1. finance
2. accounting and auditing

Benefiting from Meaningful Use
and Quality Reporting
THE GREENWAY GUIDE
Contents
TABLE OF FIGURES......................................................................................................................4
WELCOME TO GREENWAY’S GUIDE TO BENEFITING FROM MEANINGFUL USE
AND QUALITY REPORTING................................................................................................5
GETTING STARTED......................................................................................................................6
Staging the vision and goals.............................................................................................6
The numbers...........................................................................................................................7
Eligibility and applicable timelines..................................................................................8
EPs in the Medicare pathway.....................................................................................8
EPs in the Medicaid pathway.....................................................................................8
Meaningful use reporting by stage.................................................................................9
WHY PARTICIPATE?.................................................................................................................10
Incentive fund capture.....................................................................................................10
Medicare pathway......................................................................................................10
Medicaid pathway......................................................................................................11
Avoid payment adjustments..........................................................................................12
How to avoid the 2015 payment adjustment..................................................12
Ongoing hardship exceptions................................................................................13
Alignment with quality incentive programs..............................................................13
Patient-centered medical home (PCMH)...........................................................13
Physician Quality Reporting System (PQRS)....................................................16
Comprehensive Primary Care (CPC) Initiative..................................................16
Patient care..........................................................................................................................17
Care coordination, safety and outcomes..........................................................17
Benefits of patient portals.....................................................................................18
Portals and MU requirements................................................................................19
HOW TO PARTICIPATE.............................................................................................................20
Implement a meaningful use-certified EHR..............................................................20
Understanding 2011 and 2014 certification editions.........................................20
Registering per-provider for meaningful use incentives.....................................21
ASSESSING AND SELECTING MEANINGFUL USE MEASURES..............................22
Core objectives and menu sets....................................................................................22
Stage 1...........................................................................................................................22
Stage 2...........................................................................................................................23
Exclusions.....................................................................................................................26
Selecting menu items...............................................................................................26
Clinical summary and summary of care..............................................................28
Clinical quality measures.................................................................................................29
What they gauge........................................................................................................29
Where the data comes from..................................................................................29
How CMS uses the data...........................................................................................29
Recommended core sets........................................................................................30
Why these specific measures?.............................................................................31
Choosing appropriate CQMs for your practice................................................32
Reporting CQMs..........................................................................................................32
What CQMs are your colleagues reporting?.....................................................34
2
CAPTURING AND REPORTING (ATTESTING) DATA......................................................36
A note about dashboard technology...........................................................................36
Reporting timelines by stage.........................................................................................36
Attestation...........................................................................................................................36
Attestation and CQMs..............................................................................................37
Amending submitted attestations......................................................................38
Receiving your payment..................................................................................................38
Meaningful use audits......................................................................................................38
Appeals process.................................................................................................................38
WHAT’S NEXT?..........................................................................................................................39
Meaningful use Stage 3...................................................................................................39
NOW WHAT?...............................................................................................................................41
Tools to demonstrate meaningful use of HIT...........................................................41
Nothing to lose....................................................................................................................41
IT’S HEALTHCARE, SO YOU NEED THIS: GLOSSARY OF ACRONYMS.................42
CHOOSE GREENWAY...............................................................................................................43
3
Table of
Figures
Figure 1: Stages of Meaningful Use..........................................................................................9
Figure 2: Medicare EHR Incentive Payment Schedule
for Eligible Professionals.........................................................................................10
Figure 3: Medicaid EHR Incentive Payment Schedule
for Eligible Professionals.........................................................................................11
Figure 4: Examples of MU and PCMH Alignment..............................................................15
Figure 5: Stage 1 Meaningful Use Objectives for Eligible Professionals................22
Figure 6: Stage 2 Meaningful Use Objectives for Eligible Professionals................23
Figure 7: EP 2011, 2012, and 2013 90 Days Menu Objective Performance........27
Figure 8: EPs’ Plans to Attest for Stage 2...........................................................................34
Figure 9: Top-Ranked CQM Groups.........................................................................................34
Figure 10: Preventive Care and Screening..........................................................................35
Figure 11: Top-Reported Pediatric Measures....................................................................35
4
Welcome
Welcome to Greenway’s Guide to Benefiting from
Meaningful Use and Quality Reporting
The Medicare and Medicaid Electronic Health Record (EHR) Incentive
Programs, commonly known as meaningful use (MU), reward providers for
delivering high-quality care — shifting American healthcare away from fee-forservice and toward pay-for-performance models to improve care and manage
costs. Various quality programs — including accountable care organizations
(ACOs), patient-centered medical homes (PCMHs) and the Physician
Quality Reporting System (PQRS) — share the pay-for-performance goals of
meaningful use and continue to adopt its quality reporting objectives.
Public and private payer alignment will only increase as these quality initiatives
evolve from adoption and functionality incentive programs into foundational
elements of physicians’ reimbursements for care. Already, meaningful use and
related quality programs have sharpened their focus on patient outcomes and
population health management. Multi-program performance initiatives in the
2015 Medicare physician fee schedule reflect this, as do proposals pending in
Congress that would employ meaningful use, PQRS and patient engagement
strategies to help restructure the existing fee-for-service system.
To help ensure that you have the information you need to avoid financial
penalties and plan for MU and its impact on other reimbursement programs,
Greenway Health™ is delighted to present this guide to benefiting from
meaningful use and quality reporting. The guide:
»» Walks you through registration, reporting choices, timelines, and
attestation and payment cycles.
»» Details opportunities for “bundling” meaningful use with other incentive
programs offering many benefits to practices, with little additional
effort.
»» Includes insights and experiences shared by your peers, because one
of the best ways to succeed in a program like meaningful use is to
familiarize yourself with what has worked for others like you.
For your convenience, we’ve included at-a-glance charts and visual information,
links to relevant Centers for Medicare & Medicaid Services (CMS) and
Office of the National Coordinator for Health Information Technology (ONC)
materials, and data examples to show the impact meaningful use has on patient
care and care coordination.
5
Getting Started
Staging the vision and goals
Understanding that EHR adoption has financial, workflow, installation and
staffing implications, Congress supported funding the meaningful use
incentive program as part of the Health Information Technology for Economic
and Clinical Health (HITECH) Act of 2009 to encourage widespread and
accelerated adoption.
The HITECH Act charged CMS with determining program requirements in two
categories:
»» Objectives – Types of data to be captured
»» Measures – Patient population levels, thresholds or percentages at
which the data should be collected
The Act also required CMS to create a set of Clinical Quality Measures (CQMs).
Provider groups and health information technology (HIT) organizations
provided input used to shape the data capture requirements.
The vision for meaningful use is twofold:
1.To advance the functionality of EHRs and the corresponding
documentation of clinical data over time.
2.To use that data to advance evidence-based medicine by analyzing the
impact of technology-driven or automated physician support tools on
patient care, patient adherence to care plans and patient outcomes.
MU intends to improve outcomes for at-risk elderly and low-income populations
who represent the most clinically and financially challenging cases with respect
to chronic disease management and access to care. On a larger scale, MU
and related quality programs such as PQRS and PCMH aim to improve clinical
documentation and preventive care for better patient outcomes, improved
population health and lower costs for all in the United States, regardless of age
or income. 1
To meet these goals, meaningful use is organized into three stages, each with a
unique area of emphasis as prescribed by CMS and ONC:
»» Stage 1 – Data capture and reporting
»» Stage 2 – Information exchange and care coordination
»» Stage 3 – Improving outcomes
Later sections in this guide describe each stage, its requirements and its goals
in more detail.
Centers for Medicare & Medicaid Services. “Quality
Initiatives — General Information.” http://www.cms.
gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/QualityInitiativesGenInfo/index.html?redirect=/
QualityInitiativesGenInfo/01_Overview.asp
1
6
The numbers
To date, the program has proven successful in terms of adoption and incentive
capture.
According to the Centers for Disease Control and Prevention (CDC) National
Center for Health Statistics, U.S. office-based physician adoption of any type of
EHR reached 78 percent in 2013, up from 18 percent in 2001. EHR adoption has
increased by 21 percent since the beginning of the meaningful use program in
2011.2
Industry-wide, CMS reports that as of April 2014, more than $15 billion has
been paid to Eligible Professionals (EPs) in the Medicare pathway, and more
than $8 billion to EPs in the Medicaid pathway.
Meaningful Use by the Numbers
GREENWAY
NATIONALLY
10,000+
$244+ million
Medicare EPs
have received
537,600
316,303
156,640
$15.8 billion
$8.1 billion
providers and clinicians
identified as eligible for MU
EPs have registered for
Medicare incentives
EPS have registered for
Medicaid incentives
Medicare payout
Medicaid payout
3
All figures as of April, 2014
Centers for Disease Control and Prevention. NCHS Data Brief
143: “Use and Characteristics of Electronic Health Record
Systems Among Office-based Physician Practice: United States,
2001–2013.” January 2014. http://www.cdc.gov/nchs/data/
databriefs/db143.pdf
2
Centers for Medicare & Medicaid Services Medicare and
Medicaid EHR Incentive Programs HIT Policy Committee June
10, 2014 update. www.healthit.gov/facas/sites/faca/files/
HITPC_CMSUpdate_2014-06-10.pptx.
3
7
Eligibility and applicable timelines
You are eligible to benefit from the meaningful use program if you practice
within the following categories, which include both primary care and specialty
medicine.
EPS IN THE MEDICARE PATHWAY
»» Doctor of medicine or osteopathy
»» Doctor of dental surgery or dental medicine
»» Doctor of podiatry
»» Doctor of optometry
»» Chiropractor
EPS IN THE MEDICAID PATHWAY
»» 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 (FQHC) or Rural Health Clinic (RHC) that is led by a
physician assistant.
Meaningful use timelines remain flexible as to when an EP can enter either
program, which then determines how many payment years and maximum
incentive funds can be pursued.
NOTE
Those eligible for both pathways must choose only
one upon first registering for the program. Before
2015, EPs can switch — but only once — after
the first incentive payment is initiated within the
originally chosen pathway.
8
MEDICAID ELIGIBILITY THRESHOLD REQUIREMENTS
In addition to qualifying by clinician category, Medicaid EPs must:
»» Have a 30% minimum Medicaid patient volume (20% for pediatricians), or
»» Practice predominantly in an FQHC or RHC with a minimum 30% of patients
meeting the definition of needing assistance.
•C
MS defines individuals “needing assistance” as those meeting any of
the following three criteria:
1. Receiving medical assistance from Medicaid or the Children’s
Health Insurance Program (CHIP)
2 . Furnished uncompensated care by the provider
3. Furnished services at either no cost or reduced cost based on a
sliding scale determined by the individual’s ability to pay
CHIP patients do not count toward patient volume criteria.
Meaningful use reporting by stage
Overall, MU reporting (meaning the ongoing compilation and submission of
required data to CMS) is accomplished by stage, and each stage extends
over calendar years. How many calendar years depends on when an EP began
reporting Stage 1. As a general rule, the program requires that EPs report at
least two years of a given stage before advancing to the next.
Currently, subsequent reporting is required throughout an entire calendar
year after 2014. It is expected that Stage 3 will also allow the 90-day or fixed
quarter reporting for year one, as the other stages have historically done.
In recent rulings, CMS has elected to extend the timelines
of both Stage 1 and Stage 2 beyond the fixed two years
of reporting for each stage that was originally envisioned.
Figure 1 details the current reporting timeline, based on
first payment year or start date.4
NOTE
Figure 1: Stages of Meaningful Use
First
Payment Year
2011
2012
2013
2014
2015
2016
4
U.S. Dept. of Health and Human Services and the
Centers for Medicare & Medicaid Services. Notice of
Proposed Rulemaking. “Medicare and Medicaid Programs;
Modifications to the Medicare and Medicaid Electronic
Health Record Incentive Programs for 2014; and Health
Information Technology: Revisions to the Certified EHR
Technology Definition.” 79 FR 29732. May 23, 2014.
https://federalregister.gov/a/2014-11944.
2017
2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
1
1
1
1 or 2*
2
2
3
3
TBD
TBD
TBD
1
1
1 or 2*
2
2
3
3
TBD
TBD
TBD
1
1*
2
2
3
3
TBD
TBD
TBD
1*
1
2
2
3
3
TBD
TBD
1
1
2
2
3
3
TBD
1
1
2
2
3
3
1
1
2
2
3
*3 -month quarter EHR reporting period for Medicare and continuous 90-day EHR reporting period (or 3 mouths at State
option) for Medicaid EPs. All providers in their first year in 2014 use any continuous 90-day EHR reporting period
9
Why
Participate?
Incentive fund capture
The meaningful use program rewards EHR adoption and continuous reporting
through incentive funds granted per EP, no matter the size of a practice’s
clinical staff.
This holds true whether EPs are pursuing the Medicare or Medicaid pathway, but
there are fundamental differences between the two that have implications for:
»» Total incentives received
»» When an EP must begin a pathway to receive any funds
»» When the funds run out
»» Avoiding payment penalties, also known as “adjustments”
MEDICARE PATHWAY
In the Medicare pathway, incentive payments depend on when an EP enters the
program. Payment amounts decrease over time, as detailed in Figure 2.
Figure 2: Medicare EHR Incentive Payment Schedule for Eligible Professionals*
First Payment
Received in 2011
First Payment
Received in 2012
First Payment
Received in 2013
First Payment
Received in 2014
Payment
Amount in 2011
$18,000
Payment
Amount in 2012
$12,000
$18,000
Payment
Amount in 2013
$7,840
Reduction ($160)
$11,760
Reduction ($240)
$14,700
Reduction ($300)
Payment
Amount in 2014
$3,920
Reduction ($80)
$7,840
Reduction ($160)
$11,760
Reduction ($240)
$11,760
Reduction ($240)
Payment
Amount in 2015
$1,960
Reduction ($40)
$3,920
Reduction ($80)
$7,840
Reduction ($160)
$7,840
Reduction ($160)
$1,960
Reduction ($40)
$3,920
Reduction ($80)
$3,920
Reduction ($80)
$43,480
$38,220
$23,520
Payment
Amount in 2016
TOTAL
Incentive
Payments
$43,720
*As required by law, President Obama issued a sequestration order on March 1, 2013. Under mandatory reductions, Medicare
EHR incentive payments made to eligible professionals and eligible hospitals will be reduced by 2%. This 2% reduction
has been applied to any Medicare EHR incentive payment for a reporting period that ended on or after April 1, 2013. This
reduction does not apply to Medicaid EHR incentive payments.
Important deadlines and incentive caps
»» 2016 is the last year EPs are scheduled to receive a payment (despite
the overall program lasting through 2021 for Medicare or Medicaid EPs).
»» Throughout a given EP’s Medicare timeline, an EP can miss an entire
attestation year and then re-enter the program. For example, missing
year two would mean then receiving the payment for year three. (A
missed year’s payment cannot be made up, and missing a year would
count against a maximum five-year cycle and payment.)
10
MEDICAID PATHWAY
The Medicaid pathway is a maximum six-year funding program allowing a total,
per-EP incentive payment of $63,750, as shown in Figure 3. Incentive payments
in the Medicaid pathway remain the same over time, and allow more flexible
start dates to receive the maximum amount through 2021.
Figure 3: Medicaid EHR Incentive Payment Schedule for Eligible Professionals
First Payment
Received in 2011
First Payment
Received in 2012
First Payment
Received in 2013
First Payment
Received in 2014
First Payment
Received in 2015
First Payment
Received in 2016
Payment
Amount in 2011
$21,250
$0
$0
$0
$0
$0
Payment
Amount in 2012
$8,500
$21,250
$0
$0
$0
$0
Payment
Amount in 2013
$8,500
$8,500
$21,250
$0
$0
$0
Payment
Amount in 2014
$8,500
$8,500
$8,500
$21,250
$0
$0
Payment
Amount in 2015
$8,500
$8,500
$8,500
$8,500
$21,250
$0
Payment
Amount in 2016
$8,500
$8,500
$8,500
$8,500
$8,500
$21,250
Payment
Amount in 2017
$0
$8,500
$8,500
$8,500
$8,500
$8,500
Payment
Amount in 2018
$0
$0
$8,500
$8,500
$8,500
$8,500
Payment
Amount in 2019
$0
$0
$0
$8,500
$8,500
$8,500
Payment
Amount in 2020
$0
$0
$0
$0
$8,500
$8,500
Payment
Amount in 2021
$0
$0
$0
$0
$0
$8,500
TOTAL
Incentive
Payments
$63,750
$63,750
$63,750
$63,750
$63,750
$63,750
Important deadlines and notes
»» 2016 is the last year a Medicaid EP can enter the program and receive
maximum funds.
»» The maximum participation of six years does not have to be completed
during consecutive years, depending on start date.
»» Funding is administered voluntarily by states and territories, and can be
subject to the participating state’s changes in funding or funding levels.
»» The $21,250 one-time payment is for EPs who adopt, implement
or upgrade (AIU) an EHR to one that is certified by ONC to satisfy
meaningful use functionality. This initial payment does not count as the
first actual year of reporting and attestation.
GREAT
RESOURCE
You can plan or estimate current and future payment
cycles by using the charts in this guide. For more help
planning your course of action, take advantage of CMS’s
interactive online tool, My EHR Participation Timeline.
11
Avoid payment adjustments
Like incentive payments, payment adjustments in the MU program were meant
to motivate the adoption and meaningful use of EHRs.
Adjustments primarily affect EPs in the Medicare pathway.
Beginning on Jan. 1, 2015, payment adjustments will start at 1 percent of the
EP’s annual Medicare Part B claims of the Medicare Physician Fee Schedule.
They then accumulate over time to a currently projected 5 percent by 2019,
depending on national attestation rates.
Generally, the adjustments are structured on an every-other-year basis: If you
did not attest in 2013, you will incur the 1 percent adjustment in 2015, and so
on through the life of the meaningful use program. CMS is currently projecting
payment adjustments to occur through 2020.
Despite incentive payments in the Medicare pathway scheduled to end in
2016, Medicare EPs should continue with annual meaningful use reporting and
stage progression to avoid mounting payment adjustments.
NOTE
Medicaid EPs in the meaningful use program who do not
bill Medicare are not subject to payment adjustments.
But be careful to note that if you are in the Medicaid
pathway, and bill Medicare for patients who are Medicare
beneficiaries, you will be subject to payment adjustments
if you are not actively participating in meaningful use or
happen to skip a reporting year.
HOW TO AVOID THE 2015 PAYMENT ADJUSTMENT
»» EPs who attested for either 90 days or a full calendar year of Stage 1 in
2013 are not subject to the 2015 payment adjustment.
»» New practicing providers or clinicians who can be defined as an EP
enrolling for the first time to treat Medicare patients and receive
Medicare payments can avoid the 2015 payment adjustment.
»» Specialist exceptions via specialty codes as defined by the Medicare
Provider Enrollment, Chain and Ownership System (PECOS) also avoid
the 2015 adjustment. Exceptions are available for the following
specialties:
•
•
•
•
•
Diagnostic radiology (30)
Nuclear medicine (36)
Interventional radiology (94)
Anesthesiology (05)
Pathology (22)
12
ONGOING HARDSHIP EXCEPTIONS
Because payment adjustments can continue through the life of the meaningful
use program, hardship exceptions to the Medicare payment adjustments can
likewise continue past the first payment adjustment in 2015.
Hardship categories providing exceptions from payment adjustments,
according to CMS language, include:
Lack of infrastructure — Insufficient Internet access to comply with
related objectives, and “insurmountable” barriers to obtaining connectivity.
Unforeseen/uncontrollable circumstances — Natural disaster, practice
closure, financial reasons, EHR certification/vendor issues.
Lack of “control” over availability of certified EHR technology — EPs who
practice at multiple locations and are unable to control availability at one or
more locations accounting for more than 50 percent of patient encounters.
Lack of face-to-face interaction with patients — When face-to-face
interaction and follow-up with patients are outside of practice scope, or
when follow-up is “extremely rare.”
Alignment with quality incentive programs
Meaningful use provides a foundation for the workflows, clinical functionality,
documentation and reporting not only to lower barriers for entering other
quality programs, but also to align your practice’s quality reporting with other
programs offering incentive capture.
MU
EHR
REPORTING
OBJECTIVES
PQRS
PCMH
MEASURES
The CMS Physician Quality Reporting System (PQRS) — which predates
meaningful use — has increasingly aligned its electronic clinical quality
measures (CQMs) and EHR reporting requirements with those of meaningful
use, to the point that in 2014, EPs in both programs select from the same CQM
list and reporting functions.
This alignment of quality reporting requirements across programs will continue
to expand with the development of advanced payment models (APMs)
formed by CMS in collaboration with private payers (as detailed in the following
sections).
PATIENT-CENTERED MEDICAL HOME (PCMH)
If you have an EHR certified for meaningful use, you also have data capture
abilities mapping to PCMH recognition scoring. Overall, the meaningful use and
PCMH programs have like-minded goals for patient care, patient engagement
and care coordination, which lead to crossover functionality such as electronic
prescribing, using clinical decision support, maintaining medication lists,
providing summaries of care during care transitions and more.
As private payers embrace the quality reporting elements of medical homes,
the ability to report to CMS for public payer incentives, bundled with that
of private payer incentives through a PCMH program, offers an excellent
opportunity to capitalize on multiple programs.
13
After publication of the meaningful use Stage 1 final rule in 2010, the National
Committee for Quality Assurance (NCQA) launched its 2011 patient-centered
medical home (PCMH) recognition program that matched a range of its data
capture standards with nearly 30 available meaningful use objectives and
CQMs.
The NCQA recognition program recently released its 2014 standards for PCMH
level I, II and III recognition, which align with core and menu objectives from
Stage 2 of meaningful use in several key ways. Examples of this alignment
include:
»» Element 3B: Clinical Data contains several MU Stage 2 core and menu
requirements such as height/length and weight recordings for more
than 80 percent of all patients, blood pressure and date of update for
more than 80 percent of patients three years of age and older, and BMI
calculation and display by the EHR.
»» Element 3D: Use Data for Population Management contains several
MU Stage 2 core requirements related to identifying patients who
need certain preventive care, immunizations, and chronic or acute care
services and reminding them or their caregivers of the need at least
once per year.
»» Element 5B: Referral Tracking requires, among other things, that
practices have “the capacity for electronic exchange of key clinical
information” and provide electronic summaries of care upon referral for
more than 50 percent of referrals—both of which are MU Stage 2 core
requirements.
GREAT
RESOURCE
This chart shows the alignment of meaningful use
Stage 2 core and menu item objectives with 2014 PCMH
recognition standards. Scroll through the 2014 PCMH
standards to find designations of Stage 2 alignment.
TIP
Generally, the higher the recognition level achieved, the
higher the per-patient or per-visit incentive payments,
which in PCMH come from contractual agreements with
private payers such as state Blue Cross Blue Shield
programs. PCMH data is also submitted directly to the
private payer, not to CMS as in the meaningful use or
PQRS programs.
Keep in mind, however, that PCMH standards outnumber the combined
meaningful use core and menu objectives and CQMs, so not all of the
recognition standards are met by meaningful use elements. “Must-pass”
2014 PCMH standards including Element 1A: patient-centered appointment
access, Element 2D: the practice team, and Element 4B: care planning and
self-care support, among others, have no direct analogues in meaningful use
requirements.
14
Multiple PCMH standards (or clinical data factors) can, however, be found within
one meaningful use objective. For example, one core meaningful use objective
to record and chart five patient vital signs incorporates five separate PCMH
clinical data factors.
TIP
DID YOU
KNOW?
When choosing meaningful use menu items, align them
with diagnostic conditions selected for PCMH uniform
data system clinical measures.
Greenway’s MU-certified PrimeSUITE EHR enables
providers to receive auto credits toward the scores
required for recognition as NCQA patient-centered
medical homes. To learn more, visit Greenway’s
PCMH Solutions page.
Threshold and measure alignment
Meaningful use and PCMH data standards are so similar that even the specific
thresholds or percentages cross over, enabling providers to use the same
quality reporting for incentive capture across both programs
Figure 4: Examples of MU and PCMH Alignment
Meaningful Use
Patient-Centered Medical Home
Electronic prescribing
More than 40 percent of all permissible
prescriptions written by the EP are transmitted
electronically using certified EHR technology.
Generates and transmits at least 40 percent of
eligible prescriptions to pharmacies.
Providing patients
with electronic
access to
health information
(patient engagement)
More than 50 percent of all patients who request
an electronic copy of their health information are
provided it within three business days.
More than 50 percent of patients who request an
electronic copy of their health information (such
as problem list, diagnoses, diagnostic test results,
medication lists, allergies) receive it within three
business days.
Providing patients
with clinical
summaries (electronic
or manual patient
engagement)
Clinical summaries provided to patients for more
than 50 percent of all office visits within three
business days.
Clinical summaries are provided to patients for
more than 50 percent of office visits within three
business days.
Provider exchange of
clinical information/
referral tracking (care
coordination)
Capability to exchange key clinical information (for
example, problem list, medication list, medication
allergies and diagnostic test results), among
providers of care and patient-authorized entities
electronically.
Demonstrating the capability for electronic exchange
of key clinical information (such as problem list,
medication list, allergies, diagnostic test results)
between clinicians.
15
PHYSICIAN QUALITY REPORTING SYSTEM (PQRS)
There are also many similarities between the meaningful use and PQRS
programs, in part because both are administered by CMS.
In PQRS, as in meaningful use, providers and clinicians must meet eligibility
criteria to participate. PQRS eligibility requirements can be found here.
In 2014, for example, EPs in both programs can select the same CQMs to
satisfy both program requirements, provided that the measures are reported to
CMS through EHRs certified to the meaningful use program.
Payment penalties (adjustments) are part of the PQRS process. Adjustment
rules differ depending on whether the reporting entity is an individual EP or a
group practice:
»» Overall, EPs who do not participate or report in 2014 are subject to a
2016 payment adjustment.
»» Group reporting includes a requirement to register within the Group
Practice Reporting Option (GPRO). Registering and then reporting
nine CQMs through a certified EHR means avoiding a 2016 Medicare
payment adjustment.
»» PQRS EPs must report on the nine CQMs for the entire year, not the
flexible 90-day reporting period permitted in the Medicare pathway for
2014.
GREAT
RESOURCES!
The CMS website maintains a wealth of information on the
PQRS program and its alignment with meaningful use.
An example of how the three programs have historically
aligned can be found here.
When selecting quality reporting measures that fit your patient population
and clinical goals, consider choosing meaningful use, PQRS and PCMH
overlap criteria — this can maximize your incentive data capture and
streamline reporting.
COMPREHENSIVE PRIMARY CARE (CPC) INITIATIVE
Referred to in the healthcare sector as an advanced payment model, the
Comprehensive Primary Care (CPC) Initiative is a four-year pilot program begun
in 2013 by CMS in conjunction with 44 private insurance and health plan payers.
Expected to expand beyond the nearly 500 primary care practices already
participating, it is one of the growing number of quality reporting incentive
programs grounded in meaningful use.
16
As a care coordination and value-based medicine program, the CPC Initiative
incorporates a subset of meaningful use data measures into its clinical goals.
Participants complete their reporting for the initiative via EHRs certified under
the meaningful use program.
The program also allows providers to share healthcare cost savings, similar to
the CMS accountable care structures, and targets all patients of a participating
practice, not just Medicare beneficiaries as in PQRS or meaningful use.
DID YOU
KNOW?
GREAT
RESOURCES!
Multi-payer programs with expanded patient populations
outside of Medicare are good examples of opportunities
for providers and clinicians grounded in meaningful use
functionality.
Much more on the CPC program can be found here.
Patient care
CARE COORDINATION, SAFETY AND OUTCOMES
Better documentation of patient care, improved tracking of outcomes and
greater patient engagement represent major goals of meaningful use. By
following meaningful use criteria, practices can advance patients’ access to
their own health information, decrease adverse drug interactions and clinical
errors, automate preventive and follow-up care processes, and streamline
referrals for improved care coordination.
Progress toward those goals has already been made through several MU core
objectives:5
»» Electronic prescribing: More than 190 million electronic prescriptions
have been transmitted since MU began. This, coupled with a separate
required objective to use Computerized Physician Order Entry (CPOE)
for medication orders, has been credited with reducing prescription and
medication errors.
»» Patient reminders: More than 13 million reminders have been sent
for patients ages 65 and older or 5 and younger — which is driving
adherence to care plans.
»» Patient electronic access: More than 33 million patients have received
electronic access to health information via patient portals.
TIP
Tagalicod, Robert, Director, Office of E-Health Standards and
Services, Centers for Medicare and Medicaid Services. “The
Real World Impact of Meaningful Use.” http://www.cms.gov/
eHealth/ListServ_RealWorldImpact_MeaningfulUse.html.
When your practice becomes adept at meeting meaningful
use objectives, examine ways to expand select required
processes beyond your Medicare or Medicaid patients
to your entire patient population. Meaningful use data
capture and analysis is also a good way to assess internal
quality goals and patient care trends.
5
17
BENEFITS OF PATIENT PORTALS
Every day, millions of people in the U.S. transact with banks, book airfare
and reserve tables at restaurants using Internet and mobile applications, or
“apps.” They’ve grown to appreciate the convenience, access and speed with
which apps enable them to accomplish these everyday tasks. It’s no wonder,
then, that people have started to demand the same convenient access to
their health information. When you couple that demand with the healthcare
sector’s increased focus on patient engagement as a means to improve patient
outcomes and population health, a spotlight falls on patient portals and the
benefits they offer practices and patients.
Meeting meaningful use reporting requirements for patient engagement
presents a win-win situation: Through a patient portal on a practice’s website,
patients can take an active role in their own healthcare, and practices acquire
tools to boost office efficiency.
Through a portal, patients should be able to:
»» Schedule appointments
»» Request prescription refills
»» Access financial tools such as online statements and bill pay
»» Review care and office visit summaries
»» Access integrated personal health records (PHRs)
»» Review test and lab results
»» Access appointment reminders
»» Contact the office through secure messaging
»» Update insurance or contact information
Making these features available to patients can improve office efficiency by:
»» Decreasing phone calls and mail
»» Reducing time spent updating records and completing administrative
tasks
»» Minimizing waiting room paperwork
18
PORTALS AND MU REQUIREMENTS
Online patient portals can aid in meeting the following MU core requirements
and menu items:
STAGE 1 CORE REQUIREMENTS
»» Provide electronic copy of health information upon request (test results,
problem list, medication list, allergy list) to more than 50 percent of
patients requesting, within three business days.
»» Provide clinical summaries following an office visit to more than 50
percent of all patients within three business days.
STAGE 1 MENU ITEMS
»» Provide patient-specific educational resources to more than 10 percent
of patients
»» Provide timely access to health information within four days to at least
10 percent of patients
STAGE 2 CORE REQUIREMENTS
»» Provide the ability for patients to view, download and transmit (VDT)
health information within four business days of becoming available to
the EP. • More than 50 percent of unique patients are provided access to
information within four days after information is available to EP
• More than 5 percent shown to transmit data to a third party
»» Provide clinical summaries following an office visit, to more than 50
percent of patients within one business day
»» Provide educational resources to more than 10 percent of patients
PROMOTE YOUR PORTAL
Simply having a portal is no guarantee patients will use it, but you can maximize
adoption rates — and eventually, results — with promotions including:
»»
»»
»»
»»
»»
»»
»»
»»
Posters and pamphlets in waiting and exam rooms
Promotion on paper billing statements
Promotion during telephone conversations
Take-home cards with login instructions
Incentives such as preferred appointment times if requested through the portal
Registration assistance during office visits
Clear icons and prompts on practice website
Regular external information flow to patient population
• Awareness campaigns
• Office hours
• Special events
»» Physician buy-in and promotion directly to patients
DID YOU
KNOW?
Greenway Health provides practices with posters,
brochures and more to help encourage patients to use
the portal.
19
How to
Participate
Implement a meaningful use-certified EHR
The Office of the National Coordinator for Health Information Technology (ONC)
oversees the certification process of EHRs to the specifications of meaningful
use objectives and measures. ONC has designated three organizations to carry
out the testing and certification of EHRs, the names of which you should be
familiar with when assessing EHR capabilities:
»» Drummond Group
»» ICSA Labs
»» InfoGard Laboratories, Inc
GREAT
RESOURCE!
Additional information on the certification process can
be found here.
The ONC maintains a detailed website that includes a list of all complete
or modular EHRs that have been certified for meaningful use. The site is
searchable by vendor, product name or certification number.
Understanding 2011 and 2014 certification editions
You may notice that EHR software is branded with a 2011 or 2014 certification.
These certification editions are matched to the stages of meaningful use: The
2011 certification edition reflects the objectives and measures of Stage 1, and
the 2014 edition matches the objectives and measure of Stage 2. Each edition
is usable throughout multiple years of reporting, as long as it is used within the
appropriate stage.
Keep in mind that refinements have been made to certain objectives on an
annual basis since MU reporting began in 2011. As adjustments to objectives
and measures within a given stage occur, EHR developers match those changes
in the meaningful use software’s capabilities. That’s why you will encounter
designations for “2013 Stage 1” or “2014 Stage 1” objectives and measures.
For MU Stage 1, you would still use the Stage 1 — or 2011 — edition of your
certified EHR software, as the 2011 edition matches Stage 1, no matter the
reporting year adjustments.
NOTE
To ease the transition between reporting Stage 1 and
Stage 2 objectives, CMS recently proposed that a
combination of 2011- and 2014-certified editions could
be used by EPs who are still in the certified software
upgrade process but want or need to begin reporting
Stage 2 in 2014.
This proposal would allow Stage 1, 2013, Stage 1,
2014, or Stage 2 objectives to be reported using this
combination edition. A final ruling on this proposal is
expected prior to the last quarter of 2014.
After identifying meaningful use certification and implementing a certified EHR,
you are ready to register for the program.
20
Registering per-provider for meaningful use
incentives
To register for the Medicare or Medicaid incentive programs, there are a few
basic things to know and elements to have ready:
»» Registration is only required once during the life of the incentive
program
»» Registration is required for every individual EP within a practice
»» Registration requires two types of identifying information:
• National Provider Identifier (NPI)
•N
ational Plan and Provider Enumeration System (NPPES) Web
user account
– The NPPES user ID and password begins registration
DID YOU
KNOW?
– Providers may apply for and obtain an NPPES login here
CMS allows a third party — such as a group practice staff
member — to register EPs for the program. Registering
this way will create an Identity and Access Management
System (I&A) Web user account (User ID/Password),
which will be associated to the eligible professional’s NPI.
To pursue this option, get started here.
Registration Preparatory Materials and Registration Web
Portal
CMS provides detailed online guides for the registration
process, as well an online registration portal:
GREAT
RESOURCES!
»» Registration Guide: Medicare Pathway: Registration User
Guide for Medicare Eligible Professionals
»» Registration Guide: Medicaid Pathway: Registration User
Guide for Medicaid Eligible Professionals
»» Registration Portal: https://ehrincentives.cms.gov
21
Assessing
and selecting
meaningful use
measures
Core objectives and menu sets
Once you have implemented certified technology and registered for the
meaningful use program, the next step is assessing the core objectives
required for all EPs and selecting the optional menu items that best fit your care
objectives, specialty and patient population.
»» For Stage 1, EPs report all 13 core objectives and choose five of nine
menu items.
»» For Stage 2, EPs report all 17 core objectives and choose three of five
menu items.
STAGE 1
Figure 5: Stage 1 Meaningful Use Objectives for Eligible Professionals (EPs) - Core Set Measures
Measure
1
Use computerized provider
order entry (CPOE) for
medication orders.
Threshold Requirements
More than 30% of all unique patients’ medication
lists have at least one medication order entered
using CPOE.
Exclusion
Any EP who writes fewer than 100 prescriptions
during the EHR reporting period.
Optional Alternative: More than 30% of medication
orders created during the EHR reporting period are
recorded using CPOE.
2
Implement drug-drug, drugallergy checks.
Enable and have access to at least one internal or
external formulary.
No exclusion.
3
Maintain problem list.
Maintain an up-to-date current diagnoses problem
list.
No exclusion.
4
Generate and transmit
permissible prescriptions
electronically (eRx).
eRx for at least 40% of permissible scripts.
1. Any EP who writes fewer than 100
prescriptions during the EHR reporting period.
2. Any EP who does not have a pharmacy within
his or her organization and no pharmacies within
10 miles that accept eRx at the start/end of EHR
reporting period.
5
Maintain an active
medication list.
Maintain an active medication list for at least 80%
of unique patient visits and at least one entry.
No exclusion.
6
Maintain an active allergy
list.
Maintain an active allergy list for at least 80% of
unique patient visits and at least one entry.
No exclusion.
7
Record demographics.
More than 50% of all unique patients have
demographics recorded as structured data.
No exclusion.
8
Record and chart changes
in vital signs.
Record vital signs and children growth charts of
more than 50% of unique patient visits. Required
age for blood pressure is 3 years or older.
1. Any EP who sees no patients 3 years or older is
excluded from recording blood pressure.
2. Any EP who believes that height, weight and
blood pressure have no relevance to his or her
scope of practice are excluded from recording
them.
3. Any EP who believes that height and weight are
relevant to his or her practice, but blood pressure is
not, is excluded from recording blood pressure; or
4. Any EP who believes that blood pressure is
relevant to his or her practice, but height and
weight are not, is excluded from recording height
and weight.
22
Figure 5 continued: Stage 1 Meaningful Use Objectives for Eligible Professionals (EPs) - Core Set Measures
Measure
9
Record smoking status.
Threshold Requirements
Exclusion
More than 50% of all unique patients 13 years and
older have smoking status recorded as structured
data.
Any EP who sees no patients 13 years or older.
10 Launch/track clinical
decision support rule.
Implement at least one clinical decision support
rule.
No exclusion.
11 Provide patients the ability
to view online, download
and transmit their health
information.
Provide 50% or more of all unique patients seen
during the EHR reporting period, online access to
their health information within four business days.
Any EP who has no requests from patients or
their agents for an electronic copy of patient
health information during the EHR reporting
period.
12 Provide clinical summaries.
Provide clinical summaries (EPs) and discharge
summary (hospitals) for at least 50% of all
patients.
Any EP who has no office visits during the EHR
reporting period.
13 Protect electronic health
information.
Conduct or review a security risk analysis in
accordance with the requirements under 45
CFR 164.308(a)(1) and implement security
updates as necessary and correct identified
security deficiencies as part of the provider’s risk
management process.
No exclusion.
STAGE 2
Figure 6: Stage 2 Meaningful Use Objectives for Eligible Professionals (EPs) - Core Set Measures
Measure
Threshold Requirements
Exclusion
1
Use computerized provider More than 60% of medications, 30% of laboratory
order entry (CPOE) for
and 30% radiology orders created by the EP are
medication, laboratory and recorded using CPOE.
radiology orders.
Any EP who writes fewer than 100 medication,
radiology or lab orders during the EHR reporting
period.
2
Generate and transmit
permissible prescriptions
electronically (eRx).
More than 50% of all permissible scripts written
by the EP are compared to at least one drug
formulary and transmitted electronically using
certified EHR technology.
1. Any EP who writes fewer than 100
prescriptions during the EHR reporting period.
2. Any EP who doesn’t have a pharmacy within
his or her organization and no pharmacies
accept electronic prescriptions within 10 miles
of the EPs practice location at the start of his/
her EHR reporting period.
3
Record demographic
information.
More than 80% of all unique patients have
demographics recorded as structured data.
No exclusion.
4
Record and chart changes
in vital signs.
More than 80% of all unique patients have
blood pressure (over 3 years) and height/weight
recorded as structured data.
1. Any EP who sees no patient 3 years orolder is
excluded from recording blood pressure.
2. Any EP who believes that all three vital signs
of height/length, weight and blood pressure
have no relevance to his or her scope of practice
is excluded from recording them.
3. Any EP who believes that height/weight are
relevant to his or her scope of practice, but
blood pressure is not, is excluded from recording
blood pressure.
4. Any EP who believes that blood pressure is
relevant to his or her scope of practice, but
height/length and weight are not, is excluded
from recording height/length and weight.
23
Figure 6 continued: Stage 2 Meaningful Use Objectives for Eligible Professionals (EPs) - Core Set Measures
Measure
Threshold Requirements
Exclusion
5
Record smoking status for
patients 13 years old or
older.
More than 80% of all unique patients 13 years or
older have smoking status recorded as structured
data.
Any EP who writes fewer than 100 medication
orders during the EHR reporting period is
excluded from measure part two.
6
Use of clinical decision
support to improve
performance on highpriority health conditions.
1. Implement five clinical decision support
interventions related to four or more clinical
quality measures (CQMs).
Any EP who writes fewer than 100 medication
orders during the EHR reporting period is
excluded from measure part two.
2. The EP has enabled the functionality for drugdrug and drug-allergy interaction checks for entire
reporting period.
7
Provide patients the ability 1. More than 50% of all unique patients seen
to view online, download,
during the reporting period are provided timely
and transmit their health
online access to their health information.
information.
2. More than 5% of these patients view, download,
or transmit to a third party.
1. Any EP who neither orders nor creates any
of the information listed for inclusion as both
parts of the measure, except for ”Patient’s
name” and ”Provider’s name and office contact
information,” may exclude both measures.
2. Any EP who conducts 50% or more of his/
her patient encounters in a county that doesn’t
have 50% or more of its housing units with 3
Mbps broadband availability according to the
latest information available from the FCC on
the first day of the EHR reporting period may be
excluded from measure part two.
8
Provide clinical summaries
to patients for each office
visit.
Clinical summaries provided to patients within 24
hours for more than 50% of office visits.
Any EP who has no office visits during the EHR
reporting period.
9
Protect electronic health
information created or
maintained by the Certified
EHR Technology.
Conduct or review a security risk analysis in
accordance with the requirements under 45
CFR 164.308(a)(1), including addressing the
encryption/security of data at rest and implement
security updates as necessary and correct
identified security deficiencies as part of the
provider’s risk management process.
No exclusion.
10 Incorporate clinical labtest results into Certified
EHR Technology.
More than 55% of all clinical lab results ordered by
the EP with either positive/negative or numerical
format are incorporated as structured data.
Any EP who orders no lab tests where results
are either positive/negative or numerical format
during the EHR reporting period.
11 Generate lists of patients
by specific conditions
to use for quality
improvement, reduction
of disparities, research, or
outreach.
Generate at least one report listing patients of the No exclusion.
EP with a specific condition.
12 Use clinically relevant
information to identify
patients who should
receive reminders for
preventive/follow-up care.
More than 10% of unique patients who have
had two or more office visits with the EP within
24 months prior to the beginning of the EHR
reporting period were sent a reminder, per patient
preference.
Any EP who has had no office visits within the 24
months before the EHR reporting period.
13 Use Certified EHR
Technology to identify
patient-specific education
resources.
More than 10% of patients with an office visit are
provided patient-specific education resources
identified by Certified EHR Technology.
Any EP who has no office visits during the EHR
reporting period.
14 Perform medication
reconciliation.
The EP must perform medication reconciliation for
more than 50% of transitions of care in which the
patient transitioned into the care of the EP.
Any EP who was not the recipient of any
transitions of care during the EHR reporting
period.
24
Figure 6 continued: Stage 2 Meaningful Use Objectives for Eligible Professionals (EPs) - Core Set Measures
Measure
15 Provide summary of care
record for each transition
of care or referral.
Threshold Requirements
1. The EP who transitions patients to other care
settings must provide a summary of care record
for more than 50% 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 is excluded from all parts of this measure.
2. The EP must electronically submit that
transition of care using Certified EHR Technology
to a recipient with no organizational affiliation or
with a different EHR vendor more than 10% of the
time.
3. The EP must conduct one or more successful
electronic exchanges of a summary of care
document with a recipient using EHR technology
or with a different EHR vendor. Or the EP must
conduct one or more successful tests with test
designed by CMS during the EHR reporting period.
16 Submit electronic data to
immunization registries.
Successful ongoing submission of electronic
immunization data from CEHRT to an immunization
registry or immunization information system for
the entire reporting period.
Any EP who meets one or more of the following
criteria may be excluded:
1. Doesn’t administer any of the immunizations
to any of the populations for which data is
collected by their jurisdiction’s immunization
registry or immunization information system
during the EHR reporting period.
2. Operates in a jurisdiction where no
immunization registry or immunization
information system is capable of accepting
specific standards required for CERHT at the
start of their EHR reporting period.
3. Operates in a jurisdiction where no
immunization registry or immunization
information system provides information timely
on capability to receive immunization data.
4. Operates in a jurisdiction for which no
immunization registry or immunization
information system that is capable of accepting
the specific standards required by CEHRT at the
start of their EHR reporting period can enroll
additional EPs.
17 Use secure electronic
More than 5% of unique patients were sent a
messaging to
secure message using the electronic messaging
communicate with
function of Certified EHR Technology.
patients on relevant health
information.
TIP
Any EP who has no office visits during the EHR
reporting period or who conducts 50% or more
of his/her patient encounters in a county that
does not have 50% or more of its housing units
with 3Mbps broadband availability according to
the latest information available from the FCC on
the first day of the EHR reporting period.
To satisfy the secure messaging 5%+ threshold, CMS has ruled that if a patient sees
multiple EPs and has received a message from one of them, all care plan EPs can count it
toward the threshold.
25
EXCLUSIONS
As noted in the accompanying charts, some core and menu items come with
allowed exclusions, while others do not.
In previous years, meeting an exclusion criterion for a
menu item also counted as the reporting of that given
menu item.
TIP
Beginning in 2014, for both Stage 1 and Stage 2 reporting,
meeting a menu item exclusion will no longer count toward
required number of menu items (five for Stage 1 and three
for Stage 2).
SELECTING MENU ITEMS
To select the most appropriate menu items, consider these strategies:
»» Determine if the menu items are within the scope of your specialty
»» Assess whether you can meet the threshold requirements for a given
menu item
»» For Stage 1, EPs must select one public health reporting option as a
menu item
»» If you are transitioning or plan to transition from Stage 1 to Stage 2,
determine which Stage 1 menu items have moved to core items in Stage
2. If you can meet the Stage 1 menu item, you will have a workflow
bridge to a Stage 2 core objective.
26
Figure 6, provided by CMS, shows the general popularity of menu items chosen
by your peers from 2011 through 2013, during the 90-day reporting periods
allowed during the first year of Stage 1 reporting.
Figure 7: EP 2011, 2012, and 2013 90 Days Menu Objective Performance
91.5 %
Clinical Lab
Test Results
93.0 %
92.7 %
61.7 %
Patient
Reminders
62.1 %
64.3 %
72.6 %
Patient Electronic
Access
73.9 %
78.8 %
49.0 %
Patient-Specific
Education Resources
51.0 %
58.1 %
89.5 %
Medication
Reconciliation
90.0 %
90.4 %
88.9 %
Transition of
Care Summary
91.5 %
92.9 %
37.5 %
Immunization Registries
Data Submission
Syndromic Surveillance
Data Submission
35.3 %
36.3 %
6.2 %
6.4 %
4.8 %
TIP
2011
2012
2013
Among Stage 1 EPs selecting from one of two public
health reporting options, the submission of electronic data
to immunization registries fared better than submitting
syndromic surveillance data to public health agencies.
Greenway has found that syndromic surveillance registries
are handled differently, and in some cases require different
reporting mechanisms per state. If you are considering the
Stage 1 menu item of reporting syndromic surveillance,
check with your EHR vendor about its awareness of the
parameters for meeting the menu items in your state.
27
CLINICAL SUMMARY AND SUMMARY OF CARE
Different objectives and different required elements
When assessing meaningful use objectives, whether core or menu, success
is in the details. For example, the objective for providing a Clinical Summary
(Stage 1 core; Stage 2 core) to patients following an office visit is different
from the objective of providing a Summary of Care (Stage 1 menu; Stage 2
core) during patient transitions of care. These two summaries require different
data elements in the electronic document:
CLINICAL SUMMARY (20 ELEMENTS)
SUMMARY OF CARE (16 ELEMENTS)
1. Patient name
2. Provider’s name and office contact
information
3. Date and location of visit
4. Reason for office visit
5. Current problem list
6. Current medication list
7. Current medication allergy list
8. Procedures performed during the visit
9. Immunizations or medications
administered during the visit
10.Vital signs taken during the visit
(or other recent vital signs)
11.Laboratory test results
12.Lists of diagnostic tests pending
13.Clinical instructions
14.Future appointments
15.Referrals to other providers
16.Future scheduled tests
17.Demographic information maintained
in the EHR
18.Smoking status
19.Care plan fields, including goals and
instructions
20.Recommended patient decision aids
(if applicable)
1. Patient name
2. Referring or transitioning provider’s
name and office contact information
(EP only)
3. Procedures
4. Encounter diagnosis
5. Immunizations
6. Laboratory test results
7. Vital signs
8. Smoking status
9. Functional status (including activities
of daily living, cognitive and disability
status)
10. Demographic information, including
preferred language
11. Care plan field, including goals and
instructions
12. 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
13. Reason for referral
14. Current problem list (and historical
problems at discretion of EP)
15. Current medication list
16. Current medication allergy list
This is a good example of why any EP seeking reporting and attestation
success would benefit from a careful reading of the MU requirements.
A WINDOW INTO THE FUTURE OF MU
Stage 3 of meaningful use is currently scheduled to begin in 2017. Most Stage 3
objectives have been established, though they are still subject to proposed and
final rules. It is expected that Stage 3 objectives will be formalized by the fall of
2014, accompanied by increased reporting percentages and threshold measures
— as well as aspects such as the number of menu items to be selected — all in the
form of the proposed rule.
Stage 3 mixes new objectives (mostly proposed as menu items) with those
advancing from Stage 2 to emphasize improved outcomes. Changes and goals for
Stage 3 are examined in more detail in the What’s Next? section of this document.
28
Clinical quality measures
Over the last 10 years, clinical quality measures (CQMs) have become an
integral component in CMS’ drive to improve quality, reduce costs and expand
access to healthcare. As part of meaningful use and other quality-reporting
programs, EPs must report on a selection of CQMs set forth by CMS.
CMS has worked hard to align the quality-reporting requirements across the
various programs, giving providers the option to use the same set of CQMs to
report for both PQRS and meaningful use.
WHAT THEY GAUGE
»» Health outcomes
»» Clinical processes
»» Patient safety
»» Efficient use of healthcare resources
»» Care coordination
»» Patient engagement
WHERE THE DATA COMES FROM
In the past, quality measures primarily used data from claims, but as technology
has improved and become more prominent in the healthcare setting, many
quality measures now use data from the provider’s EHR.
HOW CMS USES THE DATA
Think of CQMs as part of a system of care quality “checks and balances.” By
requiring providers to track and record patient treatment via electronic health
records, CMS holds eligible professionals accountable for providing safe,
efficient, patient-centered, timely care. Data are used in the following ways:
»» To make policy decisions around quality
»» To inform the public about the level of care provided within a given
institution or by a particular provider
»» To improve the quality of healthcare nationwide by identifying
weaknesses within our healthcare system and taking action to
strengthen them
29
RECOMMENDED CORE SETS
For 2014, CMS has identified two recommended core sets of CQMs — one
for adults and one for children. Eligible professionals are encouraged to report
from the recommended core set that best suits the scope of their practice and
patient population.
Additionally, all providers must select CQMs from at least three of the six key
healthcare policy domains recommended by the Department of Health and
Human Services’ National Quality Strategy:
»» Patient and Family Engagement
»» Patient Safety
»» Care Coordination
»» Population and Public Health
»» Efficient Use of Healthcare Resources
»» Clinical Processes/Effectiveness
GREAT
RESOURCE!
A complete list of 2014 CQMs and their associated
National Quality Strategy domains are posted on the
recommended core set of CQMs for eligible providers —
all focusing on high-priority clinical conditions.
In 2014, all providers — regardless of whether they are in Stage 1 or Stage 2 of
meaningful use — will be required to report on the 2014 CQMs finalized in the
Stage 2 rule, which stipulates:
EPs must report on nine out of 64 total CQMs:
»» Nine eCQMs for adult populations that meet all of the program
requirements
»» Nine eCQMs for pediatric populations that meet all of the program
requirements
Adult recommended core measures
»» Controlling high blood pressure
»» Use of high-risk medications in the elderly
»» Preventive care and screening: Tobacco use: Screening and cessation
intervention
»» Use of imaging studies for low back pain
»» Preventive care and screening: Screening for clinical depression and
follow-up plan
»» Documentation of current medications in the medical record
»» Preventive care and screening: Body mass index (BMI) screening and
follow-up
30
»» Closing the referral loop: Receipt of specialist report
»» Functional status assessment for complex chronic conditions
See full table of recommended adult measures
Pediatric recommended core measures
»» Appropriate testing for children with pharyngitis
»» Weight assessment and counseling for nutrition and physical activity
for children and adolescents
»» Chlamydia screening for women (16 to 24 years of age)
»» Use of appropriate medications for asthma
»» Childhood immunization status
»» Appropriate treatment for children with upper respiratory infection (URI)
»» ADHD: Follow-up care for children prescribed Attention-Deficit/
Hyperactivity Disorder (ADHD) medication
»» Preventive care and screening: Screening for clinical depression and
follow-up plan
»» Children who have dental decay or cavities
See full table of recommended pediatric measures
WHY THESE SPECIFIC MEASURES?
CMS selected the recommended core sets of clinical quality measures based
on the following factors:
»» Conditions that contribute to the morbidity and mortality of the most
Medicare and Medicaid beneficiaries
»» Conditions that represent national public health priorities
»» Conditions that are common to health disparities
»» Conditions that disproportionately drive healthcare costs and could
improve with better quality measurement
»» Measures that would enable CMS, states and the provider community
to measure quality of care in new dimensions, with a stronger focus on
sparing measurement
»» Measures that include patient and/or caregiver engagement
For more detailed information on 2014 CQMs and electronic reporting options,
download the 2014 Clinical Quality Measures Tipsheet.
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CHOOSING APPROPRIATE CQMS FOR YOUR PRACTICE
The following questions can help providers understand where opportunities for
quality improvement exist and which measures are appropriate for tracking that
improvement.
»» Is the measure’s population reflected in your patient mix?
For example, a pediatrician should not choose a measure that excludes
children.
»» Does the measure correlate with specific diseases that are more
prevalent or harder to control among your patients?
For example, the practice may have many patients with diabetes, but few
with asthma.
»» Are you already using the measure for other quality measurement or
reporting activities?
Consider what the practice does for commercial payers, the state and
other initiatives. Take advantage of overlaps to streamline your data
collection and reporting activities.
»» Is your EHR certified for the measure?
Choosing clinical quality measures to report on for meaningful use can be a
daunting task. It is suggested that you begin this process by looking at your
patient population as a whole, and pulling out the top 10 to 20 diagnoses
that you typically see. From there, you can match those diagnoses against
the listing of clinical quality measures available, identify the best candidates
that align with the most common diagnoses among your patients, and work
with your vendor to ensure that your EHR system has the ability to track the
measures you select.
REPORTING CQMS
To assess providers’ compliance and progress, most programs require that
CQM data be reported. In order to capture and share patient data efficiently,
providers need an EHR that stores data in a structured format. This structured
data allows patient information to be easily retrieved and transferred, and
allows the provider to use the EHR in ways that can aid patient care.
Some of the EHR functions listed below can help improve the performance of
this data:
»» Confirm that the patient’s problem list is up to date
• Determine if patients meet exclusion or exception criteria for the
measure
• Determine if any patients are encountering specific barriers to
treatment adherence
• Review any changes in vital signs
• Use clinical decision support to highlight missing services (for
example, reminders for age-appropriate vaccinations or cancer
screenings)
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»» Review the patient’s medications, if applicable
• Use ePrescribing to obtain prescription and refill history
• Determine if there are any drug-drug or drug-allergy interactions
• Confirm that the patient’s active medication and active
medication allergy lists are up to date
• Perform a medication reconciliation if necessary
• Determine if there are barriers to medication adherence for the
patient
»» Engage the patient
• Be sure to provide updated clinical summaries at each visit
– Ensure information on the clinical summary is accurate
for the patient (for example, a mammogram reminder for a
double mastectomy patient would not be appropriate)
• Provide patient with patient-specific education resources
• Send reminders for follow-up or preventive care using the patient’s
preferred method
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WHAT CQMS ARE YOUR COLLEAGUES REPORTING?
Greenway surveyed more than 500 providers to learn more about which CQMs
they use to attest for meaningful use. The survey results offered great insight
into the most-used CQM groups and the specific measures within each group.
Figure 8: EPs’ Plans to Attest for Stage 2
8%
7%
77%
STAGE 2
STAGE 1
77%
9%
14%
8%
YES
NO, but PLAN TO attest
YES, plan to attest
NO, with NO plans to attest
DON’T KNOW
NO, with NO plans to attest
DON’T KNOW
Figure 9: Top-ranked CQM groups
»» Preventive Care and Screening (72%)
»» Hypertension (59%)
»» Diabetes (57%)
Preventive Care and Screening – 72%
Hypertension – 59%
Diabetes – 57%
Others Include:
Cancer Screening | 45%
Care Coordination/Patient Safety Measures | 44%
Asthma Measures | 39%
Pediatric Measures | 32%
Heart Failure, CAD, Atrial Fibrillation Measures | 30%
Mental Illness/Substance Abuse Measures | 25%
Elderly Care | 23%
Low Back Pain/Knee or Hip Replacement Measures | 17%
HIV/AIDS Measures | 13%
TVD Measures | 10%
Oncology Measures | 8%
Cataracts/POAG Measures | 4%
According to the CDC, more than one-third of U.S. adults (34.9%) are obese.
With a rising obesity rate and related health conditions, it’s no surprise that
these have become providers’ top CQM choices.
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Figure 10: Preventive care and screening
Americans are living longer, but with more chronic illness. This calls for more and
more preventive care, placing smoking, obesity and high blood pressure at the
top of the CQMs on which providers choose to report.
Tobacco Use: Screening and Cessation Intervention – 83%
BMI: Screening and Follow-Up – 76%
Preventive Care & Screening: Influenza Immunization – 67%
Others Include:
Screening for High Blood Pressure and Follow-up Documented | 64% Chlamydia Screening for Women | 42%
Cholesterol : Fasting Low-Density Lipoprotein (LDL-C) Testing | 56% Risk-Satisfied Cholesterol - Fasting Low-Density Lipoprotein (LDL-C) | 37%
Screening for Clinical Depression & Follow-Up | 43%
Pregnant Women that had HBsAG Testing | 30%
Figure 11: Top-reported pediatric measures
Weight assessment and ADHD top the list of the reported Pediatric
Clinical Measures. Over the past three decades, childhood obesity rates in
America have tripled, and today, nearly one in three children in America are
overweight or obese. And an estimated 6.4 million children ages 4 through
17 had received a diagnosis of attention deficit hyperactivity disorder
(ADHD) at some point in their lives. About two-thirds of those with a current
diagnosis receive prescriptions for stimulants such as Ritalin or Adderall.
Childhood Immunization
Status (NQF 0038)
96%
Weight Assessment & Counseling
for Nutrition and Physical Activity
for Children and Adolescents (NQF 024)
85%
ADHD: Follow-Up Care for Children
Prescribed Medication (NQF 0108)
71%
Appropriate Treatment for
Children with Upper Respiratory
infection (URI) (NQF 0069)
67%
Appropriate Testing for Children
with Pharyngitis (NQF 0002)
61%
Primary Caries Prevention
and Intervention as Offered by Primary
Care Providers, including Dentists
53%
Maternal Depression
Screening (NQF 1401)
44%
Hemoglobin A1c Test (NQF 0060)
43%
Children Who have Dental
Decay or Cavities
43%
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Capturing
and Reporting
(Attesting) Data
A note about dashboard technology
To capture required clinical data — core objectives, menu objectives and CQMs
— to be reported (attested) to CMS, choose certified EHR technology that
offers a “dashboard” feature. Best practice meaningful use dashboards in EHRs
capture objective and CQM data for each attesting EP. By collecting data over
time, these dashboards allow practices to view and assess each EP’s progress
on the measures well before it is time to attest.
Reporting timelines by stage
CMS requires that EPs attest for two years of a given stage before progressing
to the next.
TIP
Core objectives will not change from year to year, but EPs
can change their menu item and CQM selections annually
while remaining within the same stage.
In the first year of a given stage, CMS has historically allowed EPs to capture
core and menu objectives data over a 90-day period. In the following year, EPs
must capture the data for a full calendar year.
For 2014, EPs may report core objectives, menu objectives and CQMs for a 90day period, regardless of the EP’s reporting stage or year.
Attestation
Medicare EPs attest for meaningful use via the same online portal used to
register for the program.
NOTE
While both Medicare and Medicaid EPs register through
the CMS portal, Medicaid EPs attest through their
individual states’ Medicaid agency websites.
»» The attestation process for both Medicare and Medicaid EPs requires
the NPI number and logins, whether attestation is through the national
CMS portal or state Medicaid sites.
»» A third party may complete the attestation process on behalf of an EP.
See more about the NPI and third-party attestation requirements in the
Registration section of this guide.
For both Medicare and Medicaid EPs, CMS offers resources enabling practices
to calculate attestation success prior to submission. CMS also offers step-bystep guides for EPs within Stage 1 or Stage 2 of the program.
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STAGE 1
STAGE 2
Meaningful Use Calculator
Meaningful Use Attestation Calculator
STAGE 1
STAGE 2
Attestation User Guide for Eligible
Professionals
Attestation User Guide for Eligible
Professionals
ATTESTATION AND CQMS
NOTE
Meaningful use attestation is not complete until the EP
submits CQMs. Medicare EPs submit CQMs data to CMS.
Medicaid EPs submit CQMs data to their state Medicaid
agencies.
CQMs may be submitted along with core and menu objectives during
attestation. EPs may also choose to submit one set of CQMs to satisfy
requirements of both meaningful use and other programs requiring CQMs data
(such as PQRS).
Be aware that programs such as PQRS require a full calendar year of CQM
reporting, which can delay your meaningful use incentive payment until the
CQM submission is processed, even if your meaningful use attestation was for
a 90-day period.
See the CQMs section of this guide for more
information on clinical quality measures.
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AMENDING SUBMITTED ATTESTATIONS
Medicare EPs wishing to change or amend information after they have attested,
or who believe an error has occurred, may contact the CMS Information Center
by telephone at 1-888-734-6433.
Receiving your payment
»» Medicare EPs receive annual incentive payments in one lump sum,
generally within the calendar quarter following the date of attestation.
»» Medicare EPs eligible for an additional payment by practicing in a Health
Professional Shortage Area (HPSA) receive that payment separately
from the main meaningful use incentive payment.
»» Medicaid payments are subject to variations depending on how each
state handles incentive payments.
»» Payments are matched to EPs through the same National Provider
Identifier (NPI) or Taxpayer Identification Number (TIN) selected during
registration.
Meaningful use audits
Pre- and post-payment audits began in 2013 and remain in effect.
TIP
Retain data from each attestation for six years to cover
the timeline for a potential meaningful use audit.
Resources available from the CMS website include an overview of the audit
program, details about supporting documentation checklists, and examples of
documentation used to support data objectives.
Appeals process
For Medicare EPs, CMS maintains an appeals process for a variety of issues,
such as audit findings, EHR certification, CQM electronic reporting, program
eligibility and other topics pursued by an EP.
An overview of this process and sample submission forms can be found here.
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What’s Next?
Meaningful use Stage 3
Stage 3 is currently proposed as the last incentivized stage of the meaningful
use program. It is scheduled to begin in 2017. At that time, public and private
payer quality reporting will reflect greater standardization across programs,
though specialty- and patient volume-based menu items and CQMs will remain.
The overriding goal of Stage 3 is for the EHR to enable providers to improve
patient outcomes and to smooth the transition to advanced care delivery and
payment models.
To accomplish this goal, Stage 3 will increase, beyond Stage 2 criteria, the
objectives, measures and thresholds related to the following areas:
»» Clinical decision support (CDS)
»» Patient engagement
»» Care coordination
»» Population management
To track and quantify improvement, Stage 3 criteria are being framed and
tracked by this overall sequence:
»» Objective
»» Functionality
»» Outcomes
For example, CDS (which “provides the most evidence for improving outcomes
associated with the EHR,” according to CMS), is being framed this way:
Objective: Clinical decision support
Functionality: Track CDS interventions in cases of preventive care,
chronic disease management, medication decision support, drug-drug and
drug-allergy checks.
Outcomes: Patients receive evidence-based care; patients are not
harmed; patients do not receive inappropriate care.
To satisfy this objective, a provider will have to conduct multiple CDS
interventions, although the exact thresholds will not be determined until Stage
3 rules are finalized.
Other examples of how new objectives and increased thresholds within existing
objectives will be used to meet the goals of Stage 3 are apparent in areas such
as orders tracking and patient-generated health data.
Orders tracking: Under the proposed Stage 3 menu item of orders
tracking, the results from a provider’s order for a specialist consultation
must be returned to the ordering provider. This moves beyond the Stage 2
objective of transferring simple summaries of care to establish a twoway street of data exchange. The objective would also establish timeline
triggers and notifications, so that ordering providers are alerted when
order results have not met a prescribed deadline.
39
atient-generated health data: Under this objective, EHRs would
P
be equipped to receive completed questionnaires, surveys, and risk
assessment forms submitted electronically by patients. The EHR would
receive patient-generated information as structured or semi-structured
data.
More on Stage 3 will be presented as timelines and objectives are formalized.
The proposed Stage 3 core and menu objectives include the following:
CORE OBJECTIVES
MENU SET OBJECTIVES
Perform multiple clinical decision support
(CDS) interventions
Conduct orders tracking (new)
Provide summary of care during patient
transitions via health information exchange
Provide the means for patients to view,
download and transmit (VDT) clinical
summaries (new threshold proposing
patient ability to VDT within 24 hours of
visit)
Receive provider-requested patientgenerated health data (new)
Patient-generated health data to be
included in patient ability to view,
download, transmit
Record advance directives
Record electronic progress note in patient
records
Place/access imaging results in the EHR
(new)
Provide patients with secure messaging
Record family history as structured data
Provide patient summaries following office
visits
Submit syndromic surveillance to public
health agencies
Send patient reminders
Perform medication reconciliation
Track medications
Receive patient immunization history from
registries
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Now What?
Tools to demonstrate meaningful use of HIT
Understanding present and future meaningful use requirements is the first
step to preparing your practice for a smooth, successful attestation. Equally
important, though, is choosing the right tools to track and report your progress
toward meeting core and menu objectives. In order to participate in meaningful
use, practices need integrated practice management, electronic health record
(EHR) and data reporting solutions with the ability to exchange data with state
registries.
To aid selection, begin looking for ONC-certified complete solutions. But keep in
mind that as meaningful use and other incentive programs become increasingly
demanding, practices will benefit most from trusted healthcare IT partners who
are dedicated to helping them stay compliant and profitable.
Greenway has partnered with more than 10,000 practices to provide awardwinning clinical, operational and financial software solutions used to attest for
meaningful use and increase care quality, efficiency and patient safety.
“Greenway has well positioned us for meaningful use,” said Kevin Spencer, MD,
of Premier Family Physicians in Austin, Texas. “We attended one of their national
meaningful use training sessions and walked away educated and confident that
we will capture the incentives.”
Certified as a complete Ambulatory EHR for Stage 1 and Stage 2 under the
2014 Edition criteria, PrimeSUITE offers dozens of tools to make meaningful
use easy. For example, the visual meaningful use dashboard helps track
compliance with MU requirements; providers can easily view their progress and
adjust workflow as necessary to reach required threshold levels.
Nothing to lose
Eligible professionals who use PrimeSUITE technology toward meaningful use
certification, but do not achieve funding because of a failure of PrimeSUITE to
meet meaningful use certification criteria, will be compensated equal to the
amount of lost stimulus funds that would have been paid during the PrimeSUITE
compliance failure. That’s the Greenway Guarantee.
For more information, contact a Greenway Health representative.
41
It’s healthcare,
so you need this:
Glossary of Acronyms
ACO: Accountable Care Organization
AIU: Adopt, Implement or Upgrade
APM: Advanced Payment Model
CCHIT: the Certification Commission for Health Information Technology
CDS: Clinical Decision Support
CQMs: Clinical Quality Measures
CMS: Centers for Medicare & Medicaid Services
CPCi: Comprehensive Primary Care Initiative
EHR: Electronic Health Record
EHRA: Electronic Health Record Association
EP: Eligible Professional
FQHC: Federally Qualified Health Center
GPRO: Group Practice Reporting Option
HIT: Heath Information Technology
HITECH Act: Health Information Technology for Economic and Clinical Health
(HITECH) Act of 2009
NCQA: National Committee for Quality Assurance
NPI: National Provider Identifier
NPPES: National Plan and Provider Enumeration System
ONC: Office of the National Coordinator
PCMH: Patient-Centered Medical Home
PECOS: Medicare Provider Enrollment, Chain and Ownership System
PHR: Personal Health Record
PQRS: Physician Quality Reporting System
RHC: Rural Health Clinic
VDT: View, Download and Transmit
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Choose
Greenway
Each physician and practice is different. Choose a partner that treats you
that way. To see why thousands of your peers have selected Greenway Health™
as their EHR and health information solutions partner, visit greenwayhealth.com
or call (866) 242.3805.
PrimeSUITE, the integrated EHR and practice management solution from
Greenway, is certified for meaningful use Stage 2 and prevalidated for patientcentered medical home (PCMH).
100 Greenway Blvd. | Carrollton, GA 30117
Phone: 866.242.3805 | Fax: 770.836.3200
greenwayhealth.com
© 2014 Greenway Health, LLC. All rights reserved. Cited marks are
the property of Greenway Health, LLC or its affiliates. Other company
or product names are the property of their respective owners.
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