Final Meaningful Use Rules Add Short-Term Flexibility

Transcription

1 Final Meaningful Use Rules Add Short-Term Flexibility Allison W. Shuren, Vernessa T. Pollard, Jennifer B. Madsen MPH, and Alexander R. Cohen November 2015 INTRODUCTION On October 16, the Centers for Medicare and Medicaid Services (CMS) released its Final Rule 1 for the Medicare and Medicaid Electronic Health Record (EHR) Incentive Program (also known as Meaningful Use). The Final Rule addresses two separate proposed rules: Stage 2 regulations proposed on April 15, and Stage 3 regulations proposed on March 30, The Stage 3 Rule is described in our Advisory here. Stakeholders may submit comments on certain sections of the Final Rule until December 15, In the Final Rule, CMS intends to creat[e] consistency in the policies for the current program in 2015 through 2017 and for 2018 and subsequent years; and we have established a clear vision of how current participation will assist in meeting our long-term delivery system reform goals. We believe this sustained consistency in policy will support the planning and development for MIPS and the future use of EHR across a multitude of healthcare providers. 4 In March 2014, the Government Accountability Office (GAO) reported that while participation in Meaningful Use had increased substantially from 2011 to 2012, the agency suffered from the lack of a comprehensive strategy to ensure the department can reliably use the clinical quality measures collected in certified EHRs to improve quality. 5 In November 2014, CMS announced that fewer than 17 percent of eligible hospitals had met the Stage 2 requirements for Meaningful Use, and adoption of EHRs by eligible professionals (EPs) has generally lagged behind hospitals. 6 In 2015, both the House and Senate held numerous hearings on topics such as the interoperability of EHRs and the practice of 1 80 Fed. Reg (Oct. 16, 2015) Fed. Reg (Apr. 15, 2015) Fed. Reg (March 30, 2015) Fed. Reg. at This advisory uses the term providers to mean EPs, eligible hospitals, and CAHs consistent with the Final Rule. 5 Electronic Health Record Programs: Participation Has Increased, but Action Needed to Achieve Goals, Including Improved Quality of Care. Government Accountability Office, GAO , March 6, American Medical Association press release, Nov. 4, 2014, available here. 1

2 information blocking. 7 The level of specificity that should be included in federal standards for health information exchange and the cost of establishing interfaces that support interoperability are key issues of concern to many stakeholders. Changes to both of the proposed rules were also needed to conform the EHR Incentive Program with legislation that Congress enacted on April 14, The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) revamps Medicare s payments for physician services by: (1) ending the prior payment formula, which generated year-over-year payment cuts; (2) establishing a new payment system that includes two pathways, the Merit Based Incentive Pay System (MIPS) and Alternative Payment Models (APMs), both of which require use of EHRs; and (3) gives physicians financial incentives to join APMs as an alternative to fee-for-service. This Advisory discusses the evolution of the Meaningful Use Program and the importance of the Final Rule for providers, hospitals, and health IT developers today and in the future. CMS Stage 2 requirements for are important for providers seeking to avoid payment cuts and prepare for the new physician payment system. The Stage 3 requirements, which will be optional in 2017 and mandatory starting in 2018, will directly impact physician payment comprising 25 percent of the composite score that determines payment under one of the new payment models. Attached to this Advisory are two charts highlighting the final objectives and measures for Stages 2 and 3 of the Meaningful Use Program, and changes from the proposed rules. I. THE EVOLUTION OF MEANINGFUL USE The Meaningful Use Program started as an incentive program, became a penalty program, and will soon be a core part of all physician payment. The Health Information Technology for Economic and Clinical Health Act (HITECH Act) was passed as part of the American Recovery and Reinvestment Act of The HITECH Act established the Medicare and Medicaid EHR Incentive Programs, which provided for incentive payments and downward payment adjustments for EPs, eligible hospitals, and critical access hospitals to promote the meaningful use (MU) of interoperable health information technology (HIT). 7 and 8 P.L

3 A. The EHR Incentive Program Incentive payments were available to physicians who successfully demonstrated meaningful use of certified EHR technology (CEHRT) beginning in 2011, with the last payment year being Incentive payments were capped at five consecutive years. The last year to begin participation and receive an incentive payment was The maximum incentive payment amount for five consecutive years of successful participation was US$43, B. Adjustments for Failing to Attest Started in January 1, 2015 The Meaningful Use Program started operating as a penalty program for most providers on January 1, Providers who decided to forego incentive payments started to pay closer attention when Medicare and Medicaid payments were cut by 1 percent. Downward adjustments increase to 2 percent in 2016, and 3 percent in Eligible hospitals and critical access hospitals (CAHs) who were not meaningful users faced Medicare payment adjustments of up to 25 percent of the increase to the Inpatient Prospective Payment System (IPPS) payment rate starting on October 1, Although CMS provides hardship exceptions for infrastructure, newly practicing EPs, unforeseen circumstances, and a few other situations, these do not insulate most providers from being subject to payment adjustments. C. Stage 3 and the New Physician Payment Systems The Stage 3 requirements, discussed in further detail below, will have a soft-launch in Providers may begin attesting to Stage 3 in 2017, but are not required to. CMS incents providers to begin attesting to Stage 3 in 2017 by allowing a reduced 90-day reporting period. All providers will be required to comply with Stage 3 requirements beginning in 2018 using EHR technology certified to the 2015 Edition, and must comply with Stage 3 regardless of whether they previously participated in Stage 1 or Stage 2. In 9 See Medicare and Medicaid EHR Incentive Program Basics, CMS.gov, (last visited Oct. 30, 2015). 10 Eligible hospitals and CAHs originally reporting on a fiscal year basis (e.g., October 1 through September 30). The Final Rule changes the reporting period for eligible hospitals and CAHs to a calendar year period, in accordance with the reporting period for EPs. 3

4 2019 and future years, Meaningful Use will be a permanent part of Medicare s new two-track payment system for physician services Merit-Based Incentive Pay System (MIPS) MIPS combines the Physician Quality Reporting System (PQRS), the Value Modifier, and Meaningful Use programs into a single new payment system, starting January 1, The MIPS eliminates the penalties that would otherwise apply to Meaningful Use, as well as PQRS and the Value Modifier. All three incentive programs sunset at the end of Instead, physicians' performance will be assessed using a formula for which 25 percent of the EP s composite score is based on attaining Meaningful Use. The composite score determines a rate adjustment factor which is up to 4 percent in 2019, 5 percent in 2020, 7 percent in 2021, and 9 percent in 2022 and thereafter. This means that in 2019, an EP who receives a composite performance score of 100 (with 25 percent coming from Meaningful Use) gets a 4 percent adjustment, and an EP who receives a score of 0 gets a -4 percent adjustment. In other words, EPs must report quality measure data and use an EHR in accordance with Stage 3 requirements to avoid payment cuts that could total 4 percent in 2019 and increase to 9 percent per year by 2022 and future years. 2. Alternative Payment Models (APMs) The second track of Medicare s new physician payment system provides an alternative route to higher payments starting in 2019 and ending in An APM is defined to include certain Innovation Center models, the Medicare Shared Savings Program, and certain other demonstration projects. Under the 11 MACRA sets forth a goal for nationwide interoperability by the end of It prohibits EPs and hospitals from deliberately blocking information sharing with other EHR vendor products. The 21st Century Cures Act (H.R. 6) passed by the House in July 2015 would, if enacted, repeal this MACRA provision and replace it with an alternative roadmap to interoperability. Section 3001 of H.R. 6 says that to be considered interoperable, EHR technology must: (1) allow for secure records transfer; (2) allow access to the entirety of the patient s data; and (3) not engage in information blocking. 4

5 APM track, EPs who are qualifying APM participants receive an annual bonus equal to 5 percent of their estimated Medicare revenue for the prior year. The bonus is paid in a lump sum, and CMS must pay the bonus directly to the EP rather than through an entity that bills on behalf of many EPs. To earn the bonus, EPs must meet the standards for "qualifying" participants in APMs, which require that a significant share of a physician's revenues comes from an APM that takes on risk of financial losses, follows a quality measurement program, and uses a certified EHR. 12 II. THE NEW MEANINGFUL USE: OBJECTIVES, MEASURES, AND STRUCTURAL CHANGES The Final Rule overhauls the structure of the Meaningful Use Program, aligning Stages 2 and 3. Notably, CMS relaxes the reporting period for Stage 2 in and 2017 for providers who choose to attest to Stage 3, streamlines the objectives and measures, and brings EPs, Hospitals and CAHs on an aligned calendar year reporting period. A. Structural Changes In the Final Rule, CMS officially terminates Stage 1, requiring all providers to attest to modified 13 Stage 2 requirements in 2015 and 2016 regardless of prior participation. However, since the Final Rule was not published until after the start of the fourth quarter in 2015, CMS makes accommodations for providers attesting to Stage 1 in 2015 in specific Stage 2 objectives and measures. CMS reduces the reporting period for modified Stage 2 in 2015 and 2016 to a consecutive 90-day reporting period. Furthermore, providers who choose to attest to Stage 3 in 2017 may report on a consecutive 90-day period; all other providers attesting to Stage 2 must report for a full calendar year. In 2018, all providers will be required to report on Stage 3 objectives and measures for a full calendar year. In the past, eligible hospitals and CAHs reported on a fiscal year cycle, and EPs reported on a calendar year cycle. The Final Rule brings all providers EPs, eligible hospitals, and CAHs on a calendar year reporting period. 12 The two tracks are mutually exclusive: EPs are not considered to be "MIPS-eligible professionals" if they are in a "qualifying APM" or a "partially qualifying APM. 13 The Stage 2 requirements are designated as modified because of the changes in the Final Rule to the original Stage 2 requirements that had a core and menu set structure. 5

6 CMS significantly streamlines the Meaningful Use Program by simplifying the objectives and measures providers must successfully attest to in order to be considered a meaningful user of EHR technology and avoid payment adjustments. CMS eliminates the core and menu set structure in previous Stages 1 and 2. Instead, providers must attest to a single set of required objectives and associated measures. To accomplish this, CMS removed topped-out objectives and measures e.g., those measures that achieved widespread adoption at a high rate of performance and no longer represented a basis on which provider performance could be differentiated. 14 For example, CMS removed objectives and measures related to recording demographics, vital signs, and smoking status. CMS also modifies previous Stage 1 and 2 objectives and measures by removing all requirements or allowances for providers to use paper-based or non-electronic formats to meet certain measures. In modified Stage 2 and Stage 3, paper-based or non-electronic formats will not count towards meeting the requirements of any objective or measure. CMS notes that providers may still use paper-based materials in the practice setting, and strongly recommend[s] that providers continue to provide patients with visit summaries, patient health information, and preventative care recommendations in the format that is most relevant for each individual patient and easiest for that patient to access, 15 but a provider will not satisfy meaningful use measures by doing so. B. Modified Stage 2 and Stage 3 Objectives and Measures In the Final Rule, CMS reconciles the objectives and associated measures to align with Stage 3 to prepare providers to report Stage 3 criteria in 2018 and under MACRA in 2019 and beyond. In the long term, CMS hopes this alignment will ease the reporting burden for providers, support interoperability, and improve patient outcomes. CMS restructures the Stage 2 objectives and associated measures to include 10 objectives for EPs and nine objectives for eligible hospitals and CAHs, down from 18 and 20 total objectives in prior stages, respectively. CMS also modifies patient action measures related to patient engagement by relaxing the thresholds for the Patient Electronic Access and Secure Electronic Messaging measures. CMS consolidates the public health reporting requirements into one objective and provides flexible options for measure selection. Clinical Quality Measures (CQM) reporting requirements for EPs and Fed. Reg. at Fed. Reg. at

7 eligible hospitals/cahs remain as previously finalized in the Stage 2 rule. For those providers already attesting to Stage 1 in 2015, CMS allows special exclusions for certain objectives/measures for those previously scheduled to participate in Stage 1 for the 2015 EHR reporting period. For Stage 3 in 2017 and beyond, CMS requires all providers to attest to only eight objectives. The Stage 3 requirements are largely unchanged from the proposed rule, with the exception of a few minor modifications in several measures. More than 60 percent of the proposed measures require interoperability in Stage 3, up from 33 percent in Stage These objectives focus on advanced use of health IT, increase thresholds, and overall continuous quality improvement. Similar to Stage 2, CMS provides flexibility for measure selection in the public health reporting objective. CQM reporting requirements for EPs and eligible hospitals/cahs are aligned with the CMS quality reporting programs. Stage 3 objectives also incorporate the use of application program interfaces (APIs) to increase patient access to their own health records. Although this is a Final Rule, CMS seeks comments on Stage 3 objectives and associated measures, and the reporting periods. Comments are due by December 15, For a detailed list of the Stage 3 final objectives, measures, exclusions, and significant revisions from the Stage 3 Rule, please refer to this chart. III EDITION CERTIFIED EHR TECHNOLOGY In the Final Rule, CMS establishes a new definition of certified EHR technology in conjunction with the Office of the National Coordinator s (ONC s) 2015 Edition Health IT Certification Criteria Final Rule. 17 In the past, ONC defined CEHRT in its EHR certification requirements, and CMS referred to the ONC definition in the Meaningful Use rules. However, ONC s Final Rule broadens its applicability and discusses certified Health IT generally, not just certified EHR technology. ONC notes that many programs rely on its definition of certified technology, not just the EHR program. Accordingly, ONC and CMS define certified EHR technology separately in 2015 and beyond. However, CMS continues to link each objective to a CEHRT definition and to ONC-established certification criteria CMS Fact Sheet: EHR Incentive Programs in 2015 and Beyond, (last visited Oct. 29, 2015) Fed. Reg Fed. Reg. at

8 For 2016 and 2017, providers must use technology certified to the 2014 Edition. For Stage 3, providers must utilize 2015 Edition certified EHRs. Providers may choose to use 2015 Edition EHRs prior to Stage 3 in 2017 or 2018, but are not required to do so. CONCLUSION CMS has significantly streamlined Stages 2 and 3 of the Meaningful Use Program in anticipation of its permanent role in physician payment under MACRA. CMS creates a single set of required objectives and measures that are aligned between modified Stage 2 and 3, introduces a consecutive 90-day reporting period for modified Stage 2 in , and Stage 3 in Providers should be aware that their participation in Meaningful Use today will impact their payment in a significant way starting in For EPs who choose to report payment under MIPS, participation in Meaningful Use will comprise 25 percent of the physician s composite score, which determines whether the physician will be subject to a -4.0 percent, neutral, or +4.0 percent payment adjustment or bonus. Along with new objectives and measures, providers will also need to use 2015 Edition CEHRT to comply with Stage 3 requirements. If you have any questions about any of the topics discussed in this advisory, please contact any of the following Arnold & Porter professionals: Allison W. Shuren Allison.Shuren@aporter.com Also contributing to this Advisory Neha Patel, PharmD Victoria M. Wallace Vernessa T. Pollard Vernessa.Pollard@aporter.com Jennifer B. Madsen MPH* Jen.Madsen@aporter.com *Not admitted to the practice of law 2015 Arnold & Porter LLP. This Advisory is intended to be a general summary of the law and does not constitute legal advice. You should consult with counsel to determine Alexander R. Cohen Alexander.Cohen@aporter.com 8

9 Objective 1 - Protect Patient Health Information: Protect electronic protected health information (ephi) created or maintained by the CEHRT through the implementation of appropriate technical, administrative, and physical safeguards. Final Objectives: Hospitals and Critical Access Hospitals (CAHs) Objective 1-Protect Patient Health Information: Protect electronic protected health information (ephi) created or maintained by the CEHRT through the implementation of appropriate technical, administrative, and physical safeguards. Modifications to Meaningful Use in 2015 Through 2017 Measure: Conduct or review a security risk analysis in accordance with the requirements under 45 CFR (a)(1), including addressing the security (to include encryption) of ephi created or maintained in CEHRT in accordance with requirements under 45 CFR (a)(2)(iv) and 45 CFR (d)(3), implement security updates as necessary, and correct identified security deficiencies as part of risk management process Same. Change from the Rule No changes from the Rule. Exclusions None. Objective 2 - Clinical Decision Support: Implement clinical decision support (CDS) interventions focused on improving performance on high-priority health conditions. Objective 2 - Clinical Decision Support: Implement clinical decision support (CDS) interventions focused on improving performance on high-priority health conditions. Measure 1: The EP, eligible hospital and CAH must implement five clinical decision support interventions related to four or more CQMs at a relevant point in patient care for the entire EHR reporting period.. Absent four CQMs 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 health conditions.. Requires implementation of CDS interventions for entire EHR reporting period. Alternate Objective and Measure 1 for EPs, eligible hospitals and CAHs: Objective: Implement one clinical decision support rule relevant to specialty or high clinical priority, along with the ability to track compliance with that rule. Measure: Implement one clinical decision support rule Measure 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..

10 Objective 3-Computerized Provider Order Entry: Use computerized provider order entry (CPOE) for medication, laboratory, and diagnostic imaging orders directly entered by any licensed healthcare professional, credentialed medical assistant, or a medical staff member credentialed to and performing the equivalent duties of a credentialed medical assistant, who can enter orders into the medical record per state, local, and professional guidelines. Final Objectives: Hospitals and Critical Access Hospitals (CAHs) Objective 3-Computerized Provider Order Entry: Use computerized provider order entry (CPOE) for medication, laboratory, and diagnostic imaging orders directly entered by any licensed healthcare professional, credentialed medical assistant, or a medical staff member credentialed to and performing the equivalent duties of a credentialed medical assistant, who can enter orders into the medical record per state, local, and professional guidelines. Modifications to Meaningful Use in 2015 Through 2017 Measure 1: More than 60 percent of medication 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 computerized provider order entry. Measure 2: More than 30 percent of laboratory 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 computerized provider order entry Change from the Rule. Reduces compliance threshold from 80% to 60%. Identifies applicable emergency department POS. Requires implementation for entire EHR reporting period.. Reduces compliance threshold from 60% to 30%. Identifies applicable emergency department POS. Requires implementation for entire EHR reporting period. Exclusions Alternate Measure 1 for EPs, eligible hospitals and CAHs: For Stage 1 providers in 2015 only, more than 30 percent of all unique patients with at least one medication in their medication list seen by the EP during the EHR reporting period have at least one medication order entered using CPOE; or more than 30 percent of medication orders created by the EP during the EHR reporting period, are recorded using computerized provider order entry. Alternate Exclusion for Measure 2: Providers scheduled to be in Stage 1 for 2015 may claim an exclusion for measure 2 (laboratory orders) of the Stage 2 CPOE objective for an EHR reporting period in 2015; and, providers scheduled to be in Stage 1 in 2016 may claim an exclusion for measure 2 (laboratory orders) of the Stage 2 CPOE objective for an EHR reporting period in Measure 3: More than 30 percent 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. Reduces compliance threshold from 60% to 30%. Changes requirement from diagnostic imaging to radiology Identifies applicable Alternate Exclusion for Measure 3: Providers scheduled to be in Stage 1 for 2015 may claim an exclusion for measure 3 (radiology orders) of the Stage 2 CPOE objective for an EHR reporting period in 2015; and,

11 Final Objectives: Hospitals and Critical Access Hospitals (CAHs) Modifications to Meaningful Use in 2015 Through 2017 are recorded using computerized provider order entry. Change from the Rule emergency department POS. Requires implementation for entire EHR reporting period. Exclusions providers scheduled to be in Stage 1 in 2016 may claim an exclusion for measure 2 (radiology orders) of the Stage 2 CPOE objective for an EHR reporting period in Objective 4-Electronic Prescribing: Generate and transmit permissible prescriptions electronically (erx). Objective 4-Electronic Prescribing: Generate and transmit permissible prescriptions electronically (erx). EP Measure: More than 50% of all permissible prescriptions written by the EP are queried for a drug formulary and transmitted electronically using CEHRT.. Reduces compliance threshold from 80% to 50%. Alternate EP Measure: For Stage 1 providers in 2015 only, more than 40% of all permissible prescriptions written by the EP electronically using CEHRT. Eligible Hospital Measure: More than 10% of hospital discharge medication orders for permissible prescriptions (for new and changed prescriptions) are queried for a drug formulary and transmitted electronically using CEHRT.. Reduces compliance threshold from 25% to 10%. Alternate Eligible Hospital Exclusion: The eligible hospital or CAH may claim an exclusion for the erx objective and measure if for an EHR reporting period in 2015 they were either scheduled to demonstrate Stage 1, which does not have an equivalent measure, or if they are schedule to demonstrate Stage 2 but did not intend to select the Stage 2 erx objective for an EHR reporting period in 2015; and the eligible hospital or CAH may claim an exclusion for the erx objective and measure if for an EHR reporting period in 2016 they were either scheduled to demonstrate Stage 1 in 2015 or 2016, or if they are scheduled to demonstrate Stage 2 but did not intend to select the Stage 2 erx objective for an EHR reporting period in 2015.

12 Objective 5-Health Information Exchange: The EP provides a summary of care record when transitioning or referring their patient to another setting of care, retrieves a summary of care record upon the first patient encounter with a new patient, and incorporates summary of care information from other providers into their EHR using the functions of the EHR. Objective 6 - Patient - Specific Education: The EP provides patients with education resources identified by CEHRT. Objective 7 - Medication Reconciliation: The EP performs medication reconciliations for patients Final Objectives: Hospitals and Critical Access Hospitals (CAHs) Objective 5-Health Information Exchange: The eligible hospital or CAH provides a summary of care record when transitioning or referring their patient to another setting of care, retrieves a summary of care record upon the first patient encounter with a new patient, and incorporates summary of care information from other providers into their EHR using the functions of the EHR. Objective 6 - Patient - Specific Education: The eligible hospital or CAH provides patients with education resources identified by CEHRT. Objective 7 - Medication Reconciliation: The eligible hospital or CAH performs medication reconciliations for Modifications to Meaningful Use in 2015 Through 2017 Measure: The EP, eligible hospital or CAH that transitions or refers their patient to another setting of care or provider of care (1) uses CEHRT to create a summary of care record; and (2) electronically transmits such summary to a receiving provider for more than 10 percent of transitions of care and referrals. EP Measure: Patient-specific education resources identified by CEHRT are provided to patients for more than 10 percent of all unique patients with office visits seen by the EP during the EHR reporting period. Eligible Hospital/CAH Measure: More than 10 percent of all unique patients admitted to the EH or CAH s inpatient or emergency department (POS 21 or 23) are provided patientspecific education resources identified by CEHRT. EP Measure: The EP performs medication reconciliation for more than 50 percent of transitions of care in which the patient is transitioned... Change from the Rule Reduces compliance threshold in Measure 1 from 50% to 10%. Final Rule eliminates Measure 2 (incorporation into patient EHR electronic care summary from a source other than provider s EHR system) and Measure 3 (provider conducted clinical information reconciliation) previously articulated in the Rule. Objective 6 imposes patientspecific education requirements adapted from Rule Object 5, Measure 2, and previously noted in Stage 2 objectives, but not identified in the Rule. Reduces compliance threshold from 35% to 10%. Objective 7 breaks out the medication reconciliation requirements first identified in Stage 2 objectives, and previously Exclusions Alternate Exclusion: Provider may claim an exclusion for the measure of the Stage 2 Summary of Care objective, which requires the electronic transmission of a summary of care document if for an EHR reporting period in 2015 they were scheduled to demonstrate Stage 1, which does not have an equivalent measure. Alternate Exclusion: Provider may claim an exclusion for the measure of the Stage 2 Patient-Specific Education objective if for an EHR reporting period in 2015 they were scheduled to demonstrate Stage 1 but did not intend to select the Stage 1 Patient-Specific Education menu objective. Alternate Exclusion: Provider may claim an exclusion for the measure of the Stage 2 Medication Reconciliation objective if for an HER reporting period

13 transitioning into the EP s care. Objective 8 - Patient Electronic Access (VDT): The EP provides access for patients to view online, download, and transmit their health information, or retrieve their health information Final Objectives: Hospitals and Critical Access Hospitals (CAHs) patients admitted into the EH or CAH s inpatient or ED care. Objective 8 - Patient Electronic Access (VDT): The eligible hospital or CAH provides access for patients to view online, download, and transmit their health information Modifications to Meaningful Use in 2015 Through 2017 Change from the Rule into the care of the EP. incorporated into Objective 7 (Health Information Exchange)of the Rule. Eligible Hospital/CAH Measure: The EH or CAH performs medication reconciliation for more than 50 percent of transitions of care in which the patient is admitted to the EH or CAH s inpatient or emergency department (POS 21 or 23). Measure 1: For more than 50% of all unique patients seen by the EP or discharged from the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) the patient is provided timely access to view online, download, and transmit his or her health information. Measure 2: For 2015 and 2016: At least 1 patient seen by the EP or discharged from the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) (or a patient-authorized representative) views, downloads or transmits his or her health information during the EHR reporting period.. Reduces compliance threshold from 80% to 50%. Reduces compliance threshold from 80% to 50% Requires timely access to records instead of access within 24 hours, as previously proposed. Exclusions in 2015 they were scheduled to demonstrate Stage 1 but did not intend to select the Stage 1 Medication Reconciliation menu objective. None. New. Alternate Exclusion Measure 2: Providers may claim an exclusion for the second measure if for an HER period in 2015 they were scheduled to demonstrate Stage 1, which does not have an equivalent measure. For 2017: More than 5 percent of unique patients seen by the EP or

14 Objective 9: Secure Messaging: Use communications functions of certified EHR technology to engage with patients or their authorized representatives about the patient s care. Final Objectives: Hospitals and Critical Access Hospitals (CAHs) Objective 9: Secure Messaging: Objective is not applicable for eligible hospital and CAHs. Modifications to Meaningful Use in 2015 Through 2017 discharged from the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) (or patient authorized representative) view, download or transmit to a third party their health information during the EHR reporting period. For 2015: For an EHR reporting period in 2015, the capability for patients to send and receive a secure electronic message with the EP was fully enabled. For 2016: For at least 1 patient seen by the EP during the EHR reporting period, a secure message was sent using the electronic massaging function of CEHRT to the patient (or patient authorized representative), or in response to a secure message sent by the patient (or patientauthorized representative) during the EHR reporting period. For 2017; For more than 5 percent of unique patients seen by the EP during the EHR reporting period, a secure message was sent using the electronic messaging function of CEHRT to the patient (or the patientauthorized representative), or in response to a secure message sent by the patient (or the patient-. Change from the Rule Objective 9 modifies Rule Objective 6, and reformulates it to apply exclusively to EP. Staged phasein results in a 2017 compliance threshold of 5%, which was reduced from the Rule s benchmark of 35%. Exclusions Alternate Exclusion: An EP may claim an exclusion for the measure if for an HER reporting period in 2015 they were scheduled to demonstrate Stage 1, which does not have an equivalent measure.

15 Final Objectives: Hospitals and Critical Access Hospitals (CAHs) Modifications to Meaningful Use in 2015 Through 2017 authorized representative) during the EHR reporting period Change from the Rule Exclusions Objective 10: Public Health: The EP is in active engagement with a PHA or CDR to submit electronic public health data in a meaningful way using certified EHR technology. Objective 10: Public Health: The eligible hospital or CAH is in active engagement with a PHA or CDR to submit electronic public health data in a meaningful way using certified EHR technology Measure 1: Immunization Registry Reporting: The EP, eligible hospital or CAH is in active engagement with a public health agency to submit immunization data. Measure 2: Syndromic Surveillance Reporting: The EP, eligible hospital or CAH is in active engagement with a public health agency to submit syndromic surveillance data. Measure 3: Specialized Registry Reporting: The EP, eligible hospital or CAH is in active engagement to submit data to a specialized registry.. Final Rule consolidates Rule Objective 8 Measures 4 (engagement with PHA to submit reportable conditions) and 5 (engagement to submit data to a clinical lab registry), reverting to Stage 2 s proposal for Specialized Registry Reporting, which encompassed both registry reporting to PHAs and clinical data registry. EPs: Stage 1 EPs must meet at least 1 measure in 2015, Stage 2 Eps must meet at least 2 measures in 2015, and all Eps must meet at least 2 measures in 2016 and EH & CAHs: Stage 1 eligible hospitals and CAHs must meet at least 2 measures in 2015, Stage 2 providers must meet at least 3 measures in 2015, and all eligible hospitals and CAHs must meet at least 3 measures in 2016 and For eligible hospitals and CAHs -- Measure 4: Electronic Reportable Laboratory Result Reporting: The eligible hospital or CAH is in active engagement with a public health agency to submit ELR results.

16 Objective 1- Protect Patient Health Information: Protect electronic protected health information (ephi) created or maintained by the CEHRT through the implementation of appropriate technical, administrative, and physical safeguards. Objective 2- Electronic Prescribing: Generate and transmit permissible prescriptions electronically (erx). Objective 3-Clinical Decision Support: Implement clinical decision support (CDS) interventions focused on improving performance on Final Objectives: Hospitals and Critical Access Hospitals (CAHs) Objective 1- Protect Electronic Health Information: Protect electronic protected health information (ephi) created or maintained by the CEHRT through the implementation of appropriate technical, administrative, and physical safeguards. Objective 2- Electronic Prescribing: Generate and transmit permissible prescriptions electronically (erx). Objective 3-Clinical Decision Support: Implement clinical decision support (CDS) interventions focused on improving performance on high-priority health conditions. EHR Incentive Program -- Stage 3, 2017/2018+ Conduct or review a security risk analysis in accordance with the requirements in 45 CFR (a)(1), including addressing the security (to include encryption) of ephi data created or maintained by CEHRT in accordance with requirements in 45 CFR (a)(2)(iv) and 45 CFR (d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the provider s risk management process. EP Measure: More than 60% of all permissible prescriptions written by the EP are queried for a drug formulary and transmitted electronically using CEHRT. Eligible Hospital Measure: More than 25% of hospital discharge medication orders for permissible prescriptions (for new and changed prescriptions) are queried for a drug formulary and transmitted electronically using CEHRT. Measure 1: The EP, eligible hospital and CAH must implement five clinical decision support interventions related to four or more clinical quality measures at a relevant point in patient care. Absent four clinical quality.. Change from the Rule Alters the name of the objective from protected electronic health information in the Stage 2 final rule and protected patient health information: in the Stage 3 Objective. No exclusions were considered due to the importance ephi protection. Decreases the percentage of permissible prescriptions from 80% in the proposed rule to 60% in the final rule. No changes from the proposed rule. No changes from the proposed rule. Exclusions [or Request for Comment ] None Any EP who: (1) writes fewer than 100 permissible prescriptions; or (2) does not have a pharmacy within their organization and none of the pharmacies within 10 miles of the EP's practice location accept electronic prescriptions. Any eligible hospital or CAH that does not have an internal pharmacy that can accept electronic prescriptions and none of the pharmacies within 10 miles of the hospital or CAH accept electronic prescriptions. None.

17 high-priority health conditions. Objective 4-Computerized Provider Order Entry: Use computerized provider order entry (CPOE) for medication, laboratory, and diagnostic imaging orders directly entered by any licensed healthcare professional, credentialed medical assistant, or a medical staff member credentialed to and performing the equivalent duties of a credentialed medical assistant who can enter orders into the medical record per state, local, and professional guidelines. Final Objectives: Hospitals and Critical Access Hospitals (CAHs) Objective 4-Computerized Provider Order Entry: Use computerized provider order entry (CPOE) for medication, laboratory, and diagnostic imaging orders directly entered by any licensed healthcare professional, credentialed medical assistant, or a medical staff member credentialed to and performing the equivalent duties of a credentialed medical assistant who can enter orders into the medical record per state, local, and professional guidelines. EHR Incentive Program -- Stage 3, 2017/2018+ 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 health conditions. Measure 2: The EP, eligible hospital, or CAH has enabled and implemented the functionality for drug-drug and drug-allergy interaction checks. Measure 1: More than 60 percent of medication orders created by the EP or authorized providers of the eligible hospital's or CAH's inpatient or emergency department are recorded using computerized provider order entry. Measure 2: More than 60 percent of laboratory orders created by the EP or authorized providers of the eligible hospital's or CAH's inpatient or emergency department are recorded using computerized provider order entry. Measure 3: More than 60 percent of diagnostic imaging orders created by the EP or authorized providers of the eligible hospital's or CAH's inpatient or emergency department are recorded using computerized provider order entry. Same Same Same Change from the Rule No changes from the proposed rule. Decreases the percentage of medication orders from 80% in the proposed rule to 60% in the final rule. No changes from the proposed rule. No changes from the proposed rule. Exclusions [or Request for Comment ] Any EP who writes fewer than 100 medication orders during the EHR reporting period. Any EP who writes fewer than 100 medication orders during the EHR reporting period. Any EP who writes fewer than 100 laboratory orders during the EHR reporting period. Any EP who writes fewer than 100 diagnostic imaging orders during the EHR reporting period.

18 Objective 5-Patient Electronic Access to Health Information: The EP provides patients (or patientauthorized representative) with timely electronic access to their health information and patient-specific education. Final Objectives: Hospitals and Critical Access Hospitals (CAHs) Objective 5-Patient Electronic Access to Health Information: The EP provides patients (or patient-authorized representative) with timely electronic access to their health information and patientspecific education. EHR Incentive Program -- Stage 3, 2017/2018+ Measure 1: For more than 80% of all unique patients seen by the EP or discharged from the eligible hospital or CAH inpatient or emergency department: (1) The patient (or the patientauthorized representative)is provided timely access to view online, download, and transmit his or her health information; and (2) The provider ensures the patient s health information is available for the patient (or the patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the API in the provider s CEHRT. Change from the Rule Changes within 24 hours of its availability language in the proposed rule to timely in the final rule. Changes ONC certification for API from proposed rule to technical specifications of the API in the provider s CEHRT in the final rule. Either the first or second option under Measure 1 was required in the proposed rule; both options are required in the final rule. Exclusions [or Request for Comment ] (1) An EP with no office visits. (2) Any EP that conducts 50% or more of his or her patient encounters in a county that does not have 50% or more of housing units with 4Mbps broadband availability. (3) Any eligible hospital or CAH will be excluded from the measure if it is located in a county that does not have 50% or more of their housing units with 4Mbps broadband availability. Objective 6-Coordination of Care through Patient Engagement: Use CEHRT to engage with patients or their authorized representatives Objective 6-Coordination of Care through Patient Engagement: Use CEHRT to engage with patients or their authorized representatives Measure 2: The EP, eligible hospital or CAH must use clinically relevant information from CEHRT to identify patient-specific educational resources and provide electronic access to those materials to more than 35% of unique patients seen by the EP or discharged from the eligible hospital or CAH inpatient or emergency department. Providers must attest to all three measures but only successfully meet two of them. Measure 1: During the EHR reporting Same No changes from the proposed rule. Decreases threshold from 25% in the proposed rule to 10% in the final rule. **Note: for the 2017 EHR reporting period, an EP, eligible (1) An EP with no office visits. (2) Any EP that conducts 50% or more of his or her patient encounters in a county that does not have 50% or more of housing units with 4Mbps broadband availability. (3) Any eligible hospital or CAH will be excluded from the measure if it is located in a county that does not have 50% or more of their housing units with 4Mbps broadband availability. (1) An EP with no office visits. (2) Any EP that 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 4Mbps

19 Final Objectives: Hospitals and Critical Access Hospitals (CAHs) EHR Incentive Program -- Stage 3, 2017/2018+ about the patient s care. about the patient s care. period, more than 10% of all unique patients (or their authorized patient representatives) seen by the EP or discharged from the eligible hospital or CAH inpatient or emergency department actively engage with the electronic health record made accessible by the provider. Measure may be met by either of the following: (1) View, download or transmit to a third party their health information; (2) Access their health information through the use of an API that can be used by applications chosen by the patient and configured to the API in the provider s CEHRT; or (3) A combination of (1) and (2). Measure 2: (1) For an EHR reporting period in 2017 only, for more than 5% of all unique patients seen by the EP or discharged from the eligible hospital or CAH inpatient or emergency department, a secure message was sent using the electronic messaging function of CEHRT to the patient (or their authorized representatives),or in response to a secure message sent by the patient (or their authorized representatives); or (2) For an EHR reporting period other than 2017, for more than 25% of all unique patients seen by the EP or discharged from the eligible hospital Change from the Rule hospital or CAH may meet a threshold of 5% instead of 10%. Removes 25% threshold for options (1) and (2) from proposed rule. Changes ONC certification for API from proposed rule to technical specifications of the API in the provider s CEHRT in the final rule. New option (3) in final rule. Creates distinct thresholds for 2017 reporting period (5%) and non-2017 reporting periods (25%) from 35% for all reporting periods in the proposed rule. Exclusions [or Request for Comment ] broadband availability. (3) Any eligible hospital or CAH will be excluded from the measure if it is located in a county that does not have 50% or more of their housing units with 4Mbps broadband availability. (1) An EP with no office visits. (2) Any EP that 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 4Mbps broadband availability. (3) Any eligible hospital or CAH will be excluded from the measure if it is located in a county that does not have 50% or more of their housing units with 4Mbps broadband availability.

20 EHR Incentive Program -- Stage 3, 2017/2018+ Final Objectives: Eligible Final Objectives: Hospitals and Critical Access Hospitals (CAHs) or CAH inpatient or emergency department, a secure message was sent using the electronic messaging function of CEHRT to the patient (or their authorized representatives),or in response to a secure message sent by the patient (or their authorized representatives). Change from the Rule Exclusions [or Request for Comment ] Objective 7-Health Information Exchange: The EP provides a summary of care record when transitioning or referring their patient to another setting of care, receives or retrieves a summary of care record upon the receipt of a transition or referral or upon the first patient encounter with a new patient, and incorporates summary of care information Objective 7-Health Information Exchange: The eligible hospital or CAH provides a summary of care record when transitioning or referring their patient to another setting of care, receives or retrieves a summary of care record upon the receipt of a transition or referral or upon the first patient encounter with a new patient, and incorporates summary of care information Measure 3: Patient-generated health data or data from a non-clinical setting is incorporated into the CEHRT for more than 5% of all unique patients seen by the EP or discharged by the eligible hospital or CAH inpatient or emergency department. Providers must attest to all three measures but only successfully meet two of them. Measure 1: For more than 50% of transitions of care and referrals, the EP, eligible hospital or CAH that transitions or refers their patient to another setting of care or provider of care: (1) creates a summary of care record using CEHRT; and (2) electronically exchanges the summary of care record. (the exclusion, not the measure) Decreases threshold from 15% in proposed rule to 5% in final rule. Adds number limit for transfers and referrals in exclusion (1). (1) An EP with no office visits. (2) Any EP that 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 4Mbps broadband availability. (3) Any eligible hospital or CAH will be excluded from the measure if it is located in a county that does not have 50% or more of their housing units with 4Mbps broadband availability. (1) 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. (2) Any EP that 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 4Mbp broadband availability. (3) Any eligible hospital or CAH will be excluded from the measure if it is located in a county that does not have 50% or more of their housing units with 4Mbps broadband availability.