MAINE PRIMARY CARE ASSOCIATION JUNE 27, 2016 PRESENTED BY PATTI CHUBBUCK MaineCare Medicaid 2016 Meaningful Use Program

2016 Meaningful Use Requirements Objectives and Measures All providers are required to attest to a single set of objectives and measures. This replaces the core and menu objectives structure of previous stages. For EPs, there are 10 objectives. In 2016, all providers must attest to objectives and measures using EHR technology certified to the 2014 Edition

Alternate Exclusions and Specifications Many of the alternate exclusions that were available in 2015 are not applicable in Objective 3, Computerized Provider Order Entry (CPOE): There are alternate exclusions for measure 2 and measure 3. Providers scheduled to be in Stage 1 in 2016 may claim an exclusion for measure 2 (laboratory orders) and/or measure 3 (radiology orders) of the Stage 2 CPOE objective for an EHR reporting period in Or, the provider may choose to attest to the modified Stage 2 CPOE objective. Objective 10, Public Health Reporting: EPs scheduled to be in Stage 1 and Stage 2 in 2016 must attest to at least two measures from the Public Health Reporting measures 1 ‐ 3. However, EPs may claim an alternate exclusion for measure 2 (syndromic surveillance) and Measure 3 (specialized registry reporting) as these measures might require the acquisition of additional technologies eligible hospitals/CAHs did not previously have or did not previously intend to include in their activities of meaningful use. An alternate exclusion may only be claimed for up to two measures, then the provider must either attest to or meet the exclusion requirements for the remaining measure.

Changes to Specific Objectives/Measures in 2016 Objective 9, Secure Electronic Messaging: 2015 objective 9:  For an EHR reporting period in 2015, the capability for patients to send and receive a secure electronic message with the EP was fully enabled during the EHR reporting period Objective 9:  For an EHR reporting period in 2016, for at least 1 patient seen by the EP during the EHR reporting period, a secure message was sent using the electronic messaging function of CEHRT to the patient or in response to a secure message sent by the patient during the EHR reporting period.

EHR Reporting Period The EHR reporting period for all providers is based on the calendar year. In 2016, the EHR reporting period for all returning participants is a full calendar year (January 1 to December 31, 2016). For first ‐ time participants in 2016, the EHR reporting period is a minimum of a continuous 90 ‐ day period between January 1 and December 31, 2016.

Payment Adjustments & Attestation Deadlines New participants who successfully demonstrate meaningful use for program year 2016 will avoid the payment adjustment in CY 2017 and CY 2018 if the EP successfully attests by October 1, Returning participants who successfully demonstrate meaningful use for CY 2016 will avoid the payment adjustment in CY 2018 if the EP successfully attests by the end of Maine’s 2016 program date. We are pending CMS approval to extend the tail period for program year 2016 to May 31, 2017.

Objective 1: Protect Patient Health Information Eligible professionals must conduct or review a security risk analysis for each EHR reporting period to ensure the privacy and security of their patients’ protected health information Conducting a security risk analysis is required when certified EHR technology is adopted in the first reporting year. In subsequent reporting years, or when changes to the practice or electronic systems occur, a review must be conducted.

Objective 1: Protect Patient Health Information (cont.) Security Areas to Consider Physical Safeguards  Your facility and other places where patient data is accessed  Computer equipment  Portable devices Administrative Safeguards  Designated security officer  Workforce training and oversight  Controlling information access  Periodic security reassessment Examples of Potential Security Measure Physical Safeguards  Building alarm systems  Locked offices  Screens shielded from secondary viewers Administrative Safeguards  Staff training  Monthly review of user activities  Policy enforcement

Objective 2: Clinical Decision Support In order for EPs to meet the objective they must satisfy both of the following measures: Measure 1: Implement five clinical decision support interventions related to four or more clinical quality measures at a relevant point in patient care for the entire EHR reporting period. Absent four clinical quality measures related to an EP’s scope of practice or patient population, the clinical decision support interventions must be related to high priority health conditions. Measure 2: The EP has enabled and implemented the functionality for drug ‐ drug and drug ‐ allergy interaction checks for the entire EHR reporting period. Exclusion: For the second measure, any EP who writes fewer than 100 medication orders during the EHR reporting period.

Objective 3: Computerized Provider Order Entry An EP, through a combination of meeting the thresholds and exclusions (or both), must satisfy all three measures for this objective. Measure 1: More than 60 percent of medication orders created by the EP during the EHR reporting period are recorded using computerized provider order entry. Exclusion for Measure 1: Any EP who writes fewer than 100 medication orders during the EHR reporting period. Measure 2: More than 30 percent of laboratory orders created by the EP during the EHR reporting period are recorded using computerized provider order entry. Exclusion for Measure 2: Any EP who writes fewer than 100 laboratory orders during the EHR reporting period. Alternate Exclusion for Measure 2: Providers submitting MU for the first time in 2016 may claim an exclusion for measure 2 (laboratory orders) of the Stage 2 CPOE objective. Measure 3: More than 30 percent of radiology orders created by the EP during the EHR reporting period are recorded using computerized provider order entry. Exclusion for Measure 3: Any EP who writes fewer than 100 radiology orders during the EHR reporting period. Alternate Exclusion for Measure 3: Providers submitting MU for the first time in 2016 may claim an exclusion for measure 3 (radiology orders) of the Stage 2 CPOE objective.

Objective 4: Electronic Prescribing EP Measure: More than 50 percent of permissible prescriptions written by the EP are queried for a drug formulary and transmitted electronically using CEHRT. Exclusions: Any EP who ‐  Writes fewer than 100 permissible prescriptions during the EHR reporting period; or  Does not have a pharmacy within his or her organization and there are no pharmacies that accept electronic prescriptions within 10 miles of the EP's practice location at the start of his or her EHR reporting period.

Objective 5: Health Information Exchange Measure: The EP that transitions or refers their patient to another setting of care or provider of care must  (1) use CEHRT to create a summary of care record; and  (2) electronically transmit such summary to a receiving provider for more than 10 percent of transitions of care and referrals. Exclusion: Any EP who transfers a patient to another setting or refers a patient to another provider less than 100 times during the EHR reporting period.

Objective 6: Patient Specific Education EP Measure: Patient specific education resources identified by CEHRT are provided to patients for more than 10 percent of all unique patients with office visits seen by the EP during the EHR reporting period. Exclusion: Any EP who has no office visits during the EHR reporting period.

Objective 7: Medication Reconciliation Measure: The EP performs medication reconciliation for more than 50 percent of transitions of care in which the patient is transitioned into the care of the EP. Exclusion: Any EP who was not the recipient of any transitions of care during the EHR reporting period. Many CEHRT products count every time a medication reconciliation is done during the reporting period and do not limit to only transitions of care

Objective 8: Patient Electronic Access (VDT) EP Measure 1:  More than 50 percent of all unique patients seen by the EP during the EHR reporting period are provided timely access to view online, download, and transmit to a third party their health information subject to the EP's discretion to withhold certain information. Exclusion for Measure 1:  Any EP who: Neither orders nor creates any of the information listed for inclusion as part of the measures except for “Patient Name” and “Provider’s name and office contact information.”

Objective 8: Patient Electronic Access (VDT) (cont.) EP Measure 2:  For an EHR reporting period in 2016, at least one patient seen by the EP during the EHR reporting period (or patient ‐ authorized representative) views, downloads or transmits his or her health information to a third party during the EHR reporting period. Exclusion for Measure 2: Any EP who :  Neither orders nor creates any of the information listed for inclusion as part of the measures except for “Patient Name” and “Provider’s name and office contact information”; or  Conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period.

Objective 8: Patient Electronic Access (VDT) (cont.) Clarifications: Measure 1  The 50% count of patients seen should be based on those patients that have been given the information to access their data on the patient portal if they so choose. This is best captured at the time of checkout when the portal info is reviewed or offered.  If your vendor is not counting when each patient is provided with the information necessary to access the portal then the vendor is not capturing the data correctly.  Some vendors require an address be entered or they do not count toward the 50%.  If you have a letter from your vendor that explains why they cannot capture the data correctly you should state that on your Medicaid eligibility worksheet and attach the vendor explanation.

Objective 8: Patient Electronic Access (VDT) (cont.) Clarifications Measure 2:  The one patient can be one patient for the entire practice setting. The idea of the objective is that the system is capable of the action and not a requirement for patients to participate.

Objective 8: Patient Electronic Access (VDT) (cont.) MEASURE 1 - ACCESS The specifications for measure 1 allow the provision of access to take many forms and do not require a provider to obtain an address from the patient. Although many certified EHR technology (CEHRT) products may be designed in that fashion, it is not required by the program. If a provider’s CEHRT does require a patient address, but the patient does not have or refuses to provide an address or elects to ‘‘opt out’’ of participation, that is not prohibited by the EHR Incentive Program requirements nor does it allow the provider to exclude that patient from the denominator. The patient may also access their information through their patient authorized representative. The measure timeline for making any health information available resets to 4 business days for an EP each time new information is available to which the patient should be provided access. Therefore, although a provider does not need to enroll a unique patient a second time if the patient has a second office visit during the EHR reporting period, the provider must continue to update the information accessible to the patient each time new information is available.

Objective 8: Patient Electronic Access (VDT) (cont.) MEASURE 1 - ACCESS A patient who has multiple encounters during the EHR reporting period, or even in subsequent EHR reporting periods in future years, needs to have access to the information related to their care for each encounter where they are seen by the EP. If the provider fails to provide access to a patient upon an initial visit during the EHR reporting period, but provides access on a subsequent visit, the patient cannot be counted in the numerator because the patient did not have timely online access to health information related to the first visit. Similarly, the patient cannot be included in the numerator if access is provided on the first visit, but the provider fails to update the information within the time period required after the second visit. The measure does not address the enrollment process or how the initiation process to ‘‘turn on’’ access for a patient within an EHR system should function. The measure addresses the health information itself.

Objective 8: Patient Electronic Access (VDT) (cont.) MEASURE 1 - ACCESS NUMERATOR CLARIFICATION  To count in the numerator, health information needs to be made available to each patient for view, download, and transmit within 4 business days of its availability to the provider for each and every time that information is generated whether the patient has been ‘‘enrolled’’ for three months or for three years. DENOMINATOR CLARIFICATION  The patient needs to be seen by the EP during the EHR reporting period in order to be included in the denominator.

Objective 8: Patient Electronic Access (VDT) (cont.) QUESTIONS AND ANSWERS: related to Objective 8 Q : What does “necessary information” include?  A: Necessary information could include website address, username and password, and, if needed, instructions on how to create a username and log on to the website. Q: What health information must eligible professionals and eligible hospitals make available to patients?  A: All information available at the time the information is sent to the patient website must be made available to the patient online. However, the provider may withhold any information from online disclosure if he or she believes that providing such information may result in significant harm.

Objective 8: Patient Electronic Access (VDT) (cont.) QUESTIONS AND ANSWERS: related to Objective 8 Q: In calculating the meaningful use objectives requiring patient action, if a patient accesses his/her health information made available by their eligible professional, can the other eligible professionals in the practice get credit for the patient’s action in meeting the objectives?  A: Yes. If a patient views, downloads or transmits to a third party the health information that was made available online by their EP, that patient can be counted in the numerator of the 2nd Patient Electronic Access 5 measure for any of the EPs in that group practice who use the same CEHRT and saw that patient during their EHR reporting period. See FAQ # Q: Can an eligible professional or eligible hospital charge patients a fee to have access to their health information?  A: CMS does not believe it would be appropriate for the eligible professional or hospital to charge the patient a fee to access certified EHR technology. See FAQ #9112.

Objective 9: Secure Messaging This measure has changed from a yes/no in 2015 to a calculation for The numerator must be 1 or more Measure: For an EHR reporting period in 2016, for at least 1 patient seen by the EP during the EHR reporting period, a secure message was sent using the electronic messaging function of CEHRT to the patient (or the patient ‐ authorized representative), or in response to a secure message sent by the patient (or the patient ‐ authorized representative) during the EHR reporting period. Exclusion: Any EP who has no office visits during the EHR reporting period, or any EP who conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period.

Objective 9: Secure Messaging (cont.) Definitions of Terms Secure Message – Any electronic communication between a provider and patient that ensures only those parties can access the communication. This electronic message could be or the electronic messaging function of a PHR, an online patient portal, or any other electronic means.

Objective 9: Secure Messaging (cont.) DENOMINATOR:  Number of unique patients seen by the EP during the EHR reporting period. NUMERATOR:  The number of patients in the denominator for whom a secure electronic message is sent to the patient or in response to a secure message sent by the patient. THRESHOLD:  Numerator must be equal to or greater than 1. EXCLUSION:  Any EP who has no office visits during the EHR reporting period; or any EP who conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period.

Objective 9: Secure Messaging (cont.) Additional Information The thresholds for this measure increase over time to allow providers to work incrementally toward a high goal. This is consistent with our past policy in the program to establish incremental change from basic to advanced use and increased thresholds over time. The measure threshold for this objective was “fully enabled” for 2015, and is at least one patient for 2016, and a threshold of 5 percent for 2017 to build toward the Stage 3 threshold. Provider initiated action and interactions with a patient- authorized representative, are acceptable for the measure and are included in the numerator. A patient-initiated message would only count toward the numerator if the provider responds to the patient.

Public Health Reporting Objective:  The EP is in active engagement with a public health agency to submit electronic public health data from CEHRT except where prohibited and in accordance with applicable law and practice. Measure Options  Measure 1 ‐ Immunization Registry Reporting: The EP is in active engagement with a public health agency to submit immunization data.  Measure 2 – Syndromic Surveillance Reporting: The EP is in active engagement with a public health agency to submit syndromic surveillance data.  Measure 3 – Specialized Registry Reporting: The EP is in active engagement to submit data to a specialized registry.  Link to the Maine Public Health Registration Website:   The site is being updated and will be available after July 8, 2016

Public Health Reporting (cont.) Definition of Terms Active engagement  Means that the provider is in the process of moving towards sending "production data" to a public health agency or clinical data registry, or is sending production data to a public health agency or clinical data registry Active Engagement Option 1–Completed Registration to Submit Data:  Most Maine Providers are utilizing option 1  The EP registered to submit data with the Public Health Agency  Registration was completed prior to or within 60 days after the start of the EHR reporting period  The EP is awaiting an invitation from the PHA to begin testing and validation.  Providers that have registered in previous years do not need to submit an additional registration to meet this requirement for each EHR reporting period. Active Engagement Option 2 ‐ Testing and Validation:  The EP is in the process of testing and validation of the electronic submission of data. Providers must respond to requests from the PHA within 30 days  Failure to respond twice within an EHR reporting period would result in that provider not meeting the measure. Active Engagement Option 3 – Production:  The EP has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA.  Production data Refers to data generated through clinical processes involving patient care, and it is used to distinguish between data and “test data” which may be submitted for the purposes of enrolling in and testing electronic data transfers.

Public Health Reporting (cont.) MEASURE 1: Immunization Registry YES/NO: The EP must attest YES to being in active engagement with a public health agency to submit immunization data. EXCLUSIONS:  EP ‐ does not administer any immunizations to any of the populations during the EHR reporting period; The next 2 exclusions do not apply in Maine as we have a functional Immunization Registry; and the exclusions do not appear in the wizard  Operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards  Operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data

Public Health Reporting (cont.) MEASURE 2: Syndromic Surveillance Registry YES/NO: THE EP must attest YES to being in active engagement with a public health agency to submit syndromic surveillance data. EXCLUSIONS:  EP is not in a category of providers from which ambulatory syndromic surveillance data is collected by their jurisdiction's syndromic surveillance system ALTERNATE EXCLUSION:  EPs may claim an alternate exclusion for measure 2 (syndromic surveillance reporting) for an EHR reporting period in The next 2 exclusions do not apply in Maine as we have a Syndromic Surveillance Registry that can accept registrations; the exclusions do not appear in the wizard  Operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data from EPs in the specific standards  Operates in a jurisdiction where no public health agency has declared readiness to receive syndromic surveillance data

Public Health Reporting (cont.) MEASURE 3: Specialized Registry Note: the Cancer Registry is considered a Specialized Registry; if you registered for the Cancer Registry you should mark yes for the specialized registry and select the Cancer Registry. YES/NO: The EP must attest YES to being in active engagement to submit data to a specialized registry. EXCLUSIONS:  Does not diagnose or treat any disease or condition associated with, or collect relevant data that is required by a specialized registry ALTERNATE EXCLUSION:  EPs may claim an alternate exclusion for measure 2 (syndromic surveillance reporting) for an EHR reporting period in A provider may meet objective 10 by entering two specialized registries that you have registered with. You must include the name of each registry in the meaningful use wizard. You are required to send documentation to the Maine Medicaid EHR Incentive program of any specialized registries other than the Maine Cancer Registry that you have registered with to meet meaningful use. The next 2 exclusions do not apply in Maine as we have a Specialized Registry that can accept registrations; the exclusions do not appear in the wizard  Operates in a jurisdiction for which no public health agency is capable of receiving electronic specialized data from EPs in the specific standards  Operates in a jurisdiction where no public health agency has declared readiness to receive electronic specialized data

2016 Program Year CQM requirements The CQM measures remain the same as they were for program year 2014 and 2015 – 9 CQMs must be entered to meet the 2016 MU requirements. There are 64 CQM measures a provider may choose from. Most providers will be able to find CQMs that apply to their scope of practice. Depending on the CEHRT package purchased providers may have limited access to the number of CMQs they can choose from. If a provider does not have data for 9 CQMs they will enter the data as presented by the CEHRT. We will accept zeros if that is all that is available.

Links and Contact Information The Public Health wizard and website are currently down for updates. We plan to have them available July 8, 2016 On our website we have a test link to the 2016 attestation sample sheet. Use this to see if what you have on your reports for MU data would meet the criteria. To contact us send an to:

Links and Contact Information Maine Meaningful Use Website: CMS Meaningful Use Website Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/EHRIncentivePrograms/ Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/EHRIncentivePrograms/ Maine Public Health Registration Website: The site is being updated and will be available after July 8, Documents for Program Year 2016: 2016 What You Need to Know (.pdf*) 2016 What You Need to Know 2016 Objective Table of Contents (.pdf*) 2016 Objective Table of Contents 2016 CQM Measures Table (.pdf*) 2016 CQM Measures Table 2016 Attestation Sample Sheet (.pdf*) 2016 Attestation Sample Sheet 2016 Alternate Exclusions (.pdf*) 2016 Alternate Exclusions 2016 Public Health Reporting (.pdf*) 2016 Public Health Reporting 2016 Public Health Objective (.pdf*) 2016 Public Health Objective 2016 Security Risk Analysis (.pdf*) 2016 Security Risk Analysis 2016 Patient Electronic Access (.pdf*) 2016 Patient Electronic Access 2016 Multiple Locations Tip sheet (.pdf*) 2016 Multiple Locations Tip sheet How to Apply with Maine for Program Year 2016 (coming soon) 2016 Medicaid Eligibility Worksheet (.xlsx) 2016 Medicaid Eligibility Worksheet 2016 Guide to Completing the Medicaid Eligibility Worksheet (.pdf*) 2016 Guide to Completing the Medicaid Eligibility Worksheet Medicaid Eligibility Reporting Period and Calculation Options (.pdf) Medicaid Eligibility Reporting Period and Calculation Options All EHR software must be 2014 Certified EHR technology for a program year 2016 submission Generating a CEHRT ID Number (.pdf) Generating a CEHRT ID Number