Game Plan. Medicare Access and CHIP Reauthorization (MACRA) Act of 2015 MACRA. 3 Goals for our health care system

Transcription

1 Where to go for Help, Handouts, and Future Updates How to Navigate the Changes in Healthcare Disclosures: Dr. Henry is affiliated with and has lectured for numerous companies including Topcon, First Insight, RevolutionEHR, FoxFire, VisionWeb, SolutionReach, and the AOA Jay W. Henry, O.D., M.S. Game Plan Medicare Access and CHIP Reauthorization (MACRA) Value Based Modifier System (VM) Clinical Quality Measures (PQRS / CQMs) AOA MORE Ohio Health Information Partnership Community Health Record Meaningful Use Modifications for Meaningful Use Stage 3 final rule for 2018 Questions Medicare Access and CHIP Reauthorization (MACRA) Act of Goals for our health care system MACRA How does the Medicare Access & CHIP (Children s Health Insurance Program) Reauthorization Act of 2015 (MACRA) reform Medicare payment? The MACRA makes three important changes to how Medicare pays those who give care to Medicare beneficiaries 1. Repeals the Sustainable Growth Rate (SGR) formula for determining Medicare payments for health care providers services 2. Makes a new framework for rewarding health care providers for giving better care not just more care 3. Combines our existing quality reporting programs into one new system

2 MACRA Goals Offer multiple pathways with varying levels of risk and rewards to tie more payments to value Expand opportunities for a broad range of providers to participate in Alternate Payment Models (APMs) Minimize reporting burdens for APMs Promote understanding of each clinician s status with respect to MIPS/APMs Support multi-payer initiatives and the development of APMs in Medicaid, Medicare Advantage and other payer arrangements MACRA MACRA makes it easier for more health care providers to successfully take part in quality programs in one of two streamlined ways: 1. Merit-Based Incentive Payment System (MIPS) Streamlines existing quality reporting programs into one system under MIPS 2. Alternative Payment Models (APMs) Provides bonus payments for participation in eligible APMs EPs can participate in MIPS or meet requirements to be a qualifying APM participant MIPS can get positive, negative or zero payment adjustments APM Participant If criteria met, can receive 5 percent incentive payment for 6 years MIPS and APMs will go into effect over a timeline from 2015 through 2021 and beyond Path #1: Merit-based Incentive Payment System (MIPS) Physician Quality Reporting Program (PQRS) Meaningful Use (MU) MIPS Value-based Modifier (VM) MACRA MIPS Pathway The separate payment adjustments under PQRS, VM and EHR-MU will end on Dec 31, 2018 They will be factors in MIPS so you still need to understand the above programs January 1, 2019 the Merit-Based Incentive Payment System (MIPS) and Alternate Payment Model (APM) incentive payments begin MACRA MIPS Pathway Applies to individual EPs, groups of EPs or virtual groups Will be most common for ODs 2019 and 2020 (First two years) Physicians, PAs, CRNAs, NPs, Clinical Nurse Specialists 2021 and on may have other EPs eligible Excludes EPs if: Qualifying APM participants (QP) Partial Qualifying APM participants Low volume threshold exclusions MIPS Composite Performance Score EPs will get a single composite performance score which will range from 0 to 100 Based on 4 weighted (by year) performance categories 1. Clinical practice improvement activities 2. Meaningful Use of certified EHR technology (MU) 3. Resource use (VM) 4. Quality (PQRS) Performance score will be compared to other providers

3 MIPS Payment Adjustment EPs will receive a positive, negative, or neutral adjustment based on if their score is above, below or at the performance threshold up to the set percentages for each year (Budget Neutral) MIPS Category Weight and Adjustment Performance Categories Year Quality Measures Resource Use Clinical Improvement Activities Meaningful Use of Certified EHR Technology MIPS Adjustment Factor (+/-) % 10% 15% 25% +/- 4% * % 15% 15% 25% +/- 5% ** % 30% 15% 25% +/- 7% ** 2022 and beyond 30% 30% 15% 25% +/- 9% ** * In 2019, exceptional performers will be eligible for up to 12% increase (3 x base rate) ** In 2020 to 2026, exceptional performers will be eligible for a 10% increase Because MIPS adjustments are budget neutral a scaling factor may be applied to upward adjustments to make total upward and downward adjustments equal MIPS Excluded EPs There are 3 groups of physicians who will NOT be subject to MIPS: EPs in their first year of Medicare participation Participants in eligible Alternate Payment Models who qualify for the bonus payment Below low volume threshold that will be set May be helpful for some ODs MIPS does not apply to hospitals or facilities MACRA Pathway #2: Alternate Payment Models (APMs) APMs are new approaches to paying for medical care through Medicare that incentivize quality and value APM participants who are not using eligible APMs will receive favorable scoring under MIPS clinical practice improvement activities category plus APM specific rewards Proposed types of APMs include: Comprehensive ESRD Care Model (Large Dialysis Organization) Comprehensive Primary Care Plus (CPC+) Next Generation ACO Model Oncology Care Model Two-Sided Risk Arrangement Medicare shared savings programs Track 2 and Track 3 MACRA Alternate Payment Models Only some APMs will be Eligible APMs Eligible APM entities: Most Advanced APMs Require the use of certified EHR technology Provide for payment for covered professional services based on quality measures comparable to those measures in MIPS performance category Participants must bear financial risk for monetary losses under the APM that are in excess of a nominal amount or are medical homes MACRA Eligible APMs Participation Qualifying APM participants (QPs) Physicians who have a certain % of their patients or payments through an eligible APM QPs are not subject to MIPS Receive 5% lump sum bonus payments for years Receive a higher fee schedule update for 2026 onward

4 Potential Value-Based Rewards How will MACRA affect me? You can do any of the following: MIPS participation only You will get MIPS adjustments (discussed earlier) Partial APM participation (not eligible APMs) You will get APM specific rewards plus MIPS adjustments Eligible APM participation You will receive eligible APM specific rewards plus 5% lump sum bonus Timeline 2018 Payment Adjustments Notice MIPS and APM arrows go past 2026 so MACRA is not going away anytime soon! PQRS 2% penalty based on participation in 2016 Medicare EHR Incentive Program 3% penalty based on participation in 2016 Value Based Payment Modifier (VM) Mandatory quality-tiering for PQRS reporters Groups 2-9 EPs and solo physicians will see +/-2% adjustment based on quality-tiering Groups with 10+ EPs will see +/-4% adjustment Non-PQRS reporters will see automatic 2% penalty unless in group of 10+ and they will see 4% penalty What is the Value-Based Modifier? The VM is an adjustment made on a per-claim basis to Medicare payments for items and services furnished under the Medicare Physician Fee Schedule (PFS) 2017/2018 Value-Based Modifier The VM assesses both the quality of care furnished and the cost of that care during a performance period The VM is applied at the Taxpayer Identification Number (TIN) level and applies to all physicians and certain non-physician EPs billing under the TIN who are subject to the VM during the payment year

5 2018 VM Policies and Penalties Performance year is 2016 Applies to physicians, PAs, NPs, CNSs, and CRNAs in groups with 2+ EPs and those who are solo practitioners, as identified by their TIN Quality-tiering is mandatory Physician TINs will be subject to upward, neutral, or downward adjustments Quality-Tiering Approach 2018 VM Based on 2016 performance Automatic 2% (maximum) downward adjustment will be applied for not meeting the satisfactory reporting criteria to avoid the 2018 PQRS payment adjustment Under quality-tiering, the maximum upward adjustment is up to +5%x ( x represents the upward VM payment adjustment factor) Quality-Tiering Approch 2018 VM How does 2016 PQRS affect 2018 VM * x represents the upward VM payment adjustment factor How does 2016 PQRS affect 2018 VM QRUR Report GET THEM! Quality and Resource Use Report (QRUR) Download your 2015 mid-year report now to understand your TIN s current quality and cost performance Review quality measures benchmarks under the VM

6 How to Obtain a QRUR Payment/PhysicianFeedbackProgram/Obtain-2013-QRUR.html VM: What to expect in 2016 Fall 2016: Release of the 2015 Quality and Resource Use Report (QRUR) For all groups and solo practitioners nationwide, CMS will make available QRURs based on quality and cost data from CY 2015 The reports will show the 2017 Value Modifier payment adjustment under the PFS for all physician solo practitioners and physicians in groups with 2 or more EPs VM: What to expect in 2017 January: Application of the Value Modifier The Value Modifier will apply to physician payments under the PFS for physician solo practitioners and physicians in groups of 2 or more EPs based on performance in 2015 Spring- June 30: PQRS Group Practice Reporting Option (GPRO) Registration Open Groups with 2 or more EPs can register to participate in the 2017 PQRS GPRO Fall: Release of the 2016 QRUR For all groups and solo practitioners nationwide, CMS will make available QRURs based on quality and cost data from CY 2016 VM: What to expect in 2018 January: Application of the Value Modifier The Value Modifier will apply to payments under the Medicare Physician Fee Schedule (PFS) for physicians and non-physician eligible professionals (EPs) who are solo practitioners or in groups of 2 or more EPs Spring- June 30: Physician Quality Reporting System (PQRS) Group Practice Reporting Option (GPRO) Registration Open Groups with 2 or more EPs can register to participate in the 2018 PQRS GPRO 2019 Changes to MIPS! Clinical Quality Measures 2016 PQRS CHANGES CQMs are tools that help measure and track the quality of health care services provided by eligible professional These measures use data associated with providers ability to deliver high-quality care or relate to long term goals for quality health care

7 Clinical Quality Measures Measuring and reporting CQMs helps to ensure our health care system is delivering effective, safe, efficient, patient centered and timely care 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 2016 PQRS Measures 281 measures in the PQRS measures set 23 cross-cutting measures New Diabetic Retinopathy measures group Only available through registry reporting Added the Qualified Clinical Data Registry (QCDR) reporting option for groups 2018 payment adjustment is the last adjustment that will be issued under PQRS 2019 starts adjustment for quality reporting under Merit-Based Incentive Payment System (MIPS) National Quality Strategy domains The 281 Clinical Quality Measures are spread across the following strategy domains: Patient Safety Person and Caregiver-Centered Experience and Outcomes Communication and Care Coordination Effective Clinical Care Community / Population Health Efficiency and Cost Reduction PQRS: Claims and Registry Reporting Individual Reporting: Claims Based 2016 performance year and 2018 payment adjustment No changes for claims and registry reporting for individual EPs 9 measures covering at least 3 domains or if don t meet 9 measures or 3 domains you must report on each measure that is applicable AND You must report each measure for at least 50% of the Medicare Part B FFS patients for which the measure applies Measures with 0% rate will not count Must have 1 cross-cutting measure

8 Individual Reporting: Qualified Registry Individual Reporting: EHR Direct 2016 performance year and 2018 payment adjustment 9 measures covering at least 3 of the domains If an EP s EHR does not contain patient data for at least 9 measures covering at least 3 domains, then the EP must report on all the measures for which there is Medicare patient data Providers must use a Certified EHR Cross Cutting Measures If the EP sees 1 Medicare patient in a face-toface encounter they must report on at least 1 cross-cutting measure (included in the 9 measures) A cross-cutting measure is defined as a measure that is broadly applicable across multiple providers and specialties Cross Cutting Measures 2016 CMS Cross-Cutting Measure Set Examples: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Controlling High Blood Pressure Closing the Referral Loop: Receipt of Specialist Report Patient-Assessment- Instruments/PQRS/Downloads/2016_PQRS- Crosscutting.pdf 2016 Measures Groups 2016 Measures Groups The Diabetic Retinopathy measures group must be reported by a qualified registry Report 7 measures for a minimum of 20 patients, 11 of which must have traditional Medicare Part B insurance Easy way to successfully meet PQRS and avoid the PQRS penalty It DOES NOT satisfy for quality reporting for meaningful use it only satisfies PQRS reporting

9 The Future of PQRS Reporting Best ways to do PQRS reporting: EHR Direct Reporting Check with your EHR vendor to see if they have this! Registry Reporting AOA has created a Clinical Data Registry for Optometry It is called 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! Immediate PQRS Benefits PQRS is made easier by a registry Eliminates the need for additional F codes on claims which was claims based we discussed 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 Cost of AOA MORE $0.00 for AOA Members! $0 charged by AOA Some Vendors are charging $10/month per doc $1,800 per year for non-members

10 EHR Vendors Integrated Start and Stop? By Feb 2016 RevolutionEHR Compulink MaximEyes Coming mid 2016 Eyefinity/OfficeMate Williams Practice Director Crystal PM Goal to add: NextGen My Vision Express others 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 What Does AOA More Look Like?

11 What really is PQRS? For Medicare patients with certain diagnosis and procedures, specific clinical tasks must be completed and documented To indicate to CMS, that you completed these clinical tasks, you must then attach a Quality-Data Code (QDC) when billing Medicare Part-B Remember The Diagnosis and Procedures trigger QDC Initiatives-Patient-Assessment- Instruments/PQRS/Downloads/2016_PQRS_Im plementationguide.pdf In the future, Registry Reporting and EHR Reporting will take over This will be discussed later today What really is PQRS? Example: Medicare patient is in for an office visit Diagnosis of AMD PQRS suggests that you discuss the risks and benefits of AREDS formulation If you have documented the discussion of risks and benefits of AREDS formulation in the medical record then When submitting your billing (procedure and diagnosis) to CMS you add a PQRS code which states you completed the PQRS requirement What are they KEY CLAIMS BASED PQRS Codes? # Measure Title 2016 Active PQRS Measures for Eyecare 12 Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation 14 Age-Related Macular Degeneration (AMD): Dilated Macular Examination 19 Diabetic Retinopathy: Communication with the Physician Managing On-going Diabetes Care 110 Preventive Care and Screening: Influenza Immunization 111 Pneumonia Vaccination Status for Older Adults 117 Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient 128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up 130 Documentation and Verification of Current Medications in the Medical Record 131 Pain Assessment and Follow-Up 140 Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement 141 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care 226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented EASY STEPS FOR ALL MEDICAL DIAGNOSIS When Billing 99xxx or 92xxx Office Visit If you see a Medicare patient: For a Visit 99xxx or 92xxx AND They have ANY MEDICAL DIAGNOSIS YOU SHOULD THINK ABOUT PQRS! There are 4 PQRS Codes that apply to ANY MEDICARE PATIENT you see for a 92xxx or 99xxx visit with ANY DIAGNOSIS We recommend you use these when apply! There are 3 other PQRS codes that you could use for ANY MEDICARE PATIENT you see with ANY DIAGNOSIS but only with 99xxx office visit codes These may be used when they apply but we don t recommend them at this time

12 Medicare Patient with ANY Diagnosis 99xxx or 92xxx Office Visit Measure CPT II Code Description Medicare Patient with ANY Diagnosis 99xxx or 92xxx Office Visit Measure CPT II Code Description 130 G8427 or G8428 or G8430 Current medications with Name, Dosage, Frequency, and Route documented Incomplete / no provider documentation of current meds Documentation that patient ineligible for med assessment which includes patient refuses, urgent medical tx, or cognitively impaired F or 1036F Patient screened for tobacco use AND received tobacco cessation counseling, if identified as a tobacco user Current tobacco non-user 131 G8730 or G8731 or G8442 or G8939 or G8732 or G8509 Pain assessment documented as positive using a standardized tool and follow-up plan is documented Pain assessment using a standardized tool is documented as negative, no follow-up plan required Pain assessment NOT documented as being performed Pain assessment documented as positive, follow-up plan not documented No documentation of pain assessment Pain assessment documented as positive using a standardized tool, follow-up plan not documented, reason not given Medicare Patient with ANY Diagnosis 99xxx or 92xxx Office Visit How Do We Code It on 1500 Form? Measure 317 CPT II Code G8783 OR G8950 OR G8784 OR G8785 OR G8952 Description Normal blood pressure reading documented, follow-up not required Pre-Hypertensive or Hypertensive blood pressure reading documented, AND the indicated follow-up is documented Blood pressure reading not documented, documentation the patient is not eligible Blood pressure reading not documented, reason not given Pre-Hypertensive or Hypertensive blood pressure reading documented, indicated follow-up not Dx A: ANY MEDICAL DX Dx B: Date Service Place Service Procedure (CPT I) and QDC (CPT II) Procedure Description 1/14/ Exam 1 1/14/ G8427 List current meds (dosages) & verification with patient 1/14/ F Current tobacco non-user 1 1/14/ G8783 Normal blood pressure reading documented, follow-up not required Dx 1 1 How about the eye specific measures? EASY STEPS If you see a Medicare patient for any VISIT (99xxx or 92xxx) AND they have Primary Open Angle Glaucoma Age Related Macular Degeneration Diabetes YOU MUST THINK ABOUT the other PQRS codes that apply?

13 Medicare Patient with Diagnosis: POAG, AMD, or DM # Measure Title 12 Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation 141 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care 14 Age-Related Macular Degeneration (AMD): Dilated Macular Examination 140 Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement 19 Diabetic Retinopathy: Communication with the Physician Managing On-going Diabetes Care 117 Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient EASY STEPS Let s look at the details of these diagnosis POAG AMD DM Medicare Patient? 18 years or older? Glaucoma Diagnosis? Glaucoma Diagnosis PQRS Measure 12 POAG: Optic Nerve Evaluation If Diagnosis code is H40.10x0-H40.10x4, H40.11x0-H40.11x4, H H , H H , H H401234, H H401294, H H40.153, H and procedure code is , , , , , or AMD Diagnosis PQRS Measure 140 AMD: Counseling on Antioxident Supplement Medicare Patient? 50 years or older? AMD Diagnosis? If Diagnosis code is H35.30, H35.31, or H35.32 and procedure code is , , , , , Did you evaluate the optic nerve once in the past 12 months? Yes = 2027F Optic nerve not evaluated use modifiers 2027F - 1P = Medical Reason 2027F - 8P = No Reason Given Did you discuss the risks and benefits of AREDS formula with the patient in the past 12 months? Yes = 4177F If you did not discuss AREDS with the patient use modifier 4177F -8P = No Reason Given Diabetes Diagnosis - PQRS Measure 117 DM: Dilated Eye Exam Want All The Flow Charts Medicare Patient? Age 18 75? Diabetes Diagnosis? Did you do a Dilated Fundus Examination within the past 12 months? Yes = 2022F If Diagnosis code is E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359, E10.36, E10.39, E10.40, E10.41, E10.42, E10.43, E10.44, E10.49, E10.51, E10.52, E10.59, E10.610, E10.618, E10.620, E10.621, E10.622, E10.628, E10.630, E10.638, E10.641, E10.649, E10.65, E10.69, E10.8, E10.9, E11.00, E11.01, E11.21, E11.22, E11.29, E11.311, E11.319, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359, E11.36, E11.39, E11.40, E11.41, E11.42, E11.43, E11.44, E11.49, E11.51, E11.52, E11.59, E11.610, E11.618, E11.620, E11.621, E11.622, E11.628, E11.630, E11.638, E11.641, E11.649, E11.65, E11.69, E11.8, E11.9, O24.011, O24.012, O24.013, O24.019, O24.02, O24.03, O24.111, O24.112, O24.113, O24.119, O24.12, O24.13 and procedure code is , , , , , , , , G0270, G0271 Did you do a Dilated Fundus Examination? NO = 2022F -8P = No Reason Given or 3072F = Low Risk of Retinopathy (No Retinopathy previous year) Visit click on PQRS at top of page Available full size and in color

14 The EASY Plan? You know the PQRS codes that apply to all Medicare patients... We suggest you use the 4 that apply to the 92xxx and 99xxx office visits when they apply You know the other diagnosis (DM, POAG, AMD) that apply to eyecare Use all of them every time they apply for each diagnosis! Seeing Eye to Eye: CliniSync and Optometrists Remember, this gives you 10 Measures to worry about and makes it much easier to achieve! Governance CliniSync is a grass-roots, community and statewide organization that is now financially independent of federal funds CliniSync Community Hospitals Founders Ohio Hospital Association, Ohio Osteopathic Association, Ohio State Medical Association and Ohio Department of Insurance Public Health Physicians Board of Directors CliniSync Advisory Council Physicians, hospitals, health plans, HIT, long-term care, consumer group Physicians, hospital systems, community and children s hospitals, health plans, long-term care, behavioral health Optometrists Chiropractors Dentists Pharmacists Social Service Agencies Commercial Labs Allied Health Long-Term, Post Acute Care Behavioral Health No one is left behind 149 Total Contracted Hospitals 119 Live Hospitals 1,200 Practices 400 Long-Term, Post Acute Care 95% of hospitals in Ohio have committed to an HIE 92% of 11.5M Ohioans will be served Ohio s CliniSync HIE Go to MEMBER RESOURCES to see the full map and search by location and type of facility under tabs: OUR MEMBERS, HOSPITAL STATUS Hospital Implementation Process Data Colle ction Community Memorial Hicksville Magruder Hospital O Bleness Memorial Ohio Health (8) Trinity Twin City Data Analysis Wayne Community Wyandot Hospital Lake Health (2) The Medical Center at Elizabeth Place 149 Total Active Hospitals Certificati on Testing Firelands Fisher Titus Holzer Health System (2) Ohio State (6) Akron Children s (2) Samaritan Regional Production *Adena Health System (3) *Akron General (3) *Alliance Community *Aultman (3) LAB result delivery only *Avita (2) *Barnesville *Bellevue *Berger Hospital *Blanchard Valley (2) Cleveland Clinic (12) *Coshocton County *Community Health and Wellness (3) *Dayton Children s *East Liverpool *Elyria Memorial *Fairfield Med Ctr *Fayette County *Fremont Memorial *Fulton County *Grand Lake/Joint Twp *Genesis (2) Harrison Community *Henry County Hocking Valley RAD only *Humility of Mary (3) *Joel Pomerene Mem Health *Kettering (6) *King s Daughters *Knox Community Hospital Rad only *Licking Memorial *Signed off on results delivery *Lima Memorial *Marietta Memorial (2) *Mary Rutan *MedCentral/Ohio Health Mansfield(2) *Mercer County *Mercy Canton *Mercy Lorain (2) *Memorial Hospital Union County *Mercy Toledo (7) METROHealth *Morrow County *Mount Carmel Health System (4) Rad/Trans only *Nationwide Children s - Rad only *Parma Community *Premier Health Partners (4) *Robinson Memorial *Salem Community *SEORMC *St. John *Saint Rita s (2) *St. Vincent Charity *Southern Ohio Med Ctr *Southwest General *Trinity Health (2) Summa Health (4) *Union Hospital *University Hospitals (9) *University of Toledo Med Ctr *Van Wert Western Reserve *Wilson Memorial *Wooster Community

15 Hospital Patient Information Flow #1 Hospital System Radiology - Reports #2 CliniSync #3 Physician Office Connecting the Medical Neighborhood Registration - Admission Notice PDF File Delivery Discharge Notice -Transfer Notice Transcription -Clinical/Textual Discharge Summaries -Cardiology Reports Lab - General Chemistry - Microbology - Pathology -Normalize -Patient Matching -Build MPI inbox EHR Practice EHR Health information exchange is one critical element to coordination of patient care - Blood Bank CLINISYNC SERVICES Connect Integrate Notify Contribute Consult DIRECTory CliniSync Services AA Community Health Record Clinical Results Inbox DIRECT Messaging Clinical Results & Reports Admission & Delivery Discharge Electronic Orders Notifications Integrated DIRECT Messaging Public Health Reporting CliniSync Community Summary of Care Liaisons Document (CCD) Meaningful Use & HL7 Interfaces More DIRECT addresses of providers Health Plan Services Community Health Record: A Single Point of Access Community Health Record Access a patient s treatment history, hospital encounters, problem list, allergies, lab results, radiology and other transcribed reports exchanged through CliniSync Check patient demographic and insurance information captured by other providers The Community Health Record provides a single point of access for providers to quickly identify where and when their patients have sought care within the CliniSync community and to further coordinate care View, print or download encounter-specific or full continuity of care summaries for your records Coming soon: Query Ohio s Automated Rx Reporting System (OARRS) as required by law

16 Community Health Record Patient Search Enter the first and last name Add date of birth for common names Enter the Reason for Searching It will usually be Clinical Non-Emergent You can create your own Care Summary from all of the data available

17 You can download the care summary into your EHR as a CCD or print it You can see demographics and face sheets contributed about the patient The encounters tab provides a view of the patient s history at the encounter visit level The results tab allows you to see details of results, if you click on any result, you will see the details Results You Can Find In the Community Health Record you can see results such as: Blood work of any type: A1C levels, cholesterol levels, microbiology reports and full summaries of care from hospital settings Radiology results: MRI, CT, X-ray reports, and others Carotid testing, ultrasound testing, heart testing and many others Private practices are now beginning to contribute patient health data to the Community Health Record, which will make information more robust You Can Contribute Health Data #1 Ambulatory Organization EHR Practice EHR Patient presents to receive care, care is received and documented in EHR Visit Summary - Problems - Meds - Allergies - Screening Secure export for sharing with other treating providers #2 Secure Transport -Normalize -Patient Matching -Build MPI Methodology - model varies by EHR vendor #3 CliniSync Patient Summary -Documents Visit Summary - Problems - Meds - Allergies - Screening 104

18 For More Information Health information exchange isn t just about technology, it s about community and trust Ohio Health Information Partnership CliniSync HIE Visit us and sign up for our newsletter at: You may also call for more information 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

19 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 (Modified Stage 2) with accommodations for Stage 1 providers Attest to (Modified Stage 2) 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 (Modified Stage 2) 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

20 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 Modified Stage 2: Stage 3: Core Objectives 5 of 10 Menu Objectives Previous 2014 Stage 1 13 Core Objectives 5 of 9 Menu Objectives Current Modified Stage 2 10 Objectives (including one consolidated public health reporting objective with 3 measure options) Changes from Stage 2 for EPs Objectives (Modified Stage 2) 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 (Modified Stage 2) 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

21 Stage 3 Modified Stage 2 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 Modified Stage 2: 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)

22 Stage 3 Modified Stage 2 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 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 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

23 Modified Stage 2 for 2015 Stage 1 EPs Stage 3 Modified Stage 2 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 2016 Stage 1 EPs CPOE Details for Modified Stage 2 For 2016 Reporting period only if you were scheduled to be in Stage 1 for 2016 Measure 1: More than 60% 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 2016 only Measure 3: Provider may claim an exclusion for measure 3 (radiology orders) for an EHR reporting period of 2016 only 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 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

24 Stage 3 Modified Stage 2 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 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

25 Stage 3 Stage 3 Modified Stage 2 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 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

26 Stage 3 Modified Stage 2 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 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

27 Stage 3 Modified Stage 2 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 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

28 Stage 3 Modified Stage 2 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 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

29 Stage 3 Modified Stage 2 Stage 3 Modified Stage 2 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 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 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

30 Modified Stage 2 for 2015 Stage 1 EPs Public Health Reporting Alternate for 2016 Stage 1 EPs For 2016 reporting period only EPs may claim an Alternate Exclusion for Measure 2 and Measure 3 (Syndromic Surveillance and Specialized Registry Reporting) in 2016 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 described in (e)(10)(i)(c) 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 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

31 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 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! 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) 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

32 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 2016 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

33 Stage 3 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.

34 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 Clinical Quality Measures (CQMs) Still Required to be a Meaningful User CQMs are tools that help measure and track the quality of health care services provided by eligible professional These measures use data associated with providers ability to deliver high-quality care or relate to long term goals for quality health care Clinical Quality Measures Measuring and reporting CQMs helps to ensure our health care system is delivering effective, safe, efficient, patient centered and timely care 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

35 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 Medicare Payment Adjustments

36 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 1st, 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 1st, 2016 If you are not a meaningful user in 2015 = 3% payment reduction starting Jan 1st, 2017 If you are not a meaningful user in 2016 = 3% payment reduction starting Jan 1st, 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 Questions? Jay W. Henry, O.D., M.S. CMS EHR Incentive Audits

37 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 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, 2014 Pre Payment Audit Outcomes 5,825 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! 821 Passed Failed So, how did these entities make out? 2999

38 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% Only about 179 Post Payment audits were still in process but 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 Audit Outcomes Post Payment Audits as of Sept, Passed Failed 1,106 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%) 3495 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! 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

39 What you will receive Audit Engagement Letter 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 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 Documentation Suggested Please have a signed contract / statement from your EHR Vendor showing Proof of Possession of your Certified EHR (CEHRT) Statement should include doctor name, certified EHR version number you are using, and date you started using the certified version and that you were using it during the entire reporting period

40 Primary Documentation The source reports / document(s) from the providers CEHRT which were used during attestation are one of the most important report(s) This should provide a summary of the data that supports the information used for attestation It should show all numerators and denominators used for attestation Needs to show specific doctor and time period on report Additional documentation can be used if a report is not available or the information entered differs from the report and must demonstrate how the data was accumulated and calculated Providers should retain a report from CEHRT to validate all clinical quality measure data

41 Documentation for EXCLUSION(S) Immunization Exclusion Documentation to support each exclusion to a measure claimed by the provider Report from the certified EHR system that shows a zero denominator for the measure or otherwise documents that the provider qualifies for the exclusion Information needed during an Audit of Percentage Based Objectives Examples of Information Needed for Successful Audit Outcomes Primary document is always the report from the EHR system showing numerator, denominator, and percentage for these measures Be sure to always keep a copy of the report you used during your attestation Extra documentation: You should have a screen shot showing you completing the measure in question. For example for erx a screen shot for a patient with you as the provider in the date range you are attesting Any exclusion(s) should show denominator supports the exclusion or a letter of explanation is needed For example for erx a denominator on the report of less than 100 would meet the exclusion criteria Electronic Prescribing More than 40% of all permissible prescriptions written are transmitted electronically using certified CEHRT You can be excluded from meeting this objective if you write fewer than 100 prescriptions during the reporting period or (New Starting 2013) 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 50% of prescriptions are compared to a drug formulary and transmitted electronically 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 How to get Screen Shots Window s free Snipping Tool Start, Accessories, and find Snipping Tool PrtScn on keyboard which copies to clipboard, holding area, and then past in to Word Techsmith s advanced tool called Snagit

42 Information needed during an Audit of Non-Percentage Based Objectives These are the objectives that require a Yes attestation in order for a provider to meet the objective for meaningful use To validate provider attestation for these objectives, additional documentation is needed The following are examples of how you may support meeting these objectives Information needed during an Audit of Non-Percentage Based Objectives Primary Documentation is typically: one or more screenshots from the certified EHR system that are dated during the EHR reporting period selected for attestation Secondary Documentation if screenshot not available: a signed letter from your EHR vendor may also be helpful stating this is available, enabled and active, during the entire reporting period and audit logs show it has not been disabled

43 Drug-Drug and Drug-Allergy Checks EP has enabled the functionality to automatically check for drug-drug and drugallergy interactions for the entire EHR reporting period There is no exclusion for this objective. No longer a separate objective for Stage 2 It has been incorporated into the Stage 2 Clinical Decision Support measure One or more screenshots from the certified EHR system that are dated during the EHR reporting period selected for attestation 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? Jay W. Henry, O.D., M.S.