Understanding MU 3 Requirements

Transcription

1 Understanding MU 3 Requirements

2 Title of Presentation Title of Presentation Session presenters - Presenter-Michele Janowski; RT (R), BSRS, CMUP Senior Manager, Evident target audience: Target audience: Evident - Panelist- Sarah Richardson Manager, Evident - Panelist- Lauri Middleton Interface Manager, Evident Grady Swann, Dr. Estes Franklin County Memorial

3 Learning Objectives Requirements MU stages Key Dates Evident Requirements Cumbersome Objectives and Processes Attestation Certified Product Listing Registration and Attestation Audit Auditing Information

4 Requirements

5 (90 days) - Modified Stage 2 - Stage 3 (Optional) Title and Text MU Stages (365 days) - January 1, December 31, Stage 3

6 Title and Text Key Dates Enrollment to QNet begins on October 1, Attestation period was January 2, 2018-March 16, (90 days) - Modified Stage 2 - Stage 3 (Optional) - Data Submission period to QNet begins: January 2, February 28, (365 days) - Reporting Period: January 1, December 31, Stage 3 - Data Submission period to QNet begins: January 2, February 28, 2020

7 Evident Requirements - MU 3 Title and Text - MU 3 Bundle Order Placed - Thrive Patient Portal - Thrive UX Implemented for all Meaningful Use Users - Version for Clinical Quality Measures (QARCT) - Once the above criteria is met, each facility will be given: - MU Education Date - Trackable Presentations - Education Instruction

8 Attestation

9 - Title and Text Certified Product Listing- MU Forward for MU 3: - Evident Thrive (or Thrive Provider) 2015, Version 20 (EHR) - CPSI 2015 Edition, QARCT - Inpriva 2015 Edition, hdirect Network Services This is the number that will be used for attestation as well as the number to be placed in the EHR Certification area on the QARCT Tool for Quality Measures.

10 Certified Product Listing Thrive EHR

11 Certified Product Listing- Thrive Provider EHR

12 Title and Text Automated Measures Report 2018 Forward for MU 3 (Stats): Reporting Year - MU Stage 3 - Eligible Hospital - Medicare/Medicaid - Eligible Professional - Advancing Care Information

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20 - Changes - What to Do? - Registration on QNet - Attestation on QNet Title and Text Registration and Attestation - Guidance/Legislation/EHRIncentivePrograms/Downloads/EHRHo spital_transitionoverviewfact-sheet_ pdf - Guidance/Legislation/EHRIncentivePrograms/Eligible_Hospital_I nformation.html

21 Title and Text Changes - Beginning January 2, 2018, Eligible Hospitals and CAHs will submit their 2017 attestations, along with their quality attestations in one place. - Medicare eligible hospitals and critical access hospitals (dually eligible) will now register and attest to Quality Net Secure Portal (Qnet) - Prior year attestations will be VIEW ONLY for Medicare eligible hospitals and CAHs after December 31, 2017.

22 Title and Text Changes - Eligible Professionals(EPs) and Medicaid-only Hospital attestations will still take place through State website and/or CMS. EPs and Medicaid-only hospitals should contact their state Medicaid agencies for specific information on how to attest. - Vendors are not able to electronically attest on behalf of hospital clients. - Medicare EP attestations have been replaced with the MIPS program. Those attesting to MIPS will need to report through the QPP website,

23 Title and Text What Do I Do? - If you do not currently have an account on QNet from previous CQM submissions, you will need to create a new one. - Review QNet Enrollment User Guide Guidance/Legislation/EHRIncentivePrograms/Downloads/Qu alitynetuserguide.pdf - If you have an account, you will need to update your existing account by adding the MU Role before you begin attestation. This will allow you to see information that pertains to your MU Attestation.

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49 Audit Preparation

50 Title and Text Audit Preparation - Pre and Post Payment Audits - States can request audits - Figliozzi and Company - ALL relevant supporting documentation (in paper or electronic format) used in the completion of attestation should be retained. - Documentation that supports attestation and quality measures submission should be retained for AT LEAST 6 years postattestation.

51 Title and Text Audit Preparation - Items to Keep: - Cost Report - Vendor Letter (if requested by Auditor) - Security Risk Analysis - Statistics Report with exact numbers entered during Attestation - QRDA/Quality Meaures Reports - Public Health acknowledgement documents of Registration, Active Engagement, Submissions, Test Data - Documentation of exclusions - Documentation supporting patient population chosen during attestation - Attestation items- Screen Shots showing functionality was available during the entire reporting period.

52 Cumbersome Objectives

53 Protect Electronic Title and Text Health Information Protect electronic health information (PHI) Created or maintained by the CEHRT through the implementation of appropriate technical capabilities. - Conduct or review a security risk analysis in accordance with requirements, including addressing security (including encryption of PHI and implement security updates as necessary and correct identified deficiencies as part of the risk management process. )

54 Protect Electronic Title and Text Health Information - First Year of Stage - Analysis is required - Second Year of Stage - At a minimum, a review is required - The analysis or review can be done outside of the reporting period if that analysis (or review) is unique in the following ways: - The time scope of the review includes the reporting period - The content includes significant changes to the EHR, to the facility, or to the processing of PHI that occurred during the year.

55 Protect Electronic Title and Text Health Information - The responsibility of the Analysis is solely on the part of the Meaningful Use Entity. - EHR Vendor provides information, training, and support on the certified security technology that is included in the EHR software. - Having a Certified EHR Product in and of itself does not satisfy this requirement. A comprehensive SRA covers the CEHRT as well as all the use cases and controls that secure PHI at your facility.

56 Coordination of Care- Title and Text View, Download, Transmit - Must attest to all 3 objectives, however must only meet the threshold of 2. - VDT: Eligible Hospital: During the reporting period, at least 1 unique patient (or authorized rep) discharged from the Eligible Hospital actively engage with the EHR made accessible by the provider and 1 of the following: - VDT OR - API (Application Programming Interface) OR - Combination of the above Medicaid: More than 5% - VDT: Eligible Professional : 2018 More than 5% : More than 10% - Achieved by patient logging into their portal and viewing the medical records card, or downloading an API of their choice to connect with the EHR to download information.

57 Coordination of Care- Title and Text Secure Messaging - Must attest to all 3 objectives, however must only meet the threshold of 2. - Secure Messaging Eligible Hospital: For more than 5% of all unique patients discharged from the EH during the reporting period, a secure message was sent using the electronic messaging function of the CEHRT to the patient (or authorized rep), or in response to a secure message sent by the patient or authorized rep. Medicaid: More than 25% - Secure Messaging Eligible Professional: 2018 More than 5% : More than 10% for EP more than 25% - Met by utilizing the secure messaging function within the Communications Application and generating a message to the patient or responding to the patient s secure message.

58 Coordination of Care- Title and Text Patient Generated Health Data - Must attest to all 3 objectives, however must only meet the threshold of 2. - Patient Generated Health Data Eligible Hospital and Eligible Professional: Patient health data or data from a non-clinical setting is incorporated into the CEHRT for more than 5% of all unique patients discharged from the IP/EP during the reporting period. - Met by patients using the Thrive patient portal to upload information for their provider such as advanced directives, birth plans etc. Once documentation is uploaded by the patient on the portal, documenation is then attached to a designated image title to update the statistics in the EHR. - Met by scanning documents to the appropriate image title at the time of the visit

59 Health Information Exchange- Title and Text Summary of Care- Send - Must attest to all 3 objectives, however must only meet the threshold of 2. - Send Summary of Care Eligible Hospital: For more than 10% of transitions of care and referrals, the eligible hospital that transitions or refers their patient to another setting of care or provider of care: - Creates a Summary of Care using CEHRT; and - Electronically exchanges the summary of care record. Medicaid Only: More than 50% SOC Send Eligible Professional: More than 50% - Met by creating an outbound entry in the Referral/Transition of Care application, Creating a Summary of Care, Sending a direct Message and receiving an MDN Message back from Recipient. - Problem List, Medicaition List and Medication Allergy List Addressed

60 Health Information Exchange- Title and Text Summary of Care Request - Must attest to all 3 objectives, however must only meet the threshold of 2. - Request/Accept Summary of Care Eligible Hospital: For more than 10% of transitions or referrals received, the eligible hospital incorporates into the patient s EHR an electronic summary of care document. - Receives/Accepts a summary of care; and - Incorporates the summary of care record. Medicaid Only: More than 40% SOC Receive/Accept Eligible Professional: More than 40% - Met by creating an inbound entry in the Referral/Transition of Care application, Requesting an electronic summary of care or HIE that is capabable of returning a CCD. - If document is «un-available» patient can be excluded from measure

61 Health Information Exchange- Title and Text Clinical Information reconciliation - Must attest to all 3 objectives, however must only meet the threshold of 2. - Clinical Information Reconciliation Eligible Hospital: For more than 50% of transitions or referrals received, the eligible hospital performs a clinical information reconciliation for the following information sets: - Medication Review - Medication Allergy Review - Current Problem List Review Medicaid Only: More than 80% SOC Clinical Reconciliation Eligible Professional: More than 80% - Met by importing a summary of care that was electronically received and choosing clinical reconciliation from Health Information Resource; or - Manual reconciliation from Clinical Reconciliation - Must reconcile all 3 to meet stat

62 Title and Text - Dual-eligible hospitals report any combination of 3 measures - Medicaid-only hospitals report any combination of 4 measures - Eligible Professional- there are 5 measures to attest to. The EP must report to any combination of 2 measures. - Active Engagement - Registration - Testing - Production - Available measures Public Health Requirements - MU 3 - State Department of Health website - CMS Centralized Repository - Contact account manager if additional interfaces are required

63 Processes

64 Coordination Of Care- Title and Text Patient Generated Health Data - An Image Title needs to be set- up specifically for Health Information Capture. - Designate a person or persons to scan patient health information into the correct image title to update the statistic.

65 Health Information Exchange- Title and Text Summary of Care-Incorporate - Check Health Information Resource to determine if there is a summary to Import - If there is not a summary to import, users will need to query an HIE (if they have an available HIE). If there is no HIE to query, the user will notate it in the Referral-Inbound or Transition of Care- Inbound created for the patient (which should be created for every patient where a document would be imported). - HIE query and retreive is a separately purchased interface.

66 Health Information Exchange- Title and Text Clinical Information Reconciliation - Route, Frequency and Unit tables should be reviewed to ensure the correct codes are associated. - If there is not a Summary to import, the user will need to perform Clinical Information Reconciliation manually. - The only patients that pull to the denominator for the clinic are new patients or patients that have transfers/referrals document on the visit. However, every visit counts toward the denominator in the hospital!

67 Provide Electronic Access- Title and Text Patient Specific Education - Patient Education documents should only be given via Clinical Knowledge. - However, if giving custom documents for VDT Timely Access, those should still be given via the original pathway.

68 Title and Text Expert Area - Camille- MU Round Table - Michael Hunt- Security Round Table

69 Thank you!