common MU Data Set

Elements that are different between EP and EH/CAH

All summary of care documents must include these data elements

Page 30: OrHIMA Meaningful Use Stage 2 Presentation

Stage 2 Transitions of CareTwo measures, both must be met: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 percent 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 electronically transmits a summary of care record using Certified EHR Technology to a recipient with no organizational affiliation and using a different Certified EHR Technology vendor than the sender for more than 10 percent of transitions of care and referrals.

Page 31: OrHIMA Meaningful Use Stage 2 Presentation

Stage 2 Transitions of CareWhat this means:

Different providers, different organizations

Different EHRs, different vendors

10%

Page 32: OrHIMA Meaningful Use Stage 2 Presentation

Eligible ProfessionalsStage 1 to Stage 2 Meaningful Use

Page 33: OrHIMA Meaningful Use Stage 2 Presentation

Meaningful Use Concepts Changes Exclusions no longer count to meeting one of

the menu objectives All denominators include all patient encounters

at outpatient locations equipped with certified EHR technology

No Changes No change in 50% of EP outpatient encounters

must occur at locations equipped with certified EHR technology

Measure compliance = objective compliance

Page 34: OrHIMA Meaningful Use Stage 2 Presentation

Stage 2 EP Core Objectives

1) Use CPOE for more than 60% of medication, laboratory and radiology orders

2) 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 support

interventions + drug/drug and drug/allergy

7) Incorporate lab results for more than 55%

Page 35: OrHIMA Meaningful Use Stage 2 Presentation

Stage 2 EP Core Objectives

8) Generate patient list by specific condition 9) Use EHR to identify and provide more than

10% with reminders for preventive/follow-up

10)Provide online access to health information for more than 50% with more than 10% actually accessing

11)Provide office visit summaries in 24 hours 12)Use EHR to identify and provide education

resources more than 10%

Page 36: OrHIMA Meaningful Use Stage 2 Presentation

Stage 2 EP Core Objectives

13)More than 10% of patients send secure messages to their EP

14)Medication reconciliation at more than 50% of transitions of care

15)Provide summary of care document for more than 50% of transitions of care and referrals with 10% sent electronically

16)Successful ongoing transmission of immunization data

17)Conduct or review security analysis and incorporate in risk management process

Page 37: OrHIMA Meaningful Use Stage 2 Presentation

Stage 2 EP Menu Objectives

1) More than 40% of imaging results are accessible through Certified EHR Technology

2) Record family health history for more than 20%

3) Successful ongoing transmission of syndromic surveillance data

4) Successful ongoing transmission of cancer case information

5) Successful ongoing transmission of data to a specialized registry

Page 38: OrHIMA Meaningful Use Stage 2 Presentation

Changes to Stage 1CPOE

Optional in 2013 Required in 2014+

Vital Signs

Optional in 2013 Required in 2014+

Page 39: OrHIMA Meaningful Use Stage 2 Presentation

Changes to Stage 1

Effective in 2013

Vital Signs

Optional in 2013 Required in 2014+

Page 40: OrHIMA Meaningful Use Stage 2 Presentation

Changes to Stage 1PublicHealth

Effective in 2013E-Copy and Online Access

Required in 2014+

Page 41: OrHIMA Meaningful Use Stage 2 Presentation

Clinical Quality Measures Change from Stage 1 to Stage 2: CQMs are no longer a meaningful use core objective, but reporting CQMs is still a requirement for meaningful use.Time periods for reporting CQMs – NO CHANGE from Stage 1 to Stage 2

Page 42: OrHIMA Meaningful Use Stage 2 Presentation

Alignment Among Programs CMS is committed to aligning quality

measurement and reporting among programs Alignment efforts on several fronts: Choosing

the same measures for different program measure sets Coordinating quality measurement

stakeholder involvement efforts and opportunities for public input

Identifying ways to minimize multiple submission requirements and mechanisms

Page 43: OrHIMA Meaningful Use Stage 2 Presentation

Alignment Among Programs Lessen provider burden Harmonize with data exchange

priorities Support primary goal of all CMS

quality measurement programsTransforming our health care system to

provide: Higher quality careBetter health outcomes Lower cost through improvement

Page 44: OrHIMA Meaningful Use Stage 2 Presentation

CQM - Domains Patient and Family Engagement Patient Safety Care Coordination Population and Public Health Efficient Use of Healthcare Resources

Clinical Processes/Effectiveness

Page 45: OrHIMA Meaningful Use Stage 2 Presentation

CQM - Stage 1 to Stage 2Hospitals

Eligible Professionals

Page 46: OrHIMA Meaningful Use Stage 2 Presentation

CQM Reporting Beginning in FY201424 CQMs, ≥1 from each domain

Includes 15 CQMs from July 28, 2010 Final Rule

Considering instituting a case number threshold exemption for some hospitals

Reporting MethodsAggregate XML-based format specified by

CMS Manner similar to 2012 Medicare EHR

Incentive Program Electronic Reporting Pilot

Page 47: OrHIMA Meaningful Use Stage 2 Presentation

Payment AdjustmentsThe HITECH Act stipulates that for Medicare

EP, subsection (d) hospitals and CAHs a payment adjustment applies if they are not a meaningful EHR user.

An EP, subsection (d) hospital or CAH becomes a meaningful EHR user when they successfully attest to meaningful use under either the Medicare or Medicaid EHR incentive program

As adopt, implement and upgrade does not constitute meaningful use, a provider receiving a Medicaid incentive for AIU would still be subject to the Medicare payment adjustment.

Page 48: OrHIMA Meaningful Use Stage 2 Presentation

Eligible Professional Payment Adjustments% Adjustment assuming less than 75 percent of EPs are meaningful EHR users for CY 2018 and subsequent years

Payment Adjustment Year

2015 2016 2017 2018 2019 2020+

EP is not subject to the payment adjustment for e-Rx in 2014

99% 98% 97% 96% 95% 95%

EP is subject to the payment adjustment for e-Rx in 2014

98% 98% 97% 96% 95% 95%% Adjustment assuming more than 75 percent of EPs are meaningful EHR users for CY 2018 and subsequent years Payment Adjustment

Year2015 2016 2017 2018 2019 2020

+

EP is not subject to the payment adjustment for e-Rx in 2014

99% 98% 97% 97% 97% 97%

EP is subject to the payment adjustment for e-Rx in 2014

98% 98% 97% 97% 97% 97%

Page 49: OrHIMA Meaningful Use Stage 2 Presentation

Eligible Professional EHR Reporting PeriodEP who has demonstrated meaningful use in 2011 or 2012

Payment Adjustment Year

2015 2016 2017 2018 2019 2020

Full Year EHR Reporting Period

2013 2014 2015 2016 2017 2018

Payment Adjustment Year

2015 2016 2017 2018 2019 2020

90 Day Reporting Period 2013

Full Year EHR Reporting Period

2014 2015 2016 2017 2018

EP who has demonstrated meaningful use in 2013 for the first time

Page 50: OrHIMA Meaningful Use Stage 2 Presentation

Eligible Professional EHR Reporting Period

Payment Adjustment Year

2015 2016 2017 2018 2019 2020

90 Day Reporting Period 2014* 2014

Full Year EHR Reporting Period

2015 2016 2017 2018

EP who has demonstrated meaningful use in 2014 for the first time

*In order to avoid the 2015 payment adjustment the EP must attest no later than Oct 1, 2014 which means they must begin their 90 day EHR reporting period no later than July 2, 2014

Page 51: OrHIMA Meaningful Use Stage 2 Presentation

EP Hardship ExemptionExemptions on an application basis Insufficient internet access two years prior to

the payment 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 of year before the payment adjustment year; however, we encourage earlier submission

Page 52: OrHIMA Meaningful Use Stage 2 Presentation

EP Hardship ExemptionOther Possible Exemption Discussed in the ruleConcerned that the combination of 3 barriers

would constitute a significant hardshipLack of direct interaction with patients Lack of need for follow-up care for patients Lack of control over the availability of Certified EHR

Technology Any one of these barriers taken independently

does not constitute a significant hardship Discussion considers whether any specialty

may nearly uniformly face all 3 barriers

Page 53: OrHIMA Meaningful Use Stage 2 Presentation

Subsection (d) Hospital Payment Adjustments% Decrease in the Percentage Increase to the IPPS Payment Rate that the hospital would otherwise receive for that year

For example if the increase to IPPS for 2015 was 2% then a hospital subject to the payment adjustment would only receive a 1.5% increase

2015 2016 2017 2018 2019 2020+

% Decrease 25% 50% 75% 75% 75% 75%

Page 54: OrHIMA Meaningful Use Stage 2 Presentation

Subsection (d) Hospital EHR Reporting PeriodHospital who has demonstrated meaningful use in 2011 or 2012 (fiscal years)

Hospital who demonstrates meaningful use in 2013 for the first time

Payment Adjustment Year

2015 2016 2017 2018 2019 2020

Full Year EHR Reporting Period

2013 2014 2015 2016 2017 2019

Payment Adjustment Year

2015 2016 2017 2018 2019 2020

90 Day Reporting Period 2013

Full Year EHR Reporting Period

2013 2014 2015 2016 2017 2019

Page 55: OrHIMA Meaningful Use Stage 2 Presentation

Subsection (d) Hospital EHR Reporting PeriodHospital who demonstrates meaningful use in 2014 for the first time

*In order to avoid the 2015 payment adjustment the hospital must attest no later than July 1, 2014 which means they must begin their 90 day EHR reporting period no later than April 1, 2014

Payment Adjustment Year

2015 2016 2017 2018 2019 2020

90 Day Reporting Period 2014* 2014

Full Year EHR Reporting Period

2015 2016 2017 2019

Page 56: OrHIMA Meaningful Use Stage 2 Presentation

Subsection (d) Hospital Hardship ExemptionExemptions on an application basis• Insufficient internet access two years prior to

the payment adjustment year• New hospitals for at least 1 full year cost

reporting period• Extreme circumstances such as unexpected

closures, natural disaster, EHR vendor going out of business, etc.

Applications need to be submitted no later than April 1 of year before the payment adjustment year; however, earlier submission is encouraged

Page 57: OrHIMA Meaningful Use Stage 2 Presentation

Critical Access Hospital (CAH) Payment AdjustmentsApplicable % of reasonable costs reimbursement which absent payment adjustments is 101%

2015 2016 2017 2018 2019 2020+

% of reasonable costs

100.66%

100.33%

100% 100% 100% 100%

Page 58: OrHIMA Meaningful Use Stage 2 Presentation

CAH Hardship ExemptionExemptions on an application basisInsufficient internet access for the payment

adjustment yearNew CAHs for one year after they accept

their first patientExtreme circumstances such as unexpected

closures, natural disaster, EHR vendor going out of business, etc.

Page 59: OrHIMA Meaningful Use Stage 2 Presentation

AppealsTypesEligibility Appeals: Provider has met all the program

requirements and should have received an incentive but could not because of a circumstance outside the provider’s control

Meaningful Use Appeals: Provider has shown that he or she used certified EHR technology and met the meaningful use objectives and associated measures after a successful attestation.

Incentive Payment Appeals: (Medicare EPs only) Provider has shown that he or she provided claims data not used in determining the incentive payment amount

Page 60: OrHIMA Meaningful Use Stage 2 Presentation

AppealsDeadlines Eligibility – 30 days after the 2 month period

following the payment year Meaningful Use - 30 days from the date of the

demand letter or other finding that could result in the recoupment of an EHR incentive payment

Incentive Payment - 60 days from the date the incentive payment was issued or 60 days from any Federal determination that the incentive payment calculation was incorrect

Page 61: OrHIMA Meaningful Use Stage 2 Presentation

AppealsProcessProvider must present all relevant issues at the time of

the initial filing of an appeal An appeal in considered inchoate or premature if CMS

still has an opportunity to resolve the issue. A provider is still permitted to file the same appeal again if the issue is not resolved by the program deadlines

Appeals have two levels: (1) an informal review that is completed within 90 days from the date of filing, and (2) a reconsideration review that can be requested if the provider does not prevail in the informal review.

Providers dissatisfied can file a request for reconsideration with comments and documentation supporting the reconsideration within 15 days of the initial determination

Page 62: OrHIMA Meaningful Use Stage 2 Presentation

Appeals Process

Page 63: OrHIMA Meaningful Use Stage 2 Presentation

Medicaid- Specific Changes An expanded definition of a Medicaid encounter: To include any encounter with an individual

receiving medical assistance under 1905(b), including Medicaid expansion populations

To permit inclusion of patients on panels seen within 24 months instead of just 12

To permit patient volume to be calculated from the most recent 12 months, instead of on the CY

To include zero-pay Medicaid claims