2013 EHR INCENTIVE PROGRAM MANUAL

Transcription

1 0 EHR INCENTIVE PROGRAM MANUAL Billing Technology Results ahsrcm.com

2 Table of Contents INTRODUCTION TO EHR & MEANINGFUL USE... CMS EHR INCENTIVE PROGRAM - PARTICIPATION... COMPARISON - MEDICARE & MEDICAID PROGRAMS... 5 THE 0 MEDICARE EHR INCENTIVE PROGRAM... 5 INCENTIVE PAYMENTS & PENALTY ADJUSTMENTS... 7 HARDSHIP EXEMPTIONS REQUIREMENTS FOR REPORTING MEANINGFUL USE... 9 EHR SYSTEM CERTIFICATION... 9 STAGE OBJECTIVE REQUIREMENTS... 0 CLINICAL QUALITY MEASURES... EHR PROGRAM REGISTRATION & ATTESTATION STAGE REQUIREMENTS... 7 ADDENDUM STAGE OBJECTIVES... 8 ADDENDUM 04 CLINICAL QUALITY MEASURES... EHR INCENTIVE PROGRAM MANUAL This manual contains information for the 0 EHR Incentive Program for physicians and clinicians, referred to by CMS as eligible professionals or EPs. (Hospitals participate in their own version of the program) Updates to Stage, handed down in the Stage ruling on August, 0, are included in this manual. Stage of the program does not begin until January, 04. We have included some information on Stage at the end of the manual. However, this manual is primarily designed for EPs participating in the program in 0. INTRODUCTION TO EHR (ELECTRONIC HEALTH RECORDS) & MEANING- FUL USE (MU) The American Recovery and Reinvestment Act of 009 (Recovery Act) (ARRA) was signed into law by President Obama on February 7, 009. The law includes the Health Information Technology for Economic and Clinical Health Act, or the HITECH Act, which established programs under Medicare and Medicaid to provide incentive payments for the meaningful use or MU of certified electronic health records (EHR) technology. On December 0, 009, CMS (The Centers for Medicare and Medicaid) and ONC (Office of the Naahsrcm.com

3 tional Coordinator for Health Information Technology) issued two regulations that laid the foundation for improving quality, efficiency and safety through meaningful use of certified electronic health records (EHR) technology. The CMS regulation: Defines and specifies how to demonstrate MU of EHR technology, which is a pre-requisite for receiving the Medicare or Medicaid incentive payments. Outlines the proposed payment methodologies for both the Medicare and Medicaid incentive programs. The ONC regulation: Sets initial standards, Implements specifications and Creates certification criteria for EHR technology that should enhance the interoperability, functionality, utility and security of health information technology. The Recovery Act specifies the following components of Meaningful Use:. Use of certified EHR in a meaningful manner which includes: a. the ability to electronically capture health information in a coded format, b. usage of that information to track key clinical conditions, c. implementation of clinical decision support tools to facilitate disease and medication management, and d. the ability to report clinical quality measures and public health information. Use of certified EHR technology for electronic exchange of health information to improve quality of health care which includes: a. exchanging health data among providers, b. providing security of that data. Use of certified EHR technology to submit clinical quality measures(cqm) and other such selected measures which includes: a. using standard formats for clinical summaries and prescriptions and standard terms to describe clinical problems, procedures and tests EHR IMPLEMENTATION STAGES In July 00, CMS issued a final rule for the Electronic Health Records Incentive Program for Medicare and Medicaid, establishing a three-phase approach to implementing the require-

4 ments for demonstrating meaningful use. Stage would begin on January, 0 and through a recent ruling was extended through 0. Stage was finalized by both CMS and ONC on August, 0 to begin on January, 04. Stage is now in the design stage and is slated to be finalized in 06. Stage - meaningful use criteria focuses on electronically capturing health information in a coded format, using that information to track key clinical conditions and communicating that information for care coordination purposes. It also calls for implementing clinical decision support tools to facilitate disease and medication management and reporting clinical quality measures and public health information. Stage - expands upon the Stage criteria to encourage the use of health IT for continuous quality improvement at the point of care and the exchange of information in the most structured format possible, such as the electronic transmission of orders entered using computerized provider order entry (CPOE) and the electronic transmission of diagnostic test results (such as blood tests, microbiology, urinalysis, pathology tests, radiology, cardiac imaging, nuclear medicine tests, pulmonary function tests and other such data needed to diagnose and treat disease). Additionally they may consider applying the criteria more broadly to both the inpatient and outpatient settings. Stage - focuses on promoting improvements in quality, safety and efficiency and on decision support for national high priority conditions, patient access to self management tools, access to comprehensive patient data and improving population health. THE 0 EHR INCENTIVE PROGRAM - PARTICIPATION In order to encourage the use of EHR systems in the medical community, Medicare & Medicaid will provide incentive payments to eligible professionals that are meaningful users of certified EHR systems in order to help defray the cost of instituting acceptable EHR systems. The participation regulations for EPs in the Medicare and Medicaid programs are:. An EP can only participate in either the Medicare or Medicaid program not both. However, after the initial designation to apply for either the Medicare or Medicaid incentive, EPs are allowed to change their selection once during payment years Medicare Eligible Professionals Criteria a. Physicians - Doctors of Medicine or Osteopathy, Dental Surgery/Medicine, Podiatrists Medicine, Optometry & Chiropractors b. Hospital based EPs do NOT qualify for Medicare EHR incentive payments. A hospital based EP is one who furnishes 90% or more of their services in an inpatient or emergency room hospital setting.

5 c. To receive the maximum incentive, an EP must begin participation by 0. Medicaid Eligible Professionals Criteria a. Physicians primarily medicine and osteopathy (Pediatricians have special eligibility & payment rules) b. Nurse Practitioners (NPs), Certified Nurse-Midwives, Dentists, c. Physician Assistants who practice in a Federally Qualified Health Center (FQHC) or Rural Health Center (RHC) that is led by a Physician Assistant. d. Medicaid population must be 0% of an EPs total patient volume (billed encounters) to qualify for the Medicaid incentive program (0% for pediatricians) e. An EP that practices predominantly in an FQHC or RHC and have a 0% patient volume attributable to needy individuals f. Children s Health Insurance Programs (CHIP) do not count towards the Medicaid patient volume 4. Medicare Advantage (MA) Incentive Criteria a. Payments may be made to qualifying MA organizations (MAO) for their affiliated EPs who are meaningful users of certified EHR technology. Specifically an MA EP must either: i. Furnish, on average, at least 0 hours/week of patient-care services and be employed by the qualifying MAO, or ii. Be employed by, or be a partner of, an entity that through contract with the qualifying MAO furnishes at least 80 percent of the entity s Medicare patient care services to enrollees of the qualifying MAO 5. If an EP provides services in more than one practice or location, 50% or more of the EP s patient encounters must be in a practice(s) or location(s) equipped with certified EHR technology. Example: If an EP works in practices/locations and of the have certified EHR technology, 50% or more of the EP s patient encounters must occur at the locations that have certified EHR technology. 6. EPs who see patients in both inpatient/er and outpatient settings and certified EHR technology is available at each location, the EPs must base their meaningful use calculations on patients in only the outpatient setting(s). 4

6 COMPARISONS OF MEDICARE & MEDICAID EHR PROGRAMS NOTABLE DIFFERENCES BETWEEN THE MEDICARE & MEDICAID EHR PROGRAMS MEDICARE Run by CMS $44,000 Maximum Incentive Payment per EP - Payments over 5 consecutive years (0 & 0), reduced payments over less years for 0-06 Payment adjustments will begin in 05 for providers who are eligible but decide not to participate Providers must demonstrate meaningful use every year to receive incentive payments. Last year EP can initiate program is 04 Last payment year in program is 06 Payment adjustments begin in 05 Only Physicians MEDICAID Run by Your State Medicaid Agency $6,750 Incentive Payment per EP - Payments over 6 years, does not have to be consecutive No Medicaid payment adjustments In the first year providers can receive an incentive payment for adopting, implementing, or upgrading EHR technology. Providers must demonstrate meaningful use in the remaining years to receive incentive payments Last year EP can initiate program is 06 Last payment year in program is 0 No Payment adjustments 5 Types of EPs LIMITATIONS OF PARTICIPATION IN MULTIPLE INCENTIVE PROGRAMS PARTICIPATION IN HITECH AND OTHER MEDICARE INCENTIVE PROGRAMS OTHER EHR MEDICARE INCENTIVE PROGRAM PQRS erx (E-prescribe) erx (E-prescribe) ELIGIBLE FOR HITECH? Yes, EPs can participate in both if eligible No - if the EP chooses to participate in the MEDICARE EHR Incentive Program, they cannot participate in the erx program simultaneously Yes - If the EP chooses to participate in the MEDICAID EHR Incentive program THE MEDICARE EHR INCENTIVE PLAN NOTE: As most of our clients will not participate in the Medicaid Incentive Program, the remainder of this manual will focus only on the Medicare Incentive Program. Those interested in the Medicaid Incentive Program should visit CMS EHR Incentive Program website and review the EHR Basics and Medicaid State Information subcategories. 5

7 To qualify for Medicare incentive payments, the EP must meaningfully use certified EHR technology for the duration of the EHR reporting period of the relevant payment year. The reporting period may be any continuous 90-day period or more within the first payment year, and the entire calendar year for all subsequent years. Example: If the EP wanted to report for the year 0, the last reporting period for 0 would begin on October, 0. In the original final rule, CMS had established a timeline that required providers to progress to Stage criteria after two program years under the Stage criteria. This original timeline would have required Medicare providers who first demonstrated meaningful use in 0 to meet the Stage criteria in 0. Under the recent Stage Final Rule, CMS delayed the onset of Stage criteria for EPs until fiscal year 04. This allows providers who first demonstrated MU in 0 to have three consecutive years of MU under the Stage criteria before advancing to Stage criteria. All other providers would meet two years of meaningful use under the Stage criteria before advancing to the Stage criteria in their third year. First Year of participation providers must demonstrate MU for a 90-Day EHR reporting period. Subsequent years - full year reporting period (entire calendar year), except for 04 In the Stage ruling, CMS made an exception for the year 04 requiring only a three-month reporting period for that year in order for EPs to make the necessary changes to their systems, regardless of their stage of MU. The three-month EHR reporting period is fixed to calendar year quarters in order to align with existing CMS quality measurement programs such as PQRS. 04 is the only time CMS will permit this three-month reporting period. The following table illustrates the progression of MU stages from when a Medicare provider begins participation with the program. STAGE OF MEANINGFUL USE BY FIRST MEDICARE PAYMENT YEAR st Year STAGE OF MEANINGFUL USE BY FIRST MEDICARE PAYMENT YEAR

8 PAYMENT & ADJUSTMENT PROVISIONS OF THE EHR INCENTIVE PLAN MEDICARE PAYMENT INCENTIVES Payment provisions for qualified providers are as follows: Providers may earn incentive payment equal to 75% of their Medicare allowed charges for covered services furnished by the provider in a year, subject to the maximum payment as stated in the following chart. Those EPs who attest and successfully adopt MU in 0 and 0 are the only EPs who will reap the highest incentive of $44,000 per EP. Providers had until October, 0 to demonstrate 90 days of MU with their EHR to qualify for the full $44,000 per-provider Medicare bonus. Those who begin the process in 0 can earn a maximum of $9,000 and in 04, $4,000. There will be no incentive payments to EPs who first become meaningful EHR users in 05 or thereafter. MEDICARE & MAO FIRST CALENDAR YEAR IN WHICH EP RECEIVES INCENTIVE PAYMENT CALENDAR YEAR & later 0 $8,000 0 $,000 $8,000 0 $8,000 $,000 $5, $4,000 $8,000 $,000 $, $,000 $4,000 $8,000 $8,000 $0 06 $,000 $4,000 $4,000 $0 TOTAL $44,000 $44,000 $9,000 $4,000 $0 Additional incentives are made for Medicare EPs practicing in HPSAs. (Health Professional Shortage Area) MEDICARE PAYMENT ADJUSTMENTS (PENALTIES) For 05 and later, Medicare EPs who are not meaningful users of Certified EHR technology by 04 will face Medicare payment reductions in 05. (unless the EP is successfully participating in the Medicaid EHR Incentive Program) EPs who first demonstrated MU in 0 or 0 must demonstrate MU for a full year in 0 to avoid payment adjustments in 05 and must continue to demonstrate MU every year to avoid 7

9 payment adjustments in subsequent years. The payment adjustments will be applied to the Medicare physician fee schedule (PFS) amount for covered professional services furnished by the EP during the year. The payment adjustment is % per year and is cumulative for every year an EP is not a meaningful user. For 08 and thereafter, if it is found that the proportion of providers who are Medicare EHR users is less than 75%, then reductions will increase by % each year but not by more than 5% overall. Payment adjustments will be as follows: % in 05, % in 06, % in 07, 4% in 08, and between -5% in subsequent years. HARDSHIP EXEMPTIONS In the proposed Stage period, in addition to those EPs who petitioned CMS and ONC to not penalize EPs in unusual circumstances, many specialty organizations petitioned CMS and ONC, to refocus the EHR objectives or exempt them from the program as the program s objectives favored primary care and did not match their specialties environment. The result of both requests was the creation of four hardship exemptions in the final Stage ruling. These hardship exemptions will be granted only under specific circumstances and only if CMS determines that providers have demonstrated that those circumstances pose a significant barrier to their achieving MU. The four exemptions are: Infrastructure: Clinicians must prove that they practice in an area with inadequate internet access or insurmountable barriers to obtaining it New Practitioners: Clinicians who begin practicing in 05 would be exempt from the MU penalty in 05 and 06, but would have to demonstrate MU in 06 to avoid the penalty in 07. Unforeseen Circumstances: Natural disaster or some other unforeseeable event that prevents meeting EHR MU criteria. CMS will consider this exception on a case-by-case basis. Scope of Practice: EPs who do not see patients face-to-face or who practice in multiple locations where they have no control over the availability of EHR technology. > The face-to-face exemption is directed towards Anesthesiologists, Pathologists, and Radiologists and these EPs must be registered in Medicare s Pro- 8

10 vider Enrollment Chain and Ownership System (PECOS) with a primary specialty of anesthesiology, pathology or radiology. > The multiple locations exemption covers EPs who see patients in multiple locations such as ASCs or nursing homes where the EP has no interest or say in whether the facilities install certified EHR systems for their use. As these facilities are not required under the EHR Programs to be EHR certified, the EPs would bear the entire impact of any payment adjustment. > The ruling states that the Scope of Practice exemptions may not be awarded for more than 5 years. CMS will regularly assess meaningful use compliance levels and the overall state of health information exchange and may make regulatory changes or develop new guidance that would eliminate the need for this exception. New legislation must be passed in order to make this exemption permanent. The deadline to apply for the exemption from the 05 payment adjustment is July, 04. However, CMS has not yet published the application process. THE REQUIREMENTS FOR REPORTING MEANINGFUL USE EHR SYSTEMS MUST BE CERTIFIED FOR CMS REGULATIONS EPs must use EHR systems that have been certified to meet the CMS regulations in order to receive incentive money. CMS has approved 6 organizations to perform Complete EHR and/or EHR Module testing and certification. These ONC-Authorized Testing and Certification Bodies (ATCBs) are required to test and certify EHRs to the applicable certification criteria adopted by the Secretary under subpart C of Part 70 Part II and Part III as stipulated in the Standards and Certification Criteria Final Rule The following organizations have been selected as ONC- (ATCBs): Surescripts LLC - Arlington, VA Date of authorization: December, 00. Scope of authorization: EHR Modules: E-Prescribing, Privacy and Security. ICSA Labs - Mechanicsburg, PA Date of authorization: December 0, 00. Scope of authorization: Complete EHR and EHR Modules. SLI Global Solutions - Denver, CO Date of authorization: December 0, 00. Scope of authorization: Complete EHR and EHR Modules. InfoGard Laboratories, Inc. San Luis Obispo, CA 9

11 Date of authorization: September 4, 00. Scope of authorization: Complete EHR and EHR Modules. Certification Commission for Health Information Technology (CCHIT) - Chicago, IL Date of authorization: September, 00. Scope of authorization: Complete EHR and EHR Modules. Drummond Group, Inc. (DGI) - Austin, TX Date of authorization: September, 00. Scope of authorization: Complete EHR and EHR Modules. The Certified Health IT Product List lists all EHR systems that have been certified for the EHR Incentive Program. This online list of certified electronic health record technology is updated as ONC-ATCBs certify new products. 0 REQUIREMENTS FOR STAGE OF MEANINGFUL USE. There are a total of 5 meaningful use objectives (Core and Menu-set) for EPs. These objectives were created to show how well a provider is using EHR by ensuring basic patient information is captured in the medical record and entered into the EHR system. To qualify for an incentive payment, 0 of these 5 objectives must be met.. EPs must also report on a total of 6 quality measures: required core measures (substituting alternate core measures where necessary) and additional measures. A maximum of 9 measures would be reported if the EP needed to attest to the required core, the alternate core and the additional measures CORE & MENU-SET OBJECTIVES In order to be a meaningful user in Stage, an EP must report both the required 5 core set and 5 menu set objectives (out of 0) that are specific to eligible professionals (EPs). The Stage Ruling made some changes to the current Stage objectives which will become effective January, 0. The changes are listed next to the applicable objective. CORE OBJECTIVES - EPS ARE REQUIRED TO REPORT THE FOLLOWING 5 EHR OBJECTIVES. Computerized Provider order entry (CPOE) - CMS is adding an optional alternate measure. The current measure is based on the number of unique patients with a medication in their medication list that was entered using CPOE. The new measure is based on the total number of medication orders created during the EHR reporting periods.. Drug-drug and drug-allergy interaction checks 0

12 . Maintain an up-to-date problem list of current and active diagnoses 4. Electonic-prescribing - CMS is adding an additional exclusion for providers who are not within a 0 mile radius of a pharmacy that accepts electronic prescriptions. 5. Maintain active medication list 6. Maintain active medication allergy list 7. Record demographics 8. Record and chart changes in vital signs (optional in 0) - The current measure specifies that vital signs must be recorded for more than 50 percent of all unique patients ages and over. The new measure amends that age limit to recording blood pressure for patients ages and over and height and weight for patients of all ages. The exclusions are also changing. 9. Record smoking status for patients years and older 0. Report ambulatory clinical quality measures to CMS/States - There will no longer be a separate objective for reporting ambulatory CQMs as part of MU. The objective is incorporated directly into the definition of a meaningful EHR user.. Implement one clinical decision support rule. Provide patients with an electronic copy of their health information, upon request. Provide clinical summaries for patients for each office visit 4. Capability to exchange key clinical information among providers of care and patient-authorized entities electronically - The objective will no longer be required for Stage. 5. Protect electronic health information MENU-SET OBJECTIVES - Providers must choose 5 EHR objectives from the following menu:. Drug-formulary checks. Incorporate clinical lab test results as structured data. General lists of patients by specific conditions 4. Send reminders to patients per patient preference for preventive/follow up care 5. Provide patients with timely electronic access to their health information 6. Use certified EHR technology to identify patient-specific education resources and provide to patient, if appropriate 7. Medicare reconciliation 8. Summary of care record for each transition of care/referrals 9. Capability to submit electronic data to immunization registries/systems* 0. Capability to provide electronic syndromic surveillance data to public health agencies* *All of the Stage public health objectives will require that providers perform at least one test of their certified EHR Technology s capability to send data to public health agencies, except where prohibited.

13 Core and Menu Set Exclusions If an EP can not meet a specific MU objective because it is outside the scope of their practice they may possibly be allowed to exempt that objective. For the of the 5 criteria that have exclusions, CMS designates narrow windows for physicians to report that the objective or measure does not apply to them because they have no patients, or no or insufficient number of actions that would allow calculation of the meaningful use measure. Two examples are A physician who has no patients age 65 or older or age 5 or younger would not have to meet the requirement to send an appropriate reminder to 0 percent or more of all patients in those age groups during the EHR reporting period. An EP must write at least 00 prescriptions to be eligible for the e-prescribing objective. If an EP does not write 00 prescriptions, he/she can be exempt from that objective. Not all objectives can be excluded but if an objective is exempt, it can count the same as if that objective was met. In the aforementioned examples, the EP may give the objective a 0 and then report on the remaining 9 objectives. Detailed descriptions of all the core and menu-set objectives including the numerators, denominators, thresholds and exclusions can be found at EHRIncentivePrograms. Attestation requirements are also listed. CLINICAL QUALITY MEASURES (CQMs) Similar to PQRS, as part of the criteria for satisfying meaningful use, clinical quality measures results must also be reported to CMS in addition to the Core and Menu objectives.. In order to report quality measures from an EHR, electronic specifications were developed that include the data elements, logic, and definitions for that measure in a format that can be captured or stored in the EHR so that the data can be sent or shared electronically with other entities in a structured, standardized, and unaltered format. Each electronic specification contains the following 4 main components Measure Overview/Description Measure title, description, number, measurement period, measure steward, and other relevant information to the measure. Measure Logic population criteria and measure logic for the numerator, denominator and exclusion categories and the algorithm used to calculate performance Measure Code lists QDS (Quality Data Sets) Elements lists and describes each Quality Data Set (QDS) data element associate with the measure.

14 The Guide for Reading EP measures and each measure and its components can be viewed in the download section of the Quality Measure Specifications site. Both of the following two documents should be viewed to understand the electronic measures applicable to your practice. (The xxx below is the measure number). NQF_HQMF_HumanReadable_xxx.pdf - This file contains the emeasure specifications including measure background information, required data elements, measure logic and measure calculation instructions.. NQF_Retooled_Measure_xxx.xls This file contains all of the code lists (a synonym for value sets) referenced by all QDS data elements in the emeasures. Reporting Quality Measures EPs must report on required Core Quality Measures (CQMs), and if the denominator of one or more of the required core measures is 0, then the EPs are required to report results for up to alternate core measures (ACMs). In addition, EPs must also select additional CQMs from a set of 8 CQMs (excluding the core/ alternate core measures.) It is acceptable to have 0 denominators provided the EP does not have an applicable population. Core Quality Measures - NQF (National Quality Forum) Measure Number & PQRS Implementation Number/Clinical Measure Title). NQF 00 - Hypertension Blood Pressure Measurement. NQF 008 Preventive Care and Screening Measure Pair a. Tobacco Use Asessment b. Tobacco Cessation Intervention. NQF 04, PQRS 8 Adult Weight Screening and Follow-up Alternate Core Quality Measures - (NQF Measure Number & PQRS Implementation Number/ Clinical Measure Title). NQF 004 Weight Asssessment and Counseling for Children and Adolescents. NQF 004 PQRI 0 Preventive Care & Screening; Influenza Immunization for Patients 50 Years old and older. NQF 008 Childhood Immunization Status CLINICAL QUALITY MEASURES EPS MUST COMPLETE OF THE 8 MEASURES. Diabetes: Hemoglobin Ac Poor Control

15 . Diabetes: Low Density Lipoprotein (LDL) Management and Control. Diabetes: Blood Pressure Management 4. Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) 5. Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) 6. Pneumonia Vaccination Status for Older Adults 7. Breast Cancer Screening 8. Colorectal Cancer Screening 9. Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD 0. Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction. Anti-depressant medication management: (a) Effective Acute Phase Treatment, (b)effective Continuation Phase Treatment. Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation. Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy 4. Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care 5. Asthma Pharmacologic Therapy 6. Asthma Assessment 7. Appropriate Testing for Children with Pharyngitis 8. Oncology Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer 9. Oncology Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients 0. Smoking and Tobacco Use Cessation, Medical Assistance: a) Advising Smokers and Tobacco Users to Quit, b) Discussing Smoking and Tobacco Use Cessation Medications, c) Discussing Smoking and Tobacco Use Cessation Strategies. Diabetes: Eye Exam. Diabetes: Urine Screening 4. Diabetes: Foot Exam 5. Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-Cholesterol 6. Heart Failure (HF): Warfarin Therapy Patients with Atria Fibrillation 7. Ischemic Vascular Disease (IVD): Blood Pressure Management 8. Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 9. Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: a) Initiation, b) Engagement 4

16 0. Prenatal Care: Screening for Human Immunodeficiency Virus (HIV). Prenatal Care: Anti-D Immune Globulin. Controlling High Blood Pressure. Cervical Cancer Screening 4. Chlamydia Screening for Women 5. Use of Appropriate Medications for Asthma 6. Low Back Pain: Use of Imaging Studies 7. Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control 8. Diabetes: Hemoglobin Ac Control (<8.0%) Clinical Quality Measures Exclusions If the required core, alternate core, or other measures do not encompass the type of patients that an EP typically sees, the EP may assign a zero value. CMS guidance states: An eligible professional (EP) is not excluded from reporting core clinical quality measures. However, zero is an acceptable value to report for the denominator of a clinical quality measure if there is no patient population within the EHR to whom that clinical quality measure applies. In the event that none of the 44 clinical quality measures applies to an EP s patient population, the EP is still required to report a zero for the denominators for all six of the core and alternate core clinical quality measures... REGISTRATION & ATTESTATION FOR THE MEDICARE EHR PROGRAM REGISTRATION CMS states all EPs should register for the program even if they are not yet on an EHR system. An EP must be registered in PECOS before registering for the EHR Incentive Program. To register for EHR, the following information is needed for each EP National Provider Identifier (NPI). National Plan and Provider Enumeration System (NPPES) User ID and Password. Payee Tax Identification Number (if you are reassigning your benefits). Payee National Provider Identifier (NPI) (if you are reassigning your benefits). If you have not yet registered, see the Registration User Guide for Medicare Eligible Professionals for step-by-step registration instructions. 5

17 ATTESTATION & ereporting There are two reporting methods available for reporting the Stage measures; Attestation and ereporting Pilots. Attestation - EPs must be registered and have decided which objectives and quality measures they will perform before can attest that they are using a certified EHR product. Attestation requires completing the Attestation and Payment form. CMS will allow an EP to designate a third party to register and attest on his or her behalf. This will require the appointed party to have an Identity and Access Management System (I & A) web user account (User ID/Password), and be associated to the EP s National Provider Identifier (NPI). If the appointed person does not have an I & A web user account, visit the following website to have one created. CMS offers the following guide books offering step-by-step instructions to assist EPs to register and attest to the EHR Incentive Program. Attestation User Guide for Medicare Eligible Professionals For more information on webinar tutorials, attestation worksheets and calculators, visit CMS Registration & Attestation site. ereporting Pilots Participation in the ereporting Pilot is voluntary and enables EPs to report EHR MU and PQRS quality measures together and would satisfy requirements of both the MU and PQRS programs. The key differences between the pilot and reporting MU and PQRS separately: Reporting period is the entire year Data is submitted on Medicare B patients only Report the quality measures required for MU Providers must indicate their intent to participate via the MU attestation page. To learn more about this reporting features, click below: downloads/0pqrs_medicareehr-incentpilot_final508_--0.pdf 6

18 STAGE JANUARY, 04 Stage criteria focuses on electronically capturing health information in a coded format and using that information to track key clinical conditions while communicating that information for care coordination purposes. Stage expands upon Stage to encourage the use of health IT for continuous quality improvement at the point of care and the exchange of information in the most structured format possible. To accomplish this, Stage will still require meeting 0 objectives. These objectives will make mandatory some EHR measures that are optional for Stage as well as upgrade Stage measures to higher thresholds. The number of required core set measures is increased to 7 from 5, with EPs reporting out of 6 additional menu set measures. CORE OBJECTIVES 9 of the current Stage One 5 Core Objectives remain 7 of the 0 current menu objectives will become Core objectives new core objective will be added 6 of the current Core Objectives were either deleted or incorporated into other objectives MENU OBJECTIVES of the current menu objectives will remain 5 new objectives will be added In addition, EPs must report on 9 out of 64 total clinical quality measures (CQMs), selecting them from at least of the 6 key health care policy domains. For more information, see the Stage vs. Stage Comparison chart offered by CMS and see the Stage Core and Menu Objectives in Addendum. CLINICAL QUALITY MEASURES (CQMs) In 04, EPs must report on 9 out of 64 total clinical quality measures (CQMs), selecting them from at least of the 6 key health care policy domains. See Addendum for the 04 CQMs. Other Stage Changes Electronically reporting CQMs - Beginning in 04, all Medicare EPs beyond their first 7

19 year of demonstrating MU must electronically report their CQM data to CMS. Definition Change of Hospital-Based EP EPs who can demonstrate that they fund the acquisition, implementation, and maintenance of CEHRT (certified electronic health record technology), including supporting hardware and interfaces needed for meaningful use without reimbursement from an eligible hospital or CAH, in lieu of using the hospital s CEHRT, can be determined non-hospital-based and potentially receive an incentive payment. Adoption of 04 Technology Criteria - All EHR Incentive Programs participants will have to adopt certified EHR technology that meets ONC s Standards & Certification Criteria 04 Final Rule Reporting Period Reduced to Three Months to allow providers time to adopt 04 certified EHR technology and prepare for Stage, all participants will have a three month reporting period in 04. This will only occur in 04. Menu Objective Exclusions While EPs may continue to claim exclusions if applicable for menu objectives, starting in 04, these exclusions will no longer count towards the number of menu objectives needed if there are other menu objectives which they can select. EPs will not be penalized for selecting a menu objective and claiming the exclusion if they would also quality for the exclusions for all the remaining menu objectives. Batch Reporting - Starting in 04, groups will be allowed to submit attestation information for all of their individual EPs in one file for upload to the Attestation System, rather than having each EP individually enter data. ADDENDUM - STAGE EHR INCENTIVE PROGRAM 7 CORE OBJECTIVES (EPs must report on all) Current Core Objectives Remaining in Stage. Computerized Provider Order Entry (CPOE) (More than 60% of medication, 0% of labs, 0% of radiology). E-prescribing (more than 50% of prescriptions). Record patient demographic information (> 80% unique patients (UP)) 4. Record and chart changes in vital signs (>80% UP) 5. Record smoking status for patients years or older (>80% UP) 6. Use clinical decision support ( 5 interventions & drug/drug, drug/allergy) 7. Patient Electronic Access to their health information(>75% UP with >5% accessing) 8. Provide clinical summaries for patients for each office visit (>50% of visits) 9. Protect electronic health information 8

20 Current Menu Objectives Upgraded to Core Objectives 0. Incorporate clinical lab test results into EHR (>55%). Generate lists of patients by specific conditions. Send reminders to patients per patient preference for preventive/follow up care (0% w/ or more visits). Use certified EHR technology to identify patient-specific education resources (>0%) 4. Medication reconciliation (>50%) 5. Summary of care record for each transition of care/referral 6. Capability to submit electronic data to immunization registries/systems* New Objective 7. Use Secure electronic messaging to communicate with patients on relevant health information (>5%) 6 MENU OBJECTIVES (EPs must report on of these objectives) Current Menu Objective Remaining in Stage. Submit electronic syndromic surveillance data to public health agencies New Menu Objectives. Record electronic notes in patient records (>0% UP). Imaging results accessible through CEHRT (>0% imaging results) 4. Record patient family health history (>0% UP) 5. Identify and report cancer cases to a State cancer registry 6. Identify and report specific cases to a specialized registry (other than a cancer registry) DELETED OBJECTIVES: The following current core objectives were either deleted or incorporated into other objectives for Stage.. Drug-drug and drug-allergy interaction (Incorporated into Core Objective #6). Maintain an up-to-date problem list of current and active diagnoses (Incorporated into Stage objective #5). Maintain active medication list (Incorporated into Core Objective #5) 4. Maintain an active medication allergy list (incorporated into Core Objective #5) 5. Report ambulatory clinical quality measures (CQMs) to CMS/States (Removed as an objective but is mandated as a general part of EHR) 6. Capability to exchange key clinical information among providers of care and patient- 9

21 authorized entities electronically (Eliminated in both Stage & ) 7. Implement drug-formulary checks (Menu) (Incorporated into Core Objective ) 8. Provide patients with timely electronic access to their health information within 4 business days of information being available to EP (Menu) (Eliminated from Stage in 04 and no longer an objective for Stage ) CLINICAL QUALITY MEASURES (CQMs) FOR 04 The 64 final 04 quality measures are listed in Addendum. HEALTH CARE POLICY DOMAINS Stage will offer 64 clinical quality measures of which EPs must report on at least 9. The 9 measures must be selected from at least of the following 6 health care policy domains.. Patient and Family Engagement. Patient Safety. Care Coordination 4. Population and Public Health 5. Efficient Use of Healthcare Resources 6. Clinical Processes/Effectiveness 0

22 ADDENDUM 04 CLINICAL QUALITY MEASURES (CQMs) Italicizes measures were either available or very similar to the measures introduced in Stage. The 4-digit number is the NQF (National Quality Forum) clinical measure number. Detailed information such as the measure description, numerator and denominator statements, and the measure steward may be found on the CMS website Appropriate Testing for Children with Pharyngitis Initiation and Engagement of Alcohol and Other Drug Dependence Treatment. 008 Controlling High Blood Pressure Use of High-Risk Medications in the Elderly Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Breast Cancer Screening Cervical Cancer Screening Chlamydia Screening for Women Colorectal Cancer Screening. 006 Use of Appropriate Medications for Asthma. 008 Childhood Immunization Status. 004 Preventive Care and Screening: Influenza Immunization Pneumonia Vaccination Status for Older Adults Use of Imaging Studies for Low Back Pain Diabetes: Eye Exam Diabetes: Foot Exam Diabetes: Hemoglobin Ac Poor Control Hemoglobin Ac Test for Pediatric Patients Diabetes: Urine Protein Screening Diabetes: Low Density Lipoprotein (LDL) Management Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic Appropriate Treatment for Children with Upper Respiratory Infection (URI) Coronary Artery Disease (CAD): Beta-Blocker Therapy Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%) Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)

23 Heart Failure (HF): BetaBlocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care. 00 Falls: Screening for Future Fall Risk. 004 Major Depressive Disorder (MDD): Suicide Risk Assessment. 005 Anti-depressant Medication Management ADHD: Follow-Up Care for Children Prescribed Attention Deficit/Hyperactivity Disorder (ADHD) Medication Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use Oncology: Medical and Radiation Pain Intensity Quantified Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/ Progesterone Receptor (ER/PR) Positive Breast Cancer Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients HIV/AIDS: Medical Visit HIV/AIDS: Pneumocystis jiroveci pneumonia (PCP) Prophylaxis Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan Documentation of Current Medications in the Medical Record Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Cataracts: Complications within 0 Days Following Cataract Surgery Requiring Additional Surgical Procedures Cataracts: 0/40 or Better Visual Acuity within 90 Days Following Cataract Surgery Pregnant women that had HBsAg testing Depression Remission at Twelve Months Depression Utilization of the PHQ-9 Tool 50. Children who have dental decay or cavities Child and Adolescent Major Depressive Disorder: Suicide Risk Assessment Maternal depression screening Maternal depression screening 54. Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists 55. Preventive Care and Screening: Cholesterol Fasting Low Density Lipoprotein

24 (LDL-C) Test Performed 56. Preventive Care and Screening: Risk-Stratified Cholesterol Fasting Low Density Lipoprotein (LDL-C) 57. Dementia: Cognitive Assessment 58. Hypertension: Improvement in blood pressure 59. Closing the referral loop: receipt of specialist report 60. Functional status assessment for knee replacement 6. Functional status assessment for hip replacement 6. Functional status assessment for complex chronic conditions 6. ADE Prevention and Monitoring: Warfarin Time in Therapeutic Range 64. Preventive Care and Screening: Screening for High Blood Pressure and Follow- Up Documented