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April 10th 201212:00pm – 1:00 pm
Incorporating Meaningful Use in the Specialty Practice
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Thank you for joining us. The webinar will begin shortly.
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How to participate
Housekeeping
• You can join the audio for today’s conference by selecting “Use Mic & Speakers”
• Or, to join by phone, select “Use Telephone” in your Audio window. See exampleS b it t t ti i th
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• Submit your text question using the Questions pane
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General Information
• 1.0 AMA PRA Category 1 Credits™ (Risk Management)g y ( g )• Online evaluation and CME certificate• PowerPoint slides available for download• You will also receive this information in a reminder email,
following the webinar• Questions during the webinar may be typed into the
“questions” box on the right side of your screen• Questions will be answered at the end of the presentation
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Questions will be answered at the end of the presentation• For help with technical difficulties, call 1-888-259-8414
Faculty Introductions
ModeratorPresenter
Jeff Loughlin, MHA Christina Moran, MPH
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Massachusetts eHealth CollaborativeProject Director
,Massachusetts eHealth Collaborative
Strategy [email protected]
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Faculty Disclosures
The following faculty has indicated their financial interests and/or g yrelationships with commercial manufacturers as follows:
Jeff Loughlin, MHA, N/AChristina Moran, MPH N/A
Activity planners of today’s webinar have nothing to disclose.
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MAEHC Mission: Facilitate Universal EHR Adoption
• Company launched September 2004
–Non-profit registered in the Commonwealth of Massachusetts
• CEO on board January 2005
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• Backed by broad array of 34 non-profit MA health care stakeholders
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MAeHC Selected Three Pilot Sites From 35 Applicants: Brockton, Newburyport, North Adams
• Provided EHRs to ~600 clinicians practicing in over 200 office locations
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office locations
• Created health information exchanges connecting the physicians with each other and with the hospitals
• Created a quality data center to extract clinical data from EHRs to evaluate effectiveness and measure performance
Since the pilot program, MAeHC has expanded its experience base and involvement in a variety of projects
300 Physician EHR implementation – Beth Israel Deaconess Physician Organization (BIDPO)
Community wide EHR Implementation HIE and Quality Data Center LargeCommunity-wide EHR Implementation, HIE, and Quality Data Center – Large Healthcare Foundation
HEAL 5 New York – New York State Department of Health and New York eHealthCollaborative (NYeC)
HEAL 10 New York – Adirondack Region Medical Home Pilot
State-level HIE technical services vendor procurement – Missouri HIO
St t L l H lth I f ti E h St t i d O ti l Pl
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State Level Health Information Exchange Strategic and Operational Plan Development – New Hampshire
Regional Extension Center planning, deployment, and operations – New York, Massachusetts, Rhode Island, New Hampshire
www.maehc.org
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Polling Questions
Please note that we will be conducting a few polls during today’s webinar.
At various points during the presentation, you will be asked a brief question regarding HIT and EHR use.
At the appropriate time, a screen will pop-up on your computer.
Please select the appropriate response and click Submit.
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Goals and Objectives
Goal:
To educate providers who are planning to use Electronic Health Records (EHRs) to incorporate the objectives of Meaningful Use into their daily office routines
Objective:
For providers to understand how to use the required functionality
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within their EHR to achieve meaningful use, the specific standards required for compliance, and how the objectives can easily be incorporated into the basic workflow of a specialty office visit
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Agenda
American Recovery and Reinvestment Act Funding (ARRA)
Medicare and Medicaid Incentive Programs
What is Meaningful Use?What is Meaningful Use?
Meaningful Use in Practice
Clinical Quality Measures (CQM)
Health Information Exchange (HIE)
P tti Th Pi T th
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Putting The Pieces Together
Questions, Contact Information and Resources
American Recovery and Reinvestment Act
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Estimated ARRA Funding for HIT and HIE
$30B35
$ M di id 90/10 f d
Direct payments to individual providers15
20
25
30
$28B
$1.2B
$1.1B Medicaid 90/10 fundsHealth information exchangesRegional health IT extension centers
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10 Health Information Technology for Economic and Clinical Health(HITECH)
Massachusetts eHealth Collaborative © MAeHC. All rights reserved.
Agenda
American Recovery and Reinvestment Act Funding (ARRA)
Medicare and Medicaid Incentive Programs
What is Meaningful Use?What is Meaningful Use?
Meaningful Use in Practice
Clinical Quality Measures (CQM)
Health Information Exchange (HIE)
P tti Th Pi T th
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Putting The Pieces Together
Questions, Contact Information and Resources
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Comparison of Medicare and Medicaid Incentive Programs
Medicare MedicaidMaximum incentive $44,000 ($48,000 in HPSA) $63,750
Payment calculation 75% of submitted allowable charges in a year, up to cap
Flat payment to cover allowable costs, up to cap
Eligibility Any ambulatory Eligible Professional doing Medicare business
Any ambulatory Eligible Professional doing Medicaid business
Limitations on eligibility No mid-levels 30% of services must be Medicaid; 20% for peds
NPs, NMWs qualify; PAs only in Rural Health Clinics
Penalties Penalties for non-compliance starting in 2015
No penalties
Qualifying period Any 90 continuous days between Jan 1 2011 and Dec 31 2011
Any 90 continuous days between Jan 1 2011 and Dec 31 2011
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Qualifying logistics Attestation to CMS of all requirements, including submission of quality measure numerators and denominators for selected core measures; electronic submission of quality measures starting in 2012 (if available by CMS)
Attestation to state Medicaid of all requirements, including submission of quality measure numerators and denominators for selected core measures; electronic submission of quality measures starting in 2012 (if available by CMS)
AgendaAmerican Recovery and Reinvestment Act Funding (ARRA)
Medicare and Medicaid Incentive Programs
What is Meaningful Use?
Meaningful Use in Practice
Clinical Quality Measures (CQM)
Health Information Exchange (HIE)
Putting The Pieces Together
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Questions, Contact Information and Resources
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What is Meaningful Use
The Recovery Act specifies the 3 components of Meaningful Use:
• Use of certified EHR in a meaningful manner (e g e prescribing)• Use of certified EHR in a meaningful manner (e.g., e-prescribing)
• Use of certified EHR technology for electronic exchange of health information to improve quality of health care
• Use of certified EHR technology to submit clinical quality measures (CQM) and other such measures selected by the Secretary
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http://onc-chpl.force.com/ehrcert
Meaningful Use has five health related goals
Improve quality safety efficiency and reduce health disparitiesImprove quality, safety, efficiency and reduce health disparities
Engage patients and families in their health care
Improve care coordination
Improve population and public health
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Ensure adequate privacy and security protections for personal health information
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Objectives relate to health related goals
Meaningful Use objectives and standards correlate with health related goals
Objective 15 Core Objectives
Standard Providers must meet all
standards unless an exception applies.
Ob
ject
ive 10 Menu Objectives
Sta
ndar
d Providers may defer up to 5 items for Stage 1. One menu item selected must be related to public health reporting
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O S to public health reporting.
Exclusions are provided to account for specialties and variations in practice settings
Meaningful Use objectives and standards will change over time, focusing today on structured data and exchange
Stage 32015
Advanced clinical processes
Improved outcomes
Stage 12011-13
Stage 22014
Better clinical outcomes
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Data capture and sharing
Improved population health outcomes Increased transparency and efficiency Empowered individuals More robust research data on health system
-Standards will be become higher in Stage 2-3- Menu items will become Core objectives
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Medicare EP Meaningful Use Qualifying Periods and Payment Schedule
Calendar YearAnnual Incentive
Calendar Year2011 2012 2013 2014 2015 2016 Total
First Qualifying
Year
2011 $18,000 $12,000 $8,000 $4,000 $2,000 $44,000
2012 $18,000 $12,000 $8,000 $4,000 $2,000 $44,000
2013 $15,000 $12,000 $8,000 $4,000 $39,000
2014 $12,000 $8,000 $4,000 $24,000
2015+ $0 $0 $0
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Meaningful Use: Stage 1 Stage 2 Stage 3
Agenda
American Recovery and Reinvestment Act Funding (ARRA)
Medicare and Medicaid Incentive Programs
What is Meaningful Use?What is Meaningful Use?
Meaningful Use in Practice
Clinical Quality Measures (CQM)
Health Information Exchange (HIE)
P tti Th Pi T th
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Putting The Pieces Together
Questions, Contact Information and Resources
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Polling Question
Before we beginning discussing the details of Meaningful Use, I would like to ask the audience about your use of Certified EHR Technology:
A I use an EHR but it is not certified by ONC for MUA. I use an EHR but it is not certified by ONC for MU
B. I use an ONC Certified EHR
C. I am planning to implement an EHR soon
D. None of the above
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__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Meaningful Use is distributed throughout the clinical office visit correlating to the health related goals
CPOE RxDrug-Drug *FormularyePrescribe
DemographicsProblems _______________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
ProblemsMedications
Rx AllergyVitals
SmokingCDSCQM
*eLabs*Dx List
*RemindersPt. eCopy
Clinical Summary*Pt. eAccess `
Improve quality, safety, efficiency and reduce health disparities
Engage patients and families in their health care
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_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
*EducationHIE Capable
*Rx Reconcile*Referral summary
*Immunizations*Syndromic Data
Privacy & Security
* Menu Items
Improve care coordination
Improve population and public health
Ensure adequate privacy and security protections for personal health information
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_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Re-organizing Meaningful Use tasks can follow patient flow
*Dx List*Reminders
DemographicsVitals
SmokingRx Allergy
*Rx Reconcile ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
CPOE RxDrug-Drug*FormularyePrescribeProblems
MedicationsCDS
*eLabsPt. eCopy
Clinical Summary*Pt. eAccess
*EducationCQM
`
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___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Pre-Visit Registration Patient Intake
Provider Visit Check-Out Post Visit
CQMHIE Capable
*Referral summary*Immunizations
*Syndromic DataPrivacy & Security
* Menu Items
CMS FAQ #10151
If an eligible professional (EP) is unable to meet the measure of a Meaningful Use
objective because it is outside of the scope of his or her practice, will the EP be
excluded from meeting the measure of that objective under the Medicare and g j
Medicaid Electronic Health Record (EHR) Incentive Programs?
- - - - - - - -
Some Meaningful Use objectives provide exclusions and others do not. Exclusions
are available only when our regulations specifically provide for an exclusion. EPs
may be excluded from meeting an objective if they meet the circumstances of the
l i If EP i bl t t M i f l U bj ti f hi h
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exclusion. If an EP is unable to meet a Meaningful Use objective for which no
exclusion is available, then that EP would not be able to successfully demonstrate
Meaningful Use and would not receive incentive payments under the Medicare and
Medicaid EHR Incentive Programs.
https://questions.cms.hhs.gov/app/answers/detail/a_id/10151
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How is meaningful use different for specialists?
• It is not! The objectives may appear to have a Primary Care focus, but are required for all providers unless they qualify for an exclusion to an objective.
M l i l t th ti b t l li i t b• Many exclusions may apply to the practice, but clear policies must be documented, i.e.. Vital signs not taken.
• Must have a detailed understanding of how your EHR vendor is calculating the denominator, i.e.. Office Visits, Office Procedures, SOAP note or OP note? For example, Clinical Summaries are only required for E&M services, not procedural services.
• Often you can manipulate the reports based on visit type or document type to l d t i i it d
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exclude certain visits or procedures.
• Key data elements can be collected and entered by support staff so leveraging their skill sets and time is critical as you develop your workflow.
Meaningful Use is built into the major common components of patient visit flow and at the point of care in the clinical office
Pre-Visit Registration Patient Intake
Provider Visit Check-Out Post Visit
Privacy & Security
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Patient receives notification as a reminder of visit or clinical need
Pre-Visit Registration Patient Intake
Provider Visit Check-Out Post Visit
Privacy & Security
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Office staff generates report and reminder letters for patients with upcoming appointments and procedures
Pre-Visit
Send patient reminder letters for visit or procedure
Send reminder letter to target population by diagnosis
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Examples only
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Improve quality, safety, efficiency and reduce health disparities
Pre-Visit tasks meet two Menu objectives (I)
ective Generate lists of patients by
specific conditions to use for lit i t
ndard Generate at least one report
listing patients of the EP with a ifi diti
Obj quality improvement,
reduction of disparities, research or outreach
Sta specific condition
Requires only Yes / No Attestation Exclusion Criteria
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X None
http://healthcare.nist.gov/docs/170.302.i_GeneratePatientLists_v1.0.pdfhttp://www.cms.gov/EHRIncentivePrograms/Downloads/3_Patient_Lists.pd
Improve quality, safety, efficiency and reduce health disparities
Pre-Visit tasks meet two Menu objectives (II)
ective Send reminders to patients per
patient preference for ti / f ll
ndard More than 20% of all unique
patients 65 years or older or 5 ld t
Obj preventive/ follow up care
Sta years old or younger were sent
an appropriate reminder during the EHR reporting period
Numerator Denominator Population Exclusion Criteria
The number of patientsin the denominator who
Number of unique patients 65 years old or
Patients whose Records are
If an EP has no patients 65 years old or older or 5 years old or younger
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in the denominator who were sent the
appropriate reminder.
patients 65 years old or older or 5 years older
or younger.
Records are Maintained in
the EHR.
or older or 5 years old or younger with records maintained using
certified EHR technology
http://healthcare.nist.gov/docs/170.304.d_GeneratePatientReminders_v1.0.pdfhttp://www.cms.gov/EHRIncentivePrograms/Downloads/4_Patient_Reminders.pdf
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Patient arrives at clinical practice for services
Pre-Visit Registration Patient Intake
Provider Visit Check-Out Post Visit
Privacy & Security
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Front desk staff verify and update Patient’s demographics and billing information
Date of birth
Gender
Preferred language
Ethnicity
Race
Contact Information & Preferences
Registration
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Contact Information & Preferences
Mailing, Voicemail, Patient Portal access
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Improve quality, safety, efficiency and reduce health disparities
Registration function meets one Core objective
bjective Record demographics:
preferred language, gender, race ethnicity date of birth an
dard More than 50% of all unique
patients seen by the EP have demographics recorded as
Numerator Denominator Population Exclusion CriteriaThe number of patients in the
denominator who have all the elements of demographics (or a specific exclusion if
Number of unique patients seen by the All Unique
N
Ob race, ethnicity, date of birth
Sta demographics recorded as
structured data
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g p ( pthe patient declined to provide one or more elements) recorded as structured
data.
p yEP during the EHR reporting period.
qPatients.
None
http://healthcare.nist.gov/docs/170.306.b_RecordDemographicsIP_v1.0.pdfhttp://www.cms.gov/EHRIncentivePrograms/Downloads/7_Record_Demographics.pdf
Improve quality, safety, efficiency and reduce health disparities
Registration function meets one Core objective
bjective Record demographics:
preferred language, gender, race ethnicity date of birth an
dard More than 50% of all unique
patients seen by the EP have demographics recorded as
Ob race, ethnicity, date of birth
Sta demographics recorded as
structured data
Race Categories:
American Indian or Alaska Native
Asian
Ethnicity Categories:
Hispanic or Latino
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Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Not Hispanic or Latino
*Patients can refuse to report
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Patient moves to the clinical area to prepare for provider visit or procedure
Pre-Visit Registration Patient Intake
Provider Visit Check-Out Post Visit
Privacy & Security
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Polling Question
Before discussing the overview of the Patient Intake, I would like to ask the audience a question:
Do you currently utilize a Technician Medical Assistant LPN or RN to assist in theDo you currently utilize a Technician, Medical Assistant, LPN, or RN to assist in the clinical visit?
Yes, No
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Medical assistants update Patient’s vital signs in structured data fields and review or update her medical summary information
Record blood pressure
Record height, weight, calculate BMI
Plot and display growth chart (age appropriate)
Record or review smoking status
Patient Intake
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Verify, update allergy list, or NKDA
Verify, update current medications, or annotate “none”
If Vital Signs are clinically relevant or appropriate
Improve quality, safety, efficiency and reduce health disparities
Patient Intake meets four Core objectives (I)
ective Maintain active medication list
ndard More than 80% of all unique
patients seen by the EP have at
Numerator Denominator Population Exclusion Criteria
The number of patients in the denominator who have a medication (or
Number of unique patients seen by the All Unique
Obje
Stan least one entry (or an indication
that the patient is not currently prescribed any medication) recorded as structured data
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an indication that the patient is not currently prescribed any medication)
recorded as structured data.
patients seen by the EP during the EHR reporting period.
All Unique Patients.
None
http://healthcare.nist.gov/docs/170.302.d_medicationlist_v1.0.pdfhttp://www.cms.gov/EHRIncentivePrograms/Downloads/5_Active_Medication_List.pdf
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Improve quality, safety, efficiency and reduce health disparities
Patient Intake meets four Core objectives(II)
ective Maintain active medication
allergy list
ndard More than 80% of all unique
patients seen by the EP have at
Numerator Denominator Population Exclusion CriteriaThe number of unique patients in the
denominator who have at least one entry Number of unique
Obje
Stan least one entry (or an
indication that the patient has no known medication allergies) recorded as structured data
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(or an indication that the patient has no known medication allergies ‐ NKDA) recorded as structured data in their
medication allergy list.
patients seen by the EP during the EHR reporting period.
All Unique Patients.
None
http://healthcare.nist.gov/docs/170.302.e_allergylist_v1.0.pdfhttp://www.cms.gov/EHRIncentivePrograms/Downloads/6_Medication_Allergy_List.pdf
Improve quality, safety, efficiency and reduce health disparities
Patient Intake meets four Core objectives (III)
ective Record and chart changes in
vital signs: Height, Weight, Bl d C l l t d
ndard For more than 50% of all unique
patients age 2 and over seen by th EP h i ht i ht d bl d
Numerator Denominator Population Exclusion CriteriaThe number of patients in the denominator who have
Number of unique ti t 2
Patients whose Any EP who either see no patients 2
ld h b li th t ll
Obj Blood pressure, Calculate and
display BMI, Plot and display growth charts for children 2‐20 years, including BMI
Sta the EP height, weight and blood
pressure are recorded as structured data
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at least one entry of their height, weight and blood pressure are recorded as
structure data.
patients age 2 or over seen by the EP during the EHR reporting
period.
records are maintained in
the EHR.
years or older, or who believes that allthree vital signs of height, weight, and blood pressure of their patients have no relevance to their scope of practice
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Improve quality, safety, efficiency and reduce health disparities
Patient Intake meets four Core objectives (IIIa)
ective Record and chart changes in
vital signs: Height, Weight, Bl d C l l t d
ndard For more than 50% of all unique
patients age 2 and over seen by th EP h i ht i ht d bl d
Obj Blood pressure, Calculate and
display BMI, Plot and display growth charts for children 2‐20 years, including BMI
Sta the EP height, weight and blood
pressure are recorded as structured data
http://healthcare.nist.gov/docs/170.302.f.1_vitalsigns_v1.0.pdf
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http://healthcare.nist.gov/docs/170.302.f.2_BMI_v1.0.pdf
http://healthcare.nist.gov/docs/170.302.f.3_growthcharts_v1.0.pdf
http://www.cms.gov/EHRIncentivePrograms/Downloads/8%20Record%20Vital%20Signs%202011.pdf
Improve quality, safety, efficiency and reduce health disparities
Patient Intake meets four Core objectives (IV)
jective Record smoking status for
patients 13 years old or older
andard More than 50% of all unique
patients 13 years old or older seen by the EP have smoking
Numerator Denominator Population Exclusion Criteria
The number of patients in the denominator with ki t t d d
Number of unique patients age 13 or older seen by the EP during
Patients whose Records are M i t i d i
EPs who see no patients 13 years or ld
Obj
Sta seen by the EP have smoking
status recorded as structured data
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smoking status recorded as structured data.
y gthe EHR reporting
period.
Maintained in the EHR.
older
http://healthcare.nist.gov/docs/170.302.g_smokingstatus_v1.0.pdfhttp://www.cms.gov/EHRIncentivePrograms/Downloads/9_Record_Smoking_Status.pdf
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Improve quality, safety, efficiency and reduce health disparities
Patient Intake meets four Core objectives (IVa)
bjective Record smoking status for
patients 13 years old or older
tandard More than 50% of all unique
patients 13 years old or older seen by the EP have smoking
O S status recorded as structured data
Smoking status types must include:
current every day smoker
current some day smoker
former smoker
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never smoker
smoker
current status unknown
unknown if ever smoked
Improve care coordination
Patient Intake meets one Menu objective
bjec
tive The EP who receives a patient
from another setting of care or provider of care or believes an ta
ndar
d The EP performs medication reconciliation for more than 50% of transitions of care in
Numerator Denominator Population Exclusion Criteria
The number of transitions of care in the denominator
h di i
Number of transitions of care during the EHR reporting period for
Patients whose Records are
If an EP was not on the receiving end f i i f d i h
Ob
encounter is relevant should perform medication reconciliation
St
which the patient is transitioned into the care of the EP
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where medication reconciliation was
performed.
reporting period for which the EP was the receiving party of the
transition.
Records are Maintained in
the EHR.
of any transition of care during the EHR reporting period
http://healthcare.nist.gov/docs/170.302.j_%20MedicationReconciliation_v1.0.pdfhttp://www.cms.gov/EHRIncentivePrograms/Downloads/7_Medication_Reconciliation.pdf
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Improve care coordination
Patient Intake meets one Menu objective
bjec
tive The EP who receives a patient
from another setting of care or provider of care or believes an ta
ndar
d The EP performs medication reconciliation for more than 50% of transitions of care in
Ob
encounter is relevant should perform medication reconciliation
St
which the patient is transitioned into the care of the EP
Transition of Care – The movement of a patient from one setting of care
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(hospital, ambulatory primary care practice, ambulatory specialty care
practice, long‐term care, home health, rehabilitation facility) to another.
Provider and Patient interact at point of care
Pre-Visit Registration Patient Intake
Provider Visit Check-Out Post Visit
Privacy & Security
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Provider conducts patient consult or procedure
Provider documents consult or procedure
Provider determines problem or diagnosis
Update patient problem list, or document “none”
Provider Visit
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The use of templates can increase speed, efficiency and accuracy but is not required for MU. The use of dictation, voice recognition or free text is possible, but you may lose the ability to use Evaluation and Management (E&M) coders.
Improve quality, safety, efficiency and reduce health disparities
Provider assessment meets one Core objective
ectiv
e Maintain an up‐to‐date problem list of current and
i di ndar
d More than 80% of all unique patients seen by the EP have
l
Numerator Denominator Population Exclusion Criteria
The number of patients in the denominator who have at least one entry
Number of unique patients seen by the All Unique
Obj
e active diagnoses
Sta
n at least one entry, or an indication that no problems are known for the patient, recorded as structured data
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or an indication that no problems are known for the patient recorded as structured data in their problem list.
patients seen by the EP during the EHR reporting period.
All Unique Patients.
None
http://healthcare.nist.gov/docs/170.302.c_problemlist_v1.0.pdfhttp://www.cms.gov/EHRIncentivePrograms/Downloads/3_Maintain_Problem_ListEP.pdf
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Provider determines Patient’s care plan
Reviews alerts, reminders, quality indicators
Uses diagnosis based order sets or clinical decision tools
Use EHR to order and transmit lab request
Provider Visit
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A lab interface is not required for Stage 1 but facilitates the ability to comply with CQM, results management and patient engagement
Improve quality, safety, efficiency and reduce health disparities
Provider care plan meets one Core objective
jective Implement one clinical
decision support rule relevant to specialty or high clinical an
dard Implement one clinical
decision support rule
Obj to specialty or high clinical
priority along with the ability to track compliance with that rule
Sta
Requires only Yes / No Attestation Exclusion Criteria
X None
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http://healthcare.nist.gov/docs/170.304.e_ClinicalDecisionSupportAmb_v1.0.pdfhttp://www.cms.gov/EHRIncentivePrograms/Downloads/11_Clinical_Decision_Support_Rule.pdf
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Improve quality, safety, efficiency and reduce health disparities
Provider care plan meets one Menu objective
Objective Incorporate clinical lab test
results into certified EHR technology as structured data
Standard More than 40% of all clinical lab
tests results ordered by the EP during the EHR reporting period
Numerator Denominator Population Exclusion CriteriaThe number of lab test results whose results are expressed in a positive or
Number of lab tests ordered during the EHR reporting period by the
Patients whose If an EP orders no lab tests whose
O S whose results are either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data
- 52 -Massachusetts eHealth Collaborative © MAeHC. All rights reserved.
expressed in a positive or negative affirmation or as a
number which are incorporated as structured
data.
reporting period by the EP whose results are expressed in a positive or negative affirmation
or as a number.
Records are Maintained in
the EHR.
results are either in a positive/negative or numeric format during the EHR reporting period
http://healthcare.nist.gov/docs/170.302.h_IncorpLabTest_v1.0.pdfhttp://www.cms.gov/EHRIncentivePrograms/Downloads/2_Clinical_Lab_Test_Results.pdf
Provider selects and prescribes medication as needed
Review drug-to-drug and drug-to-allergy interactions
Review patient’s insurance formulary
Use EHR to generate prescription and transmit to pharmacy
Provider Visit
- 53 -Massachusetts eHealth Collaborative © MAeHC. All rights reserved.
Formulary checking is not required for Stage 1 but may have direct financial impact on the patient based upon the medications selected by provider
28
Improve quality, safety, efficiency and reduce health disparities
Using EHR medication management and ePrescribing meets three Core objectives (I)
ective Use CPOE for medication orders
directly entered by any licensed h l h f i l h
ndard More than 30% of unique
patients with at least one di i i h i di i
Obje healthcare professional who can
enter orders into the medical record per state, local and professional guidelines
Stan medication in their medication
list seen by the EP have at least one medication order entered using CPOE
Numerator Denominator Population Exclusion Criteria
The number of patientsin the denominator h h l
Number of unique patients with at least
di i i
Patients whose records are
If an EP’s writes fewer than one hundred i i d i h EHR i
- 54 -Massachusetts eHealth Collaborative © MAeHC. All rights reserved.
that have at least one medication order
entered using CPOE.
one medication in their medication list
seen by the EP.
records are maintained in
the EHR.
prescriptions during the EHR reporting period
http://healthcare.nist.gov/docs/170.306.a_CPOEIP_v1.0.pdfhttp://www.cms.gov/EHRIncentivePrograms/Downloads/2_Clinical_Lab_Test_Results.pdf
Improve quality, safety, efficiency and reduce health disparities
Using EHR medication management and ePrescribing meets three Core objectives (II)
ective Implement drug‐drug and drug‐
allergy interaction checks
ndard The EP has enabled this
functionality for the entire EHR i i d
Obje
Stan reporting period
Requires only Yes / No Attestation Exclusion Criteria
X None
- 55 -Massachusetts eHealth Collaborative © MAeHC. All rights reserved.
X None
http://healthcare.nist.gov/docs/170.302.a_DrugDrugDrugAllergy_v1.0.pdfhttp://www.cms.gov/EHRIncentivePrograms/Downloads/2_Drug_Interaction_ChecksEP.pdf
29
Improve quality, safety, efficiency and reduce health disparities
Using EHR medication management and ePrescribing meets three Core objectives (III)
jective Generate and transmit
permissible prescriptions electronically (eRx) an
dard More than 40% of all
permissible prescriptions written by the EP are
Numerator Denominator Population Exclusion Criteria
The number of prescriptions in the
d i t
Number of prescriptions written for drugs requiring a
i ti i dPatients whose R d
This objective and associated measure do t l t EP h it f th
Obj electronically (eRx)
Sta written by the EP are
transmitted electronically using certified EHR technology
- 56 -Massachusetts eHealth Collaborative © MAeHC. All rights reserved.
denominator generated and transmitted electronically.
prescription in order to be dispensed other
than controlled substances during the EHR reporting period.
Records are Maintained in
the EHR.
not apply to any EP who writes fewer than one hundred prescriptions during the EHR
reporting period.
http://healthcare.nist.gov/docs/170.304.b_ExchangePrescriptionInformation_v1.0.pdfhttp://www.cms.gov/EHRIncentivePrograms/Downloads/4_e-prescribing.pdf
Improve quality, safety, efficiency and reduce health disparities
Using EHR medication management and ePrescribing meets one Menu objective
ective Implement drug formulary
checks
ndard The EP has enabled this
functionality and has access
Requires only Yes / No Attestation Exclusion Criteria
X
Any EP who writes fewer than one hundred prescriptions during the EHR reporting period
Obje
Stan
yto at least one internal or external drug formulary for the entire EHR reporting period
- 57 -Massachusetts eHealth Collaborative © MAeHC. All rights reserved.
Xshould be excluded from this objective and
associated measure.
http://healthcare.nist.gov/docs/170.302.b_DrugFormularyChecks_v1.0.pdfhttp://www.cms.gov/EHRIncentivePrograms/Downloads/1_Drug_Formulary_Checks.pdf
30
Patient completes clinical visit
Pre-Visit Registration Patient Intake
Provider Visit Check-Out Post Visit
Privacy & Security
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Patient receives information before leaving the practice
Patient provided with educational information
Patient provided with clinical summary
Patient provided with CD of medical information if requested
Clinical information and results are sent to Patient Portal
Check-Out
- 59 -Massachusetts eHealth Collaborative © MAeHC. All rights reserved.
• Generating educational material through the EHR is a menu item but makes it easier to keep up-to-date information.
• Patient Portal is not required for Stage 1 but facilitates patient engagement and communication
31
Engage patients and families in their health care
Check-Out process meets two Core objectives (I)
Objective Provide patients with an
electronic copy of their health information (including diagnostic test results problem St
andard More than 50% of all patients
of the EP who request an electronic copy of their health information are provided it
Numerator Denominator Population Exclusion Criteria
The number of patients in the denominator who
receive an electronic copy
The number of patients of the EP who request an electronic copy of their electronic health
Patients whose Records are
If the EP has no requests from patients or their agents for an
O diagnostic test results, problem list, medication lists, medication allergies), upon request
information are provided it within 3 business days
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receive an electronic copy of their electronic health information within three
business days.
their electronic health information four
business days prior to the end of the EHR reporting period.
Records are Maintained in
the EHR.
electronic copy of patient health information during the EHR
reporting period
http://healthcare.nist.gov/docs/170.304.f_ElectronicCopyOfHealthInformation_v1.0.pdfhttp://www.cms.gov/EHRIncentivePrograms/Downloads/12_Electronic_Copy_of_Health_Information.pdf
Engage patients and families in their health care
Check-Out process meets two Core objectives (II)
bjective Provide clinical summaries for
patients for each office visit
tandard Clinical summaries provided to
patients for more than 50% of all office visits within 3 business
Numerator Denominator Population Exclusion Criteria
Number of patients in the denominator who are provided a clinical
Number of unique patients seen by the EP
Patients whose Records are EPs who have no office visits during
Ob St days
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provided a clinical summary of their visit
within three business days.
during the EHR reporting period.
Maintained in the EHR.
the EHR reporting period
http://healthcare.nist.gov/docs/170.304.h_ClinicalSummaries_v1.0.pdfhttp://www.cms.gov/EHRIncentivePrograms/Downloads/13_Clinical_Summaries.pdf
32
Engage patients and families in their health care
Check-Out process meets two Core objectives (IIa)
ective Provide clinical summaries for
patients for each office visit
ndard Clinical summaries provided to
patients for more than 50% of ll ffi i i i hi 3 b i
Obje
Stan all office visits within 3 business
days
Clinical summaries include, at a d l
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minimum, diagnostic test results, problem list, medication list, and medication allergy list.
Engage patients and families in their health care
Check-Out process meets two Core objectives (IIa)
ective Provide clinical summaries for
patients for each office visit
ndard Clinical summaries provided to
patients for more than 50% of ll ffi i i i hi 3 b i
Obje
Stan all office visits within 3 business
days
Office visits include separate, billable encounters that result from evaluation and management services provided to the patient and include: (1) Concurrent care or transfer of care visits (2) Consultant visits or (3) Prolonged Physician Service
- 63 -Massachusetts eHealth Collaborative © MAeHC. All rights reserved.
transfer of care visits, (2) Consultant visits, or (3) Prolonged Physician Service without Direct (Face‐To‐Face) Patient Contact (tele‐health). A consultant visit occurs when a provider is asked to render an expert opinion/service for a specific condition or problem by a referring provider.
33
Engage patients and families in their health care
Check-Out process meets two Menu objectives (I)
Objective Provide patients with timely
electronic access to their health information (including lab results, problem list, medication lists, St
andard More than 10% of all unique
patients seen by the EP are provided timely electronic access to their health information
Numerator Denominator Population Exclusion CriteriaThe number of patients in the denominator who have timely (available to the patient within four
Number of unique patients seen by the EP All Unique
If an EP neither orders nor creates any of the information listed in the ONC final rule 45 CFR 170 304(g)
medication allergies) within four business days of the information being available to the EP
subject to the EP’s discretion to withhold certain information
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business days of being updated in the certified
EHR technology) electronic access to their health information online.
patients seen by the EP during the EHR reporting period.
All Unique Patients.
ONC final rule 45 CFR 170.304(g) and therefore included in the
minimum data for this objective during the EHR reporting period
http://healthcare.nist.gov/docs/170.304.f_ElectronicCopyOfHealthInformation_v1.0.pdfhttp://www.cms.gov/EHRIncentivePrograms/Downloads/5_Patient_Electronic_Access.pdf
Engage patients and families in their health care
Check-Out process meets two Menu objectives (II)
ective Use certified EHR technology to
identify patient‐specific d i d
ndard More than 10% of all unique
patients seen by the EP are id d i ifi
Numerator Denominator Population Exclusion Criteria
Number of patients in the denominator who are
Number of unique patients seen by the EP All Unique
N
Obje education resources and
provide those resources to the patient if appropriate
Stan provided patient‐specific
education resources
- 65 -Massachusetts eHealth Collaborative © MAeHC. All rights reserved.
provided patient education specific resources.
p yduring the EHR reporting period.
qPatients.
None
http://healthcare.nist.gov/docs/170.302.m_EducationResources_v1.0.pdfhttp://www.cms.gov/EHRIncentivePrograms/Downloads/6_Patient-Specific_Education_Resources.pdf
34
Provider has completed visit and all test results and quality indicators are complete
Pre-Visit Registration Patient Intake
Provider Visit Check-Out Post Visit
Privacy & Security
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Consult note sent back to referring provider and key elements of structured data transmitted externally
Consult note and medical summary sent to referring provider
Clinical quality measures are transmitted to CMS
Immunization information is sent to State Registry
Syndromic data is sent to Public Health organizations
Post Visit
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• CQM do not have to be sent electronically today
• Stage 1 requires only one public health reporting menu item – Immunizations or Syndromic data
35
Improve care coordination
Post visit exchange of data meets one Core objective
bjective Capability to exchange key
clinical information (for example problem list an
dard Performed at least one test of
certified EHR technology's capacity to electronically
Ob example, problem list,
medication list, medication allergies, diagnostic test results), among providers of care and patient authorized entities electronically
Sta capacity to electronically
exchange key clinical information
Requires only Yes / No Attestation Exclusion Criteria
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X None
http://healthcare.nist.gov/docs/170.306.f_ExchangeClinicalinfoSummaryRecordIP_v1.0.pdfhttp://www.cms.gov/EHRIncentivePrograms/Downloads/14_Electronic_Exchange_of_Clinical_Information.pdf
Improve care coordination
Post visit exchange of data meets one Menu objective
Objective The EP who transitions their
patient to another setting of care or provider of care or refers their patient to another provider St
andard The EP who transitions or refers
their patient to another setting of care or provider of care provides a summary of care
Numerator Denominator Population Exclusion Criteria
The number of transitions of care and referrals in the
Number of transitions of care and referrals
during the EHR Patients whose Records are
If an EP does not transfer a patient to another setting or refer a patient
their patient to another provider of care should provide summary of care record for each transition of care or referral
provides a summary of care record for more than 50% of transitions of care and referrals
- 69 -Massachusetts eHealth Collaborative © MAeHC. All rights reserved.
denominator where a summary of care record
was provided.
reporting period for which the EP was the transferring or referring
provider.
Records are Maintained in
the EHR.
to another setting or refer a patient to another provider during the EHR
reporting period
http://healthcare.nist.gov/docs/170.304.i_ExchangeClinicalinforPatientSummaryRecordAmb_v1.0.pdfhttp://www.cms.gov/EHRIncentivePrograms/Downloads/8_Transition_of_Care_Summary.pdf
36
Improve quality, safety, efficiency and reduce health disparities
Post visit reporting and submission of CQM and public health data meet one Core objective
bjective Report ambulatory clinical quality
measures to CMS or the States: Core: Hypertension, Tobacco Use ta
ndard For 2011, provide aggregate
numerator, denominator, and exclusions through attestation as
Ob yp ,
Assessment & Cessation Intervention, Adult Weight Screening (NQF 13, 28, 421 or PQRI 128) Menu: Must choose 3 measures to report
St
gdiscussed in section II(A)(3) of this final rule. For 2012, electronically submit the clinical quality measures.
Requires only Yes / No Attestation Exclusion Criteria
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X None
http://healthcare.nist.gov/docs/170.304.j_CalcSubmitClinQualityMeasures_v1.0.pdfhttp://healthcare.nist.gov/docs/170.306.i_CalcSubmitClinQualityMeasures_v1.0.pdf
http://www.cms.gov/EHRIncentivePrograms/Downloads/10_Clinical_Quality_Measures.pdf
Improve population and public health
Post visit reporting and submission of CQM and public health data meets two Menu objectives
jective Capability to submit electronic
data to immunization registries or Immunization Information an
dard Performed at least one test of
certified EHR technology's capacity to submit electronic
Obj or Immunization Information
Systems and actual submission in accordance with applicable law and practice
Sta capacity to submit electronic
data to immunization registries and follow up submission if the test is successful
Requires only Yes / No Attestation Exclusion Criteria
EPs that have not given any immunizations
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XEPs that have not given any immunizations
during the EHR reporting period are excluded from this measure.
http://healthcare.nist.gov/docs/170.302.k_Immunizations_v1.0.pdfhttp://www.cms.gov/EHRIncentivePrograms/Downloads/9_Immunization_Registries_Data_Submission.pdf
37
Improve population and public health
Post visit reporting and submission of CQM and public health data meets two Menu objectives
bjective Capability to submit electronic
Syndromic surveillance data to public health agencies and an
dard Performed at least one test of
certified EHR technology's capacity to provide electronic
Ob public health agencies and
actual submission in accordance with applicable law and+C17 practice
Sta capacity to provide electronic
Syndromic surveillance data to public health agencies and follow‐up submission if the test is successful
Requires only Yes / No Attestation Exclusion Criteria
If an EP does not collect any reportable
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X
y psyndromic information on their patients
during the EHR reporting period, then they are excluded from this measure.
http://healthcare.nist.gov/docs/170.302.l_PublicHealthSurveillance_v1.0.pdfhttp://www.cms.gov/EHRIncentivePrograms/Downloads/10_Syndromic_%20Surveillance_Data_SubmissionEP.pdf
Polling Question
Before discussing the risk assessment portion, I would like to ask the audience a question:
Do you currently use complex passwords as a requirement for your staff logins?Do you currently use complex passwords as a requirement for your staff logins?
Yes, No
- 73 -Massachusetts eHealth Collaborative © MAeHC. All rights reserved.
38
Promoting the privacy & security of EHRs by incorporating practice policies, procedures, and password management
underlies each step in the patient and visit flow
Pre-Visit Registration Patient Intake
Provider Visit Check-Out Post Visit
Privacy & Security
- 74 -Massachusetts eHealth Collaborative © MAeHC. All rights reserved.
Conduct periodic risk assessment and risk mitigation and ensure written policies are in place
Physical security of hardware and devices
Password management and role-based security access
Portable and mobile device policies
Data encryption and network security
Privacy&
Security
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HIPAA compliance
39
Ensure adequate privacy and security protections for personal health information
Conducting periodic risk analysis and risk mitigation meets one Core objective
tive Protect electronic health
i f ti t d
ard Conduct or review a security
i k l i 45 CFR
Object information created or
maintained by the certified EHR technology through the implementation of appropriate technical capabilities
Stand risk analysis per 45 CFR
164.308 (a)(1) and implement security updates as necessary and correct identified security deficiencies as part of its risk management process
Requires only Yes / No Attestation Exclusion Criteria
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X None
Ensure adequate privacy and security protections for personal health information
Conducting periodic risk analysis and risk mitigation meets one Core objective
ective Protect electronic health
information created or i i d b h ifi d
ndard Conduct or review a security
risk analysis per 45 CFR 164 308 ( )(1) d i l
Obje maintained by the certified
EHR technology through the implementation of appropriate technical capabilities
Stan 164.308 (a)(1) and implement
security updates as necessary and correct identified security deficiencies as part of its risk management process
http://healthcare.nist.gov/docs/170.302.u_GeneralEncryption_v1.0.pdfhttp://healthcare.nist.gov/docs/170.302.v_EncryptionHIE_v1.0.pdfhttp://healthcare.nist.gov/docs/170.302.o_AccessControl_v1.0.pdfhttp://healthcare nist gov/docs/170 302 t Authentication v1 0 pdf
- 77 -Massachusetts eHealth Collaborative © MAeHC. All rights reserved.
http://healthcare.nist.gov/docs/170.302.t_Authentication_v1.0.pdfhttp://healthcare.nist.gov/docs/170.302.q_AutomaticLogOff_v1.0.pdf
http://www.cms.gov/EHRIncentivePrograms/Downloads/15_Core_ProtectElectronicHealthInformation.pdf
40
Meaningful Use is built into the major components of patient visit flow and at the point of care in the clinical practice
Pre-Visit Registration Patient Intake
Provider Visit Check-Out Post Visit
Privacy & Security
- 78 -Massachusetts eHealth Collaborative © MAeHC. All rights reserved.
Using basic EHR functionality and performing common tasks can meet objectives for 15 Core and 10 Menu items
AgendaAmerican Recovery and Reinvestment Act Funding (ARRA)
Medicare and Medicaid Incentive Programs
What is Meaningful Use?
Meaningful Use in Practice
Clinical Quality Measures (CQM)
Health Information Exchange (HIE)
Putting The Pieces Together
- 79 -Massachusetts eHealth Collaborative © MAeHC. All rights reserved.
Questions, Contact Information and Resources
41
Polling Question
Before discussing the Clinical Quality Measures, I would like to ask the audience a question:
Do you currently participate in another quality initiative or payor program thatDo you currently participate in another quality initiative or payor program that requires you to submit quality measures or data? i.e. PQRS?
Yes, No
- 80 -Massachusetts eHealth Collaborative © MAeHC. All rights reserved.
CQM concerns
• CMS has acknowledged that the CQM reporting requirement in Stage 1 is no more than that—a reporting requirement meant to get physicians comfortable with the process of reportingcomfortable with the process of reporting.
• CMS is under no illusions that the data collected will be meaningful as a measure of the level or quality of care being provided.
• Many physicians will be reporting on problems for which they are not treating the patients, which means that measure numerators will be zero (or very low) and that duplicate data will be submitted by different physicians for the same patients for the same conditions which will result in an
- 81 -Massachusetts eHealth Collaborative © MAeHC. All rights reserved.
the same patients for the same conditions, which will result in an underestimation of the true care being delivered.
• In some cases, providers may be submitting data for CQMs that are not directly tied to their specialty or focus of care.
Massachusetts eHealth Collaborative © MAeHC. All rights reserved.
42
CQM today is based on current standards – NQF, PQRI
- 82 -Massachusetts eHealth Collaborative © MAeHC. All rights reserved.
http://www.ama-assn.org/ama1/pub/upload/mm/399/ehr-clinical-quality-measures.pdf
Population may be all patients, patients seen, or unique patients
Future framework for the reporting of CQM
- 83 -Massachusetts eHealth Collaborative © MAeHC. All rights reserved.
The intention is to broaden the scope of reporting to address a wider spectrum of factors affecting care and to accommodate all types of providers. All providers will find measures relevant to their specialty in the core set as well as in each of the domains
43
Key to CQM success today
• Code and document completely; missing values or missing information = lower performance
• Information should be kept as structured data in searchable/sortable fields rather than free-text
• Establish workflows and maximize staff capabilities to enter data elements, i.e. support staff can enter problems, medications, allergies and history
• Patient/Medical/System reasons for exclusions should be documented and
- 84 -Massachusetts eHealth Collaborative © MAeHC. All rights reserved.
• Patient/Medical/System reasons for exclusions should be documented and coded; helps to improve scores by legitimately reducing the denominator
Massachusetts eHealth Collaborative © MAeHC. All rights reserved.
AgendaAmerican Recovery and Reinvestment Act Funding (ARRA)
Medicare and Medicaid Incentive Programs
What is Meaningful Use?
Meaningful Use in Practice
Clinical Quality Measures (CQM)
Health Information Exchange (HIE)
Putting The Pieces Together
- 85 -Massachusetts eHealth Collaborative © MAeHC. All rights reserved.
Questions, Contact Information and Resources
44
• Lab results delivery
• Prescribing
• Health summaries for continuity of care2011
Increases volume of transactions that are most commonly happening today– Lab to provider
Meaningful Use objectives requiring health exchange
Meaningful Use and Health Information Exchange (HIE)
• Health summaries for continuity of care
• Quality & immunization reporting, if available
2011 Lab to provider– Provider to pharmacySummary of care record is new process step
• Registry and public health reporting
• Claims and eligibility checking
• Electronic ordering
• Receive public health alerts
• Home monitoring
2014
Substantially steps up exchange– Provider to lab– Pharmacy to provider– Office to hospital & vice versa– Office to office– Hospital/office to public health & vice versa
H it l t ti t
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Home monitoring
• Populate PHRs– Hospital to patient– Office to patient & vice versa– Hospital/office to reporting entities
• Access comprehensive data from all available sources
• Experience of care reporting
• Medical device interoperability
2015Starts to envision routine availability of relatively rich exchange transactions– “Anyone to anyone”– Patient to reporting entities
AgendaAmerican Recovery and Reinvestment Act Funding (ARRA)
Medicare and Medicaid Incentive Programs
What is Meaningful Use?
Meaningful Use in Practice
Clinical Quality Measures (CQM)
Health Information Exchange (HIE)
Putting The Pieces Together
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Questions, Contact Information and Resources
45
ADOPTIONRegional Extension Centers
HITECH – how the pieces fit together
Medicare and Medicaid Incentives and Penalties
Improved Individual &Population HealthOutcomes
IncreasedTransparency &Efficiency
ImprovedAbility to Study &
ADOPTIONWorkforce Training
MEANINGFUL USE
- 88 -Massachusetts eHealth Collaborative © MAeHC. All rights reserved.
Ability to Study &Improve Care Delivery
EXCHANGE
State Grants forHealth Information Exchange
Standards & Certification Framework
Privacy & Security Framework
88
AgendaAmerican Recovery and Reinvestment Act Funding
Medicare and Medicaid Incentive Programs
Meaningful UseMeaningful Use
Meaningful Use in the Medical Practice
ARRA – Health Information Exchange (HIE)
Putting The Pieces Together
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Questions, Contact Information and Resources
46
Resources
Get information, tip sheets and more at CMS’ official website for the EHR incentive programs:http://www.cms.gov/EHRIncentivePrograms
For questions about the Meaningful Use objectives and how to comply with the standards:https://questions.cms.gov/
Learn about certification and certified EHRs, as well as other ONC programs designed to support providers as they make the transition:http://healthit hhs gov
- 90 -Massachusetts eHealth Collaborative © MAeHC. All rights reserved.
http://healthit.hhs.gov
For additional information about MAeHC and access to additional presentations and services:http://www.maehc.org
Questions?
ModeratorPresenter
Jeff Loughlin, MHA Christina Moran MPH
- 91 -Massachusetts eHealth Collaborative © MAeHC. All rights reserved.
Jeff Loughlin, MHAMassachusetts eHealth Collaborative
Project [email protected]
www.maehc.org
Christina Moran, MPHMassachusetts eHealth Collaborative
Strategy [email protected]
www.maehc.org
47
Evaluation, CME Credit & Resource Information
To complete your evaluation, please visit: http://www.massmed.org/MU2012evalAfter completing the evaluation you will be directed to the MMS CMEAfter completing the evaluation, you will be directed to the MMS CME Certificate portal.
• Enter the CME Activity Code: EHR041012
• Enter your FIRST and LAST name.
To access today’s presentation and other resources, visithttp://www.massmed.org/MU2012presentation
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Questions regarding CME certificates and/or presentations, contact MMS Continuing Education at 800-322-2303, x7306 or email [email protected]