Meaningful Use 2016 and beyond

Meaningful Use 2016 and beyond Main Street Medical Consulting May 12, 2016 Meaningful use, MACRA, MIPS? Whaaaaat? 1

Reporting Period and Timeline In 2016 all providers are required to use CEHRT versions of software, they may use either 2014 or 2015 versions. In 2016, any provider who has successfully demonstrated Meaningful Use will report for the entire calendar year. (First year participants will still report for 90 calendar days) In 2016 providers will attest to a single set of objectives with alternate exclusions and specifications for those scheduled to attest to Stage 1* In 2017 providers may attest to either the same set of objectives (without the alternates) or they may attest to the Stage 3 measures. In 2017, the EHR reporting period will be one full calendar year for all participants except new participants and/or providers who choose to implement Stage 3. (Reporting period is 90 days for those providers) Alternate Exclusions and Specifications 2016 Provisions were made for those providers prepared to attest for Stage 1 in 2015 Many of these alternate exclusions are not available in 2016. The alternate exclusions in 2016 are for CPOE and Public Health: 2

Document! Document! Document! It is the responsibility of the practice to maintain documentation that fully supports meaningful use AND quality measure data submitted during attestation Retain ALL relevant supporting documentation (either paper or electronic format) used in completion of attestation Documentation should be retained for SIX YEARS post attestation Audits may include a review of ANY documentation needed to support the information that was entered during attestation Retain all reports used during attestation including Clinical Quality Measures If a non-calculable measure, retain one or more screen shots to support the attestation States and their contractors will perform audits for Medicaid providers Measures and Objectives 2016 3

Objective 1: Protect Patient Health Information Objective: Protect electronic protected health information (ephi) 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, including addressing the security (to include encryption) of ephi created or maintained by CEHRT, and implement security updates as necessary and correct identified security deficiencies as part of the risk management process. A review must be conducted for each EHR reporting periodand any security updates and deficiencies that are identified should be included in the provider's risk management process and implemented or corrected as dictated by that process. The HHS Office for Civil Rights (OCR) has issued guidance on conducting a security risk analysis in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Security Rule http://www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/rafinalguidancepdf.pdf. Other free tools and resources available to assist providers include a Security Risk Assessment (SRA) Tool developed by ONC and OCR http://www.healthit.gov/providersprofessionals/security-risk-assessment-tool. (Cont.) Objective 1: Protect Patient Health Information It is acceptable for the security risk analysis to be conducted outside the EHR reporting period; however, the analysis must be unique for each EHR reporting period, the scope must include the full EHR reporting period, and the analysis or review must be conducted prior to the date of attestation The analysis/review must be conducted within the same calendar year as the EHR reporting period, and if the provider attests prior to the end of the calendar year, it must be conducted prior to the date of 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. However, each EP is individually responsible for their own attestation and for independently meeting the objective. THERE IS NO EXCLUSION TO THIS OBJECTIVE 4

Objective 2: Clinical Decision Support (2-Part Measure) Objective: Use clinical decision support to improve performance on high-priority health conditions. Measure: In order for EPs, to meet the objective they mustsatisfy both of the following measures: Measure 1: Implement five clinical decision support interventions related to four or more clinical quality measures for the entire EHR reporting period. Absent four clinical quality measures related to an EP s scope of practice, the clinical decision support interventions must be related to high priority health conditions. EXCLUSION:THERE IS NO EXCLUSION FOR THIS PORTION OF THE MEASURE Measure 2: The Eligible Provider has enabled and implemented the functionality for drugdrug and drug allergy interaction checks for the entire EHR reporting period. Drug-drug and drug-allergy interaction alerts are separate from the 5 clinical decision support interventions and do not count toward the 5 required for the first measure. EXCLUSION: Any EP who writes fewer than 100 medication orders during the EHR reporting period may be excluded. Objective 3: Computerized Provider Order Entry (3-Part Measure) MicroMD Report Core #1A, 1B, 1C 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: An EP, through a combination of meeting the thresholds and exclusions (or both), must satisfy all three measures for this objective: Measure 1: More than 60 percent of medication orders created by the EP during the EHR reporting period are recorded using computerized provider order entry. EXCLUSION: Any EP who writes fewer than 100 medication orders during the EHR reporting period may be excluded. Measure 2: More than 30 percent of laboratory orders created by the EP during the EHR reporting period are recorded using computerized provider order entry. EXCLUSION: Any EP who writes fewer than 100 laboratory orders during the EHR reporting period. may be excluded. 5

(Cont.) Objective 3: Computerized Provider Order Entry (3-Part Measure) Objectives: (Continued) Measure 3: More than 30 percent of radiology orders created by the EP 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 reporting period may be excluded. Alternate Measure for providers in Stage 1: Measure 2:Providers scheduled to be in Stage 1 in 2016 may claim an exclusion for measure 2 (laboratory orders) of the Stage 2 CPOE objective for an EHR reporting period in 2016. Measure 3:Providers scheduled to be in Stage 1 in 2016 may claim an exclusion for measure 3 (radiology orders) of the Stage 2 CPOE objective for an EHR reporting period in 2016. The CPOE function must be used to create the first record of the order that becomes part of the patient's medical record and before any action can be taken on the order to count in the numerator. Objective 4: Electronic Prescribing MicroMD Report Core #2 Objective: Generate and transmit permissible prescriptions electronically (erx). Measure: More than 50 percent of permissible prescriptions written by the EP are queried for a drug formulary and transmitted electronically using CEHRT. Must have formulary feature turned on in EMR for entire reporting period. (Tools > User Preferences > Prescriptions > do not check Disable formulary panel ) Problem list must be present or an indication that No Active Problems exists must be documented. Instances where patients specifically request a paper prescription may not be excluded from the denominator of this measure. The denominator includes all prescriptions written by the EP during the EHR reporting period. EXCLUSION: An 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 the EHR reporting period 6

Objective 5: Health Information Exchange MicroMD Report Core #15B, requires the use of CIN/Mail Messaging and Portal 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 provides a summary care record for each transition of care or referral. Measure: The EP 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 percent of transitions of care and referrals. 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 may take this exclusion. An EP must verify that the fields for problem list, medication list, and allergy list are not blank and include the most recent information as of the time of generating the summary of care document or include a notation of no current problem, medication and/or medication allergies.. Objective 6: Patient Specific Education MicroMD Report Core #13 Objective: Use clinically relevant information from CEHRT to identify patient-specific education resources and provide those resources to the patient. Measure: Patient-specific education resources identified by CEHRT are provided to patients for more than 10 percent 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 reporting period. The EP must use elements within certified EHR technology (CEHRT) to identify educational resources specific to patients' needs. The EP can then provide these educational resources to patients in a useful format for the patient (such as, electronic copy, printed copy, electronic link to source materials, through a patient portal or PHR). The education resources or materials do not have to be stored within or generated by the CEHRT. 7

Objective 7: Medication Reconciliation MicroMD Report Core #14 Objective: The eligible provider that receives a patient from another setting of care or provider of care or believes an encounter is relevant performs medication reconciliation. Measure: The eligible provider performs medication reconciliation for more than 50 percent of transitions of care in which the patient is transitioned into the care of the EP EXCLUSION:Any EP who was not the recipient of any transitions of care during the EHR reporting period may qualify for this exclusion. The electronic exchange of information is not a requirement for medication reconciliation. Medication Reconciliation The process of identifying the most accurate list of all medications that the patient is taking, including name, dosage, frequency, and route, by comparing the medical record to an external list of medications obtained from a patient, hospital or other provider. Objective 8: Patient Electronic Access (2-Part Measure) MicroMD Report Core #7a & 7b 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. Measure: In order for providers to meet the objective they mustsatisfy both of the following measures: Measure 1: More than 50 percent 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. Measure 2: 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 their health information during the EHR reporting period. EXCLUSION: Any eligible provider who Neither orders nor creates any of the information listed for inclusion as part of the measures; 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. 8

Objective 8: Patient Electronic Access (2-Part Measure) The patient must be able to access this information on demand, such as through a patient portal or personal health record (PHR) or by other online electronic means. If a patient elects to "opt out" of participation, that patient must still be included in the denominator. Objective 9: Secure Electronic Messaging MicroMD Report Core #17 Objective: Use secure electronic messaging to communicate with patients on relevant health information. Measure: For at least 1 patient seen during the EHR reporting period, a secure message was sent using the electronic messaging function to the patient, or in response to a secure message sent by the patient. EXCLUSION: Any eligible provider who Has no office visits during the EHR reporting period, or 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. A patient-initiated message would only count toward the numerator if the provider responds to the patient. The thresholds for this measure increase over time to allow providers to work incrementally toward a higher goal. The measure threshold for this objective was fully enabled for 2015, and is at least one patient for 2016, and a threshold of 5 percent for 2017 to build toward the Stage 3 threshold. 9

Objective 10: Public Health & Clinical Data Registry Reporting (3-Part Measure) Objective: The eligible provider 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: In order for providers to meet the objective they mustsatisfy 2 of the following 3 measures: Measure 1: Immunization Registry Reporting:The eligible provider is in active engagement with a public health agency to submit immunization data. Exclusion: Measure1 Exclusions: Any EP meeting one or more of the following criteria may be excluded from the immunization reporting measure. If the EP 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 at the start of the EHR reporting period. (Slide 2) Objective 10: Public Health & Clinical Data Registry Reporting Measure 2 Syndromic Surveillance Reporting: The eligible provider is in active engagement with a public health agency to submit syndromic surveillance data. Exclusion:Measure 2 Exclusions: An 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. 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 reporting period. Alternate Exclusion for Measure 2: EPs may claim an alternate exclusion for measure 2 (syndromic surveillance reporting) for an EHR reporting period in 2016. 10

(Slide 3) Objective 10: Public Health & Clinical Data Registry Reporting Measure 3 Specialized Registry Reporting:The eligible provider is in active engagement to submit data to a specialized registry. Exclusions:Measure 3 Exclusions: An EP meeting at least one of the following criteria may be excluded from the specialized registry reporting measure. If the EP 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 CEHRT definition at the start of the EHR reporting period; or Operates in a jurisdiction where no specialized registry for which the EP is eligible has declared readiness to receive electronic registry transactions at the beginning of the EHR reporting period. Alternate Exclusion for Measure 3: EPs may claim an alternate exclusion for measure 3 (specialized registry reporting) for an EHR reporting period in 2016. Clinical Quality Measures Reporting Period for 2016 is the full calendar year unless you are a first year Stage 1 participant (90-days). Providers may report results including zeroes in numerator. Report on 9 quality measures covering at least 3 of the National Quality Strategy domains: Patient and Family Engagement Patient Safety Care Coordination Population/Public Health Efficient Use of Healthcare Resources Clinical Process/Effectiveness 11

CQM Reporting Pay close attention to the guidelines for these as they are very specific in order for numbers to populate. (LOINC codes, SNO- Meds) NQF 0028 / CMS138V3 SMOKING CESSATION PREVENTIVE CARE AND SCREENING: TOBACCO USE: SCREENING AND CESSATION INTERVENTION Denominator **Patients in Age Range > = 18 years(checked before the start of the measurement period )AND: ***Who have had at least 1 Encounter of Preventive Care Services Numerator ** MedInfo > Histories > Habits AND MedInfo > Medical > Diagnostic Test MedInfo > Health Maintenance > Screening and Prevention Encounter Plan -- Procedure Orders Proposed Stage 3 Measures, Objectives & Changes 12

Stage 3 Proposed Timeline and Measures Optional 90-day reporting period for those wishing to participate in 2017. Full calendar year reporting period for providers in 2018 (Proposed final year for the Medicare EHR Incentive Program) Limited exception for Medicaid providers in their first year of demonstrating meaningful use. Set of 8 objectives with associated measures designed to meet the following: Align with national health care quality improvement efforts Promote interoperability and health information exchange. Focus on the 3-part aim of reducing cost, improving access and improving quality. Stage 3 is planned to be the final stage of the meaningful use framework, while establishing a single set of objectives to promote best practices and continued improvement in health outcomes. Stage 3 Proposed Objectives Objective 1: Protect Patient Health Information (Security Risk Analysis) -Same as Stages 1&2 with addition of implementation of administrative and physical safeguards -Analysis must be done upon installation of software or upon upgrades to new versions, and reviewed in subsequent years Objective 2: Electronic Prescribing -More than 60 percent of all permissible prescriptions written by the EP are queried for a drug formulary and transmitted electronically using CEHRT Objective 3: Clinical Decision Support (2-part measure)-implement five clinical decision support interventions related to four or more CQMs at a relevant point in patient care for the entire EHR reporting period, AND have enabled and implemented the functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period. Objective 4: (CPOE) Computerized Provider Order Entry (3-part measure) - Use computerized provider order entry (CPOE) for medication, laboratory, and diagnostic imaging orders directly entered into the EHR. Objective 5: Patient Electronic Access(2-part measure) -The EP provides patients (or patient-authorized representative) with timely electronic access to their health information and patient-specific education. 13

Stage 3 Proposed Objectives Objective 6: Coordination of Care through Patient Engagement(3-part measure) -Use CEHRT to engage with patients or their authorized representatives about the patient's care. More than 10 percent of all unique patients seen actively engage with the electronic health record made accessible by the provider and either: (1) View, download or transmit to a third party their health information; or (2) access their health information or (3) a combination of (1) and (2). For more than 25 percent of all unique patients seen, a secure message was sent using the electronic messaging function Patient generated health data or data from a nonclinical setting is incorporated into the CEHRT for more than 5 percent of all unique patients. Objective 7: Health Information Exchange (3-part measure)-the EP provides a summary of care record when transitioning or referring their patient to another setting of care; receives or retrieves a summary of care record upon the receipt of a transition or referral or upon the first patient encounter with a new patient; and incorporates summary of care information from other providers into their EHR using the functions of CEHRT. Objective 8: Public Health and Clinical Data Registry Reporting-Eligible providers must choose 3 measures of the following: Immunization Registry Reporting, Syndromic Surveillance Reporting, Electronic Case Reporting, Public Health Registry Reporting, Clinical Data Registry Reporting The End for Meaningful Use? 14

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) "In 2016, MU (meaningful use) as it has existed with MACRA will now be effectively over and replaced with something better," tweeted Andy Slavitt, the administrator of the Centers for Medicare & Medicaid Services (CMS). President Obama signed the MACRA into law on April 16, 2015. MACRA repealed the sustainable growth rate formula for physician pay and shifts Medicare compensation from fee-for-service to pay-for-performance (PFP), also known as pay-for-value. Under MACRA, physicians choose between two PFP models. The alternative payment model (APM), which is more advanced, is for physicians participating in patient-centered medical homes, accountable care organizations, and Medicare shared-savings programs. The less advanced model is the Merit-Based Incentive Payment System (MIPS). It will incorporate and align EHR meaningful use and two other incentive programs the Physician Quality Reporting System and the Value-Based Payment Modifier. Medicare will increase or decrease a physician's fee-for service reimbursement in MIPS according to his or her quality of care, use of medical resources, clinical practice improvement, and meaningful use of EHRs. MIPS: Merit-Based Incentive Payment System What is MIPS? MIPS promotes better care, healthier people, and smarter spending by evaluating EPs using a Composite Performance Score that incorporates EP performance on quality, resource use, clinical practice improvement activities, and meaningful use of certified electronic health records. Based on the Composite Performance Score, EPs may receive an upward payment adjustment, a downward payment adjustment, or no payment adjustment. Most practitioners will be subject to MIPS What are the options for EPs under the MACRA? EPs can participate in MIPS or meet requirements to be a qualifying APM participant. EPs in MIPS can receive a positive, downward, or neutral payment adjustment, starting at +/-4 percent in 2019 and growing to +/-9 percent in 2022 and later. EPs who are determined to be qualifying APM participants (QPs) for a given year will be excluded from MIPS and receive a 5 percent lump sum incentive payment for that year. 15

Merit Based Incentive Program MIPS sunsets (ends) PQRS, VBM and Meaningful Use in 2018 and begins in 2019 but Medicaid EHR Initiative and Medicare for Hospitals will continue First proposed performance period is January 1, 2017 through December 31, 2017. MIPS combines the requirements of the Physician Quality Reporting System, the Value Modifier Program, and the Medicare EHR Incentive Program into a single, improved reporting program. Therefore, the last performance period for these separate reporting programs would be January 1, 2016 through December 31, 2016. The first payment/adjustment year will be 2019, based on 2017 performance. Negative adjustments will increase over time, and positive adjustments will correspond. The maximum negative adjustments for each year are: MIPS: Calculating the Composite Score MIPS allows Medicare clinicians to be paid for providing high quality, efficient care through success in four performance categories: COST : (10 percent of total score in year 1; replaces the cost component of the Value Modifier Program, also known as Resource Use): The score would be based on Medicare claims, meaning no reporting requirements for clinicians. This category would use more than 40 episode-specific measures to account for differences among specialties. QUALITY: (50 percent of total score in year 1; replaces the Physician Quality Reporting System and the quality component of the Value Modifier Program): Clinicians would choose to report six measures versus the nine measures currently required under the Physician Quality Reporting System. This category gives clinicians reporting options to choose from to accommodate differences in specialty and practices. CLINICAL PRACTICE IMPROVEMENT ACTIVITIES: (15 percent of total score in year 1): Clinicians would be rewarded for clinical practice improvement activities such as activities focused on care coordination, beneficiary engagement, and patient safety. Clinicians may select activities that match their practices goals from a list of more than 90 options. In addition, clinicians would receive credit in this category for participating in Alternative Payment Models and in Patient-Centered Medical Homes. ADVANCING CARE INFORMATION: (25 percent of total score in year 1; replaces the Medicare EHR Incentive Program for physicians, also known as Meaningful Use ): Clinicians would choose to report customizable measures that reflect how they use electronic health record (EHR) technology in their day-to-day practice, with a particular emphasis on interoperability and information exchange. Unlike the existing Meaningful Use program, this category would not require all-or-nothing EHR measurement or quarterly reporting. 16

Helpful Stuff 2016 INFORMATION https://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/Downloads/2016_EPWhatYouNeedtoKnowfor2016.pdf PATIENT ELECTRONIC ACCESS TIPSHEET: https://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/Downloads/2016_PatientElectronicAccess.pdf PUBLIC HEALTH REPORTING TIPSHEET: https://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/Downloads/2016_EPPublicHealthReporting.pdf ALTERNATE EXCLUSIONS TIPSHEET: https://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/Downloads/2016_AlternateExclusionsfor2016.pdf RISK ANALYSIS TIPSHEET: https://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/Downloads/2016_SecurityRiskAnalysis.pdf AUDIT GUIDANCE: https://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2_AuditGuidance.pdf CMS/MIPS PRGRAM INFORMATION: https://www.cms.gov/medicare/quality-initiatives-patient- Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Payment-Program.html ADVANCING CARE INFORAMTION: https://www.cms.gov/medicare/quality-initiatives-patient-assessment- Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Advancing-Care-Information-Fact-Sheet.pdf QUALITY PAYEMNT PROGRAM FACT SHEET: https://www.cms.gov/medicare/quality-initiatives-patient- Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/NPRM-QPP-Fact-Sheet.pdf Contact Us As us about our Consulting Packages to help manage your journey to Meaningful Use Main Street Medical Consulting: (412) 428-7700 Fax (412) 429-4244 www.msmedcon.com 17