1. Kentucky Regional Extension Center Your EHR Resource Contact: Dr. Martha Riddell and Dr. Carol Ireson Meaningful Use Advisors, Kentucky REC Martha.Riddell@uky.edu Clires0@email.uky.edu 859-323-3090 Medicare & Medicaid EHR Incentive Program Meaningful Use Stage 1

2. Pillars of Meaningful Use 1) Improve quality, safety, efficiency, and reduce health disparities ▪ Provide access to comprehensive patient health data for patient’s health care team ▪ Use evidence-based order sets and CPOE ▪ Apply clinical decision support at the point of care ▪ Generate lists of patients who need care and use them to reach out to patients 2) Engage patients and families ▪ Provide patients and families with timely access to data, knowledge, and tools to make informed decisions and to manage their health 3) Improve care coordination ▪ Exchange meaningful clinical information among professional health care team 4) Improve population and public health ▪ Submit immunization, syndromic surveillance and reportable disease data to public health agencies 5) Ensure privacy and security protection for personal health information ▪ Protect confidential information through operating policies, procedures, and technologies ▪ Provide transparency of data sharing to patient

3. Kentucky Regional Extension Center Mission The Kentucky Regional Extension Center based at the University of Kentucky will assist primary care providers and critical access/rural hospitals with EHR adoption, HIE participation, and achievement of meaningful use. Vision The long-term vision of the Kentucky Regional Extension Center is to improve the quality and value of health care for the people of Kentucky and to serve as a model for other areas that face similar challenges.

4. Incentives for Meaningful Use (MU) The federal government will pay eligible professionals who meet meaningful use (MU): Up to $44,000 under Medicare or Up to $63,750 under Medicaid The ARRA/HITECH Act authorizes incentive funding for health care providers who demonstrate “meaningful use of health information technology.”

5. Medicare Incentives – MU Stages Stage ThreeStage TwoStage One

6. What are the Three Main Components of Meaningful Use? The Recovery Act specifies the following 3 components of Meaningful Use: 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

7. E ligible Providers must comply with 20 objectives to reach meaningful use. Providers must attest to 15 core objectives along with another 5 objectives chosen off a menu list of 10 objectives. How to get to MU: What are the provisions?

8. Core ObjectiveStage 1 measure Generate and Transmit permissible prescriptions electronically (eRx) More than 40% of all permissible prescriptions written by the eligible provider are transmitted electronically using EHR certified technology Applicable core objectives and menu objectives have specific thresholds a provider must meet. For more information on thresholds for stage one Meaningful use contact KYREC@UKY.EDU Thresholds

9. 1.Use computerized order entry for medication orders. 2.Implement drug-drug, drug-allergy checks. 3.Generate and transmit permissible prescriptions electronically. 4.Record demographics. 5.Maintain an up-to-date problem list of current and active diagnoses. 6.Maintain active medication list. 7.Maintain active medication allergy list. 8.Record and chart changes in vital signs. 9.Record smoking status for patients 13 years old or older. 10.Implement one clinical decision support rule. 11.Report ambulatory quality measures to CMS or the States. 12.Provide patients with an electronic copy of their health information upon request. 13.Provide clinical summaries to patients for each office visit. 14.Capability to exchange key clinical information electronically among providers and patient authorized entities. 15.Protect electronic health information (privacy & security ) Core Set

10. Core ObjectiveStage 1 measure Computer provider order entry (CPOE) for medication orders. More than 30% of patients with at least one medication in their medication list have at least one medication ordered through CPOE. Implement drug-drug and drug-allergy interaction checks. Functionality is enabled for these checks for the entire reporting period. Implement capability to electronically exchange key clinical information (for example, problem list, medication list, medication allergies, and diagnostic test results) among providers and patient-authorized entities. Perform at least one test of EHR’s capacity to electronically exchange information. Implement one clinical decision support rule and ability to track compliance with the rule. One clinical decision support rule implemented.

11. Core ObjectiveStage 1 measure Record patient demographics (sex, race, ethnicity, date of birth, and preferred language). More than 50% of patients’ demographic data recorded as structured data. Record vital signs and chart changes (height, weight, blood pressure, body-mass index, growth charts for children). More than 80% of patients have at least one entry recorded as structured data. Maintain up-to-date problem list of current and active diagnoses. More than 80% of patients have at least one entry recorded as structured data. Maintain active medication allergy list. More than 80% of patients have at least one entry recorded as structured data. Core Set

12. Core ObjectiveStage 1 measure Maintain active medication list.More than 80% of patients have at least one entry recorded as structured data Record smoking status for patients 13 years of age or older. More than 50% of patients 13 years of age or older have smoking status recorded as structured data. Provide patients with clinical summaries for each office visit. Clinical summaries provided to patients for more than 50% of all office visits within 3 business days On request, provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, and medication allergies). More than 50% of requesting patients receive electronic copy within 3 business days. Core Set

13. Core ObjectiveStage 1 measure Generate and transmit permissible prescriptions electronically More than 40% are transmitted electronically using certified EHR technology. Implement systems to protect privacy and security of patient data in the EHR. Conduct or review a security risk analysis, implement security updates as necessary, and correct identified security deficiencies. Report clinical quality measures to CMS or states. Clinical summaries provided to patients for more than 50% of all office visits within 3 business days Core Set

14. 1.Implement drug-formulary checks. 2.Incorporate clinical lab-test results into certified EHR as structured data. 3.Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach. 4.Send reminders to patients per patient preference for preventive/ follow-up care 5.Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies) 6.Use certified EHR to identify patient-specific education resources and provide to patient if appropriate. 7.Perform medication reconciliation as relevant 8.Provide summary care record for transitions in care or referrals. 9.*Capability to submit electronic data to immunization registries and actual submission. 10.*Capability to provide electronic syndromic surveillance data to public health agencies and actual transmissions Menu Set

15. Core ObjectiveStage 1 measure Implement drug formulary checksDrug formulary check system is implemented and has access to at least one internal or external drug formulary for the entire reporting period. Incorporate clinical laboratory test results into EHRs as structured data. More than 40% of clinical laboratory test results whose results are in positive/negative or numerical format are incorporated into EHRs as structured data. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach. Generate at least one listing of patients with a specific condition.

16. Menu Set Core ObjectiveStage 1 measure Use EHR technology to identify patient-specific education resources and provide those to the patient as appropriate More than 10% of patients are provided patient-specific education resources. A physician who receives a patient from another setting of care should perform medication reconciliation. Medication reconciliation is performed for more than 50% of transitions of care.

17. Core ObjectiveStage 1 measure The physician who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary care record for each transition of care or referral. Summary of care record is provided for more than 50% of patient transitions or referrals. Capability to submit electronic data to immunization registries or immunization information systems and actual submission in accordance with applicable law and practice. Perform at least one test of EHR’s capacity to submit electronic data to immunization registries and follow up submission if the test is successful (unless none of the immunization registries to which the physician submits such information have the capacity to receive the information electronically). Menu Set

18. Objective Submit electronic syndromic surveillance data to public health agencies. Send reminders to patients (per patient preference) for preventive and follow-up care. Provide patients with timely electronic access to their health information (including laboratory results, problem list, medication lists, and medication allergies). Core ObjectiveStage 1 measure Submit electronic syndromic surveillance data to public health agencies. Perform at least one test of data submission and follow-up submission (where public health agencies can accept electronic data) Send reminders to patients (per patient preference) for preventive and follow-up care. More than 20% of patients 65 years of age or older or 5 years of age or younger are sent appropriate reminders. Provide patients with timely electronic access to their health information (including laboratory results, problem list, medication lists, and medication allergies). More than 10% of patients are provided electronic access to information within 4 days or its being updated in the EHR. Menu Set

19. In addition to the 20 core and menu measures, providers must report 6 clinical quality measures: 3 core quality measures and an additional 3 from a set of 38. Clinical Quality Measures *There are no thresholds for these quality measures; providers only need to submit them to meet the requirement.

20. Core Clinical Quality Measures Blood Pressure Measurement Tobacco Use Assessment & Counseling Adult Weight Screening Alternate Core Measures Weight Assessment & Counseling for Children Influenza Vaccination for Pts >50 yrs Childhood Immunization Status Clinical Quality Measures

21. Core Core MeasureDescription Preventive Care and Screening Measure Pair: a. Tobacco Use Assessment, b. Tobacco Cessation Intervention. Percentage of patients aged 18 years and older who have been seen for at least 2 office visits who were queried about tobacco use one or more times within 24 months. b. Percentage of patients aged 18 years and older identified as tobacco users within the past 24 months and have been seen for at least 2 office visits, who received cessation intervention. Hypertension: Blood Pressure Measurement.Percentage of patient visits for patients aged 18 years and older with a diagnosis of hypertension who have been seen for at least 2 office visits, with blood pressure (BP) recorded. Adult Weight Screening and Follow-Up.Percentage of patients aged 18 years and older with a calculated BMI in the past six months or during the current visit documented in the medical record AND if the most recent BMI is outside parameters, a follow-up plan is documented.

22. Choose 3 of 38 additional clinical quality measures. Examples: Pneumonia Vaccination for Patients 65 Years and Older Screening Mammography Colorectal Cancer Screening Cervical Cancer Screening Controlling High Blood Pressure Asthma: Pharmacologic Therapy Diabetes Mellitus: Foot Exam Clinical Quality Measures

23. Menu MeasureDescription Diabetes: Hemoglobin A1c Poor Control. Percentage of patients 18-75 years of age with diabetes (type 1 or type 2) who had hemoglobin A1c > 9.0%. Diabetes: Low Density Lipoprotein (LDL) Management and Control Percentage of patient visits for patients aged 18 years and older with a diagnosis of hypertension who have been seen for at least 2 office visits, with blood pressure (BP) recorded. Diabetes: Blood Pressure Management. Percentage of patients 18-75 years of age with diabetes (type 1 or type 2) who had LDL-C < 100mg/dL). Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD). Percentage of patients aged 18 years and older with a diagnosis of heart failure and LVSD (LVEF < 40%) who were prescribed ACE inhibitor or ARB therapy. Clinical Quality Measures

24. Menu MeasureDescription Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI). Percentage of patients aged 18 years and older with a diagnosis of CAD and prior MI who were prescribed beta-blocker therapy. Pneumonia Vaccination Status for Older Adults. Percentage of patients 65 years of age or older who have ever received a pneumococcal vaccine. Breast Cancer Screening. Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer. Colorectal Cancer Screening. Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer. Clinical Quality Measures

25. Menu MeasureDescription Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD. Percentage of patients aged 18 years and older with a diagnosis of CAD who were prescribed oral antiplatelet therapy. Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD). Percentage of patients aged 18 years and older with a diagnosis of heart failure who also have LVSD (LVEF < 40%) and who were prescribed beta-blocker therapy. Anti-depressant medication management (a) Effective Acute Phase Treatment, (b) Effective Continuation Phase Treatment. The percentage of patients 18 years of age and older who were diagnosed with a new episode of major depression, treated with antidepressant medication, and who remained on an antidepressant medication treatment. Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation. Percentage of patients aged 18 years and older with a diagnosis of POAG who have been seen for at least two office visits who have an optic nerve head evaluation during one or more office visits within 12 months. Clinical Quality Measures

26. Menu MeasureDescription Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy. Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits with 12 months. Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care. Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months. Asthma Pharmacologic Therapy. Percentage of patients aged 5 through 40 years with a diagnosis of mild, moderate, or severe persistent asthma who were prescribed either the preferred long-term control medication (inhaled corticosteroid) or an acceptable alternative treatment. Clinical Quality Measures

27. Menu MeasureDescription Asthma Assessment. Percentage of patients aged 5 trough 40 years with a diagnosis of asthma and who have been seen for at least 2 office visits, who were evaluated during at least one office visit within 12 months for the frequency (numeric) of daytime and nocturnal asthma symptoms. Appropriate Testing for Children with Pharyngitis. Percentage of children 2-18 years of age who were diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode. Oncology Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer. Percentage of female patients aged 18 years and older with Stage IC through IIIC, ER or PR positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12-month reporting period. Oncology Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients. Percentage of patients aged 18 years and older with Stage IIIA through IIIC colon cancer who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy, or have previously received adjuvant chemotherapy within the 12-month reporting period. Clinical Quality Measures

28. Menu MeasureDescription Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients. Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low risk of recurrence receiving interstitial prostate brachytherapy, OR external bean radiotherapy to the prostate, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer. Smoking and Tobacco Use Cessation, Medical assistance: a. Advising Smoking and Tobacco Users to Quit, b. Discussing Smoking and Tobacco Use Cessation Medications, c. Discussing Smoking and Tobacco Use Cessation Strategies. Percentage of patients 18 years of age and older who were current smokers or tobacco users, who were seen by a practitioner during the measurement year and who received advice to quit smoking or tobacco use or whose practitioner recommended or discussed smoking or tobacco use cessation medications, methods, or strategies. Diabetes: Eye Exam. Percentage of patients 18-75 years of age with diabetes (type 1 or type 2) who had a retinal or dilated eye exam or a negative retinal eye exam (no evidence of retinopathy) by an eye care professional. Diabetes: Urine Screening. Percentage of patients 18-75 years of age with diabetes (type 1 or type 2) who had a nephropathy screening test or evidence of nephropathy. Clinical Quality Measures

29. Menu MeasureDescription Diabetes: Foot Exam. The percentage of patients aged 18-75 years with diabetes (type 1 or type 2) who had a foot exam (visual inspection, sensory exam with monofilament, or pulse exam). Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-Cholesterol. Percentage of patients aged 18 years and older with a diagnosis of CAD who were prescribed a lipid-lowering therapy (based on current ACC/AHA guidelines). Heart Failure (HF): Warfarin Therapy Patients with Atrial Fibrillation. Percentage of all patients aged 18 years and older with a diagnosis of heart failure and paroxysmal or chronic atrial fibrillation who were prescribed warfarin therapy. Ischemic Vascular Disease (IVD): Blood Pressure Management. Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) from January 1-November 1 of the year prior to the measurement year, or who had a diagnosis ischemic vascular disease (IVD) during the measurement year and whose recent blood pressure is in control (< 140/90mmHg). Clinical Quality Measures

30. Menu MeasureDescription Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic. Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PCTA) FROM January 1-November 1 of the year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during the measurement year and who had documentation of the use of aspirin or another antithrobotic during the measurement year. Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: (a) Initiation, (b) Engagement. The percentage of adolescent and adult patients with a new episode of alcohol and other drug (AOD) dependence who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis and who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit. Prenatal Care: Screening for Human Immunodeficiency Virus (HIV). Percentage of patients, regardless of age, who gave birth during a 12-month period who were screened for HIV infection during the first or second prenatal care visit. Prenatal Care: Anti-D Immune Globulin. Percentage of D (Rh) negative, unsensitized patients, regardless of age, who gave birth during a 12-month period who received anti-D immune globulin at 26-30 weeks gestation. Clinical Quality Measures

31. Menu MeasureDescription Controlling High Blood Pressure. The percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose BP was adequately controlled during the measurement year. Cervical Cancer Screening. Percentage of women 21-64 years of age, who received one of more Pap tests to screen for cervical cancer. Chlamydia Screening for Women. Percentage of women 15-24 years of age who were identified as sexually active and who had at least one test for Chlamydia during the measurement year. Use of Appropriate Medications for Asthma. Percentage of patients 5-50 years of age who were identified as having persistent asthma and were appropriately prescribed medication during the measurement year. Report three age stratifications (5-11 years, 12-50 years, and total). Clinical Quality Measures

32. Menu MeasureDescription Low Back Pain: Use of Imaging Studies. Percentage of patients with a primary diagnosis of low back pain who did not have an imaging study (plain x-ray, MRI, CT scan) within 28 days of diagnosis. Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control. Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous transluminal angioplasty (PTCA) from January 1-November 1 of the year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during the measurement year and the year prior to the measurement year and who had a complete lipid profile performed during the measurement year and whose LDL-C<100mg/dL. Diabetes: Hemoglobin A1c Control (<8.0%). The percentage of patients 18-75 years of age with diabetes (type 1 or type 2) who had hemoglobin A1c<8.0%. Clinical Quality Measures

33. Steps for Meaningful Use 1.Register for the Incentive Program Medicare: Eligible professionals can register starting in January 2011. Registration will be online at http://cms.gov/EHrIncentivePrograms/http://cms.gov/EHrIncentivePrograms/ Medicaid: The registration process will be the same as for Medicare. A registration link will be available when the New York state program begins. 2.Implement and meaningfully use certified EHR Technology 3.Achieve and Attest to the Meaningful Use functional measures and the clinical quality measures For 2011, CMS will accept provider attestations for demonstration of all the meaningful use measures, including clinical quality measures. Starting in 2012, CMS will continue attestation for most of the meaningful use objectives but plans for electronic submission of the clinical quality measures. States will also support attestation initially and then subsequent electronic submission of clinical quality measures for Medicaid providers’ demonstration of meaningful use. 4.Payments CMS expects to initiate Medicare incentive payments May 2011. For Medicaid, States are determining their own deadlines, but are required to make timely payments. CMS expects that the majority of States will have launched their programs by the summer of 2011.

34. Adopt/Implement/Upgrade for Incentives MEDICAID –Only for first participation year Adopted –Acquired and Installed Eg: Evidence of installation prior to incentive Implemented –Commenced Utilization of Eg: Staff training, data entry of patient demographic information into HER Upgraded –Expanded Upgraded to certified EHR technology or added new functionality to meet the definition of certified EHR technology Must be certified EHR technology capable of meeting meaningful use No EHR reporting period

35. Medicare Incentive Payment Schedule 20102011 Fall 2010 Certification of EHR vendors will start April 2011 Attestation of meaningful use begins 2011-2012 Clinicians can begin using a certified EHR in a meaningful Manner (must use for 90 days) Jan. 2011 Registration with CMS can begin. This will be done through PECOS May 2011 CMS payments Will begin *Medicaid EHR incentives will be managed by states

36. Questions? http://hitrc-collaborative.org/jeopardy/frameset.htm

37. Dr. Martha Riddell Meaningful Use Advisor Kentucky REC Martha.Riddell@uky.edu 859-323-3090 Dr. Carol Ireson Meaningful Use Advisor Kentucky REC Clires0@email.uky.edu 859-323-3090 Contact Information General REC Information Contact: Kentucky Regional Extension Center 2333 Alumni Park Plaza, Suite 200 Lexington, KY 40517 Toll Free: 866-KY-RECEHR 859-323-3090 KYREC@uky.edu