CHCANYS 2016 Meaningful Use Webinar # 2

Transcription

1 CHCANYS 2016 Meaningful Use Webinar # 2 May 18 th, 2016 Presented by PTSO Date

2 Agenda Introductions Program Updates 2015 Attestations Meaningful Use Stage Preparing for the Reporting Period UDS Reporting Gender Identity and Sexual Orientation Please take our Webinar Survey at the end! 2

3 Introductions PTSO Chief Medical Officer: Dr. Julie Colin Grant Lead: Katherine Gudgel Meaningful Use Advisor: Marta Sylvia 3

4 Introductions Updates on progress Syracuse? Brownsville? Does anyone have questions on upgrades in process? 4

5 Health Center Experience Experiences to share? Progress for 2015 Attestations? 5

6 Meaningful Use: Medicaid AIU Stage 1 Stage 2 Stage 3 AIU Adopt, Implement, Upgrade OR Demonstrate Stage 1 Stage 1 Objective: Data capture and sharing 15 Core objectives of 10 Menu Objectives 6 Clinical Quality Measures Modified Stage Objective: Advance clinical processes 10 Core Objectives 0 Menu Objectives 9 Clinical Quality Measures Stage 3 Objective: Improved Outcomes 8 Objectives 2017 or Clinical Quality Measures EHR Incentive Programs CMS.gov. Retrieved October 7 th, 2015 from, 6

7 Reminder: Goals of the Changes 1. Align Stages 1 and 2 with Stage 3 2. Reduce Complexity of the Program 3. Reduce Reporting Burden 4. Work toward shift to single set of sustainable objectives EHR Incentive Programs CMS.gov. Retrieved October 7 th, 2015 from, 7

8 Reminder: 2015 Changes - Reduce 2015 ONLY to a 90 Day Reporting Period - Realign measures to support Stage 3 structure with single phase for all participants and no menu measures - Remove duplicative, repetitive, and topped out measures - Adjust patient engagement measure thresholds - Consolidate public health objectives Measures allow exclusions for providers who would be submitting for Stage 1 - Updated Medicare payment penalties EHR Incentive Programs CMS.gov. Retrieved October 7 th, 2015 from, 8

9 2015 Attestations Attestations: - NY State Modified Stage Attestations timeline still to be announced. The website will be open for 60 days. - Sign up for notifications of webinars with instructions on the new process and website here: - AIU Attestations for 2015 have closed (unless you were approved for an extension). EHR Incentive Programs CMS.gov. Retrieved October 7 th, 2015 from, 9

10 Reporting Timeframes - Year 1 Reporting 90 Days - All other EP s Report 365 Days is last year to enter MU program and attest for AIU Measures 2016 Changes - All EP s will be on the same set of measure objectives, NO alternate exclusions with two exceptions - CPOE Measure and Public Health Objective have the only alternate exclusions for EP s reporting in their first year - Several Patient Engagement Measures have updated thresholds to accommodate difficult measures 10

11 Measure Removals Measures Removed in 2015 and Beyond: - Record Demographics - Record Vital Signs - Record Smoking Status - Clinical Summaries - Structured Lab Results - Patient List - Patient Reminders - Summary of Care - Measure 1 Any Method - Measure 3 Test - Electronic Notes - Imaging Results - Family Health History EHR Incentive Programs CMS.gov. Retrieved October 7 th, 2015 from, 11

12 Implementation Timeline First Year of MU Stage of Meaningful Use Modified Stage 2 (90) 2012 Modified Stage 2 (90) 2013 Modified Stage 2* (90) 2014 Modified Stage 2* (90) Modified Stage 2 (365) Modified Stage 2 (365) Modified Stage 2 (365) Modified Stage 2 (365) 2015 AIU Modified Stage 2 (90) Modified Stage 2 (365) or Stage 3 (90) Modified Stage 2 (365) or Stage 3 (90) Modified Stage 2 (365) or Stage 3 (90) Modified Stage 2(365) or Stage 3 (90) Modified Stage 2 (365) or Stage 3 (90) 2016 N/A AIU Modified Stage 2 (90) or Stage 3 (90) Stage 3 (365) Stage 3 (365) Stage 3 (365) Stage 3 (365) Stage 3 (365) Stage 3 (365) * Allowable alternate thresholds and measure exclusions where there is no equivalent Stage 1 Measure. Stage 3 will require new certified version. EHR Incentive Programs CMS.gov. Retrieved October 7 th, 2015 from, 12

13 Core Measures: 1. Protect Patient Health Information 2. Clinical Decision Support 3. Computerized Physician Order Entry (CPOE) 4. Electronic Prescribing 5. Health Information Exchange 6. Patient Specific Education 7. Medication Reconciliation 8. Patient Electronic Access (VDT) 9. Secure Messaging Modified Stage 2 Definition 10. Public Health Reporting: 1. Electronic Immunization Registry 2. Electronic Syndromic Surveillance Data 3. Specialized Data Registry Public Health Objective Note: 2016 allows an alternate exclusion for providers scheduled to be in Stage 1 for Syndromic Surveillance and Specialized Registry Reporting 2017 requires two submissions for all EP s No changes to CQM selection or reporting scheme in Stage 2. Department of Health and Human Services,. 42 CFR Part 495. Centers for Medicare & Medicaid Services, from 13

14 Core 1: Protect Patient Health Information Objective: Protect electronic health information created or maintained by the CEHRT through the implementation of appropriate technical capabilities. NextGen Workflow: Conduct or review a security risk analysis in accordance with the requirements in 45 CFR (a)(1), including addressing the security (to include encryption) of ephi created or maintained by CEHRT in accordance with requirements under 45 CFR (a)(2)(iv) and 45 CFR (d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the EP's risk management process. Threshold: Yes/No Numerator: N/A Denominator: N/A Exclusion: None 2016 Changes 2015 Changes No changes. Updated to include data encryption stored in CEHRT. EHR Incentive Programs: Stage 2 Overview Tipsheet CMS.gov. Retrieved October 7 th, 2015 from, 14

15 Core 1: Protect Patient Health Information - Advanced Audit functionality added to All features must be turned on in System Administrator 15

16 Core 1: Protect Patient Health Information What is Advanced Auditing Module? Advanced Auditing module in 5.8 captures and records users actions in the EHR. The events are encrypted in accordance with CCHIT certification, HIPAA/HITECH, and Stage 2 Meaningful Use. The tool allows reporting by enterprise, practice, user, event/action, person, and date range. Reporting policies should be written and used in your Security Risk Analysis. The Advanced Auditing module should be set up on a non-production server so it doesn t slow down Production performance. When configuring the HQM reporting you will need to link the server where the Advanced Auditing module is run with the portal. Open a ticket with NG AFTER you have upgraded to 5.8/8.3 for instructions. 16

17 Core 1: Protect Patient Health Information Security Risk Analysis Tips: 1. There are NO Exclusions (SRA is also part of HIPAA compliance!) 2. The SRA is still the responsibility of the practice when hosted 3. Small practices are still required to complete the SRA 4. A checklist will not suffice as an SRA 5. The SRA needs to be reviewed yearly (Dates must reflect your must current review, auditors will check!) 6. If there are risks identified deficiencies must be corrected on the timeline established by the provider s risk management process (not the MU attestation deadline). 7. Analysis or review must be conducted within the same calendar year as the EHR reporting period, it must be conducted prior to the date of the attestation. An organization may conduct one security risk analysis or review which is applicable to all EPs within the organization, provided it is within the same calendar year and prior to any EP attestation for that calendar year. Guidance/Legislation/EHRIncentivePrograms/Downloads/SecurityRiskAssessment_Fa ctsheet_updated pdf EHR Incentive Programs: Stage 2 Overview Tipsheet CMS.gov. Retrieved October 7 th, 2015 from, 17

18 Core 2: Clinical Decision Support (1 of 2) Objective: Use clinical decision support to improve performance on high-priority health conditions. Measure 1: Implement 5 clinical decision support interventions related to 4 or more Clinical Quality Measures at a relevant point in patient care for the entire reporting period. Must be related to high-priority health conditions if not CQMs. NextGen suggestions include Clinical Decision Support reference buttons, My Plan Order Sets, Health Promotion Plan, Vital Signs Alerts, Care Guidelines, or utilization of drug-disease, geriatric, or pediatric interaction checking. Threshold: Yes/No Numerator: N/A Denominator: N/A Exclusion: None 2016 Changes 2015 Changes No exclusions. Alternate exclusion to submit 1 intervention instead of 5. EHR Incentive Programs: Stage 2 Overview Tipsheet CMS.gov. Retrieved October 7 th, 2015 from, 18

19 Core 2: Clinical Decision Support (1 of 2) Clinical Decision Support HIT functionality that builds on the foundation of an EHR to provide persons involved in care processes with general and personspecific information, intelligently filtered and organized, at appropriate times, to enhance health and health care. Several NextGen Recommendations: 1. Clinical Decision Support Reference Buttons 2. Order Sets available from My Plan 3. Health Promotion Plan 4. Care Guidelines 5. Vital Signs Alerts 6. Drug-disease, Geriatric, or Pediatric interaction checking 7. Immunizations Due Many others are available. ALL should be documented with screenshots at the beginning, middle, and end of you reporting period and placed in your audit binder. Reference the CMS guidelines: Guidance/Legislation/EHRIncentivePrograms/Downloads/ClinicalDecisio nsupport_tipsheet-.pdf EHR Incentive Programs: Stage 2 Overview Tipsheet CMS.gov. Retrieved October 7 th, 2015 from, 19

20 Core 2: Clinical Decision Support (1 of 2) 1. Clinical Decision Support Reference Buttons From the Medication, Orders, Allergy, Procedure, and Problem modules use the Clinical Decision Support reference link to access information pertinent to the patient s information. The reference site can be set up in Practice Preferences. Standard link provided is to Medline Plus a part of the US National Library of Medicine and can be updated per module. 20

21 Core 2: Clinical Decision Support (1 of 2) 2. Order Sets From My Plan select a diagnosis with recommended order and instructions. Order sets are shipped with the product and can be added, updated, removed on the Ngkbm Assessment Customize practice template. 21

22 Core 2: Clinical Decision Support (1 of 2) 3. Health Promotion Plan From the Vital Signs panel and the Assessment Panel on SOAP the Health Promotion Plan pop up can be accessed. NextGen recommends instructions, diet orders, or referrals for patients with an out of range BMI, BP, and/or positive depression screening. 22

23 Core 2: Clinical Decision Support (1 of 2) 4. Care Guidelines From the framework template set select the Care Guidelines link from any template. Apply guidelines for patients on Health Maintenance and other specified conditions as necessary. Orders will be suggested along with suggested timeframes. Place orders directly from the Care Guidelines pop up. 23

24 Core 2: Clinical Decision Support (1 of 2) 5. Vital Signs Alerts Vital signs alerts come shipped out of the box for normal/abnormal alerts. Alert ranges can be modified in Ngkbm Vital Signs template. 24

25 Core 2: Clinical Decision Support (1 of 2) 6. Drug-disease, geriatric, or pediatric interaction checking From the medication module any medications prescribed that may have an interaction associated with the patient s age or diseases will display a DUR alert. In order to submit for this measure ensure the minimum thresholds for users are set to 1 (not 0) in System Administrator. 25

26 Core 2: Clinical Decision Support (1 of 2) 7. Immunizations Due The Orders module has incorporated Immunizations that are due, up to date, or past due on adult and pediatric recommendations. 26

27 Core 2: Clinical Decision Support (2 of 2) Objective: Use clinical decision support to improve performance on high-priority health conditions. Measure 2: The EP has enabled drug-drug and drug allergy interaction checks for the entire EHR reporting period. Threshold: Yes/No Numerator: N/A Denominator: N/A Exclusion: Any EP who writes fewer than 100 medication orders during the reporting period Changes 2015 Changes No changes. Combined from independent measure. EHR Incentive Programs: Stage 2 Overview Tipsheet CMS.gov. Retrieved October 7 th, 2015 from, 27

28 Core 2: Clinical Decision Support (2 of 2) 28

29 Core 3: CPOE Objective: Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines. NextGen Workflow: Medications counted as entered by the EP or externally credentialed staff members are those where the provider has clicked Accept or Renew and is listed as the user who created the medication. The provider must have a relationship set to self in the System Administrator module. The medication must also be printed, faxed or eprescribed by ANY user. Lab and Radiology orders are counted as entered by the EP or externally credentialed staff members where the lab or radiology order is present in the Orders Module. Threshold: Medications 60% Labs 30% Radiology 30% Numerator: Number of medication, lab, and radiology orders in the denominator entered using CPOE Denominator: Number of medication, lab, and radiology orders created by the EP during the reporting period. Exclusion: An EP who writes fewer than 100 medication, lab, or radiology orders can be excluded from the portion that meets that criteria. Any EP who was scheduled to participate in Stage 1 in 2016 may exclude lab and/or radiology order measures Changes 2015 Changes Updated threshold for medications and addition of lab and radiology order inclusion. Exclusion for Stage 1 Providers to only submit Medications at 30% threshold. EHR Incentive Programs: Stage 2 Overview Tipsheet CMS.gov. Retrieved October 7 th, 2015 from, 29

30 Core 3: CPOE Clarification: Externally Credentialed staff members can enter orders for the EP and will count if the Credentialed Staff check box is used. Credentialed Date only needs to be entered if a nonprovider user acquires their credentialed status DURING the reporting period. 30

31 Externally Credentialed Definition: Core 3: CPOE FAQ 9058 states that if the staff member is appropriately credentialed and performs similar assistive services as an MA but carries a more specific title due to either specialization of their duties or to the specialty of the medical profession they assist, this staff member can use CPOE and have it count towards the measure. He or she must be credentialed to perform the MA services by an organization other than the employing organization. EHR Incentive Programs: Stage 2 Overview Tipsheet CMS.gov. Retrieved October 7 th, 2015 from, CMS: FAQs FAQ Retrieved March 27, Questions.cms.gov. 31

32 Core 3: CPOE Medications: Note the medication must also be printed, faxed, or e-prescribed to be counted in the denominator. Alternate for 2015 Stage 1 Providers is removed in 2016! EHR Incentive Programs: Stage 2 Overview Tipsheet CMS.gov. Retrieved October 7 th, 2015 from, 32

33 Labs: Lab orders must be in the Orders Module or processed from the templates to the Orders Module. The provider must hit Save if using the Orders Module or Place Order from the template. Any user can process the order to the module. Core 3: CPOE Orders do not need to be sent electronically to count as long as they are in the Orders Module. 33

34 Radiology: Radiology orders can be ordered in either the module or on the template and do not need to be processed to the module. Core 3: CPOE Orders do not need to be sent electronically to count as long as they are in the Orders Module. 34

35 Core 4: Electronic Prescribing Objective: Generate and transmit permissible prescriptions electronically (erx). NextGen Workflow: Prescriptions must be sent using the erx button from the medication module. In addition, each patient must be queried for formulary eligibility with the Pharmacy Benefit Manager. Threshold: 50% Numerator: Number of prescriptions in the denominator generated and transmitted electronically and checked against a medication formulary. Denominator: Number of permissible prescriptions written for drugs requiring a prescription in order to be dispensed during the EHR reporting period. Exclusion: Any EP who writes fewer than 100 prescriptions during the EHR reporting period. Any EP with NO pharmacies within 10 miles of practice location at the start of reporting period accepting erx Changes 2015 Changes Updated threshold. Alternate for Stage 1 Providers of 40% threshold and no requirement for formulary checking. EHR Incentive Programs: Stage 2 Overview Tipsheet CMS.gov. Retrieved October 7 th, 2015 from, 35

36 Core 4: Electronic Prescribing - Permissible Prescription: may include or not include controlled substances based on provider selection and where allowable by state and local law. - Eligibility with formulary must be queried, it does not need to be used. - Note the medication must also be printed, faxed, or e-prescribed to be counted in the denominator. Controlled substances can be included optionally. 36

37 Core 4: Electronic Prescribing Configuration 1: Formularies must be installed and turned on Either SureScripts or InfoScan 37

38 Core 4: Electronic Prescribing Configuration 2: Eligibility must be checked in one of the following ways 1. Manually in the medication module 2. From the Inbox in a batch for all appointments on the day s schedule 3. Automatically when the encounter is created (Recommended) 4. Automatically when the medication module is opened 38

39 Core 4: Electronic Prescribing Configuration 3: Provider must be enrolled in Eligibility checking under Mail Order Service Only 39

40 Core 5: Health Information Exchange Objective: The EP who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary care record for each transition of care or referral. Measure: The EP who transitions or refers their patient to another setting of care or provider of care must (1) use CEHRT to create a summary of care record; and (2) electronically transmit such summary to a receiving provider for more than 10% of referrals. Threshold: 10% Numerator: Number of transitions of care and referrals in the denominator where a summary of care record was created using CEHRT and exchanged electronically. Denominator: Number of transitions of care and referrals during the EHR reporting period for which the EP was the transferring or referring provider. Exclusion: An EP who neither transfers a patient to another setting or refers a patient to another provider less than 100 times during the EHR reporting period Changes 2015 Changes Only exclusion for providers ordering less than 100 referrals. Measure 2 exclusion for providers in Stage 1. Measure 1 and 3 Removed. EHR Incentive Programs: Stage 2 Overview Tipsheet CMS.gov. Retrieved October 7 th, 2015 from, 40

41 Core 5: Health Information Exchange Denominator: 1. Referral Orders (Not including Internal Referrals ) 2. PHI Log Transitions of Care EHR Incentive Programs: Stage 2 Overview Tipsheet CMS.gov. Retrieved October 7 th, 2015 from, 41

42 Numerator: Core 5: Health Information Exchange Summary of Care Record Requirements (Electronic CCDA ONLY) Patient name Referring or transitioning provider's name and office contact information (EP only) Procedures Encounter diagnosis Immunizations Laboratory test results Vital signs (height, weight, blood pressure, BMI) Smoking status Functional status, including activities of daily living, cognitive and disability status Demographic information (preferred language, sex, race, ethnicity, date of birth) Care plan field, including goals and instructions. Care team including the primary care provider of record and any additional known care team members beyond the referring or transitioning provider and the receiving provider Reason for referral (EP only) Current problem list* Current medication list* Current medication allergy list* *An EP must verify that the fields for current problem list, current medication list, and current medication allergy list are not blank and include the most recent information known by the EP as of the time of generating the summary of care document A provider must have the ability to transmit all data pertaining to laboratory test results in the summary of care document, but may work with their system developer to establish clinically relevant parameters for the most appropriate results for the given transition or referral. This policy is limited to laboratory test results. EHR Incentive Programs: Stage 2 Overview Tipsheet CMS.gov. Retrieved October 7 th, 2015 from, 42

43 Core 5: Health Information Exchange Numerator: 1. NextGen Share (Free!) Must be on 5.8 UD1 and KBM or later 43

44 Core 5: Health Information Exchange Numerator: 1. NextGen Share (Free!) Must be on 5.8 UD1 and KBM or later 44

45 Core 5: Health Information Exchange Numerator: 2. NextGen Direct Interface (Interfaces with specific HISP) 3. EHR Connect (Bundle of Interfaces for HIE Gateway) 45

46 Core 6: Patient-Specific Education Objective: Use clinically relevant information from CEHRT to identify patient-specific education resources and provide those resources to the patient. NextGen Workflow: Order Instructions via an Order Set off of My Plan, order instructions from applicable Health Promotion Plans, or Save/Print a Healthwise education document to the patient s chart. This is most easily accomplished in conjunction with Clinical Quality Measures relating to Depression, BMI, or Hypertension. Threshold: 10% Numerator: Number of patients in the denominator who are provided patientspecific education resources. Denominator: Number of unique patients seen by the EP during the reporting period. Exclusion: Any EP with no office visits during the reporting period Changes 2015 Changes Removed exclusion for Stage 1 providers. Exclusion for providers in Stage 1 not intending to submit for this menu measure. EHR Incentive Programs: Stage 2 Overview Tipsheet CMS.gov. Retrieved October 7 th, 2015 from, 46

47 Core 6: Patient-Specific Education Instruction orders must be suggested by CEHRT by being included in the saved Order Set for the patient s diagnosis configured on Ngkbm Assessment Customize. Free text instructions and My Instructions will not count. 47

48 Core 6: Patient-Specific Education Instructions can also be identified by the Health Promotion Plans. The following categories provide SNOMED coded suggested education: Depression: Follow-Up section Hypertension: Diet, Physical Activity, and Lifestyle sections BMI: Diet and Physical Activity sections *Note not all selection options qualify for reporting. See NG s white paper for this measure to validate your selections meet the requirements. 48

49 Core 6: Patient-Specific Education *Note not all selection options qualify for reporting. See NG s white paper for this measure to validate your selections meet the requirements. The white paper can be found at The following selections are currently valid: Completion of mental health crisis plan Counseling about alcohol consumption Counseling about alcohol consumption (procedure) Diet Education Diet Leaflet given Dietary education for weight gain Dietary management education, guidance, and counseling Dietary Needs Education Emotional support education Exercise education Exercise leaflet given Exercise on prescription Exercise promotion: stretching Exercise promotion: strength training Exercises education, guidance, and counseling Food education, guidance, and counseling Giving encouragement to exercise High fiber diet education High protein diet education Hypertension education Lifestyle education Lifestyle education regarding diet Low carbohydrate diet education Low cholesterol diet education Mental health care education Mental health treatment education Nutrition/feeding management Nutrition education Nutrition surveillance Nutrition therapy Nutritionist education, guidance, and counseling Obesity diet education Patient advised about exercise Patient given written advice on benefits of physical activity Prescribed activity/exercise education Prescribed diet education Reassuring about exercise Recommendation to carer regarding child s diet Recommendation to change carbohydrate intake Recommendation to change diet 49 Recommendation to change dietary fiber intake Recommendation to change dietary intake Recommendation to change food and drink intake Recommendation to change food intake Recommendation to change nutrient intake Recommendation to mobilize part Recommendation to undertake activity Referral to dietetics services Special diet education Target weight discussed Toddler nutrition education Vegan diet education Vegetarian diet education Weight control education Weight gain advised Weight loss advised Weight monitoring Weight-reducing diet education

50 Core 6: Patient-Specific Education From a module or the File Menu, Healthwise education can be launched (if purchased and installed) from the INTERNAL education link or the External link can be used. Select a document and save to the encounter and print to give to the patient. Healthwise is not required to submit for this measure, however it can assist for those who don t order instructions. 50

51 Core 6: Patient-Specific Education Education can also be ordered from 1 st, 2 nd, and 3 rd trimester OB education and Peds Well Child Exams. 51

52 Core 6: Patient-Specific Education Medication monograph launched from Medication Module. 52

53 Core 6: Patient-Specific Education Advanced Audit must be turned on to capture save, print, and search actions when using Healthwise. Advanced Audit is configured/enabled in System Administrator. Configuration should occur when 5.8 is installed. 53

54 Core 7: Medication Reconciliation Objective: The EP who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation. NextGen Workflow: Patient's qualify for the denominator based on a New patient visit procedure code, New patient visit type, or there was a documented Summary of Care received. Additionally when a CCDA is received electronically the patient is included in the denominator. Documentation to meet the numerator include patients with documented No Active Medications, Medications Reviewed check box, or completing review in the Clinical Reconciliation module. Threshold: 50% Numerator: Number of transitions of care in the denominator where medication reconciliation was performed. Denominator: Number of transitions of care during the EHR reporting period for which the EP was the receiving party of the transition. Exclusion: An EP who was not the recipient of any transitions of care during the EHR reporting period Changes 2015 Changes Removed exclusion for Stage 1 providers. Exclusion for providers in Stage 1 not intending to submit for this menu measure. EHR Incentive Programs: Stage 2 Overview Tipsheet CMS.gov. Retrieved October 7 th, 2015 from, 54

55 Core 7: Medication Reconciliation Denominator: A patient will be included in the denominator if they are identified as a new patient by their visit type or a new patient visit code is submitted to the procedures module. They will also be included in the denominator if a Summary of Care record is received. The Summary of Care records can be provided by either the patient or the referring/transitioning provider or institution and do not have to be electronic. A patient will also be included in the denominator if an electronic C-CDA is received. 55

56 Core 7: Medication Reconciliation Numerator: *Note if a patient does not have any medications the check box in the template/medication module must indicate the patient is not taking any medications. 1. Document Medications reconciled 2. OR Complete reconciliation in the Clinical Reconciliation module Reconciliation here is accessed in the medication module and can be done against the SureScripts download or an imported document. 56

57 Core 8: Patient Electronic Access (1 of 2) Objective: Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, and allergies) within 4 business days of the information being available to the EP. Measure 1: Send any completed visit documents or a C-CDA to the Patient Portal. Additional configuration is required to automatically send PHR to the portal, use a different document other than the Lab documents identified by NextGen, and exclude certain labs if necessary. Patients must either have a token to the portal within 4 business days of the first encounter in the reporting period or completed the enrollment process to count in the numerator. Threshold: 50% Numerator: Number of patients in the denominator who were given timely access to their information online for every visit. Denominator: Number of unique patients seen by the EP during the reporting period. Exclusion: None 2016 Changes 2015 Changes No changes. No changes. EHR Incentive Programs: Stage 2 Overview Tipsheet CMS.gov. Retrieved October 7 th, 2015 from, 57

58 Patient Electronic Access must include: Core 8: Patient Electronic Access (1 of 2) Summary of Care Record Requirements Patient name. Allergy List and Allergy History Provider name and office contact information Vital signs (height, weight, blood pressure, BMI, growth charts) Current and Past Problem List Procedures Lab Test Results Smoking status Demographic information (preferred language, sex, race, ethnicity, date of birth) Care plan field, including goals and instructions Current Medication List and Medication History Any known care team members including the primary care provider (PCP) of record EHR Incentive Programs: Stage 2 Overview Tipsheet CMS.gov. Retrieved October 7 th, 2015 from, 58

59 Core 8: Patient Electronic Access (1 of 2) Numerator: Enable the Patient Portal to have all patient documentation automatically uploaded to the portal (PHR Download). As long as a patient has received their token prior to their encounter (even if they haven t finalized enrollment) the C-CDA will automatically be available on the portal once locked and the patient meets the numerator. **Open a ticket with NG support to complete Automatic PHR Download configuration. 59

60 Core 8: Patient Electronic Access (1 of 2) OR If the PHR Download to Patient Portal is not turned on: 2. Any encounter a document or C-CDA must be uploaded to Portal within 4 business days (not including weekends or federal holidays). 3. Any lab result accepted/signed off in the PAQ after qualifying encounter requires a lab document upload or C-CDA document uploaded to NextMD within 4 business days (not including weekends or federal holidays). 1. Lab documents include LabResults, LabResults_All, or other as determined by HQM Configuration 2. Note some labs may be excluded during HQM Configuration 60

61 Core 8: Patient Electronic Access (1 of 2) Challenges with Enrolling Patients in the Portal: **REMINDER THERE ARE NO EXCLUSIONS FOR THIS MEASURE** 1. Some patients don t have addresses - No Longer Required to create a Token as of Portal Version 2.1 (Auto-released on Feb 1 st, 2015) 2. Handling guardians of pediatric patients - Set expiration date for guardian access to the portal 3. Cumbersome Enrollment Process - Configure/utilize bulk enrollment - Turn on patient initiated enrollment 4. Staff Communication - Script communication at each level including check in, clinical intake, providers, and check out - Handouts for the patient - Show patients how to change the language 61

62 Core 8: Patient Electronic Access (2 of 2) Objective: Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, and allergies) within 4 business days of the information being available to the EP. Measure 2: : At least one patient (or authorized representatives) seen by the EP during the reporting period views, downloads, or transmits to a third party their health information. 2017: More than 5% of all unique patients (or authorized representatives) seen by the EP during the reporting period view, download, or transmit to a third party their health information. Threshold: Patient % Numerator: Number of patients in the denominator who viewed, downloaded, or transmitted their information online. Denominator: Number of unique patients seen by the EP during the reporting period. Exclusion: Any EP Conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may exclude only the second measure Changes 2015 Changes Removed exclusion for Stage 1 Providers. Measure 2 threshold was updated to at least 1 patient in 2015 and is excluded for Stage 1 Providers in EHR Incentive Programs: Stage 2 Overview Tipsheet CMS.gov. Retrieved October 7 th, 2015 from, 62

63 Core 8: Patient Electronic Access (2 of 2) Numerator: 63

64 Core 9: Secure Messaging Objective: Use secure electronic messaging to communicate with patients on relevant health information. 2015: The capability for patients to send and receive a secure electronic message with the provider was fully enabled during the EHR reporting period. 2016: At least 1 patient seen by the EP during the EHR reporting period, a secure message was sent using the electronic messaging function of CEHRT to the patient (or the patient-authorized representative), or in response to a secure message sent by the patient (or the patient-authorized representative) during the EHR reporting period. 2017: More than 5 percent of unique patient seen by the EP during the EHR reporting period, a secure message was sent using the electronic messaging function of CEHRT to the patient (or the patient-authorized representative), or in response to a secure message sent by the patient (or the patient-authorized representative) during the EHR reporting period. Threshold: 2015 Yes/No Patient % Numerator: Number of patients or patient-authorized representatives in the denominator who were SENT a secure electronic message to the EP that is received using the electronic messaging function of CEHRT during the EHR reporting period. Denominator: Number of unique patients seen by the EP during the reporting period. Exclusion: Any EP who has no office visits during the EHR reporting period, or any EP who conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period Changes 2015 Changes Updated threshold and removed Stage 1 Provider exclusion. Threshold changed per year. Updated from patient action to provider action. Exclusion for providers scheduled to submit for Stage 1. EHR Incentive Programs: Stage 2 Overview Tipsheet CMS.gov. Retrieved October 7 th, 2015 from, 64

65 Numerator: - New messages sent to patient - Replies to patient messages - Replies to medication refill requests - Send Online forms to patient - Reply to appointment request Core 9: Secure Messaging Tips: - Updated to measure messages sent to the patient, including responses to patient initiated messages. - The EP can determine the best form of follow up for the patient including phone call or office visit. - If a patient sees multiple EP s in a practice, both receive numerator credit for the incoming message. 65

66 Core 10: Public Health Registry Reporting Objective: The EP is in active engagement with two public health agencies to submit electronic public health data from CEHRT except where prohibited and in accordance with applicable law and practice. Measure 1: Immunization Registry Reporting (x1) Measure 2: Syndromic Surveillance Reporting (x1) Measure 3: Specialized Registry Reporting (x2) Threshold: Yes/No Numerator: N/A Denominator: N/A Exclusion: See next slide Changes 2015 Changes All providers must submit 2 measures. Moved to consolidated Public Health Objective. Submit 1 for providers scheduled to submit for Stage 1 EHR Incentive Programs: Stage 2 Overview Tipsheet CMS.gov. Retrieved October 7 th, 2015 from, 66

67 Exclusions: Core 10: Public Health Registry Reporting Measure 1 Immunizations: 1. The EP does not administer any of the immunizations to any populations for which data is collected by their jurisdiction s immunization registry during the reporting period. 2. The EP operates in a jurisdiction for which no immunization registry is capable of accepting the specific standards required for CEHRT at the start of their EHR reporting period. 3. The EP operates in a jurisdiction for which no immunization registry has declared readiness to receive immunization data at the start of the reporting period. Measure 2 Syndromic Surveillance: 1. Is not in a category of providers from which ambulatory syndromic surveillance data is collected by their jurisdiction s syndromic surveillance system. 2. The EP operates in a jurisdiction for which no public health agency is capable of receiving the electronic syndromic surveillance data from Eps in the specific standards required for CEHRT at the start of their EHR reporting period. 3. The EP operates in a jurisdiction where no public health agency has declared readiness to receive syndromic surveillance data at the start of the reporting period. Measure 3 Specialized Disease Registry: 1. The EP does not diagnose or treat any disease or condition associated with or collect relevant data that is required by a specialized disease registry in their jurisdiction during the reporting period. 2. The EP operates in a jurisdiction for which no specialized disease registry is capable of accepting electronic registry transactions in the specific standards required for CEHRT at the start of their EHR reporting period 3. The EP operates in a jurisdiction where no specialized disease registry has declared readiness to receive electronic registry transactions at the start of the reporting period. EHR Incentive Programs: Stage 2 Overview Tipsheet CMS.gov. Retrieved October 7 th, 2015 from, 67

68 Alternate Exclusions: Core 10: Public Health Registry Reporting Providers scheduled to be in Stage 1 and Stage 2 in 2016 may claim an alternate exclusion for the Public Health Reporting measure(s) that might require acquisition of additional technologies that they did not previously have or did not previously intend to include in their activities for meaningful use. EPs may claim an alternate exclusion for measure 2 (syndromic surveillance) and measure 3 (specialized registry reporting). Measure 2 Syndromic Surveillance: 1. EPs may claim an alternate exclusion for measure 2 (syndromic surveillance reporting) for an EHR reporting period in Measure 3 Specialized Disease Registry: 1. EPs may claim an alternate exclusion for measure 3 (specialized registry reporting) for an EHR reporting period in Tipsheet: Guidance/Legislation/EHRIncentivePrograms/Downloads/2016_AlternateExclusionsfor2016. pdf FAQ 14397: FAQ 14401: EHR Incentive Programs: Stage 2 Overview Tipsheet CMS.gov. Retrieved May 4 th, 2016 from, 68

69 Active Engagement Defined: Core 10: Public Health Registry Reporting 1. Completed Registration of Intent to Submit Data within 60 days (FEBRUARY 29 TH, 2016) after the start of the reporting period. The EP is awaiting testing or validation with a PHA who has limited resources. Registration is only required once and does not need to be repeated for each reporting period. 2. Testing and Validation is in the process. Providers must respond to requests within 30 days; failure to respond twice within an EHR reporting period would results in the provider not meeting that measure. 3. Production data is being electronically submitted after completion of testing and validation. EHR Incentive Programs: Stage 2 Overview Tipsheet CMS.gov. Retrieved October 7 th, 2015 from, 69

70 Core 10: Public Health Registry Reporting When completing immunizations in the new module ensure the registry is selected and when complete the user selects Save & Send. 70

71 Core 10: Public Health Registry Reporting Immunization Registry, Specialized Disease Registry (New York City EP s only) and Cancer Registry (New York City EP s only) Requirements for eligible sites: Exclusions can be submitted to the state, but is not required. Documentation to support an exclusion must be kept for an audit. Contact the NYDOH at MUPublicHealthHELP@health.state.ny.us. If testing is successful, follow up submissions are required to be scheduled on a regular basis. Registration of Intent must be submitted within 60 days of the start of their reporting period on the Meaningful Use Registration for Public Health Application at (note a Health Systems Commerce Account is required before the application can be submitted). Guide to submissions can be found here: ** Only one application for Immunization, Syndromic Surveillance, Cancer Registry and Specialized Disease Registries is necessary. Meaningful Use and Public Health New York State Department of Health. Retrieved April 16 th, 2014 from, 71

72 New York City s Disease Registry: - NYC is meeting the measure objective through the export of CCD documents in XML formatting - The following conditions are considered notifiable conditions: Amebiasis Anaplasmosis (Human granulocytic anaplasmosis) Animal bite Anthrax Arboviral infections, acute Babesiosis Botulism (including infant, foodborne, and wound) Brucellosis Campylobacteriosis Carbon Monoxide poisoning Chancroid Chlamydia Cholera Creutzfeldt-Jakob disease Cryptosporidiosis Cyclosporiasis Dengue Diphtheria Drowning (whether resulting in death or not) Ehrlichiosis (Human monocytic ehrlichiosis) Encephalitis Escherichia coli O157:H7 infection Falls from windows Food poisoning in a group of two or more individual Giardiasis Glanders Gonorrhea Granuloma inguinale (donovanosis) Haemophilus influenzae (invasive disease) Hantavirus Hemolytic uremic syndrome Hepatitis A Hepatitis B Hepatitis B in pregnancy or post-partum/delivery Core 10: Public Health Registry Reporting Hepatitis C Hepatitis D Hepatitis E Hepatitis, other suspected infectious viral hepatitides Herpes, neonatal HIV/AIDS Influenza, seasonal Influenza, novel strain with pandemic Influenza-related pediatric death Kawasaki syndrome Lead poisoning Legionellosis Leprosy (Hansen s disease) Leptospirosis Listeriosis Lyme disease Lymphocytic choriomeningitis virus Lymphogranuloma venereum Malaria Measles (rubeola) Melioidosis Meningitis, viral (aseptic) Meningitis, bacterial Meningococcal disease, invasive Monkeypox Mumps Norovirus Paratyphoid fever Pertussis (whooping cough) Pesticide poisoning Plague Poisoning by drugs or other toxic agents Poliomyelitis Psittacosis Q fever Rabies and exposure to rabies (see animal bite) Respiratory syncytial virus Ricin poisoning Rickettsialpox Rocky Mountain spotted fever (5) Rotavirus Rubella (German measles) Rubella syndrome, congenital Salmonellosis Severe coronavirus (e.g., SARS, MERS-CoV) Shiga toxin producing Escherichia coli (STEC) infection Shigellosis Smallpox (variola) Staphylococcal enterotoxin B poisoning Staphylococcus aureus, methicillin-resistant Staphylococcus aureus, vancomycin intermediate (VISA) Streptococcus (Group A), invasive Streptococcus (Group B), invasive Streptococcus pneumoniae, invasive Syphilis, all stages, including congenital syphilis Tetanus Toxic shock syndrome Trachoma Transmissible spongiform encephalopathies Trichinosis Tuberculosis Tularemia Typhoid fever Vaccinia disease Varicella Vibrio species, non-cholera Viral hemorrhagic fever West Nile viral neuroinvasive disease Yellow fever Yersiniosis, non-plague Reporting Diseases and Conditions New York City Department of Health and Mental Hygiene. Retrieved April 16 th, 2014 from, 72

73 Core 10: Public Health Registry Reporting CPCI Registry: Starting in 2016 will qualify as a Specialized Registry Check the CPCI website for Announcements Once available submit a survey request for providers to receive a letter stating CPCI is in use More information can be found here: %20Care%20Informatics%20Data%20Warehouse&category=HIT 73

74 2016 Bottom Line Measure Brief Overview 2016 Threshold 1. Protect Patient Health Information Conduct or Review Security Risk Assessment 2. Clinical Decision Support 1. 5 CDS Interventions 2. Drug-drug and Drug-Allergy Interaction Checks 3. CPOE 1. Medication Orders 2. Lab Orders 3. Radiology Orders 4. Electronic Prescribing Erx Medications and query a drug formulary 5. Health Information Exchange Send C-CDA Electronically for Referrals 10% 6. Patient Specific Education Provide education to patients 10% Yes/No Yes/No 1. 60% 2. 30%** Exclusion for Stage 1 EP s 3. 30%** Exclusion for Stage 1 EP s 50% Requires NGShare! 7. Medication Reconciliation Reconciles medications for transitions in care 8. Patient Electronic Access 1. Patients provided access to portal 2. Patient accesses portal 9. Secure Electronic Messaging Patient sends a message or patient receives a message in the portal 10. Public Health Reporting 1. Immunization Registry 2. Syndromic Surveillance Registry 3. Specialized Disease Registry 50% 1. 50% 2. At least one patient per EP Requires Portal At least one patient seen by the EP Must attest to Active Engagement in 2 of 3 Reporting Mechanisms Requires 2 Registries! 74

75 PREPARING FOR YOUR ATTESTATION PERIOD 75

76 Preparing for your Attestation Time Frame 1. Decide on the preferred reporting period 2. Ensure you have documentation proving your EP s eligibility for Medicaid and/or Medicare (30%) 3. Initiate Documentation for Attestation and Audits on or BEFORE your reporting period EHR Incentive Programs: EHR Supporting Documentation Audits CMS.gov. Retrieved April 15 th, 2015 from, 76

77 Preparing for your Attestation Time Frame 1. Decide on all measures you will be attesting for and the preferred reporting period 1. Workflows required to meet your measures 2. Clinical Quality Measure Goals **Confirm you are on the correct version to meet all of your measure goals. It s also a good idea to configure and run your reports on a weekly basis for several months prior to the reporting period to ensure you will meet minimum thresholds for core objectives. EHR Incentive Programs: EHR Supporting Documentation Audits CMS.gov. Retrieved April 15 th, 2015 from, 77

78 Preparing for your Attestation Time Frame 2. Ensure you have documentation proving your EP s eligibility for Medicaid and/or Medicare Eligible Professionals (EP) who enroll in the Medicaid EHR Incentive Program must demonstrate each year that at least 30% of their patient volume is attributed to Medicaid during a 90 day reporting period they choose (see section below for more details). EPs must also attest to the Medicaid patient volume requirement by attesting to either the standard or alternative patient volume methods in the Medicaid EHR Incentive Payment Administrative Support Service (MEIPASS). Additionally, EP in groups have an option to combine the totals of all EPs in the group and attest using aggregate totals, and there is assistance available for those who have difficulty assembling their Medicaid Patient Volume. - NY Medicaid EHR Incentive Program EHR Incentive Programs: EHR Supporting Documentation Audits CMS.gov. Retrieved April 15 th, 2015 from, 78

79 Preparing for your Attestation Time Frame 2. Ensure you have documentation proving your EP s eligibility for Medicaid and/or Medicare - Calculate this yourself using NextGen per Eligible Provider - Calculate this yourself using NextGen for the whole practice ( Aggregate Patient Volume ) - Request assistance getting reports for the Alternative Patient Volume Method which calculates patients who are Medicaid Beneficiaries of a Managed Care program. hit@health.state.ny.us or call Option 2. It is recommended to get your data pre-validated before the reporting period opens to expedite your attestations. EHR Incentive Programs: EHR Supporting Documentation Audits CMS.gov. Retrieved April 15 th, 2015 from, 79

80 Preparing for your Attestation Time Frame 2. Ensure you have documentation proving your EP s eligibility for Medicaid and/or Medicare Add the following columns: - Encounter - Pat Name - Per Nbr - Dt of Svc - Payer Name and Policy Number - Sec Payer and Policy Number - Tert Payer and Policy Number - Rendering Provider Filter your service date for any 90 day period within the calendar year prior to your attestation period. EHR Incentive Programs: EHR Supporting Documentation Audits CMS.gov. Retrieved April 15 th, 2015 from, 80

81 Preparing for your Attestation Time Frame 2. Ensure you have documentation proving your EP s eligibility for Medicaid and/or Medicare - Sort by Payer Name, Sec Payer, then Tert Payer - Select to Count Records - Run the report to count your denominator EHR Incentive Programs: EHR Supporting Documentation Audits CMS.gov. Retrieved April 15 th, 2015 from, 81

82 Preparing for your Attestation Time Frame 2. Ensure you have documentation proving your EP s eligibility for Medicaid and/or Medicare - Export your results to Excel - Filter by Primary payer and count - Filter by Secondary payer and count - Filter by Tertiary payer and count - Add Primary, Secondary, and Tertiary counts together to get the Medicaid Total and to use this as your numerator - Divide your Medicaid Total by Total Encounters. This must be at least 30% to be eligible SAVE THE REPORT FOR YOUR AUDIT FILES EHR Incentive Programs: EHR Supporting Documentation Audits CMS.gov. Retrieved April 15 th, 2015 from, 82

83 Preparing for your Attestation Time Frame 3. Initiate Documentation for Attestation and Audits on or BEFORE your reporting period Create an Audit Binder (or electronic folder) for each Eligible Provider who will be attesting to include: - Eligibility report (either for the EP or the Aggregate practice) - EHR Certification Number ( - MU Audit Report for each Provider *Request report from NG with ticket if you don t have it* - Screenshots of each Self Attestation measure - Add to this section when any new screenshots are taken throughout the reporting period - Copy of the report with the data you will be submitting for attestation - Core and CQM - CMS requires documentation to be retained for 6 years post attestation ** Also note it is a good idea to keep copies of staff who are licensed for CPOE orders on hand with HR** EHR Incentive Programs: EHR Supporting Documentation Audits CMS.gov. Retrieved April 15 th, 2015 from, 83

84 Preparing for your Attestation Time Frame 3. Initiate Documentation for Attestation including preparation for audits on or BEFORE your reporting period Note in order to physically attest the only portion you need from this list are reports showing your numerators and denominators of the Core and Clinical Quality Measures to enter into MEIPASS. Preparing for an Audit before attesting is highly recommended. CHCANYS Tool for Tracking Providers: gory=nys_hccn EHR Incentive Programs: EHR Supporting Documentation Audits CMS.gov. Retrieved April 15 th, 2015 from, 84

85 Preparing for your Attestation Time Frame 3. Initiate Documentation for Attestation including preparation for audits on or BEFORE your reporting period Example Electronic Documentation of Audit Preparations: 85

86 Reporting Two Options for Reporting: 1. NextGen Health Quality Measure (HQM) Portal 2. CPCI No longer available Contact CHCANYS with any questions on CPCI CPCI Certification: 86

87 HQM: Configuration - All clients should already have the Health Quality Measure Portal installed. If you don t open a support ticket Reports are available NOW - HQM Configuration will be covered during the coaching calls - Attestation requires use of the SUMMARY report only, however other reports are useful for regular monitoring - Measure Summary Report is useful for comparing providers across multiple measures - Provider Patient Report is useful for identifying workflow issues with staff (treatment opportunities shows patients not meeting the numerator) - Flexible Date Range Reporting is useful for reporting on timeframes other than the intended attestation period 87

88 HQM: Reports 88

89 HQM: Reports 89

90 HQM: Reports 90

91 Documentation for Self Attestation Measures Modified Stage 2 Self Attestation Measures: 1. Protect Patient Health Information 2. Clinical Decision Support 3. Clinical Decision Support: Drug/Allergy Checks 4. CPOE: Credentialed Staff 5. E-Prescribing: Drug Formulary Checks 6. Secure Messages 7. Immunization Registry 8. Syndromic Surveillance Registry 9. Specialized Disease Registry Start taking screenshots for highlighted measures now You must have DATED screenshots from within the reporting period for each measure or you will likely fail any audit (pre or post payment). 91

92 Documentation for Attestation Only Measures General Guidelines for Taking Screenshots: - Screenshots should be dated to prove when they were taken - Screenshots should include the NextGen logo to prove they were taken from the certified technology - Screenshots should have PHI removed (or covered) - For measures where something is turned on or used by the provider it s a good idea to take dated screenshots at the beginning, middle, and end of reporting period to show it was turned on/utilized for the entire reporting period - Screenshots taken from within the application showing use should be taken for each Eligible Provider CMS Guide: Guidance/Legislation/EHRIncentivePrograms/Downloads/EHR_Suppo rtingdocumentation_audits.pdf EHR Incentive Programs: EHR Supporting Documentation Audits CMS.gov. Retrieved April 15 th, 2015 from, 92

93 Documentation for Attestation Only Measures Run and Save all portions of the MU Audit Report for Additional Information: 93

94 UDS Reporting Changes Reporting Sexual Orientation and Gender Identity: - New addition to be reported under Table 3B for UDS The following screens can be used to report the data - It is recommended to update your configuration to more easily access these screens - Recommend training staff ASAP to start collecting this data - Reporting will be mapped in UDS Reporting tool - Please note that any health center can contact the UDS Helpline regarding UDS content and reporting, including hardships. The UDS Helpline and are: (866) and udshelp330@bphcdata.net. After the health center reports a potential hardship to the UDS Helpline, it will be noted in the health center s file and in the UDS tracking system. Additionally the UDS production staff and the health center s assigned UDS reviewer will be notified of this reporting hardship. HRSA Program Assistance Letter 2016: PAL Uniform Data System (UDS) Program Assistance Letters Retrieved May15 th, 2016 from, BPHC.HRSA.Gov. 94

95 UDS Reporting Changes 95

96 UDS Reporting Changes Recommend configuring sub-navigation to encourage streamlined data entry You must turn on this configuration to document gender identity 96