This document discusses changes from Stage 1 to Stage 2 of meaningful use for eligible professionals and hospitals. Key changes include increased objectives for clinical decision support, electronic prescribing, patient engagement and health information exchange. Stage 2 places more emphasis on care coordination through increased objectives for medication reconciliation, patient summaries and electronic transmission of health information between providers. The document also outlines new clinical quality reporting requirements and certification criteria for electronic health records.

1. Oregon Health Information Management Association
May 19th
2013
Brian Ahier

2. IOM Quality Chasm Report
“If we want safer, higher-quality care, we will need to
have redesigned systems of care, including the use of
information technology to support clinical and
administrative processes.”
IOM, Quality Chasm report, 2001

3. What is Meaningful Use?
Meaningful Use is using certified EHR technology to
Improve quality, safety, efficiency, and reduce health
disparities
Engage patients and families in their health care
Improve care coordination
Improve population and public health
All the while maintaining privacy and security
Meaningful Use mandated in law to receive incentives

4. Stage 2 MU
ACOs
Stage 3 MU
PCMHs
3-Part Aim
Registries to
manage patient
populations
Team based care,
case management
Enhanced access
and continuity
Privacy & security
protections
Care coordination
Privacy & security
protections
Patient centered
care coordination
Improved
population health
Registries for
disease
management
Evidenced based
medicine
Patient self
management
Privacy & security
protections
Care coordination
Structured data
utilized
Data utilized to
improve delivery
and outcomes
Data utilized to
improve delivery
and outcomes
Patient informed
Patient engaged,
community
resources
Stage 1 MU
Privacy & security
protections
Basic EHR
functionality,
structured data
Improve access
to information
Use information
to transform
Meaningful Use as Building Blocks
Utilize
technology to
gather
information

5. Standards and Certification Criteria
Stage 2 Meaningful Use

6. Here’s what it looks like today…
Certified EHR Technology

7. Here’s the future…
Certified EHR Technology

8. 2014 Edition CEHRT

9. Base EHR

10. 2014 Edition CEHRT EP/EH/CAH would only need to
have EHR technology with
capabilities certified for the MU
menu set objectives & measures
for the stage of MU they seek to
achieve.
EP/EH/CAH would need to have
EHR technology with capabilities
certified for the MU core set
objectives & measures for the
stage of MU they seek to achieve
unless the EP/EH/CAH can meet
an exclusion.
EP/EH/CAH must have EHR
technology with capabilities
certified to meet the definition of
Base EHR.

11. 2014 Certification Criteria associated with a
Base EHR:
• Demographics (170.314(a)(3))
• Vital signs, BMI, & growth charts
(170.314(a)(4))
• Problem list (170.314(a)(5))
• Medication list (170.314(a)(6))
• Medication allergy list (170.314(a)(7))
• Drug-drug, drug-allergy interaction
checks (170.314(a)(2))
• CPOE (170.314(a)(1))
• Clinical decision support (170.314(a)(8))
• Clinical quality measures (170.314(c)(1)-
(2))
• Transition of Care – incorporate
summary care record (170.314(b)(1))
• Transition of Care – create and
transmit summary care record
(170.314(b)(2))
• View, download, and transmit to 3rd
Party (170.314(e)(1))
• Privacy and Security CC:
o Authentication, Access Control, &
Authorization (170.314(d)(1))
o Auditable events & tamper resistance
(170.314(d)(2))
o Audit report(s) (170.314(d)(3))
o Amendments ( 70.314(d)(4))
o Automatic log-off ( 170.314(d)(5))
o Emergency access (170.314(d)(6))
o Encryption of data at rest (170.314(d)(7))
o Integrity (170.314(d)(8))
o Accounting of disclosures (optional)
(170.314(d)(9))
• Automated numerator recording (170.314(g)(1))
• Automated measure calculation (170.314(g)(2))
• Non-%-based measure use report (170.314(g)(3))
• Safety -enhanced design (170.314(g)(4))
2014 Certification Criteria associated with MU Menu
Stage 2:
• Imaging (170.314(a)(12))
• Transmission to cancer registries (170.314(f)(8))
• Cancer case information (170.314(f)(7))
• Public health surveillance (170.314(f)(3))
• Transmission to public health agencies (170.314(f)
(4))
• Family health history (170.314(a)(13))
• Smoking status (170.314(a)(11))
• eRx (170.314(b)(3))
• Drug formulary checks (170.314(a)
(10))
• Patient lists (170.314(a)(14))
• Patient reminders (170.314(a)(15))
• Patient-specific education resources
(170.314(a)(16))
• Clinical information reconciliation
(170.314(b)(4))
• Clinical summaries (170.314(e)(2))
• Secure messaging (170.314(e)(3))
• Incorporate lab test and
results/values (170.314(b)(5))
• Immunization information (170.314(f)
(1))
• Transmission to immunization
registries (170.314(f)(2))
2014 Certification Criteria
associated with MU Core Stage 2:
1 2 3

12. 3 ways to meet
CEHRT definition
Complete EHR
EHR Module(s) that do just enough:
Combination of EHR Modules
Single EHR Module

13. What’s in the Rule
Minor changes to Stage 1 of meaningful use
Stage 2 of meaningful use
New clinical quality measures
New clinical quality measure reporting mechanisms
Appeals
Details on the Medicare payment adjustments
Minor Medicare Advantage program changes
Minor Medicaid program changes

14. Medicaid EHR Incentive Program - Updates

15. Medicaid encounter definition changes:
* A program year for hospitals is the federal fiscal
year and is the calendar year for eligible
professionals

16. Patient volume measurement
timeframes

17. Patient volume measurement examples

18. Practices Predominantly

19. Meaningful Use

20. 1099 Changes from the IRS
Current Process (through Tax Year 2012)
1099s are issued to recipients of incentive payments, or the Payee.
Revised Process (effective Tax Year 2013)
Starting with the 2013 tax year (1099s issued in early 2014), the 1099
will be issued to the attesting provider, even if that provider
designates another entity as the Payee. If the provider has assigned
his/her payment to a third party, it is that provider’s responsibility to
issue a 1099 to the third party, and offset the 1099 he/she receives.

21. Hospitals
Stage 1 to Stage 2 Meaningful Use

22. Stage 2 Hospital Core Objectives
1) Use CPOE for more than 60%of medication,
laboratory and radiology orders
2) Record demographics for more than 80%
3) Record vital signs for more than 80%
4) Record smoking status for more than 80%
5) Implement 5 clinical decision support
interventions + drug/drug and drug/allergy
6) Incorporate lab results for more than 40%

23. Stage 2 Hospital Core Objectives
7) Generate patient list by specific condition
8) More than 10% of medication orders are tracked
using EMAR
9) Provide online access to health information for
more than 50% with more than 10% actually
accessing
10) Use EHR to identify and provide education
resources more than 10%
11) Medication reconciliation at more than 50% of
transitions of care

24. Stage 2 Hospital Core Objectives
12) Provide summary of care document for more than
50% of transitions of care and referrals with 10%
sent electronically
13) Successful ongoing transmission of
immunization data
14) Successful ongoing submission of reportable
laboratory results
15) Successful ongoing submission of electronic
syndromic surveillance data
16) Conduct or review security analysis and incorporate
in risk management process

25. Stage 2 Hospital Menu Objectives
1) Record indication of advanced directive for more
than 50%
2) Incorporate more than 40% of imaging results
3) Record family health history for more than 20%
4) E-Rx for more than 10% of discharge
prescriptions

26. Stage 2 Transitions of Care
Eliminated Stage 1 objective of “Exchange of key clinical
information”
More robust health information exchange for Stage 2
“Transition of care” objective

27. Stage 2 Transitions of Care
What a summary of care must include:
Patient name.
Procedures.
Relevant past diagnoses.
Laboratory test results.
Vital signs (height, weight, blood pressure, BMI, growth charts).
Smoking status.
Demographic information (preferred language, gender, race,
ethnicity, date of birth).
Care plan field, including goals and instructions, and
Any additional known care team members beyond the referring
or transitioning provider and the receiving provider.
Discharge instructions

28. Stage 2 Transitions of Care
AND:
An up-to-date problem list of current and active diagnoses
An active medication list
An active medication allergy list
The Transitions of Care objective combines elements of
previous Stage 1 objectives that are no longer being
measured individually:
Maintain an up-to-date problem list
Maintain an active medication list
Maintain an active medication allergy list
If there are no problems, meds, or med allergies = Indication in record

29. Transitions of Care – EPs Transitions of Care – EH/CAHs
Patient name Patient name
Sex Sex
Date of birth Date of birth
Race (OMB Race and Ethnicity) Race (OMB Race and Ethnicity)
Ethnicity (OMB Race and Ethnicity) Ethnicity (OMB Race and Ethnicity)
Preferred language Preferred language
Smoking status (SNOMED-CT value set) Smoking status (SNOMED-CT value set)
Problems (SNOMED-CT value set) Problems (SNOMED-CT value set)
Medications (RxNorm) Medications (RxNorm)
Medication allergies (RxNorm) Medication allergies (RxNorm)
Laboratory test(s) (LOINC) Laboratory test(s) (LOINC)
Laboratory value(s)/result(s) Laboratory value(s)/result(s)
Vital signs (height, weight, blood pressure, BMI) Vital signs (height, weight, blood pressure, BMI)
Care plan field(s), including goals and instructions Care plan field(s), including goals and instructions
Procedures (SNOMED-CT or HCPCS/CPT-4), optional CDT, optional ICD-10-PCS Procedures (SNOMED-CT or HCPCS/CPT-4), optional CDT, optional ICD-10-PCS
Care Team Member(s), including the primary care provider of record and any additional
known care team members beyond the referring or transitioning provider and the
receiving provider
Care Team Member(s), including the primary care provider of record and any additional
known care team members beyond the referring or transitioning provider and the
receiving provider
Encounter diagnosis (ICD-10-CM or SNOMED-CT) Encounter diagnosis (ICD-10-CM or SNOMED-CT)
Immunizations (HL7 Standard Code Set CVX) Immunizations (HL7 Standard Code Set CVX)
Functional status, including activities of daily living and cognitive and disability status Functional status, including activities of daily living and cognitive and disability status
The following are Elements that are different between EP and EH/CAH
Reason for referral
Discharge instructions
Referring or transitioning provider's name and office contact information
Common MU Data Set
Data Elements in Common Between EP and EH/CAH in Addition to Common
MU Data Set
Elements that are different between EP and EH/CAH
All summary of care documents
must include these data elements

30. Stage 2 Transitions of Care
Two measures, both must be met:
1) The EP, eligible hospital or CAH that transitions or refers
their patient to another setting of care or provider of care
provides a summary of care record for more than 50
percent of transitions of care and referrals.
2) The EP, eligible hospital or CAH that transitions or refers
their patient to another setting of care or provider of care
electronically transmits a summary of care record using
Certified EHR Technology to a recipient with no
organizational affiliation and using a different Certified
EHR Technology vendor than the sender for more than
10 percent of transitions of care and referrals.

31. Stage 2 Transitions of Care
What this means:
Different providers, different organizations
Different EHRs, different vendors
10%

32. Eligible Professionals
Stage 1 to Stage 2 Meaningful Use

33. Meaningful Use Concepts
Changes
Exclusions no longer count to meeting one of the menu
objectives
All denominators include all patient encounters at
outpatient locations equipped with certified EHR
technology
No Changes
No change in 50% of EP outpatient encounters must
occur at locations equipped with certified EHR
technology
Measure compliance = objective compliance

34. Stage 2 EP Core Objectives
1) Use CPOE for more than 60% of medication,
laboratory and radiology orders
2) E-Rx for more than 65%
3) Record demographics for more than 80%
4) Record vital signs for more than 80%
5) Record smoking status for more than 80%
6) Implement 5 clinical decision support
interventions + drug/drug and drug/allergy
7) Incorporate lab results for more than 55%

35. Stage 2 EP Core Objectives
8) Generate patient list by specific condition
9) Use EHR to identify and provide more than 10%
with reminders for preventive/follow-up
10) Provide online access to health information for
more than 50% with more than 10% actually
accessing
11) Provide office visit summaries in 24 hours
12) Use EHR to identify and provide education
resources more than 10%

36. Stage 2 EP Core Objectives
13) More than 10% of patients send secure messages
to their EP
14) Medication reconciliation at more than 50% of
transitions of care
15) Provide summary of care document for more than
50% of transitions of care and referrals with 10%
sent electronically
16) Successful ongoing transmission of
immunization data
17) Conduct or review security analysis and incorporate
in risk management process

37. Stage 2 EP Menu Objectives
1) More than 40% of imaging results are accessible
through Certified EHR Technology
2) Record family health history for more than 20%
3) Successful ongoing transmission of syndromic
surveillance data
4) Successful ongoing transmission of cancer case
information
5) Successful ongoing transmission of data to a
specialized registry

38. Changes to Stage 1
CPOE
Optional in 2013 Required in 2014+
Vital Signs
Optional in 2013 Required in 2014+

39. Changes to Stage 1
Effective in 2013
Vital Signs
Optional in 2013 Required in 2014+

40. Changes to Stage 1
Public
Health
Effective in 2013
E-Copy and Online Access
Required in 2014+

41. Clinical Quality Measures
Change from Stage 1 to Stage 2:
CQMs are no longer a meaningful use core objective,
but reporting CQMs is still a requirement for
meaningful use.
Time periods for reporting CQMs – NO CHANGE from
Stage 1 to Stage 2

42. Alignment Among Programs
CMS is committed to aligning quality
measurement and reporting among programs
Alignment efforts on several fronts: Choosing the
same measures for different program measure sets
Coordinating quality measurement stakeholder
involvement efforts and opportunities for public
input
Identifying ways to minimize multiple
submission requirements and mechanisms

43. Alignment Among Programs
Lessen provider burden
Harmonize with data exchange priorities
Support primary goal of all CMS quality
measurement programs
Transforming our health care system to provide:
Higher quality care
 Better health outcomes
 Lower cost through improvement

44. CQM - Domains
Patient and Family Engagement
Patient Safety
Care Coordination
Population and Public Health
Efficient Use of Healthcare Resources
Clinical Processes/Effectiveness

45. CQM - Stage 1 to Stage 2
Hospitals
Eligible Professionals

46. CQM Reporting Beginning in FY2014
24 CQMs, ≥1 from each domain
Includes 15 CQMs from July 28, 2010 Final Rule
Considering instituting a case number
threshold exemption for some hospitals
Reporting Methods
Aggregate XML-based format specified by CMS
Manner similar to 2012 Medicare EHR Incentive
Program Electronic Reporting Pilot

47. Payment Adjustments
The HITECH Act stipulates that for Medicare EP,
subsection (d) hospitals and CAHs a payment
adjustment applies if they are not a meaningful EHR
user.
An EP, subsection (d) hospital or CAH becomes a
meaningful EHR user when they successfully attest to
meaningful use under either the Medicare or
Medicaid EHR incentive program
As adopt, implement and upgrade does not constitute
meaningful use, a provider receiving a Medicaid
incentive for AIU would still be subject to the
Medicare payment adjustment.

48. Eligible Professional Payment Adjustments
% Adjustment assuming less than 75 percent of EPs are
meaningful EHR users for CY 2018 and subsequent years
Payment Adjustment Year 2015 2016 2017 2018 2019 2020+
EP is not subject to the
payment adjustment for e-Rx in
2014
99% 98% 97% 96% 95% 95%
EP is subject to the payment
adjustment for e-Rx in 2014
98% 98% 97% 96% 95% 95%
% Adjustment assuming more than 75 percent of EPs
are meaningful EHR users for CY 2018 and subsequent
yearsPayment Adjustment Year 2015 2016 2017 2018 2019 2020+
EP is not subject to the
payment adjustment for e-Rx in
2014
99% 98% 97% 97% 97% 97%
EP is subject to the payment
adjustment for e-Rx in 2014
98% 98% 97% 97% 97% 97%

49. Eligible Professional EHR Reporting Period
EP who has demonstrated meaningful use in 2011 or 2012
Payment Adjustment Year 2015 2016 2017 2018 2019 2020
Full Year EHR Reporting Period 2013 2014 2015 2016 2017 2018
Payment Adjustment Year 2015 2016 2017 2018 2019 2020
90 Day Reporting Period 2013
Full Year EHR Reporting Period 2014 2015 2016 2017 2018
EP who has demonstrated meaningful use in 2013 for
the first time

50. Eligible Professional EHR Reporting Period
Payment Adjustment Year 2015 2016 2017 2018 2019 2020
90 Day Reporting Period 2014* 2014
Full Year EHR Reporting Period 2015 2016 2017 2018
EP who has demonstrated meaningful use in 2014 for
the first time
*In order to avoid the 2015 payment adjustment the
EP must attest no later than Oct 1, 2014 which
means they must begin their 90 day EHR reporting
period no later than July 2, 2014

51. EP Hardship Exemption
Exemptions on an application basis
Insufficient internet access two years prior to the
payment adjustment year
Newly practicing EPs for two years
Extreme circumstances such as unexpected closures,
natural disaster, EHR vendor going out of business,
etc.
Applications need to be submitted no later than July 1 of
year before the payment adjustment year; however,
we encourage earlier submission

52. EP Hardship Exemption
Other Possible Exemption Discussed in the rule
Concerned that the combination of 3 barriers
would constitute a significant hardship
Lack of direct interaction with patients
Lack of need for follow-up care for patients
Lack of control over the availability of Certified EHR
Technology
Any one of these barriers taken independently
does not constitute a significant hardship
Discussion considers whether any specialty may
nearly uniformly face all 3 barriers

53. Subsection (d) Hospital Payment
Adjustments
% Decrease in the Percentage Increase to the IPPS
Payment Rate that the hospital would otherwise receive
for that year
For example if the increase to IPPS for 2015 was 2% then
a hospital subject to the payment adjustment would
only receive a 1.5% increase
2015 2016 2017 2018 2019 2020+
% Decrease 25% 50% 75% 75% 75% 75%

54. Subsection (d) Hospital EHR Reporting Period
Hospital who has demonstrated meaningful use in 2011
or 2012 (fiscal years)
Hospital who demonstrates meaningful use in 2013 for
the first time
Payment Adjustment Year 2015 2016 2017 2018 2019 2020
Full Year EHR Reporting Period 2013 2014 2015 2016 2017 2019
Payment Adjustment Year 2015 2016 2017 2018 2019 2020
90 Day Reporting Period 2013
Full Year EHR Reporting Period 2013 2014 2015 2016 2017 2019

55. Subsection (d) Hospital EHR Reporting Period
Hospital who demonstrates meaningful use in 2014 for
the first time
*In order to avoid the 2015 payment adjustment the
hospital must attest no later than July 1, 2014 which
means they must begin their 90 day EHR reporting
period no later than April 1, 2014
Payment Adjustment Year 2015 2016 2017 2018 2019 2020
90 Day Reporting Period 2014* 2014
Full Year EHR Reporting Period 2015 2016 2017 2019

56. Subsection (d) Hospital Hardship Exemption
Exemptions on an application basis
• Insufficient internet access two years prior to the
payment adjustment year
• New hospitals for at least 1 full year cost reporting
period
• Extreme circumstances such as unexpected closures,
natural disaster, EHR vendor going out of business,
etc.
Applications need to be submitted no later than April 1
of year before the payment adjustment year; however,
earlier submission is encouraged

57. Critical Access Hospital (CAH) Payment Adjustments
Applicable % of reasonable costs reimbursement
which absent payment adjustments is 101%
2015 2016 2017 2018 2019 2020+
% of reasonable
costs
100.66% 100.33% 100% 100% 100% 100%

58. CAH Hardship Exemption
Exemptions on an application basis
Insufficient internet access for the payment
adjustment year
New CAHs for one year after they accept their first
patient
Extreme circumstances such as unexpected closures,
natural disaster, EHR vendor going out of business,
etc.

59. Appeals
Types
Eligibility Appeals: Provider has met all the program
requirements and should have received an incentive but
could not because of a circumstance outside the
provider’s control
Meaningful Use Appeals: Provider has shown that he or
she used certified EHR technology and met the
meaningful use objectives and associated measures after
a successful attestation.
Incentive Payment Appeals: (Medicare EPs only)
Provider has shown that he or she provided claims data
not used in determining the incentive payment amount

60. Appeals
Deadlines
Eligibility – 30 days after the 2 month period following
the payment year
Meaningful Use - 30 days from the date of the demand
letter or other finding that could result in the
recoupment of an EHR incentive payment
Incentive Payment - 60 days from the date the
incentive payment was issued or 60 days from any
Federal determination that the incentive payment
calculation was incorrect

61. Appeals
Process
Provider must present all relevant issues at the time of the initial
filing of an appeal
An appeal in considered inchoate or premature if CMS still has an
opportunity to resolve the issue. A provider is still permitted to file
the same appeal again if the issue is not resolved by the program
deadlines
Appeals have two levels: (1) an informal review that is completed
within 90 days from the date of filing, and (2) a reconsideration
review that can be requested if the provider does not prevail in the
informal review.
Providers dissatisfied can file a request for reconsideration with
comments and documentation supporting the reconsideration
within 15 days of the initial determination

62. Appeals Process

63. Medicaid- Specific Changes
An expanded definition of a Medicaid encounter:
To include any encounter with an individual receiving
medical assistance under 1905(b), including Medicaid
expansion populations
To permit inclusion of patients on panels seen within 24
months instead of just 12
To permit patient volume to be calculated from the most
recent 12 months, instead of on the CY
To include zero-pay Medicaid claims