Medicare & Medicaid EHR Incentive Programs

1. Medicare & MedicaidEHR Incentive Programs Proposed Rule for Stage 2 Meaningful Use Requirements http://www.cms.gov/EHRIncentivePrograms/

2. Proposed Rule Everything discussed in this presentation is part ofa notice of proposed rulemaking (NPRM). We encourage anyone interested in Stage 2 of meaningful use to review the NPRM for Stage 2of meaningful use and the NPRM for the 2014certification of EHR technology at CMS Rule: http://www.ofr.gov/OFRUpload/OFRData/2012-04443_PI.pdfONC Rule: http://www.ofr.gov/OFRUpload/OFRData/2012-04430_PI.pdfComments can be made starting March 7 through May 6 at www.regulations.gov http://www.cms.gov/EHRIncentivePrograms/

3. What is Meaningful Use? • Meaningful Use is using certified EHRtechnology 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 receiveincentives 11 http://www.cms.gov/EHRIncentivePrograms/

5. MU and Implementation • Put each objective in the context of the goal Why does CPOE improve quality, safety and efficiency? • Is it measurable? • How can usability and workflow be better? 13 http://www.cms.gov/EHRIncentivePrograms/

6. Stages of Meaningful Use Stage of Meaningful Use 1st 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Year 1 1 1 2 2 3 3 TBD TBD TBD TBD 2011 2 21 2 3 32 3 TBD TBD 3 TBD TBD TBDTBD TBD 1 1 2012 1 2013 2 21 2 3 32 3 TBD TBD 3 TBD 1 1 2014 1 2015 2 21 2 3 32 3 1 1 2016 1 2017 16 http://www.cms.gov/EHRIncentivePrograms/

7. Stage 1 to Stage 2Meaningful Use Eligible Professionals Eligible Professionals 15 core objectives 17 core objectives 5 of 10 menu objectives 3 of 5 menu objectives 20 total objectives 20 total objectives Eligible Hospitals & CAHs Eligible Hospitals & CAHs 14 core objectives 16 core objectives 5 of 10 menu objectives 2 of 4 menu objectives 19 total objectives 18 total objectives 17 http://www.cms.gov/EHRIncentivePrograms/

8. 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 18 http://www.cms.gov/EHRIncentivePrograms/

9. Stage 2 EP Core Objectives 1. Use CPOE for more than 60% of medication, laboratory and radiology orders 2. E-Rx 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 interventions + drug/drug and drug/allergy 7. Incorporate lab results for more than 55% 19 http://www.cms.gov/EHRIncentivePrograms/

10. 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% 20 http://www.cms.gov/EHRIncentivePrograms/

11. Stage 2 EP Core Objectives 13. More than 10% of patients send secure messages to their EP 14. Medication reconciliation at more than 65% of transitions of care 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 immunization data 17. Conduct or review security analysis and incorporate in risk management process 21 http://www.cms.gov/EHRIncentivePrograms/

12. 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 ongoingtransmission of data to a specialized registry 22 http://www.cms.gov/EHRIncentivePrograms/

13. Stage 2 Hospital Core Objectives 1. 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 55% 23 http://www.cms.gov/EHRIncentivePrograms/

14. Stage 2 Hospital Core Objectives 7. Generate patient list by specific condition 8. EMAR is implemented and used for more than 10% of medication orders 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 65% of transitions of care 24 http://www.cms.gov/EHRIncentivePrograms/

15. Stage 2 Hospital Core Objectives 12.Provide summary of care document for more than 65% 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 25 http://www.cms.gov/EHRIncentivePrograms/

16. Stage 2 Hospital Menu Objectives 1. Record indication of advanced directive for more than 50% 2. More than 40% of imaging results are accessible through Certified EHR Technology 3. Record family health history for more than 20% 4. E-Rx for more than 10% of discharge prescriptions 26 http://www.cms.gov/EHRIncentivePrograms/

17. Changes to Stage 1 CPOE Denominator: Unique Denominator: Number of Patient with at least one Orders during the EHR medication in their med list Reporting Period Optional in 2013 Required in 2014+ Vital Signs Age Limits: Age 2 for Age Limits: Age 3 for Blood Pressure & Blood Pressure, No age Height/Weight limit for Height/Weight Optional in 2013 Required in 2014+ 27 http://www.cms.gov/EHRIncentivePrograms/

18. Changes to Stage 1 Vital Signs Exclusion: All three Exclusion: Allows BP to elements not relevant be separated from to scope of practice height/weight Optional in 2013 Required in 2014+ Test of Health Information Exchange One test of electronic transmission of key clinical information Requirement removed effective 2013 Effective 2013 28 http://www.cms.gov/EHRIncentivePrograms/

19. Changes to Stage 1 E-Copy and Online Access Replacement Objective:Provide patients the ability to Objective: Provide patients with e-copy of health information upon request view online, download and transmit their health information Objective: Provide electronicaccess to health information Required in 2014+ Public Health Objectives Immunizations Addition of “except where prohibited” to all three Reportable LabsSyndromic Surveillance Effective 2013 29 http://www.cms.gov/EHRIncentivePrograms/

20. CQM Reporting for HospitalsBeginning in FY2014 • 24 CQMs, ≥1 from each domain • Includes 15 CQMs from July 28, 2010 Final Rule • Considering instituting a case number thresholdexemption for some hospitals • Reporting Methods 1) Aggregate XML-based format specified by CMS 2) Manner similar to 2012 Medicare EHR Incentive Program Electronic Reporting Pilot • Requirements for pilot in CY 2012 OutpatientProspective Payment System (76 FR 74122) 46 http://www.cms.gov/EHRIncentivePrograms/

21. CLINICAL QUALITYMEASURES 30 http://www.cms.gov/EHRIncentivePrograms/

22. Clinical Quality Measures Change from Stage 1 to Stage 2: CQMs are no longer a meaningful usecore objective, but reporting CQMs isstill a requirement for meaningful use. 31 http://www.cms.gov/EHRIncentivePrograms/

23. CQM - Timing Time periods for reporting CQMs - NO CHANGEfrom Stage 1 to Stage 2 Provider Reporting Submission Period for Reporting Period Submission Period Type Period for 1st 1st year of MU (Stage 1) for Subsequent for Subsequent years year of MU years of MU (2nd of MU (2nd year and (Stage 1) year and beyond) beyond) EP 90 consecutive Anytime immediately 1 calendar year 2 months following the days within the following the end of the 90- (January 1 - end of the EHR reporting calendar year day reporting period , but no December 31) period (January 1 - later than February 28 of the February 28) following calendar year Eligible 90 consecutive Anytime immediately 1 fiscal year (October 2 months following the Hospital/ days within the following the end of the 90- 1 - September 30) end of the EHR reporting CAH fiscal year day reporting period , but no period (October 1 - later than November 30 of November 30) the following fiscal year 32 http://www.cms.gov/EHRIncentivePrograms/

24. CQM - Criteria forSelection • Statutory requirements • Implemented within the capacity ofCMS infrastructure • Alignment of Quality MeasurementPrograms 33 http://www.cms.gov/EHRIncentivePrograms/

25. CQM - Criteria forSelection (cont’d) • Measures that address known gaps inquality of care • Measures that address areas of care fordifferent types of eligible professionals • Support CMS and HHS priorities forimproved quality of care based on theNational Quality Strategy and HITPCrecommendations. 34 http://www.cms.gov/EHRIncentivePrograms/

26. 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 programmeasure sets • Coordinating quality measurement stakeholder involvement efforts and opportunities for public input • Identifying ways to minimize multiple submissionrequirements and mechanisms 35 http://www.cms.gov/EHRIncentivePrograms/

27. Alignment Among Programs(cont’d) • 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 36 http://www.cms.gov/EHRIncentivePrograms/

28. CQM Priorities • Making care safer by reducing harmcaused in the delivery of care. • Ensuring that each person and familyare engaged as partners in their care. • Promoting effective communicationand coordination of care. 37 http://www.cms.gov/EHRIncentivePrograms/

29. CQM Priorities (cont’d) • Promoting the most effective prevention andtreatment practices for the leading causes ofmortality, starting with cardiovascular disease. • Working with communities to promote wide useof best practices to enable healthy living. • Making quality care more affordable for individuals, families, employers, and governments by developing and spreading newhealth care delivery models. 38 http://www.cms.gov/EHRIncentivePrograms/

30. CQM - Domains • Patient and Family Engagement • Patient Safety • Care Coordination • Population and Public Health • Efficient Use of Healthcare Resources • Clinical Processes/Effectiveness 39 http://www.cms.gov/EHRIncentivePrograms/

31. CQM - Changes from July 28, 2010 Final Rule 2010 Final Rule 2012 Proposed Rule Eligible Professionals Eligible Professionals 1a) 12 CQMs (≥1 per domain) 1b) 11 core + 1 menu CQMs 3 core OR 3 alt. core CQMs plus 2) PQRS 3 menu CQMs Group Reporting 6 total CQMs 12 total CQMs Eligible Hospitals & CAHs Eligible Hospitals & CAHs 15 total CQMs 24 CQMs (≥1 per domain) 24 total CQMs Align with ONC’s2014 Edition Certification 40 Align with ONC’s2011 Edition Certification http://www.cms.gov/EHRIncentivePrograms/

32. 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: 1) Attestation 2) 2012 Electronic Reporting Pilots extended to 2013 3) Medicaid - State-based e-submission 41 http://www.cms.gov/EHRIncentivePrograms/

33. CQM Reporting for EPsBeginning in CY2014 • EHR Incentive Program Only • Option 1a: 12 CQMs, ≥1 from each domain • Option 1b: 11 “core” CQMs + 1 “menu” CQM • Medicaid - State based e-submission • Aggregate XML-based format specified by CMS • EHR Incentive Program + PQRS • Option 2: Submit and satisfactorily report CQMsunder PQRS EHR Reporting option using CEHRT • Requirements for PQRS are in CY 2012 MedicarePhysician Fee Schedule final rule (76 FR 73314) 42 http://www.cms.gov/EHRIncentivePrograms/

34. CQM Reporting for EPsBeginning in CY2014 • Group Reporting (3 options): (1) ≥ 2 EPs, each with a unique NPI under one Submit 12 CQMs from EPmeasures table, ≥1 from eachdomain TIN (2) EPs in an ACO (Medicare Shared Satisfy requirements of MedicareShared Savings Program usingCertified EHR Technology Savings Program) (3) EPs satisfactorily reporting via PQRS GPRO option Satisfy requirements of PQRSGPRO option using CertifiedEHR Technology 43 http://www.cms.gov/EHRIncentivePrograms/

35. Core CQMs for EPs CMS selected the CQMs for the proposed coreset based on analysis of several factors: • Conditions that contribute to the morbidity andmortality of the most Medicare and Medicaidbeneficiaries • Conditions that represent national public/population health priorities • Conditions that are common to health disparities 44 http://www.cms.gov/EHRIncentivePrograms/

36. Core CQMs for EPs(cont’d) • Conditions that disproportionately drive healthcare costs and could improve with betterquality measurement • Measures that would enable CMS, States, andthe provider community to measure quality ofcare in new dimensions, with a stronger focus onparsimonious measurement • Measures that include patient and/or caregiverengagement 45 http://www.cms.gov/EHRIncentivePrograms/

37. Proposed Rule Standards & Certification Criteria 2014 Edition Steve Posnack, MHS, MS, CISSP Director, Federal Policy Division

38. Agenda • Regulatory History • 2011 vs. 2014 Edition EHR Certification Criteria • Major Highlights - Overview of the 2014 Edition - Redefining CEHRT Proposal - Standards - Clinical Quality Measures - Permanent Certification Program ProposedChanges 9

39. Regulatory History • Standards and Certification Criteria • Certification Programs • Metadata Standards 10

40. Certification Criteria “Editions” S&CC July ‘10 final rule S&CC Feb ‘12 NPRM • § 170.302 (general) • § 170.314 (a) Clinical (n=18) • § 170.304 (ambulatory) (b) Care Coordination (n=6) • § 170.306 (inpatient) (c) CQMs (n=3) Total = 41 + 1 (d) Privacy and Security (n=8+1) (e) Patient Engagement (n=3) (f) Public Health (n=8) (g) Utilization (n=4) Total = 50 +1 11

41. “New” Certification Criteria Ambulatory & Inpatient Inpatient Only Ambulatory Only Electronic medication Electronic Notes Secure messaging administration record Cancer case Imaging (access to) eRx (for discharge) information Transmission of electronic Transmission to Family Health History lab tests and values/results cancer registries to ambulatory providers Amendments View, Download, & Transmit to 3rd party Auto numerator recording Non-%-based measure usereport Safety-enhanced design 12

42. “Revised” Certification Criteria Ambulatory & Inpatient Ambulatory Only Drug-drug, drug-allergy Incorporate lab tests and eRx interaction checks values/results Demographics CQMs Clinical summaries Auditable events andtamper-resistance Problem list Inpatient Only Clinical decision support Audit report(s) Transmission of Patient-specific educationresources Encryption of data at rest reportable lab tests and values/results TOC - Incorporate summarycare record Immunization Information TOC - Create transmit Transmission to summary care record Immunization Registries Clinical information Automated measure reconciliation calculation 13

43. “Unchanged” Certification Criteria Ambulatory & Inpatient CPOE Drug-formulary checks Vital signs, BMI, & growth Medication list charts Smoking status Medication allergy list Patient reminders Patient lists Authentication, access control,& authorization Accounting of disclosures Automatic log-off Advance directives Emergency access Public health surveillance Integrity Immunization information Reportable lab tests and Incorporate lab test results values/results (inpatient only) • Roughly 40% of 2014 Edition Certification Criteria Eligible for “Gap Certification” 14

44. Redefining Certified EHR Technology Why we think it is important… 1. Provides greater flexibility 2. Clearer definition of CEHRT and its requirements 3. Promotes continued progress towards increased interoperability requirements 4. Reduces regulatory burden (EO 13563) 15

45. Certified EHR Technology Here’s what it looks like today… Here’s what we are proposing… 16

46. 2014 Edition CEHRT Base EHR 17

47. Base EHR Certification Criteria Required to Satisfy the Definition of a Base EHR Base EHR Capabilities Certification Criteria Demographics § 170.314(a)(3) Includes patient demographic and clinical Vital Signs § 170.314(a)(4) health information, such as medical history Problem List § 170.314(a)(5) and problem lists Medication List § 170.314(a)(6) Medication Allergy List § 170.314(a)(7) Drug-Drug and Drug-Allergy Interaction Checks § 170.314(a)(2) Clinical Decision Support § 170.314(a)(8) Capacity to provide clinical decision support Capacity to support physician order entry Computerized Provider Order Entry § 170.314(a)(1) Capacity to capture and query information Clinical Quality Measures § 170.314(c)(1) and (2) relevant to health care quality Transitions of Care § 170.314(b)(1) and (2) Capacity to exchange electronic health information with, and integrate such View, Download, and Transmit to 3rd Party § 170.314(e)(1) information from other sources Capacity to protect the confidentiality, integrity, and availability of health Privacy and Security § 170.314(d)(1)-(8) information stored and exchanged 18

48. 2014 Edition CEHRT Easy as 1, 2, 3 + C *C = CQMs EP/EH/CAH would only need to haveEHR technology with capabilities certified for the MU menu set objectives & measures for the stage ofMU they seek to achieve. EP/EH/CAH would need to have EHR technology with capabilities certifiedfor the MU core set objectives &measures for the stage of MU theyseek to achieve unless the EP/EH/CAH can meet an exclusion. Base EHR EP/EH/CAH must have EHR technology with capabilities certified to meet the 1 definition of Base EHR. 19

50. 3 proposed ways to meet CEHRT definition • Complete EHR (ultimate assurance) • EHR Module(s): - Combination of EHR Modules - Single EHR Module • In the case of EHR Modules, the new proposal would make it possible for an eligible provider tohave just enough EHR Technology certified to the2014 Edition EHR certification criteria to meet thedefinition of CEHRT 21