Game Plan. Meaningful Use Where are We? So is Anyone Registering? So, are EPs getting any money? $31,968,176,183

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1 Meaningful Use Update ( and Stage 3) Where to go for Help, Handouts, and Future Updates Disclosures: Dr. Henry and Dr. Gross are affiliated with and have lectured for numerous companies including Topcon, First Insight, RevolutionEHR, FoxFire, VisionWeb, SolutionReach, and the AOA. Jay W. Henry, O.D., M.S. Philip J. Gross, O.D. Game Plan Meaningful Use Summary and Statistics Meaningful Use Modifications for Meaningful Use Stage 3 final rule for 2018 Clinical Quality Measures The Future of Meaningful Use EHR Incentive Program Audits Overview Questions Meaningful Use Where are We? So is Anyone Registering? Over 564,621 eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) have registered for the Medicare and/or Medicaid EHR Incentive Programs as of January, ,941 Optometrists have registered as of January, 2016 So, are EPs getting any money? More than $ 19.6 Billion (Stage 1) & $1.5 Billion (Stage 2) in Medicare EHR Incentive Program payments have been made as of January, 2016 More than $ 10.3 Billion in Medicaid EHR Incentive Program payments have been made as of January, 2016 Total amount paid under Medicare and Medicaid as of January, 2016 $31,968,176,183

2 EHR Incentive Payments to OD s As of January, 2016 Medicare EHR Incentive Payments 30,079 Optometrists have attested and been paid Which totals $327,345,140 15,779 Ophthalmologists have attested Which totals $212,840,537 Incentive Payments by Specialty Incentive Payments by Specialty under Medicare As of January, Family Practice 81, Internal Medicine 74, Optometry 30, Cardiology 28, Chiropractors 23, Orthopedic Surgery 23, Podiatry 21, OB/GYN 20, Gastroenterology 17, General Surgery 16, Ophthalmology 15, Neurology 13,215 More than 94% of eligible hospitals have registered to participate More than 82% of all EPs have registered to participate More than 75% of all EPs have received an EHR incentive payment Proportion of Physicians Using an EHR By Type in 2014 More than 8 in 10 Physicians had adopted an EHR

3 Majority of EPs Used Basic EHR Functions Only 6 in 10 Electronically Viewed Imaging Majority EPs Used Certified EHRs Regardless of Participation in EHR Incentive Program Meaningful Use Attestations (thru October, 2015) 305,394 EPs successfully attested 305,181 were successful 213 Unsuccessful 60,324 = Attested to Stage 2 Highlights of Attestations On average all thresholds were greatly exceeded, but every threshold had some providers on the borderline Little difference among specialties in performance, but differences in exclusions Most popular menu items for EPs Drug Formulary Immunization registries Patient list Least popular menu items for EPs Transition of care summary Patient reminders EP Stage 2 Performance EP Stage 2 Performance

4 EP Stage 2 Performance EP Stage 2 Performance Changes for The Meaningful Use Monster Changes Once Again Final Rule (Published 10/16/2015) to Modify MU in ! Why change now? Goal is to align Stage 1 and Stage 2 objectives and measures with the Stage 3 rules More specifically they want to: Build progress toward milestones Reduce complexity Simplify providers reporting Focus on the more advanced use of certified EHR technology Support the health information exchange and quality improvement Improve outcomes for patients Changes for The goal is to simplify and streamline MU while making ongoing changes easier to implement This will be accomplished by: Reducing overall number of objectives Removing measures that have become redundant, duplicative, or have reached wide-spread adoption Meaningful Use Changes Where does all of this information come from? CMS published: Medicare and Medicaid Programs; Electronic Health Record Incentive Program - Stage 3 and Modifications to Meaningful Use in 2015 Through 2017 Final Rule in the Federal Register on 10/16/2015

5 Changes That Impacted 2015 Reporting period was any continuous 90-day period from Jan 1, 2015 Dec 31, 2015 No 2015 attestations for Medicare were accepted until January 1, 2016 Attestation Submission Period for 2015: January 1 st March 11th, 2016 Changes for Reporting Period For 2016 & 2017: All returning participants will use an EHR reporting period of the full 2016 calendar year EPs demonstrating MU for the first time in 2016 or 2017 can use an EHR reporting period of any continuous 90 days during 2016 or 2017 For 2018: First time Medicaid participants may use 90-day EHR reporting period All other providers must use EHR reporting period of full calendar year (Jan 1 Dec 31, 2018) Changes for EHR Technology For : Providers will continue to use EHR technology certified to the 2014 standards As long as your vendor has updated you recently, this should be the version you are currently using Participation Timeline Attest to modified criteria for () with accommodations for Stage 1 providers Attest to () criteria. Some alternate exclusions remain in 2016 for Stage 1 providers For 2018: Providers must update / upgrade software to the 2015 EHR standards Attest to either () criteria or full version of Stage 3 Attest to full version of Stage 3 First Year as a Meaningful EHR User 2011 Stage 1 Future of Meaningful Use Stage of Meaningful Use Stage Stage 1 Stage 1 Stage Stage Stage 2 Stage 2 Stage 1 Stage 1 Modified Stage 2 Modified Stage 2 Modified Stage 2 Modified Stage 2* 2015 Modified Stage 2* 2016 * Modified stage 2 includes alternate exclusions for certain objectives for providers that were scheduled to demonstrate stage 1 in 2015 Modified Stage 2 Modified Stage 2 Modified Stage 2 Modified Stage 2 Modified Stage 2* Modified Stage 2* Modified 2 or Stage 3 Modified 2 or Stage 3 Modified 2 or Stage 3 Modified 2 or Stage 3 Modified 2 or Stage 3 Modified 2 or Stage 3 Stage 3 Stage 3 Stage 3 Stage 3 Stage 3 Stage 3 Changes for Providers will attest to a single set of blended Stage 1 and Stage 2 objectives and measures beginning in 2015 No core or menu measures This set of objectives is being called modified Stage 2 This is done by leveraging existing objectives and measures of MU To assist providers who were previously scheduled to be in Stage 1 for 2015/2016 there are alternate exclusions and specifications within individual objectives. These include: Allowing providers who were previously scheduled to be in Stage 1 in 2015/2016 to use a lower threshold for certain measures Allowing providers to exclude for Stage 2 measures for which there is no Stage 1 equivalent CQMs will be reported electronically or attested to; CQM 90 day period doesn t need to coincide with the 90 day MU attestation period Because of delayed attestation in 2015, 1 st time attesters that attest after Oct. 1 st will have the CMS penalties reversed after the attestation is complete

6 Changes for Objective / Measure Changes CMS proposes to eliminate the distinction between core and menu objectives, and all retained objectives would be required CMS has identified the following objectives as either redundant, duplicative, or topped out and will no longer require attestation on them Record Demographics Record Vital Signs Record Smoking Status Clinical Summaries Structured Lab Results Patient List Patient Reminders Electronic Notes Imaging Results Family Health History Summary of Care Measure 1 Any Method Measure 3 - Test Changes for Objective / Measure Changes CMS states that many of these redundant, duplicative, or topped out objectives and measures may be valuable to providers and patients They recommend that you continue to monitor them and utilize them because they impact other measures and CQMs They encourage providers to continue to conduct these activities if it suits their practice and patient population Changes from Stage 1 for EPs Original Stage 1 Objective Changes : Stage 3: Core Objectives 5 of 10 Menu Objectives Previous 2014 Stage 1 13 Core Objectives 5 of 9 Menu Objectives Current Objectives (including one consolidated public health reporting objective with 3 measure options) Changes from Stage 2 for EPs Objectives () Previous EP Stage 2 Objectives 17 Core Objectives including public health objectives 3 of 6 Menu Objectives Protect Patient Health Information Clinical Decision Support Computerized Provider Order Entry Electronic Prescribing Current () Objectives 10 Objectives (including one consolidated public health reporting objective with 3 measure options) Health Information Exchange Patient Specific Education Medication Reconciliation Patient Electronic Access (VDT) Secure Messaging Public Health Reporting

7 Stage 3 Goals of Stage / 2018 Stage 3 Objectives 1 Provide a flexible, clear framework to simplify the meaningful use program and reduce provider burden Protect Patient Health Information Electronic Prescribing Clinical Decision Support 2 Ensure future sustainability of Medicare and Medicaid EHR Incentive Programs Computerized Provider Order Entry Patient Electronic Access to Health Information Coordination of Care through Patient Engagement 3 Advance the use of health IT to promote health information exchange and improved outcomes for patients Health Information Exchange (HIE) Public Health & Clinical Data Registry Reporting : Stage 3: 2018 Objectives in Detail Protect Electronic Health Information Conduct or review a security risk analysis including addressing the encryption/security of data stored in CEHRT and implement security updates as needed and correct identified security deficiencies as part of the risk management process No exclusion Conduct or review a security risk analysis including addressing the security (including encryption) of data created or maintained by CEHRT and implement security updates as necessary, and correct identified security deficiencies as part of the provider s risk management process No exclusion Protect electronic health information A major goal of the Security Rule is to protect the privacy of individuals health information while allowing covered entities to adopt new technologies to improve the quality and efficiency of patient care This is similar to the current HIPAA security rules You must document and conduct or review a security risk analysis and implement updates as necessary Should be done once prior to end of reporting period Your software vendor should be able to provide you with tools to complete the risk analysis Protect electronic health information HIPAA protects the privacy of individually identifiable health information, called protected health information (PHI) Security Rule protects a subset of information covered by the Privacy Rule, which is all individually identifiable health information a covered entity creates, receives, maintains or transmits in electronic form. The Security Rule calls this information electronic protected health information (e-phi)

8 for 2015 Stage 1 EPs Stage 3 Annual Security Risk Assessment Cycle Conduct a security risk assessment Protect electronic health information Where to get more help: Monitor results Identify risks, threats, and vulnerabilities Mitigate risks threats and vulnerabilities Develop remediation plan Clinical Decision Support (CDS) Measure 1: Implement five clinical decision support interventions related to four or more clinical quality measures at a relevant point in patient care for the entire EHR reporting period Measure 2: The EP has enabled and implemented the functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period For Measure 2, you can be excluded if you write fewer than 100 medication orders during the reporting period Measure 1: Implement five clinical decision support interventions related to four or more clinical quality measures at a relevant point in patient care for the entire EHR reporting period Measure 2: The EP has enabled and implemented the functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period For Measure 2, you can be excluded if you write fewer than 100 medication orders during the reporting period Clinical Decision Support Alternate for 2015 Stage 1 EPs For 2015 Reporting period only if you were scheduled to be in Stage 1 for 2015 Implement one clinical decision support rule relevant to specialty or high clinical priority, along with the ability to track compliance with that rule Clinical Decision Support Details Clinical Decision Support: Functionality that builds upon the foundation of an EHR to provide persons involved in care processes with general and person-specific information, intelligently filtered and organized, at appropriate times, to enhance health and health care

9 Stage 3 for 2015 Stage 1 EPs Implement clinical decision support Clinical Significance? These are rules designed to help us meet the standard of care in terms of testing and follow up care Examples: If a patient has an active medication of Plaquenil listed, has a macular visual field, color vision testing, and a SD OCT been ordered? When an IOP is above a specific level, a warning of possible glaucoma is triggered If a diagnosis of glaucoma is entered, is the patient scheduled or have they had a VF or a scanning laser within the last 6-12months Computerized Provider Order Entry You must create using CPOE the following: Measure 1: More than 60% of medication orders Measure 2: More than 30% of laboratory orders Measure 3: More than 30% of radiology orders You can be excluded individually from meeting each of the above measures for the ones that you have fewer than 100 orders during the reporting period Use CPOE for medication, lab, & diagnostic imaging orders directly entered by any licensed healthcare professional, credentialed medical assistant, or medical staff member credentialed to and performing the duties of a credentialed medical assistant; who can enter orders into the medical record per state, local and professional guidelines Measure 1: More than 60% of medication orders Measure 2: More than 60% of laboratory orders Measure 3: More than 60% of diagnostic imaging orders Includes radiology, ultrasound, MRI, computed tomography, and other diagnostic imaging You can be excluded individually from meeting each of the above measures for the ones that you have fewer than 100 orders during the reporting period Computerized Provider Order Entry Alternate for 2015 Stage 1 EPs For 2015 Reporting period only if you were scheduled to be in Stage 1 for 2015 Measure 1: More than 30% of medication orders, created by the EP, during the EHR reporting period are recorded using CPOE Measure 2: Provider may claim an exclusion for measure 2 (lab orders) for an EHR reporting period in 2015 only Measure 3: Provider may claim an exclusion for measure 3 (radiology orders) for an EHR reporting period of 2015 only CPOE Details for Computerized Provider Order Entry (CPOE): A provider's use of computer assistance to directly enter medical orders from a computer or mobile device Laboratory Order: Order for any service provided by a laboratory that could not be provided by a nonlaboratory Radiology Order: Order for any imaging services that uses electronic product radiation. The EP can include orders for other types of imaging services that do not rely on electronic product radiation in this definition as long the policy is consistent across all patient and for the entire EHR reporting period CPOE Details for Stage 3 Computerized Provider Order Entry (CPOE): A provider's use of computer assistance to directly enter medical orders from a computer or mobile device Laboratory Order: Order for any service provided by a laboratory that could not be provided by a non-laboratory Diagnostic Imaging Order: Order for any imaging services that uses ultrasound, magnetic resonance, computed tomography, radiologic, and other imaging

10 Stage 3 for 2015 Stage 1 EPs Computerized Provider Order Entry Clinical Significance? Directly entering orders into a computer has the benefit of reducing errors by minimizing the ambiguity of hand-written orders, but a much greater benefit is seen with the combination of CPOE and clinical decision support tools Implementation of CPOE is being increasingly encouraged as an important solution to the challenge of reducing medical errors, and improving health care quality and efficiency CPOE Lab Test Order Entry CPOE Diagnostic Imaging Order Electronic Prescribing More than 50% of all permissible prescriptions written by the EP are queried for a drug formulary and transmitted electronically using CEHRT You can be excluded from meeting this objective if you write fewer than 100 prescriptions during the reporting period or Do not have a pharmacy within your organization and there are no pharmacies that accept electronic prescriptions within 10 miles of the EP's practice location at the start of your EHR reporting period More than 60% of all permissible prescriptions written by the EP are queried for a drug formulary and transmitted electronically using CEHRT You can be excluded from meeting this objective if you write fewer than 100 prescriptions during the reporting period or Do not have a pharmacy within your organization and there are no pharmacies that accept electronic prescriptions within 10 miles of the EP's practice location at the start of your EHR reporting period Electronic Prescribing Alternate for 2015 Stage 1 EPs For 2015 Reporting period only if you were scheduled to be in Stage 1 for 2015 More than 40% of all permissible prescriptions written by the EP are transmitted electronically using Certified EHR Technology

11 Stage 3 for 2015 Stage 1 EPs Stage 3 E-Prescribing (erx) Clinical Significance? Improves medication safety Better management of medication costs Improved prescribing accuracy and efficiency Increase practice efficiency Reducing health care costs Reduction of adverse drug events Health Information Exchange The EP that transitions or refers their patient to another setting of care or provider of care must: Measure 1: Use CEHRT to create a summary of care record Measure 2: Electronically transmit such summary to a receiving provider more than 10% of transitions of care and referrals You can be excluded if you transfer a patient to another setting or refer a patient to another provider less than 100 times during the EHR reporting period See next Slide Health Information Exchange You must attest to the numerator and denominator for all 3 measures, but would only be required to successfully meet the threshold for two of the three measures listed to meet the objective Measure 1: For more than 50% of transition of care and referrals the EP that transitions or refers their patient to another setting of care or provider of care (1) creates a summary of care record using CERHT and (2) electronically exchanges the summary of care record Measure 2: For more than 40% of transitions or referrals received and patient encounters in which the provider has never before encountered the patient, the EP incorporates into the patient s EHR an electronic summary of care document from a source other than the provider s EHR system Measure 3: For more than 80% of transitions or referrals received and patient encounters in which the provider has never before encountered the patient, the EP performs a clinical information reconciliation. Reconciliation must be done for: Meds, Med Allergies, and Current problem list You may be excluded if: The total of transitions or referrals received and encounters in which you have never before encountered the patient is fewer than 100 during the reporting period You conduct 50% or more of encounters in a county that does not have 50% or more housing units with 4Mbps broadband availability Summary of Care Record Alternate for 2015 Stage 1 EPs For 2015 Reporting period only if you were scheduled to be in Stage 1 for 2015 The EP that transitions or refers their patient to another setting of care or provider of care must: Measure 1: Use CEHRT to create a summary of care record Measure 2: You are excluded from the electronic transmission of a summary of care document if for an EHR reporting period in 2015 you were scheduled to demonstrate Stage 1

12 Stage 3 Summary of Care Record for Transitions of Care Clinical Significance? You must provide a summary of care record to the provider you are referring the patient to This is important because it allows the next provider of care to understand your clinical findings which may impact the patients care You could use the clinical summary or your electronic copy You must have 10% of the summaries transmitted electronically This is why secure (direct) messaging is so important! Eventually you will be able to look up a doctors direct address on the NPPES website Patient Specific Education Patient specific education resources identified by CEHRT are provided to patients for more than 10% of all unique patients with office visits during the reporting period. To count for this objective educational material given must be identified by the CEHRT You can be excluded if you have no office visits during the reporting period Covered under the Stage 3 Objective: Patient Electronic Access to Health Information

13 Stage 3 for 2015 Stage 1 EPs for 2015 Stage 1 EPs Patient Specific Education Alternate for 2015 Stage 1 EPs For 2015 reporting period only Provider may claim an exclusion for Patient specific education 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 item Patient specific education resources Clinical Significance? It is our job as a doctor to properly educate our patients on all of their clinical findings and diagnosis as well as risks and benefits of each treatment option Certified EHRs have the ability to identify patient specific educational resources based on the problem list, medication list, or lab test results The EHR technology must identify the patient educational material or resources The resources do not have to be stored within or generated by the EHR Medication Reconciliation The EP performs medication reconciliation (including name, dosage, frequency, and route) for more than 50% of transitions of care in which the patient is transitioned into your care You can be excluded if you are not the recipient of any transitions of care during the EHR reporting period Covered under Stage 3 Objective: Health Information Exchange Medication Reconciliation Alternate for 2015 Stage 1 EPs For 2015 reporting period only Provider may claim an exclusion for the measure of Medication reconciliation 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 Medication reconciliation menu objective

14 Stage 3 Medication Reconciliation Clinical Significance? This is very important to our patient care Unintended inconsistencies in medication regimens may occur at any point of transition in care The goal is to review all medications a patient it taking with them and provide them with a current updated list after each encounter This helps avoid negative drug interactions as well as drug duplication Medication reconciliation is the process of identifying the most accurate list of all medications the patient is taking by comparing the medical record to an external list of medications obtained from a patient, hospital or other provider Patient Electronic Access Measure 1: More than 50% of all unique patients seen by the EP during the reporting period are provided timely (within 4 business days after the info is available to the EP) access to view online, download, and transmit to a 3 rd party their health information subject to the EP s discretion to withhold certain information For Measure 2: At least one patient seen by the EP during the reporting period (or their authorized representatives) views, downloads, or transmits their health information to a third party For 2017 Measure 2: More than 5% of unique patients seen by the EP during the reporting period view, download, or transmit to a 3 rd party their health information You can be excluded if you neither order nor create any of the info listed for inclusion You can be excluded if you conduct 50% or more of encounters in a county that does not have 50% or more housing units with 4Mbps broadband availability Measure 1: For more than 80% of all unique patients seen by the EP (1) The patient (or patient-authorized rep) is provided timely electronic access to view online, download, and transmit their health information (2) The EP ensures the patient s health information is available for the patient (or auth rep) to access using any application of their choice that is configured to meet the technical specification of the API in the provider s CEHRT Measure 2: EP 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 during the reporting period You can be excluded from both measures if you have no office visits during the reporting period You can be excluded from Measure 1 if you conduct 50% or more of encounters in a county that does not have 50% or more housing units with 4Mbps broadband availability

15 for 2015 Stage 1 EPs Patient Electronic Access Alternate for 2015 Stage 1 EPs For 2015 reporting period only Measure 1: More than 50% of all unique patients are provided timely (within 4 business days after the info is available to the EP) online access to their health information Measure 2: Providers may claim an exclusion for this part (at least one patient seen by the EP during the reporting period (or their authorized representatives) views, downloads, or transmits their health information to a third party) if for an EHR reporting period in 2015 they were scheduled to demonstrate Stage 1 Patient Electronic Copy and Electronic Access Clinical Significance? Patient access will allow patients to understand what clinical testing was completed during an encounter as well as the results of those tests Online electronic access through either a patient portal or personal health record (PHR) will satisfy this objective The minimal information to be included is: Lab test results, problem list, medication list, and medication allergy list You may withhold information from the electronic copy in accordance with HIPAA Patient Electronic Copy and Electronic Access: API Application Programming Interface (API) API is a set of programming protocols Enables access to data via third-party applications More flexible than a patient portal If API provides view, download, transmit than a patient portal is not needed separately

16 Stage 3 for 2015 Stage 1 EPs Secure Electronic Messaging For 2015: During the entire reporting period, the capability for patients to send and receive a secure electronic message with the provider was fully enabled For 2016: At least 1 patient seen by the EP during the reporting period, a secure message was sent using CEHRT to the patient (or authorized rep) For 2017: For more than 5% of unique patients seen by the EP during the reporting period, a secure message was sent using CEHRT to the patient (or authorized rep) You can be excluded if you have no office visits You can be excluded if you conduct 50% or more of encounters in a county that does not have 50% or more housing units with 3Mbps broadband availability Covered under the Stage 3 Objective: Coordination of Care Through Patient Engagement Secure Electronic Messaging Alternate for 2015 Stage 1 EPs For 2015 reporting period only An EP may claim an exclusion for this measure if for an EHR reporting period in 2015 you were scheduled to demonstrate Stage 1 Secure Electronic Messaging Secure Message: Any electronic communication between a provider and patient that ensures only those parties can access the communication This electronic message could be secure or the electronic messaging function of a PHR, an online patient portal, or any other electronic means that is authenticated (both patient and EHR user) and encrypted

17 Stage 3 for 2015 Stage 1 EPs Public Health Reporting EPs required to choose from measures 1-3, and required to successfully attest to any combination of two measures. Some measures may be used more than once Measure 1: Immunization registry reporting can count 1 time toward objective Measure 2: Syndromic Surveillance reporting can count 1 time toward objective Measure 3: Specialized Registry Reporting can count 2 times toward objective You may be excluded from the measures that don t apply but you can only claim an exclusion once you can exclude from all remaining measures EPs required to choose from measures 1-5, and required to successfully attest to any combination of two measures. Some measures may be used more than once Measure 1: Immunization registry reporting can count 1 time toward obj. Measure 2: Syndromic Surveillance reporting can count 1 time toward obj. Measure 3: Case Reporting can count 1 time toward objective Measure 4: Public Health Registry reporting can count 2 times toward obj. Measure 5: Clinical Data Registry reporting can count 2 times toward obj. You may be excluded from the measures that don t apply but you can only claim an exclusion once you can exclude from all remaining measures Public Health Reporting Alternate for 2015 Stage 1 EPs For 2015 reporting period only EPs scheduled to be in Stage 1 in 2015 must report on at least one measure below unless they can exclude from all available measures Measure 1: Immunization registry reporting can count 1 time toward objective Measure 2: Syndromic Surveillance reporting can count 1 time toward objective Measure 3: Specialized Registry Reporting can count 2 times toward objective You may be excluded from the measures that don t apply but you can only claim an exclusion once you can exclude from all remaining measures Public Health Reporting To meet this objective you must be in active engagement with a Public Health Agency or clinical data registry to submit electronic data in a meaningful way using CEHRT, except where prohibited and in accordance with applicable law and practice Public Health Reporting: Active Engagement Active engagement is defined as: Option 1: Completed registration to submit data: Registration was completed within 60 days after the start of the EHR reporting period and the EP is awaiting an invitation from the PHA or CDR to begin testing Option 2: Testing and Validation: EP is in the process of testing and validation of the electronic submission of data. EPs must respond to requests from the PHA within 30 days; failure to respond twice within a reporting period would result in failure to meet this objective Option 3: Production: EP has completed testing and validation and is electronically submitting produciton data to PHA or CDR Stage 2 & 3: Public Health Reporting Measure 1: Immunization Registry EP is in active engagement with a PHA to submit immunization data and receive immunization forecasts and histories You may excluded from this measure: If you do not administer any immunizations to any of the populations for which data is collected Operate in a jurisdiction for which no immunization registry is capable of accepting the specific standards required Operate in a jurisdiction where no immunization registry has declared readiness to receive data at the start of the reporting period

18 Stage 2 & 3: Public Health Reporting Measure 2: Syndromic Surveillance EP is in active engagement with a PHA to submit syndromic surveillance data Any EP meeting one or more of the following criteria may be excluded from this measure: EP is not in a category of providers from which ambulatory syndromic surveillance data is collected by their jurisdiction s syndromic surveillance system Operates in a jurisdiction for which no PHA is capable of receiving electronic syndromic data in the specific standards required Operates in a jurisdiction where no PHA has declared readiness to receive syndromic surveillance data from EPs at the start of the EHR reporting period for stage 2 or as of 6 months prior to the start of the EHR reporting period for stage 3 Stage 2 only: Public Health Reporting Measure 3: Specialized Registry Reporting EP is in active engagement to submit data to a specialized registry (Public Health Agencies and Clinical Data Registries) Any EP may be excluded from the specialized registry reporting if the EP: Does not treat or diagnose any disease or condition associated with or collect relevant data that is required by a specialized registry in their jurisdiction Operates in a jurisdiction for which no specialized registry is capable of accepting electronic registry transactions in the specific standards required Operates in a jurisdiction where no specialized registry for which the EP is eligible has declared readiness to receive electronic registry transactions at the start of the EHR reporting period for stage 2 or as of 6 months prior to the start of the EHR reporting period for stage 3 Stage 2 only: Public Health Reporting Measure 3: Specialized Registry Reporting We now have a Specialized Registry, specifically a Clinical Data Registry AOA MORE Why Registries are Important to You! Part of the new Medicare payment reform Registry use = get paid more Don t use one = get paid less Required in Meaningful Use Can no longer exclude from registries Simplifies PQRS 62% of ODs did not do PQRS in 2013 Got penalized in 2015 Penalties are about to increase! Medicare Payment Reform Medicare Access and CHIP Reauthorization Act Your payments will be based on all of these: Meaningful Use PQRS Physician Payment Modifier Specific parts of this legislation require you to use a health care registry CMS knows that professions using registries are improving health care outcomes

19 Medicare Payment Reform $$$$ Medicare will reward quality and penalize others 4-12% payment increases for meeting quality targets in 2019 Up to 27% for highest achievers in 2022 Immediate Meaningful Use Benefits Meaningful Use 2016 Using AOA MORE qualifies you for MU in 2016 Even if your vendor is not integrated By signing up, you will qualify! Legislation is budget neutral Payment reductions for those not meeting quality targets! CMS Mandates Deadline You must be enrolled with a registry by Feb 29 to qualify for using that registry for MU in 2016 (CMS ruling) Immediate PQRS Benefits PQRS is made easier by a registry Eliminates the need for additional F codes on claims Automatically calculates your PQRS for you You must know what data fields in your EHR counts towards PQRS Ask you EHR vendor for help Immediate PQRS Benefits Registry-based PQRS items vary from claims-based PQRS AOA MORE will not have identical PQRS items as traditional claims-based CMS rules dictate which PQRS items are registry-eligible CMS is moving away from claims-based PQRS Will require EHR-based reporting (some vendors can t do that) or registry-based reporting Other AOA MORE Benefits Benchmark and Outcomes Helping you in your exam room to see how you compare to ODs across the country Advocacy Optometry writes it s own script! Gives us information about our own care Evidence-Base

20 Cost of AOA MORE EHR Vendors Integrated $0.00 for AOA Members! $0 charged by AOA Some Vendors are charging $10/month per doc $1,800 per year for non-members By Feb 2016 RevolutionEHR Compulink MaximEyes Coming mid 2016 Eyefinity/OfficeMate Williams Practice Director Crystal PM Goal to add: NextGen My Vision Express others Where is AOA MORE? ODs started signing up in June 2015 But didn t start using until 2016 With the start of ICD-10 and other CMS changes to registries, the use of AOA MORE was not able to start until 2016 Start and Stop? You can start 2016 doing claims-based PQRS and then switch to AOA MORE Ensure your AOA MORE metrics for each PQRS item are over 50% before stopping claims-based You will see this on the AOA MORE dashboard once you begin using it AOA MORE calculates all of 2016, even though you didn t start using AOA MORE on January 1 Please verify with your EHR vendor the data fields in your EHR that are tracked for PQRS» Known to your vendor as ecqms Stage 2 only: Public Health Reporting Measure 3: Specialized Registry Reporting 2015 Reporting Year AOA MORE did not accept data for the purposes of meeting the Specialized Registry Reporting measure for the 2015 program year Therefore, if there are no other registries available for you to report data EPs should claim the exclusion for this measure in 2015

21 Stage 2 only: Public Health Reporting Measure 3: Specialized Registry Reporting 2016 Reporting Year AOA MORE will declare readiness to accept data for Specialized Registry reporting for the 2016 program year To use or to actively engage AOA MORE for 2016 be sure to: Register by February 29, 2016 visit or qualityimprovement@aoa.org to indicate you intend to submit data for 2016 even if you vendor is not yet included Keep a record of the confirmation you receive from AOA MORE Start using the registry as soon as you EHR is registry capable Stage 3 only: Public Health Reporting Measure 3: Electronic Case Reporting EP is in active engagement with a PHA to submit case reporting of reportable conditions PHA collects reportable conditions as defined by the state, territorial, or local PHA to monitor disease trends and support management of outbreaks Any EP may be excluded from the case reporting if the EP: Does not treat or diagnose any reportable diseases Operates in a jurisdiction for which no PHA is capable of receiving electronic case reporting in the specific standards required Operates in a jurisdiction where no PHA has declared readiness to receive electronic case reporting data as of 6 months prior to the start of the EHR reporting period Stage 3 only: Public Health Reporting Measure 4: Public Health Registry EP is in active engagement with a PHA to submit data to public health registries Public Health Registry is a registry that is administered by, or on behalf of, a local, state, territorial, or national PHA and which collects data for public health purposes Any EP may be excluded from public health registry reporting if the EP: Does not diagnose or directly treat any disease or condition associated with a public health registry in their jurisdiction during the reporting period Operates in a jurisdiction for which no public health registry is capable of accepting electronic transactions in the specific standards required Operates in a jurisdiction where no public health registry for which the EP is eligible has declared readiness to receive electronic registry transactions as of 6 months prior to the start of the EHR reporting period Stage 3 only: Public Health Reporting Measure 5: Clinical Data Registry EP is in active engagement with a PHA to submit data to a clinical data registry Clinical data registries are administered by, or on behalf of, other non-public health agencies Clinical data registries can be used to monitor health care quality and resource use Any EP may be excluded from clinical data registry reporting if the EP: Does not diagnose or directly treat any disease or condition associated with a clinical data registry Operates in a jurisdiction for which no clinical data registry is capable of accepting electronic registry transactions in the specific standards required Operates in a jurisdiction where no clinical data registry for which the EP is eligible has declared readiness to receive electronic registry transactions as of 6 months prior to the start of the EHR reporting period Stage 3 only: Public Health Reporting Measure 5: Clinical Data Registry Be sure to continue using AOA MORE to meet the Clinical Data Registry 2016 Alternate Public Health Exclusion CMS does not intend to inadvertently penalize providers for changes to their systems or reporting made necessary by the provisions of the 2015 EHR Incentive Programs Final Rule For 2016, EPs scheduled to be in Stage 1 or Stage 2 must attest to at least 2 measures from the Public Health Reporting Objective Measures 1-3 CMS will allow providers to claim an alternate exclusion for the Public Health Reporting measure(s) which might require the acquisition of additional technologies providers did not previously have or did not previously intend to include in their activities for meaningful use

22 Stage Alternate Public Health Exclusion CMS will allow Alternate Exclusions for the Public Health Reporting Objective in 2016 as follows: EPs scheduled to be in Stage 1 and Stage 2: Must attest to at least 2 measures from the Public Health Reporting Objective Measures 1-3 May claim an Alternate Exclusion for Measure 2 and Measure 3 (Syndromic Surveillance and Specialized Registry Reporting) An Alternate Exclusion may only be claimed for up to two measures, then the provider must either attest to or meet the exclusion requirements for the remaining measure Measure 1: Immunization registry reporting Coordination of Care Through Patient Engagement You must attest to the numerator and denominator for all 3 measures, but would only be required to successfully meet the threshold for two of the three measures listed to meet the objective Measure 1: For 2017 more than 5% and for 2018 and beyond more than 10% of all unique patients seen by the EP during the reporting period actively engage with the electronic health record and either: (1) View, download, or transmit to a third party their health information (2) Access their health information through the use of an API (3) Use a combination of (1) and (2) above Measure 2: For 2017 more than 5% and for 2018 and beyond more than 25% of all unique patients seen by the EP during the reporting period, a secure message was sent using CEHRT to the patient (or auth rep), or in response to a secure message sent by the patient Measure 3: Patient-generated health data or data from a non-clinical setting is incorporated into the CEHRT for more than 15% of all unique patients seen by the EP during the reporting period You may exclude from both parts of measure 1, measure 2, and measure 3 : If you have no office visits If you conduct 50% or more of encounters in a county that does not have 50% or more housing units with 4Mbps broadband availability Information From Patient or Non-Clinical Setting Information from patient Patient generates the data on their own Recording own vital signs, activity and exercise, medication intake, nutrition Information from non-clinical setting Non-EP or non-hospital provider who doesn t have access to the EPs EHR Nutritionists, physical therapists, occupational therapists, psychologists, home health providers Could include: Social service data, advanced directives, medical device data, fitness monitoring, etc.

23 How to Survive Don t forget about the deleted measures Continue to monitor them and utilize them because they impact other measures and CQMs Run Stage 2 reports for all providers (even those in Stage 1 for ) This will identify gaps and workflow issues to meet the modified Stage 2 Objectives Clinical Quality Measures (CQMs) Still Required to be a Meaningful User Clinical Quality Measures CQMs are tools that help measure and track the quality of health care services provided by eligible professional Clinical Quality Measures Measuring and reporting CQMs helps to ensure our health care system is delivering effective, safe, efficient, patient centered and timely care These measures use data associated with providers ability to deliver high-quality care or relate to long term goals for quality health care

24 Clinical Quality Measures CQMs measure many aspects of care including: Health outcomes Clinical processes Patient safety Efficient use of health care resources Care coordination Patient engagements Population and public health Adherence to clinical guidelines Clinical Quality Measures To participate in the Medicare and Medicaid EHR incentive programs and receive a payment providers are required to submit CQM data from certified EHR technology CQMs may be reported electronically or via attestation Clinical Quality Measures For 2015 and EPs will need to report 9 (of 64 possible) measures These 9 measures must cover at least 3 of the 6 National Quality Strategy domains Patient and Family Engagement Patient Safety Care Coordination Population/Public Health Efficient Use of Healthcare Resources Clinical Process/Effectiveness CMS encourages eligible professionals to report from the recommended set to the extent those CQMs are applicable to your scope of practice and patient population Clinical Quality Measures Samples of 2015 /2016 CQMs Controlling High Blood Pressure Use of High-Risk Medications in the Elderly Preventive Care and Screening: Tobacco Use Documentation of Current Medications in the Medical Record Preventive Care and Screening: Body Mass Index Screening and Follow-Up Closing the Referral Loop Receipt of Specialist Report Need Help Understanding CQMs for 2015? CQM webpage Guidance/Legislation/EHRIncentivePrograms/Cli nicalqualitymeasures.html

25 Payment Adjustments Medicare Payment Adjustments As part of ARRA EPs who do not successfully demonstrate MU will receive reduced Medicare Payments The Medicare payment adjustments started in Jan 1 st, 2015 and will sunset and be replaced at the end of 2018 per the MACRA Act The payment adjustment is based on MU performance 2 years prior If you were not a meaningful user in 2014 = 2% payment reduction starting Jan 1 st, 2016 If you are not a meaningful user in 2015 = 3% payment reduction starting Jan 1 st, 2017 If you are not a meaningful user in 2016 = 3% payment reduction starting Jan 1 st, 2018 How to Avoid the Payment Penalty in 2017 if You Did Not Meet MU in 2015 Patient Access and Medicare Protection Act (PAMPA) was enacted Dec. 28 th, 2015 Requires CMS to make it easier for EPs to request hardship exceptions from the payment adjustments for reimbursement in 2017 This means if you did not meet MU in 2015 you can apply for a hardship exception and avoid the payment penalty in 2017 How to Avoid the Payment Penalty in 2017 if You Did Not Meet MU in 2015 EPs that wish to use the streamlined application must submit their hardship application by July 1, 2016 Download application at Guidance/Legislation/EHRIncentivePrograms/Downloads/ HardshipApplication.pdf Meaningful Use What s Next Meaningful Use The Future?? Andy Slavitt, acting CMS Administrator said the following at the J.P. Morgan Healthcare Conference on Jan. 11 th, 2016 In 2016, MU as it has existed-- with MACRA-- will now be effectively over and replaced with something better Many jumped on this and have said MU is over and will end any day now.

26 Meaningful Use What s Next Andy Slavitt and Karen DeSalvo clarified things on January 19 th by saying: The administration (CMS) is working on an important transition for EHR Incentive Program We are working side by side with EPs and have listened to the needs and concerns of them We will be putting out additional details in a few months but here are some updates Meaningful Use What s Next The EHR incentive program was designed in the initial years to encourage the adoption of new technology and measure the benefits for patients While it has helped us make progress, it has created real concerns about placing too much burden on EPs and pulling their time away form caring for patients Meaningful Use What s Next Last year congress took two steps to put patients at the center of how we pay for care: They set a goal that 30% in 2016 and 50% in 2018 of Medicare payments be linked to getting better results for patients, providing better care, spending healthcare dollars wisely, and keeping people healthy Passage of the Medicare Access and CHIP Reauthorization Act (MACRA) considers quality, cost, and clinical practice improvement in calculating how Medicare physician payments are determined Meaningful Use What s Next While MACRA requires that physicians be measured on their meaningful use, it provides an opportunity to transition the EHR incentive program towards where we want to go Meaningful Use What s Next The following principles will guide what comes next: Rewarding providers for the outcomes technology helps them achieve with their patients Allowing providers flexibility to customize health IT to their individual practice needs Leveling the technology playing field to promote innovation, by unlocking the EHR through open APIs Prioritizing interoperability by implementing federally recognized, national interoperability standards and focusing on real-world uses of technology such as: Continuity of care during referrals, finding ways for patients to engage in their own care Meaningful Use What s Next As we transition from staged Meaningful Use as we know it today keep in mind: The current law requires that we continue to measure meaningful use, MACRA allows the adjustment of payment incentives it does not eliminate MU Nothing will happen over night The challenge is moving from the principles outlined to reality The process will be ongoing and we must all commit to learning and improving and collaborating on the best solutions

27 Questions? CMS EHR Incentive Audits Jay W. Henry, O.D., M.S. Philip J. Gross, O.D. Audit Selection Providers who receive an EHR incentive payment for either the Medicare or Medicaid EHR Incentive Program are subject to an audit 5 10% who have attested will be audited CMS will oversee Medicare Incentive Audits Individual States will oversee Medicaid Incentive Audits Audit Selection First, random audits are being done In addition, risk profile of suspicious / anomalous data will also trigger audits CMS is not going to make the risk profile public You may be subject to successive audits Pre- and Post- Payment Audits Post-Payment Audits are those which occur after you have received an EHR Incentive Payment. They began in July, Pre-Payment Audits are those which occur before you have received an EHR Incentive Payment. They began in January, If you have a post-payment audit for your first year of participation, you will typically get a prepayment audit for the following year

28 Audit Statistics In 2014, a Freedom of Information Act request was filed to obtain information on those audited since the program started For unknown reasons, the data is not automatically published by CMS The initial look at this data is scary! Pre Payment Audits as of Sept, ,825 Pre Payment Audits have been undertaken for EPs. 3,820 of 5,825 Pre Payment audits have been completed which is 66% Over 2000 Pre Payment audits still in process! So, how did these entities make out? Pre Payment Audits as of Sept, of 3,820 (21%) pre-payment audits completed did not meet meaningful use and failed! CMS is citing two main reasons for failing Failure to use a certified EHR (7.1%) Failure to meet the appropriate objectives and associated measures (92.9%) Take away Know the measures! Post Payment Audits as of Sept, ,780 Post Payment Audits have been undertaken for EPs. 4,601 of 4,780 Post Payment Audits have been completed which is 96% CMS says these are getting ready to gear back up as they catch up on the Pre Payment Audits So, how did these entities make out? Post Payment Audits as of Sept, ,106 of the 4,601 post payment audits completed did not meet meaningful use and failed! 1 in 4 failed (24%) CMS is citing two main reasons for failing Failure to use a certified EHR (1.1%) Failure to meet the appropriate objectives and associated measures (98.9%) You really have to know the measures! Audits as of Sept, 2014 CMS is stating that of those EPs who failed audits they are returning between $41.92 and $19,800 per provider Average returned incentive was $16,862 per provider A large problem for many EPs who are audited is no longer employing the person who was responsible for attesting! Please have a game plan in place to create and protect your MU and audit information!

29 Medicare Audit Process Figliozzi and Co will send initial request letter Letter will be sent electronically from CMS to in provider s EHR registration Follow-up by phone and mail, as needed Providers selected for audits will be required to submit, as soon as possible, supporting documentation to validate their submitted attestation data Initial review is a desk review What you will receive that contains a number of items DR - 1 EP Audit Engagement Letter in PDF format DR 2 Document Request Letter Eligible Professionals in Microsoft Excel 97 format DR 3 Attachment 1 Accessing Web Portal in PDF format DR 3.1 Attachment 2 Web Portal FAQ Audit Engagement Letter Preparing Documentation Requested It is the provider s responsibility to maintain documentation that fully supports the meaningful use and clinical quality measure data submitted during attestation Documentation should be retained for six years post-attestation Save all electronic or paper documentation that would help support your attestation and support the values you entered in the Attestation Module including the clinical quality measures

30 Medicare Audit Determination Provider will receive an Audit Determination Letter back from the audit contractor (Figliozzi & Co) This will inform the provider whether they are successful in meeting meaningful use If the provider is found not to be eligible for an EHR incentive payment then the payment will be recouped Providers must use the appeals process if they believe they received an incorrect adverse audit finding CMS and ONC personnel cannot intervene in the audit determination process Medicare Fraud & Abuse CMS may pursue additional measures against providers who attest fraudulently to receive an EHR incentive payment It is a crime to defraud the Federal Government and its programs Punishment may involve imprisonment, significant fines, or both Providers can lose Medicare participation or their licenses to practice Questions? Philip J. Gross, O.D. Jay W. Henry, O.D., M.S.