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5/5/2016 1

Meaningful Use: Past, Present and Future

Bruce Maki, MA M-CEITA / Altarum Institute

Regulatory Analyst and Project Manager

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Agenda

1. Overview of M-CEITA

2. Meaningful Use: Past, Present & Future

3. Questions

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Who is M-CEITA?

▲ Michigan Center for Effective Information Technology Adoption (M-CEITA)

▲ One of 62 ONC Regional Extension Centers (REC) originally funded to provide education & technical assistance to primary care providers across the country

▲ Founded as part of the HITECH Act to accelerate the adoption, implementation, and effective use of electronic health records (EHR), e.g. 90-days of MU

▲ Originally Funded by ARRA of 2009 (Stimulus Plan)

▲ Purpose: support the Triple Aim by achieving 5 overall performance goals

Meaningful Use

Improve

Quality, Safety &

Efficiency

Performance Measurement

Certified Technology Infrastructure

Engage

Patients &

Families

Improve Care

Coordi- nation

Improve Population

And Public Health

Ensure Privacy

And Security

Protections

Improve patient experience

Improve population health

Reduce costs 3 THE TRIPLE AIM

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Meaningful Use Support

Security Risk Assessment

Targeted Process Optimization (Lean)

Audit Preparation

M-CEITA Services

Technical assistance, including workflow redesign, security risk assessment and MU compliance. (e.g. patient portal and clinical quality measures)

Support meeting the requirements of MU Measure: Protect Electronic Health Information, including an assessment using our exclusive tool.

A workflow analysis and redesign of core processes using Lean principles to increase efficiency and reduce duplication. (e.g. chart prep, doc. Management)

A review of Meaningful Use attestation documentation using our exclusive Audit File Checklist to correct any issues before completing the process.

PQRS Support Technical Assistance for the Physician Quality Reporting System including measure selection as well as reporting method selection and assistance.

GLPTN - Great Lakes Practice Transformation Network No cost Technical Assistance to eligible providers in support of quality

improvement initiatives, PQRS support, and preparing for upcoming advanced payment model changes under MACRA/MIPS

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The Past

A Brief History

of Meaningful Use

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Meaningful Use…as defined by CMS

▲ Meaningful Use is using certified electronic health record (EHR) technology to:

– Improve quality, safety, efficiency, and reduce health disparities

– Engage patients and families

– Improve care coordination and population and public health

– Maintain privacy and security of patient health information

▲ Ultimately, it is hoped that Meaningful Use compliance will result in:

– Better clinical outcomes

– Improved population health outcomes

– Increased transparency and efficiency

– Empowered individuals

– More robust research data on health systems

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Stage 1

Data capture and sharing

Stage 2

Advanced clinical processes

Stage 3

Improved outcomes

Meaningful use: Path to better outcomes and quality

For more information on meaningful use of EHRs, visit: http://www.cms.gov/EHRIncentivePrograms/35_Meaningful_Use.asp

Better clinical outcomes Improved population health outcomes Increased transparency and efficiency Empowered individuals More robust research data on health

systems

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Original Meaningful Use Timeline

First Year of MU

Stage of Meaningful Use

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021

2011 1 1 1 2 2 3 3 TBD TBD TBD TBD

2012 1 1 2 2 3 3 TBD TBD TBD TBD

2013 1 1 2 2 3 3 TBD TBD TBD

2014 1 1 2 2 3 3 TBD TBD

2015 1 1 2 2 3 3 TBD

2016 1 1 2 2 3 3

2017 1 1 2 2 3

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Medicare EHR Incentive Program

▲ Incentive amount varies based on Fee-for-Service allowable charges

▲ Maximum of $44,000 over 5 years

– Payments after 4/1/13 reduced by 2% due to mandatory federal sequestration

▲ Requires 5 consecutive years: may not skip a year

▲ Administered by CMS

▲ Payment reductions starting in 2015 if eligible provider is not participating by 2013 (1% in 2015, increasing 1%/yr to 5%)

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Medicaid EHR Incentive Program

▲ Requires at least 30% Medicaid patient visit volume (20% for pediatricians) to be eligible to participate

▲ Program allows some mid-level providers (e.g. nurse practitioners) as well as physicians to participate

▲ Maximum of $63,750 over 6 years of participation

▲ May “skip” years

▲ Administered by state Medicaid agencies

▲ No Medicaid payment reductions if not participating

▲ First year: Adopt / Implement / Upgrade (AIU)

– Adopt: purchase access to certified EHR

– Implement: begin using certified EHR

– Upgrade: upgrade existing EHR to certified version

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Medicare Payment Schedule for EPs (with 2% Sequestration reduction)

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Medicaid Incentive Payments (not affected by Sequestration)

▲ Medicaid payments are made over 6 years

▲ The last year Medicaid eligible professionals can join is 2016

▲ Participation does not need to be during consecutive years

▲ If joining in 2016, however, EP cannot skip a year without missing

an incentive payment as no payments will be made after 2021

Annual Incentive Payment by Year of Meaningful Use

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Eligible Professionals (EP’s)

Who is an Eligible Professional under the Medicare Program?

▲ Eligible professionals under the Medicare EHR Incentive Program include:

Doctor of medicine or osteopathy

Doctor of dental surgery or dental medicine

Doctor of podiatry

Doctor of optometry

Chiropractor

Who is an Eligible Professional under the Medicaid Program?

▲ Eligible professionals under the Medicaid EHR Incentive Program include:

Physicians (primarily doctors of medicine and doctors of osteopathy)

Nurse practitioner

Certified nurse-midwife

Dentist

Physician assistant who furnishes services in a Federally Qualified Health Center or Rural Health Clinic that is led by a physician assistant.

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The Present

Modified Stage 2

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▲ Released: October 6, 2015

▲ Published: October 16, 2015

▲ Effective: December 15, 2015

▲ Medicare EPs can attest to a 2015 reporting period in the Federal RAS between 1/4/16 – 3/11/16

▲ Medicaid EPs can attest to a 2015 reporting period in CHAMPS/eMIPP between 2/14/16 – 4/30/16

▲ Medicaid EPs can begin attesting to a 2016 reporting period on 6/1/16

Medicare and Medicaid Programs; Electronic Health Record Incentive Program—Stage 3 and Modifications

to Meaningful Use in 2015 Through 2017 Final Rule with Comment Period

(aka Modified Stage 2 / Stage 3 Final Rule)

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Key changes in the Modified Stage 2 Rule

▲ Stage 1 and Stage 2 objectives and measures restructured to align with Stage 3

▲ Streamlined the program by removing redundant, duplicative, and topped out (RDT) measures

▲ One set of objectives and measures for all participants

▲ Patient engagement objectives that require “patient action” were modified

▲ Limited accommodations for “Scheduled” Stage 1 EPs in 2016 (CPOE)

▲ Significant changes to the Public Health objective

▲ Optional “Alternate Exclusions” added to Public Health (2015-2016)

– No proof of intent/documentation required to claim Alt Exclusions

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Meaningful Use Progression for EPs

2011 - 2013

2014 2015 - 2017

2018

Stage 1

15 Core

5 Menu

6 CQMs

Stage 1

13 Core

5 Menu

9 CQMs

Stage 2

17 Core

3 Menu

9 CQMs

Modified Stage 2

10 Objectives

9 CQMs

Stage 3

Optional: 2017

8 Objectives,

some with

lowered

thresholds

Stage 3

8 Objectives

CQM reporting

is required by

regulations;

Medicare PFS

rulemaking to

address

reporting

requirements

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Meaningful Use Reporting Periods

▲ 2016

– New Participants: Any continuous 90 days within the Calendar Year (CY)

– Returning Participants: Full Calendar Year (366 days)

Pending congressional legislation my reduce this to 90 days

▲ 2017

– New Participants: Any continuous 90 days within the CY

– Providers electing Stage 3: Any continuous 90 days within the CY (requires 2015 CEHRT)

– Returning Participants: Full Calendar Year (365 days)

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Measures removed under Modified Stage 2 (…but “Still Meaningful”)

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Gone…but “Still Meaningful” (cont’d)

▲ Many of these objectives and measures include actions that may be valuable to providers and patients, such as providing a clinical summary to a patient

▲ Conduct these activities as best suits the practice and the preferences of the patient population

▲ The removal is not intended as a withdrawal of an endorsement for these best practices or to discourage providers from conducting and tracking these activities for their own quality improvement goals

▲ No longer required to separately calculate and attest to the results of these measures for MU

▲ Some of the removed measures contain data elements that are still needed within other measures such as Patient Electronic Access (patient portal) and Health Information Exchange (Summary of Care) or are needed to calculate various Clinical Quality Measures

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2016 Requirements

▲ In addition to meeting the measures or exclusions for the remaining 10 objectives, as in previous years, all EPs have to report on Clinical Quality Measures

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“Modified Stage 2” Meaningful Use Objectives:

1. Protect Patient Health Information (SRA)

Not Episodic, should cover entire program year

Conduct within same CY as reporting period, acceptable to be conducted outside of reporting period if reporting period is < CY but must be conducted prior to attestation

2. Clinical Decision Support (CDS) (2 measures)

Implement CDS Interventions

Implement Interaction Checks

3. Computerized Provider Order Entry (CPOE) (3 measures)

Medication Orders

Laboratory Orders**

Radiology Orders**

** EPs scheduled to be in Stage 1 in 2016 are not required to report on Lab and Radiology orders, only Medication orders

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4. Electronic Prescribing (eRx)

5. Health Information Exchange (formerly Summary of Care)

6. Patient Specific Education

7. Medication Reconciliation

8. Patient Electronic Access (VDT/Pt Portal) (2 measures)

Timely Access

Usage

9. Secure Electronic Messaging

10. Public Health Reporting (3 measures)

Immunization Registry

Syndromic Surveillance Registry

Specialized Registry

“Modified Stage 2” MU Objectives (cont’d):

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Objective 5: Health Information Exchange (HIE)

Measure Threshold Exclusion

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 (SOC) record; and (2) electronically transmit such summary to a receiving provider for > 10% of transitions of care (TOC) and referrals

> 10%

EP who transfers a patient to another setting or refers a

patient to another provider < 100 times during the RP

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Objective 5: HIE (cont’d)

▲ Options for counting a transition in the numerator:

– EP must generate the Summary of Care (SoC) document from CEHRT and must electronically transmit it to the receiving EP via Direct

OR

– EP can now electronically transmit to a Health Information Exchange (HIE) who can then USE ANY MEANS available to route the SoC document to the receiving provider

HIE does not need to use CEHRT to deliver to receiving provider

HIE can use ANY available means to deliver the SoC document

Proof of receipt (“reasonable certainty”) is still required by the sending provider but this too can use non-tech methods. Onus is on HIE to provide this.

– The issue here is that transmitting the SoC document to an HIE will likely NOT trigger the EHR MU measure report; thus this change may necessitate manually tracking

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Objective 10: Public Health Reporting

Measure Exclusion

Measure Option 1: Immunization Registry Reporting – The EP is in active engagement with a public health agency to submit immunization data

MI EPs: Does not administer any immunizations for which data is collected by the immunization registry

Measure Option 2: Syndromic Surveillance Reporting – The EP is in active engagement with a public health agency to submit syndromic surveillance data

MI EPs in Non-Urgent Care Settings: Is not in a category of providers from which ambulatory syndromic data is

collected by the PHA

Measure Option 3: Specialized Registry Reporting – The EP is in active engagement to submit data to a qualified specialized registry

EP (a) does not diagnose/treat any disease/condition associated with, or collect relevant data that is collected

by, a specialized registry in their jurisdiction during the RP; (b) 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 RP; or (c) 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 RP

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Public Health (cont’d)

▲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 organization 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 to begin testing and validation.

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.

Option 3 – Production

The EP, eligible hospital, or CAH has completed testing and validation of the electronic submission and is electronically submitting production data.

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Public Health Reporting (cont’d)

▲Alternate Exclusions for 2016:

– EPs previously scheduled to be in Stage 1 or Stage 2

May claim an Alternate Exclusion for Measure 2 (Syndromic Surveillance) and Measure 3 (Specialized Registry)

An Alternate Exclusion may only be claimed for up to two measures, then the provider must either attest to or meet the exclusion requirements for the remaining measure described in 495.22 (e)(10)(i)(C)

▲Another Option for Syndromic Surveillance in 2016:

To accommodate EPs struggling to find and register with an alternate registry, MSSS has agreed to allow EPs who were Actively Engaged on 12/31/15 to maintain that status through 12/31/16 with no additional work/submissions/onboarding needed from the EP

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Objective 10: Public Health Measure 3 Specialized Registry Reporting:

▲ To qualify as a “MU valid” specialized registry, the registry must do the following:

1. Publically declare readiness to accept electronic data (by 1st day of RP)

– Failure to declare by 1st day of EP reporting period does not mean EP cannot use registry to achieve MU in that program year. Instead, it creates an option.

2. Be able to accept electronic submissions – manual data entry into a website does not count, but an electronic file upload would

3. Be able to support the registration/onboarding and production processes

4. Be able to provide documentation to EP as evidence of “Active Engagement”

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What obligations do EPs have for finding a Specialized Registry for 2016?

▲ Determine if the specialized registries offered by a Public Health Agency (PHA) in MI are relevant to the provider’s scope of practice

Birth Defects Registry

Cancer Registry (must have EHR certified to Cancer reporting standards)

MiDR: Michigan’s Dental Registry (did not declare readiness by 1/1/16, thus consideration is optional until 2017)

▲ Determine if a Medical Society with which the provider is affiliated endorses or sponsors a MU valid specialized registry

▲ If no to both, EP can claim the exclusion in 2016

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Clinical Quality Measures (CQMs)

▲2016 and 2017

– New Participants

Any continuous 90 days w/in CY

Does not need to be same as MU 90 days

Attest through Medicare RAS or Medicaid eMIPP

Or attest using established methods for electronic reporting

– Returning Participants

Full Calendar Year

Attest through Medicare RAS or Medicaid eMIPP

Or attest using established methods for electronic reporting

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Stage 3

The Future of Meaningful Use

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MIPS: Merit-Based Incentive Payment System

Beginning in 2017, providers will be annually

measured in 4 performance categories:

• Meaningful Use (proposed rename: “Advancing

Care Information”)

• Value Based Modifier for Cost

• PQRS & Value Base Modifier for Quality

• Clinical Practice Improvement

These programs make up 85% of the MIPS score.

The best thing an organization can do to

prepare is improve on these programs NOW.

Meaningful Use IS expected to change again under MACRA/MIPS, but it is not

going away. Also, the pending changes will affect the Medicare MU program but

not necessarily the Medicaid MU program currently scheduled to end in 2021.

Meaningful Use is not dead!

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Newly Proposed Changes to Medicare MU

Changes from the Medicare EHR Incentive

Program to Advancing Care Information

Meaningful Use New Proposal

Must report on all objective and measure

requirements

New proposal streamlines measures and emphasizes

interoperability, information exchange, and security

measures. Clinical Decision Support and Computerized

Provider Order Entry are no longer required.

One-size-fits-all—every measure reported and

weighed equally

Customizable—Physicians or clinicians can choose

which best measures fit their practice

All-or-nothing EHR measurement and quality

reportingFlexible—multiple paths to success

Misaligned with other Medicare reporting

programs

Aligned with other Medicare reporting programs. No

need to report quality measures as part of this category

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Advancing Care Information

Objective Measure

Protect Patient Health Information Security Risk Analysis

Electronic Prescribing ePrescribing

Patient Access

Patient-Specific Education

View, Download and Transmit (VDT)

Secure Messaging

Patient-Generated Health Data

Exchange Information with Other Physicians or Clinicians

Exchange Information with Patients

Clinical Information Reconciliation

Immunization Registry Reporting

(Optional) Syndromic Surveillance Reporting

(Optional) Electronic Case Reporting

(Optional) Public Health Registry Reporting

(Optional) Clinical Data Registry Reporting

MIPS Advancing Care Information Objectives and Measures

Patient Electronic Access

Coordination of Care Through Patient Engagement

Health Information Exchange

Public Health and Clinical Data Registry Reporting

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Meaningful Use Stage 3

2017 Modified Stage 2 Crosswalk to Stage 3

Objectives Modified Stage 2 Stage 3 (2018)*

SRA Conduct or Review during CY and prior to attestation including

addressing encryption/security of data created or maintained in CEHRT

CPOE

Medications > 60% > 60%

Labs > 30% > 60%

Radiology > 30% > 60%

eRx

> 50% of all permissible prescriptions are queried for a

drug formulary AND transmitted electronically

> 60% of all permissible prescriptions are queried for a drug

formulary AND transmitted electronically

Clinical Decision Support

Rules 5 Enabled for Entire Reporting Period (RP)

Interactions Enabled for Entire Reporting Period (RP)

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Meaningful Use Stage 3 (cont’d)

Objectives Modified Stage 2 Stage 3 (2018)*

Patient Education > 10% Incorporated into Patient Electronic Access

View, Download

and Transmit

(VDT)

Access > 50% w/in 4 days Incorporated into Patient Electronic Access

Usage > 5% Incorporated into Coordination of Care through

Patient Engagement

Patient Electronic

Access

Access

N/A

> 80% of all unique patients are provided timely access to VDT their health information AND

ensure health information is available for the patient to access using any application of their choice that is configured to meet the technical

specifications of the API in the EPs CEHRT

Patient Education

For > 35% of unique patients, CEHRT is used to identify educational resources to which electronic

access is provided

Secure Messaging > 5% Incorporated into Coordination of Care through

Patient Engagement

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Meaningful Use Stage 3 (cont’d)

Objectives Modified Stage 2 Stage 3 (2018)*

Coordination of Care through

Patient Engagement

VDT

N/A

> 10% of unique patients engage with EHR by either 1) VDT health information or 2) access health information via an API or 3) a combination of

both

Secure Messaging > 25% of unique patients, or

in response to a secure message sent by patient

Patient Generated Health Data

> 5% of unique patients incorporate non-clinical

setting data into the CEHRT

Medication Reconciliation > 50% Incorporated into Health

Information Exchange

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Meaningful Use Stage 3 (cont’d)

Objectives Modified Stage 2 Stage 3 (2018)*

Health Information

Exchange

Provide SoC Electronically

Use CEHRT to create a SoC AND transmit electronically for

> 10% of ToCs

Use CEHRT to create a SoC AND transmit electronically for > 50% of ToCs

Receive or Retrieve SoC

N/A

EP receives or retrieves a SoC for > 40% of ToCs in which the EP has never encountered

the patient AND incorporates it into the patient’s CEHRT record

Reconciliation of Clinical

Information N/A

Perform a reconciliation of clinical information for > 80% of transitions/referrals or for patient

encounters in which the EP has never encountered the patient

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Meaningful Use Stage 3 (cont’d)

Objectives Modified Stage 2 Stage 3 (2018)*

Public Health

Imms Registry

Actively Engaged w/2 of 3

Actively Engaged w/3 of 5

Syndromic Surveillance

Specialized Registry

Electronic Case Reporting N/A

PH Registry Reporting Included as Specialized

Registry Clinical Data Registry Reporting

* As Stage 3 is optional in 2017, some measure thresholds have been reduced to allow early adopters ease in transitioning to the 2018 Stage 3 required thresholds

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CMS HITECH funds to support connection with non-EPs

▲ Letter to State Medicaid Directors issued on 2/29/2016

▲ Funds to promote HIE and encourage the adoption of certified EHR technology by other Medicaid providers

▲ Behavioral health providers, substance abuse treatment providers, long-term care providers, home health providers, pharmacies, laboratories, correctional health providers, emergency medical service providers, and public health providers.

▲ Funds can be spent on HIE interoperability & infrastructure but cannot be spent on purchasing EHR technology.

▲ Activities must directly support achievement of MU by EPs.

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Expanded M-CEITA Support for non-EPs

▲In partnership with the State of Michigan, M-CEITA is proposing to expand services in 2017 to include:

–Support of Medicaid BH providers adoption and implementation of Electronic Consent Management (eConsent) for the electronic exchange of patient information

–Support for EHR Adoption, Optimization and HIE by Long Term and Post Acute Care organizations in support of Medicaid EP Meaningful Use

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Resources

Modified Stage 2 Final Rule: http://federalregister.gov/a/2015-25595

MIPS/APM Proposed Rule: https://s3.amazonaws.com/public-

inspection.federalregister.gov/2016-10032.pdf

2016 Tipsheet: https://www.cms.gov/Regulations-and-

Guidance/Legislation/EHRIncentivePrograms/Downloads/2016_EPWhatYou

NeedtoKnowfor2016.pdf

Modified Stage 2 Tipsheet: https://www.cms.gov/Regulations-and-

Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage3Overview2

015_2017.pdf

2016 Program Requirements and Tools https://www.cms.gov/Regulations-

and-

Guidance/Legislation/EHRIncentivePrograms/2016ProgramRequirements.ht

ml

Hardship Exception Application: https://www.cms.gov/Regulations-and-

Guidance/Legislation/EHRIncentivePrograms/PaymentAdj_Hardship.html

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Bruce Maki

bruce.maki@altarum.org

734-302-4744

Questions? www.mceita.org