Medicare and Medicaid EHR Incentive Program. Stage 3 and Modifications to Meaningful Use in 2015 through 2017 Final Rule with Comment

Medicare and Medicaid EHR Incentive Program Stage 3 and Modifications to Meaningful Use in 2015 through 2017 Final Rule with Comment Measures, and Proposed Alternative Measures with Select Proposed 1 Protect Patient Health Information Objective: Protect electronic health information created or maintained by the CEHRT through the implementation of appropriate technical capabilities. Measure: Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ephi data stored in Certified EHR Technology in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the EP, eligible hospital, or CAHs risk management process. N/A Final Measures & Objective 1: Protect electronic health information created or maintained by the CEHRT through the implementation of appropriate technical capabilities. Measure: Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ephi created or maintained by CEHRT in accordance with requirements under 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the EP, eligible hospital, or CAH's risk management process. N/A Ok for security risk analysis to be conducted outside of EHR reporting period if reporting period is less than one year. However, analysis /review must be conducted within the same calendar year as the EHR reporting period and if provider attests prior to end of year it must be conducted prior to date of attestation. Provider may conduct a single risk analysis for all EPs within the organization so long as is within same calendar year and prior to EP attestation for calendar year. FAQs will be update to reflect this. 1

2. Clinical Decision Support Objective: Use clinical decision support to improve performance on high-priority health conditions. In order for EPs, eligible hospitals, and CAHs to meet the objective they must satisfy both of the following measures: Measure 1: Implement five CDS interventions related to four or more clinical quality measures at a relevant point in patient care for the entire EHR Absent four clinical quality measures related to an EP, eligible hospital or CAH's scope of practice or patient population, the clinical decision support interventions must be related to high-priority health conditions. It is suggested that one of the five clinical decision support interventions be related to improving healthcare efficiency. Measure 2: The EP, eligible hospital, or CAH has enabled and implemented the functionality for drug-drug and drug allergy interaction checks for the entire EHR If for an EHR reporting period in 2015, the provider is scheduled to demonstrate Stage 1: Alternate Objective and Measure (For Measure 1): Objective: Implement one clinical decision support rule relevant to specialty or high clinical priority, or high priority hospital condition, along with the ability to track compliance with that rule. Final Measures & Objective: Use clinical decision support to improve performance on high-priority health conditions. Measure 1: Implement five CDS support interventions related to four or more clinical quality measures at a relevant point in patient care for the entire EHR Absent four clinical quality measures related to an EP, eligible hospital, or CAH's scope of practice or patient population, the clinical decision support interventions must be related to high-priority health conditions. Measure 2: The EP, eligible hospital or CAH has enabled and implemented the functionality for drug-drug and drug allergy interaction checks for the entire EHR EP : For the second measure, any EP who writes fewer than 100 medication orders during the EHR For an EHR reporting period in 2015 only, an EP, eligible hospital or CAH who is scheduled to participate in Stage 1 in 2015 may satisfy the following in place of Measure 1: Alternate Objective and Measure (For Measure 1): Objective: Implement one CDS rule relevant to specialty or high clinical priority, or high priority hospital condition, along with the ability to track compliance with that rule. Measure: Implement one CDS rule. V2015 final rule provide more guidance on standards for implementing CDS within CEHRT Provider discretion allowed to identity high-priority health conditions Provider has discretion for implementing CDS for drug-drug and drug-allergy checks in manner best suited for their organization Under exception for 2 nd measure, the 100 count cannot be pro-rated for a reporting period of 90 days. It remains 100. In order to meet this objective providers must use the capabilities and standards of CEHRT EP Exclusion: For the second measure, any EP who writes fewer than 100 medication orders during the EHR 2

3 CPOE Objective: Use computerized provider order entry for medication, laboratory, and radiology orders directly entered by any licensed healthcare professional that can enter orders into the medical record per state, local, and professional guidelines. Must meet all three Measure 1: More than 60% of medication orders created by the EP or by authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry. EP Exclusion: Any EP who writes fewer than 100 medication orders during the EHR Measure 2: More than 30% of laboratory orders created by the EP or by authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry. If for an EHR reporting period in 2015, the provider is scheduled to demonstrate Stage 1: Alternate Measure 1: More than 30% of all unique patients with at least one medication in their medication list seen by the EP or admitted to the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period have at least one medication order entered using CPOE; or more than 30% of medication orders created by the EP during the EHR reporting period, or created by the authorized providers of the eligible hospital or CAH for patients admitted to their inpatient or emergency departments (POS 21 or 23) during the EHR reporting period, are recorded using computerized provider order entry. Alternate Exclusion for Measure 2: Provider may Final Measures & Objective: Use computerized provider order entry for medication, laboratory, and radiology orders directly entered by any licensed healthcare professional that can enter orders into the medical record per state, local, and professional guidelines. Measure 1: More than 60% of medication orders created by the EP or by authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry. EP Exclusion: Any EP who writes fewer than 100 medication orders during the HER Measure 2: More than 30% of laboratory orders created by the EP or by authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry. EP Exclusion: Any EP who writes fewer than 100 laboratory orders during the EHR 2015 Alternate Measure 1: For Stage 1 providers in 2015, more than 30% of all unique patients with at least one medication in their medication list seen by the EP or admitted to the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period have at least one medication order entered using CPOE; or more than 30% of medication orders created by the EP during the EHR reporting period, or created by the authorized providers of the eligible hospital or CAH for patients admitted to their inpatient or emergency departments (POS 21 or 23) during the EHR reporting period, are recorded using computerized provider order entry. 2015 & 2016 Alternate Exclusion for Measure 2: Providers scheduled to be in Stage 1 in: Define CPOE as entailing the provider s use of computer assistance to directly enter medical orders (for example, medications, consultations with other providers, laboratory services, imaging studies, and other auxiliary services) from a computer or mobile device. The order is then documented or captured in a digital, structured, and computable format for use in improving the safety and efficiency of the ordering process. CPOE improves quality and safety by allowing clinical decision support at the point of the order, and therefore, influences the initial order decision. Provider may determine who is qualified through proper credentialing, training, and duties of medical staff to enter orders. Interns who have completed their training and are working towards licensure are included. CMS maintains position that scribes are not included as medical staff who may enter orders for purposes of meeting the CPOE objective. They note that the policy is not jobspecific to a job title but rather to medical training, knowledge and experience For standing orders / protocols may be excluded from numerators and denominators Each order associated with a specific code counts as an order 3

EP Exclusion: Any EP who writes fewer than 100 laboratory orders during the HER Measure 3: More than 30% of radiology orders created by the EP or by authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry. EP Exclusion: Any EP who writes fewer than 100 radiology orders during the EHR claim an exclusion for measure 2 (laboratory orders) of the Stage 2 CPOE objective for an EHR reporting period in 2015 since there is no equivalent Stage 1 measure. Alternate Exclusion for Measure 3: Provider may claim an exclusion for measure 3 (radiology orders) of the Stage 2 CPOE objective for an EHR reporting period in 2015 since there is no equivalent Stage 1 measure. Final Measures & Measure 3: More than 30% of radiology orders created by the EP or by authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry. Exclusion: Any EP who writes fewer than 100 radiology orders during the EHR 2015: May claim an exclusion for measure 2 (laboratory orders) of the Stage 2 CPOE objective for an EHR reporting period in 2015; 2016: May claim an exclusion for measure 2 (laboratory orders) of the Stage 2 CPOE objective for an EHR reporting period in 2016. Alternate Exclusion for Measure 3: Providers scheduled to be in Stage 1 in: Multiple tests ordered at same time count individually if the fall under a different order code (i.e. lab panels) In order to meet this objective providers must use the capabilities and standards of CEHRT 2015: May claim an exclusion for measure 3 (radiology orders) of the Stage 2 CPOE objective for an EHR reporting period in 2015; 2016: May claim an exclusion for measure 3 (radiology orders) of the Stage 2 CPOE objective for an EHR reporting period in 2016. 4

4 eprescribing (erx) EP Objective: Generate and transmit permissible prescriptions electronically (erx). EP Measure: More than 50% of all permissible prescriptions, or all prescriptions, written by the EP are queried for a drug formulary and transmitted electronically using Certified EHR Technology. EP : Any EP who: Writes fewer than 100 permissible prescriptions during the EHR reporting period; or Does not have a pharmacy within his or her organization and there are no pharmacies that accept electronic prescriptions within 10 miles of the EP's practice location at the start of his or her EHR EH Objective: Generate and transmit permissible discharge prescriptions electronically (erx). EH Measure: More than 10% of hospital discharge medication orders for permissible prescriptions (for new, changed and refilled prescriptions) are queried for a drug formulary and transmitted electronically using Certified EHR Technology. If for an EHR reporting period in 2015, the provider is scheduled to demonstrate Stage 1: Alternate EP Measure: More than 40% of all permissible prescriptions written by the EP are transmitted electronically using Certified EHR Technology. Alternate EH Exclusion: Provider may claim an exclusion for the erx objective and measure if for an EHR reporting period in 2015 they were either scheduled to demonstrate Stage 1, which does not have an equivalent measure, or if they are scheduled to demonstrate Stage 2, but did not intend to select the Stage 2 erx menu objective for an EHR reporting period in 2015. Final Measures & EP Objective: Generate and transmit permissible prescriptions electronically (erx). EP Measure: More than 50% of all permissible prescriptions, or all prescriptions, written by the EP are queried for a drug formulary and transmitted electronically using CEHRT. EP : Any EP who: Writes fewer than 100 permissible prescriptions during the EHR reporting period; or Does not have a pharmacy within his or her organization and there are no pharmacies that accept electronic prescriptions within 10 miles of the EP's practice location at the start of his or her EHR Eligible Hospital/CAH Objective: Generate and transmit permissible discharge prescriptions electronically (erx). EH Measure: More than 10% of hospital discharge medication orders for permissible prescriptions (for new and changed prescriptions) are queried for a drug formulary and transmitted electronically using CEHRT. EP : Any eligible hospital or CAH that does not have an internal 2015 Alternate EP Measure: For Stage 1 providers in 2015, more than 40% of all permissible prescriptions written by the EP are transmitted electronically using CEHRT. 2015 & 2016 Alternate Eligible Hospital/CAH Exclusion: The eligible hospital or CAH may claim an exclusion: 2015: If for the reporting period they were either scheduled to demonstrate Stage 1, or if they are scheduled to demonstrate Stage 2 but did not intend to select the Stage 2 erx objective for an EHR reporting period in 2015; 2016: If for the reporting period they were either scheduled to demonstrate Stage 1 in 2015 or if they are scheduled to demonstrate Stage 2 but did not intend to select Inclusion of controlled substances is an option but is not required for inclusion Permissible prescriptions are defined as all drugs meeting the current Stage 2 definition of a prescription modified to include controlled substances where feasible and allowed by law as proposed in Stage 3. For EHs, prescriptions from internal pharmacies and drugs dispensed on site may be excluded from the denominator. If no formulary is available for a prescription, the provider may still count the patient in the numerator for the measure. Providers can count a patient in the numerator where no formulary exists to conduct a query. Providers can also limit their effort to query a formulary to just using the function available to them in their CEHRT with no further action required. For EHs refills may be excluded. If no query function available in CEHRT then provider not required to any manual action to complete query. 5

5 Health Information Exchange (formerly Summary of Care) EH exclusion: Any eligible hospital or CAH that does not have an internal pharmacy that can accept electronic prescriptions and is not located within 10 miles of any pharmacy that accepts electronic prescriptions at the start of their EHR Objective: The EP, eligible hospital or CAH who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care provides a summary care record for each transition of care or referral. Measure: The EP, eligible hospital or CAH that transitions or refers their patient to another setting of care or provider of care (1) uses CEHRT to create a summary of care record; and (2) electronically transmits such summary to a receiving provider for more than 10% of transitions of care and referrals. EP Exclusion: Any EP who transfers a patient to another setting or refers a patient to another provider less than 100 times during the EHR reporting period. Alternate Exclusion: Provider may claim an exclusion for Measure 2 of the Stage 2 Summary of Care objective if for an EHR reporting period in 2015 they were scheduled to demonstrate Stage 1, which does not have an equivalent measure Final Measures & pharmacy that can accept electronic prescriptions and is not located within 10 miles of any pharmacy that accepts electronic prescriptions at the start of their EHR Objective: The EP, eligible hospital or CAH who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care provides a summary care record for each transition of care or referral. Measure: The EP, eligible hospital or CAH that 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 transitions of care and referrals. EP Exclusion: Any EP who transfers a patient to another setting or refers a patient to another provider less than 100 times during the EHR reporting period. the Stage 2 erx objective for the EHR reporting period in 2016. Alternate Exclusion: Provider may claim an exclusion for the Stage 2 measure that requires the electronic transmission of a summary of care document if for an EHR reporting period in 2015, they were scheduled to demonstrate Stage 1, which does not have an equivalent measure. Objective renamed Health Information Exchange from Summary of Care Previously measure specified the manner in which the SoC could be electronically transmitted. Providers are permitted to send SoC through an electronic method of their choice All SoC documents used to meet this objective must have the following information if known by the provider: o Patient name. o Referring or transitioning provider's name and office contact information (EP only). o Procedures. o Encounter diagnosis o Immunizations. o Laboratory test results. o Vital signs (height, weight, blood pressure, BMI). o Smoking status. o Functional status, including activities of daily living, cognitive and disability status o Demographic information (preferred language, sex, race, ethnicity, date of birth). 6

Final Measures & o Care plan field, including goals and instructions. o 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. o Discharge instructions (Hospital Only) o Reason for referral (EP only) In circumstances where there is no information (due to exclusion or there is nothing to record) provider can leave field blank All SoC documents used to meet this objective must include the following in order to be considered a SoC document for this objective: o Current problem list (providers may also include historical problems at their discretion), o Current medication list, and o Current medication allergy list. An EP or hospital must verify these three above fields are not blank and include the most recent information known by the EP or hospital as of the time of generating the SoC A provider must have the ability to send all laboratory test results in the SoC, but they may work with their system developer to establish clinically relevant parameters based on their specialty, patient population, or for certain transitions and referrals which allow for clinical relevance 7

6 Patient Specific Education Objective: Use clinically relevant information from CEHRT to identify patient-specific education resources and provide those resources to the patient. EP Measure: Patient-specific education resources identified by Certified EHR Technology are provided to patients for more than 10% of all unique patients with office visits seen by the EP during the EHR reporting period. EP Exclusion: Any EP who has no office visits during the EHR reporting period. EH Measure: More than 10% of all unique patients admitted to the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) are provided patient-specific Alternate Exclusion: Providers may claim an exclusion for the measure of the Stage 2 Patient- Specific Education objective if for an EHR reporting period in 2015 they were scheduled to demonstrate Stage 1 but did not intend to select the Stage 1 Patient Specific Education menu objective. Final Measures & Objective: Use clinically relevant information from CEHRT to identify patient-specific education resources and provide those resources to the patient. EP Measure: Patient-specific education resources identified by CEHRT are provided to patients for more than 10% of all unique patients with office visits seen by the EP during the EHR reporting period. Exclusion: Any EP who has no office visits during the EHR EH Measure: More than 10% of all unique patients admitted to the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are provided patient-specific education resources identified by CEHRT. Alternate Exclusion: Providers may claim an exclusion for the measure of the Stage 2 Patient-Specific Education objective if for an EHR reporting period in 2015 they were scheduled to demonstrate Stage 1 but did not intend to select the Stage 1 Patient Specific Education menu objective. to determine the most appropriate results for given transition or referral. When a provider limits the info sent they must send full results upon request including patient request. When providers share access to the EHR, a transition or referral may still count toward the measure if the referring providers creates the SoC document using CEHRT and sends the SoC document electronically. CEHRT must be used to identify patientspecific education resources, however these resources not have to be maintained within or generated by the CEHRT. External resources may be can be queried via CHERT (inked to specific consumer health content) Provider should use CEHRT in a manner in which the technology suggests patientspecific educational resources based on the information created or maintained in the CEHRT. CEHRT is certified to use the patient's problem list, medication list, or laboratory test results to identify the patient-specific educational resource Provision of patient-specific education does not have to occur during office visit or hospital stay. May occur outside of the reporting period but for: o EPs: Must occur no earlier than the start of the same year as the EHR reporting period if the EHR reporting 8

7 Medication Reconciliation education resources identified by CEHRT. Objective: The EP, eligible hospital, or CAH who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation. Measure: The EP, eligible hospital or CAH performs medication reconciliation for more than 50% of transitions of care in which the patient is transitioned into the care of the EP or admitted to the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23). EP Exclusion: Any EP who was not the recipient of any transitions of care during the EHR Alternate and Specifications for Stage 1 Providers for Meaningful Use in 2015: Any provider scheduled to demonstrate Stage 1 of meaningful use for an EHR reporting period in 2015 who was not intending to attest to the Stage 1 Medication Reconciliation menu objective, may claim an exclusion to the measure. Alternate Exclusion: Provider may claim an exclusion for the measure of the Stage 2 Medication Reconciliation objective if for an EHR reporting period in 2015 they were scheduled to demonstrate Stage 1 but did not intend to select the Stage 1 Final Measures & Objective: The EP, eligible hospital or CAH that receives a patient from another setting of care or provider of care or believes an encounter is relevant performs medication reconciliation. Measure: The EP, eligible hospital or CAH performs medication reconciliation for more than 50% of transitions of care in which the patient is transitioned into the care of the EP or admitted to the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23). EP Exclusion: Any EP who was not the recipient of any transitions of care during the EHR Exclusion: Provider may claim an exclusion for the measure of the Stage 2 Medication Reconciliation objective if for an EHR reporting period in 2015 they were scheduled to demonstrate Stage 1 but did not intend to select the Stage 1 Medication Reconciliation menu objective. period is less than one full calendar year and no later than the date of attestation. o EH: Must be provided after the patient's admission to the hospital, and no later than the date of attestation. EP, eligible hospital, or CAH must use the capabilities and standards of as defined for as defined CEHRT The denominator includes when the provider is the recipient of the transition or referral, first encounters with a new patient and encounters with existing patients where a summary of care record (of any type) is provided to the receiving provider For those EPs who have no office visits, or face -to face encounters, and therefore should not have to include patient encounters for these services (such as only reading an EKG) electronic summary of care document is not required for medication reconciliation. HIE is not a prerequisite for performing medication reconciliation. For providers who are on the receiving end of a transition of care or referral, the denominator includes first encounters with a new patient and encounters with existing patients where a summary of care record (of any type) is provided to the receiving provider. 9

8. Patient Electronic Access EP Objective: Provide patients the ability to view online, download, and transmit their health information within 4 business days of the information being available to the EP. EP Measure 1: More than 50% of all unique patients seen by the EP during the EHR reporting period are provided timely (within 4 business days after the information is available to the EP) online access to their health information subject to the EP's discretion to withhold certain information. EP Measure 2: At least one patient seen by the EP during the EHR reporting period (or their authorized representatives) views, downloads, or transmits his or her health information to a third party. EP : Any EP who--(a) Neither orders nor creates any of the information listed for inclusion as part of the measures; or (b) Conducts 50% or more of his or her patient encounters in a county that does not have 50% or more of its housing units with 4Mbps broadband availability according to the latest information Medication Reconciliation menu objective. Alternate Exclusion Measure 2: Providers may claim an exclusion for the second measure if for an EHR reporting period in 2015 they were scheduled to demonstrate Stage 1, which does not have an equivalent measure. Final Measures & EP Objective: Provide patients the ability to view online, download, and transmit their health information within 4 business days of the information being available to the EP. EP Measure 1: More than 50% of all unique patients seen by the EP during the EHR reporting period are provided timely access to view online, download, and transmit to a third party their health information subject to the EP's discretion to withhold certain information. EP 2015 & 2016 EP Measure 2: For an EHR reporting period in 2015 and 2016, at least one patient seen by the EP during the EHR reporting period (or patient-authorized representative) views, downloads or transmits to a third party his or her health information during the EHR : Any EP who: Neither orders nor creates any of the information listed for inclusion as part of the measures; or Conducts 50% or more of his or her patient encounters in a county that Alternate Exclusion: Providers may claim an exclusion for the second measure if for an EHR reporting period in 2015 they were scheduled to demonstrate Stage 1, which does not have an equivalent measure. EP, eligible hospital, or CAH must use the capabilities and standards of as defined for as defined CEHRT For EPs for Measure 2: To meet the objective the following info must be made available to patients electronically within 4 business days of the information being made available to the EP: Patient name. Provider's name and office contact information. Current and past problem list. Procedures. Laboratory test results. Current medication list and medication history. Current medication allergy list and medication allergy history. Vital signs (height, weight, blood pressure, BMI, growth charts). Smoking status. Demographic information (preferred language, sex, race, ethnicity, date of birth) Care plan field(s), including goals and instructions. Any known care team members including the primary care provider (PCP) of record. For EHs for Measure 2: To meet the objective the following info must be made available to patients electronically within 4 business days of the information being made available to the EH/CAH: 10

available from the FCC on the first day of the EHR EH Objective: Provide patients the ability to view online, download, and transmit their health information within 36 hours of hospital discharge. EH Measure 1: More than 50% of all patients who are discharged from the inpatient or emergency department (POS 21 or 23) of an eligible hospital or CAH have their information available online within 36 hours of discharge. EH Measure 2: At least 1 patient who is discharged from the inpatient or emergency department (POS 21 or 23) of an eligible hospital or CAH (or his or her authorized representative) views, downloads or transmits to a third party his or her information during the EHR EH Exclusion: Any eligible hospital or CAH that is located in a county that does not have 50% 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. Final Measures & does not have 50% 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 EP 2017 For an EHR reporting period in 2017, more than 5% of unique patients seen by the EP during the EHR reporting period (or his or her authorized representatives) view, download or transmit to a third party their health information during the EHR reporting period. : Any EP who: Neither orders nor creates any of the information listed for inclusion as part of the measures; or Conducts 50% or more of his or her patient encounters in a county that does not have 50% 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 EH Objective: Provide patients the ability to view online, download, and transmit their health information within 36 hours of hospital discharge. Patient name. Admit and discharge date and location. Reason for hospitalization. Care team including the attending of record as well as other providers of care. Procedures performed during admission. Current and past problem list. Vital signs at discharge. Laboratory test results (available at time of discharge). Summary of care record for transitions of care or referrals to another provider. Care plan field(s), including goals and instructions. Discharge instructions for patient. Demographics maintained by hospital (sex, race, ethnicity, date of birth, preferred language). Smoking status. CMS notes that obtaining a patient s email is not the only way to meet the measure and provision of access to meet CDT can take many forms. If a provider s CEHRT does require a patient email and patient refuses to give or does not have one or elects to opt out this is not prohibited by MU. However, excluding these patients from the denominator is not allowed. The provider may still meet the measure by providing the patient all the necessary 11

Final Measures & EH Measure 1: More than 50% of all unique patients who are discharged from the inpatient or emergency department (POS 21 or 23) of an eligible hospital or CAH are provided timely access to view online, download and transmit to a third party their health information. EH 2015 & 2016 EH Measure 2: For an EHR reporting period in 2015 and 2016, at least one patient who is discharged from the inpatient or emergency department (POS 21 or 23) of an eligible hospital or CAH (or patient-authorized representative) views, downloads or transmits to a third party his or her health information during the EHR EH Exclusion: Any eligible hospital or CAH that is located in a county that does not have 50% 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 EH/CAH 2017 EH Measure 2: For an EHR reporting period in 2017, more than 5% of unique information required for the patient to subsequently access their information, obtain access through a patientauthorized representative, or otherwise opt-back-in without further follow-up action required by the provider. Patient needs to be seen by the EP or discharged from the hospital during the HER reporting period in order to be included in the denominator. Providers cannot count any action in any time period before the HER reporting period to count in the numerator. The calculation can include actions take before, during, or after the reporting period if the period is less than a full year, however, actions must be taken no earlier than start of same year as reporting period and no later than attestation date. Providers who are covered by civil rights laws, including the Americans with Disabilities Act, Section 504 of the Rehabilitation Act of 1973, or Section 1577 of the Affordable Care Act, must provide individuals with disabilities equal access to information and appropriate auxiliary aids and services as provided in the applicable statutes and regulations. More info can be found at: http://www.ada.gov/effectivecomm.htm. EP, eligible hospital, or CAH must use the capabilities and standards of as defined for as defined CEHRT 12

Final Measures & patients discharged from the inpatient or emergency department (POS 21 or 23) of an eligible hospital or CAH (or patient-authorized representative) view, download or transmit to a third party their health information during the EHR 9: Secure Electronic Messaging (EP Only) Objective: Use secure electronic messaging to communicate with patients on relevant health information. Measure: The capability for patients to send and receive a secure electronic message with the provider was fully enabled during the EHR Exclusion: Any EP who has no office visits during the EHR reporting period, or any EP who conducts 50% or more of his or her patient encounters in a county that does not have 50% or more of its housing units with 4Mbps broadband availability according to the latest information available from Alternate Exclusion: An EP may claim an exclusion for the measure if for an EHR reporting period in 2015 they were scheduled to demonstrate Stage 1, which does not have an equivalent measure. EH Exclusion: Any eligible hospital or CAH that is located in a county that does not have 50% 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 EP Objective: Use secure electronic messaging to communicate with patients on relevant health information. 2015 EP Measure: For an EHR reporting period in 2015, the capability for patients to send and receive a secure electronic message with the EP was fully enabled during the EHR reporting period. 2016 EP Measure: For an EHR reporting period in 2016, for 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 patientauthorized representative), or in response to a secure message sent by Alternate Exclusion: An EP may claim an exclusion for the measure if for an EHR reporting period in 2015 they were scheduled to demonstrate Stage 1, which does not have an equivalent measure. Patient-initiated message would only count toward the numerator if the provider responded to the patient as that is part of measuring the provider action rather than the patient action for this measure. The calculation may include actions taken before, during, or after the EHR reporting period if the period is less than one full year. However, these actions must be taken no earlier than the start of the same year as the EHR reporting period and no later than the date of attestation. 13

the FCC on the first day of the HER Final Measures & the patient (or the patient-authorized representative) during the EHR 2017 EP Measure: For an EHR reporting period in 2017, for more than 5% of unique patients 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 10 Public Health and Clinical Data Registry Reporting Objective: The EP, eligible hospital or CAH is in active engagement with a Public Health Agency (PHA) or clinical data registry (CDR) to submit electronic public health data in a meaningful way using CEHRT, except where prohibited and in accordance with applicable law and practice. In 2015 only for providers scheduled to be in Stage 1: EPs: Choose from Measures 1 through 5 and attest to one measure. EHs: Choose from Measures 1 through 6 and attest to two measures. EP Exclusion: Any EP who has no office visits during the EHR reporting period, or any EP who conducts 50% or more of his or her patient encounters in a county that does not have 50% 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 Objective: The EP, eligible hospital or CAH is in active engagement with a public health agency to submit electronic public health data from CEHRT except where prohibited and in accordance with applicable law and practice. Measure 1 Immunization Registry Reporting: The EP, eligible hospital, or Alternate Specification: An EP scheduled to be in Stage 1 in 2015 may meet 1 measure and an eligible hospital or CAH scheduled to be in Stage 1 in 2015 may meet two measures. Number of Measures reduced from 6 to 4. Those at Stage 2: o EPs required to meet two Measures o EHs / CAHs required to meet three Measures BI-directional requirement for Measure 1 is removed and providers do not need to display an immunization forecast from an Immunization Information System 14

Active Engagement Option 1 Completed Registration to Submit Data: The EP, eligible hospital or CAH registered to submit data with the PHA or, where applicable, the CDR to which the information is being submitted; registration was completed within 60 days after the start of the EHR reporting period; and the EP, eligible hospital, or CAH is awaiting an invitation from the PHA or CDR to begin testing and validation. Proposed Active Engagement Option 2 - Testing and Validation: The EP, eligible hospital, or CAH is in the process of testing and validation of the electronic submission of data. Providers must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within an EHR reporting period would result in that provider not meeting the measure. Proposed Active Engagement Option 3 Production: The EP, eligible hospital, or CAH has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR. CMS proposed 6 possible measures: Final Measures & CAH is in active engagement with a public health agency to submit immunization data. Exclusion: Any EP, eligible hospital, or CAH meeting one or more of the following criteria may be excluded from the immunization registry reporting measure if the EP, eligible hospital, or CAH: Does not administer any immunizations to any of the populations for which data is collected by its jurisdiction's immunization registry or immunization information system during the EHR reporting period; Operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required to meet the CEHRT definition at the start of the EHR reporting period; OR Operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data from the EP, eligible hospital, or CAH at the start of the EHR Measure 2 Syndromic Surveillance Reporting: The EP, eligible hospital, or CMS clarifies that while the active engagement for 2015 to 2017 replace the ongoing submission" requirement included in the Stage 2 final rule, they are not mutually exclusive. For providers who have already planned for and/or acted toward meeting any of the Stage 1 or Stage 2 public health reporting objectives, those actions would count toward meeting the active engagement options. Exclusion from Measure would not count towards meeting 2 Measures. If EPs qualified for multiple exclusions and remaining measures available is fewer than 2 then EP could have met objective by the meeting the remaining measure and claiming exclusions. If no Measures remain, EP could have met objective by claiming exclusions for all measures. If EH / CAH qualifies for multiple exclusions and total number remaining is fewer than 3 then EH can meet the objective by meeting all the remaining measures available and claiming exclusions. If no Measures remain, EH / CHA can meet objective by claiming applicable exclusions for all measures Public Health and Clinical Data Registry Reporting can be counted more than once if more than one of each are available. Providers would only need to register once with a public health agency or a clinical data registry and could register before the reporting period begins. 15

EPs: Pick from Measures 1-5 and attest to any combo of 2 measures EHs: Pick from Measures 1-6 and attest to any combo of 3 Measures Proposed Measure 1 Immunization Registry Reporting: The EP, eligible hospital, or CAH is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS). To successfully meet the requirements of this measure, bi-directional data exchange between the provider's CEHRT system and the immunization registry/iis is required. Exclusion: Any EP, eligible hospital, or CAH meeting one or more of the following criteria may be excluded from the immunization registry reporting measure if the EP, eligible hospital, or CAH: Does not administer any immunizations to any of the populations for which data is collected by its jurisdiction's immunization registry or immunization information system during the EHR reporting period; Final Measures & CAH is in active engagement with a public health agency to submit syndromic surveillance data. EP Exclusion: Any EP meeting one or more of the following criteria may be excluded from the syndromic surveillance reporting measure if the 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 public health agency is capable of receiving electronic syndromic surveillance data from EPs in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period; or Operates in a jurisdiction where no public health agency has declared readiness to receive syndromic surveillance data from EPs at the start of the EHR EH Exclusion: Any eligible hospital or CAH meeting one or more of the following criteria may be excluded from the syndromic surveillance reporting measure if the eligible hospital or CAH: Does not have an emergency or urgent care department; Operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic Previous registrations with a public health agency or clinical data registry that occurred in a previous stages of MU could count toward Active Engagement Option 1 for any of the EHR reporting periods in 2015, 2016, or 2017. Providers must register with a PHA or CDR for each measure they intend to use to meet meaningful use. To meet Active Engagement Option 1, registration with the applicable PHA or CDR is required where a provider seeks to meet meaningful use using a measure they have not successfully attested to in a previous EHR Providers can demonstrate meaningful use by using communications and information provided by a PHA or CDR to the provider directly. 16

Operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required to meet the CEHRT definition at the start of the EHR reporting period; OR Operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data from the EP, eligible hospital, or CAH at the start of the EHR Proposed Measure 2 Syndromic Surveillance Reporting: The EP, eligible hospital or CAH is in active engagement with a public health agency to submit syndromic surveillance data from a non-urgent care ambulatory setting where the jurisdiction accepts syndromic data from such settings and the standards are clearly defined for EPs, or an emergency or urgent care department for eligible hospitals and CAHs (POS 23). Exclusion for EPs: Any EP meeting one or more of the following criteria may be excluded from the syndromic surveillance reporting measure if the EP: Final Measures & surveillance data from eligible hospitals or CAHs in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period; OR Operates in a jurisdiction where no public health agency has declared readiness to receive syndromic surveillance data from eligible hospitals or CAHs at the start of the EHR Measure 3 Specialized Registry Reporting: The EP, eligible hospital, or CAH is in active engagement to submit data to a specialized registry. : Any EP, eligible hospital, or CAH meeting at least one of the following criteria may be excluded from the specialized registry reporting measure if the EP, eligible hospital, or CAH: Does not diagnose or treat any disease or condition associated with or collect relevant data that is required by a specialized registry in their jurisdiction during the EHR reporting period; Operates in a jurisdiction for which no specialized registry is capable of accepting electronic registry transactions in the specific standards required to meet the 17

Does not treat or diagnose or directly treat any disease or condition associated with a syndromic surveillance system in his or her jurisdiction; Operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data from EPs in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period; or Operates in a jurisdiction where no public health agency has declared readiness to receive syndromic surveillance data from EPs at the start of the HER EH Exclusion: Any eligible hospital or CAH meeting one or more of the following criteria may be excluded from the syndromic surveillance reporting measure if the eligible hospital or CAH: Does not have an emergency or urgent care department; Operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data from eligible hospitals or CAHs in the specific standards required to Final Measures & CEHRT definition at the start of the EHR reporting period; OR Operates in a jurisdiction where no specialized registry for which the EP, eligible hospital, or CAH is eligible has declared readiness to receive electronic registry transactions at the beginning of the EHR reporting period. Measure 4 Electronic Reportable Laboratory Result Reporting: The eligible hospital or CAH is in active engagement with a public health agency to submit electronic reportable laboratory (ELR) results. Exclusion: Any eligible hospital or CAH meeting one or more of the following criteria may be excluded from the electronic reportable laboratory result reporting measure if the eligible hospital or CAH: Does not perform or order laboratory tests that are reportable in their jurisdiction during the EHR reporting period; Operates in a jurisdiction for which no public health agency is capable of accepting the specific ELR standards required to meet the CEHRT definition at the start of the EHR reporting period; OR Operates in a jurisdiction where no public health agency has declared 18

meet the CEHRT definition at the start of the EHR reporting period; OR Operates in a jurisdiction where no public health agency has declared readiness to receive syndromic surveillance data from eligible hospitals or CAHs at the start of the EHR Final Measures & readiness to receive electronic reportable laboratory results from eligible hospitals or CAHs at the start of the EHR Proposed Measure 3-Case Reporting: The EP, eligible hospital, or CAH is in active engagement with a public health agency to submit case reporting of reportable conditions. Proposed : Any EP, eligible hospital, or CAH meeting one or more of the following criteria may be excluded from the case reporting measure if the EP, eligible hospital, or CAH: Does not treat or diagnose any reportable diseases for which data is collected by their jurisdiction's reportable disease system during the EHR reporting period; Operates in a jurisdiction for which no public health agency is capable of receiving electronic case reporting data in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period; OR 19