1. Eligible Hospitals (EH) & Critical Access Hospitals (CAH)
Stage 2 Meaningful Use
Eligible Hospitals (EH)
&
Critical Access Hospitals (CAH)

2. Conflict of Interest Disclosures
None

3. Changes to Stage 1 Objectives
CPOE
Denominator: More than 30% of medication orders created by the EP or authorized providers of the EH or CAH’s inpatient or emergency dept (POS 21 or 23) during the EHR reporting period are recorded using CPOE
Vital Signs
Denominator: More than 50% of all unique patient seen admitted to the EH or CAH’s inpatient or emergency dept (POS 21 or 23) during the EHR reporting period have blood pressure (for ages 3+ only) and height and weight (for all ages) recorded as structured data
Clinical Quality Measures
Objective removed
Hospitals are still required to report on CQMs
Now follow 2014 CQM requirements

4. Where Are We At? Stage 3 and Beyond… Stage 2 Stage 1
Leveraging Information for Improved Patient Care
Stage 2
Reporting
Exchanging Information
Patient Engagement
Stage 1
Capture Information

5. Understanding the Timing of Stage 2

6. Stage 2 Meaningful Use Report on total of 19 Objectives
Plus Clinical Quality Measures (CQM)
16 Core Objectives
All Required
Many Stage 1 combined
6 Menu Objectives
Choose 3
Clinical Quality Measures (CQM)
Report on 16 of 29 approved CQMs
Selected CQMs must cover at least 3 of 6 National Quality Strategy Domains
Electronically repot to CMS

7. MU in 2014
For 2014 only:
All EHs and CAHs regardless of their stage of meaningful use are only required to demonstrate meaningful use for a 3-month EHR reporting period.
CMS is permitting this one-time 3-month reporting period in 2014 only so that all hospitals who must upgrade to 2014 Certified EHR Technology will have adequate time to implement their new Certified EHR systems.

8. MU in 2014 Reporting Period = 3 month quarter (2014 Only)
Must be a fixed calendar quarter
January – March
April – June
July – September
October – December
Must be completed by December 31st
Start no later than October 1
Payment Adjustments begin in 2015

9. Avoiding Payment Adjustments
If you’re beginning in 2014
Must demonstrate 90 days before 4th quarter
Must attest NO LATER than October 1, 2014
Avoiding Medicare payment adjustments in the future
Must continue to demonstrate every year
If eligible for Medicare and Medicaid, must demonstrate every year
If eligible for Medicaid ONLY, you are not subject to adjustments

10. Computer Provider Order Entry (CPOE)
Objective
Use CPOE for medication, laboratory, and radiology orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines.
Denominator
Medications: Number of medication orders created by the EH or CAH’s inpatient or emergency department (POS 21 or 23) during the EHR reporting period.
Radiology: Number of radiology orders created by the EH or CAH’s inpatient or emergency department (POS 21 or 23) during the reporting period.
Laboratory: Number of lab orders created by the EH or CAH’s inpatient or emergency department (POS 21 or 23) during the reporting period.
Numerator
The number of orders in the denominator recorded using CPOE
Threshold:
Medications: > 60%
Labs: > 30%
Radiology: > 30%
Increased medication threshold 30% to 60%
30% radiology and 30% lab orders added to objective
Denominator changes to number of orders

11. Record Demographics Objective Denominator Numerator
Record all of the following demographics:
Preferred Language
Sex
Race
Ethnicity
Date of Birth
Date & Preliminary Cause of Death (in the event of mortality in the EH or CAH)
Denominator
Number of unique patients admitted to the EH or CAH’s inpatient or emergency department (POS 21 or 23) during the EHR reporting period.
Numerator
Number of patients in the denominator who have all the elements of demographics (or a specific notation if the patient declined to provide one or more of the elements) recorded as structured data.
Threshold: > 80%
Threshold increased from 50% to 80%
Terminology change: “Gender” replaced with “Sex”

12. Record Vital Signs Objective Denominator Numerator Threshold: > 80%
Record and chart changes in the following vital signs:
Height/Length & Weight (no age limit)
Blood Pressure (ages 3 and over)
Calculate & Display BMI
Plot & Display Growth Charts for Patients 0 – 20 yrs (including BMI)
Denominator
Number of unique patients admitted to the EH or CAH’s inpatient or emergency department (POS 21 or 23) during the EHR reporting period.
Numerator
Number of patients in the denominator who have at least one entry of their height and weight (all ages) and/or blood pressure (ages 3 and over) recorded as structured data.
Threshold: > 80%
Threshold increased from 50% to 80%
Blood pressure on patients aged 2 yr olds no longer required
Patients aged 0-2 yrs old now included in Growth Charts

13. Record Smoking Status Objective Denominator Numerator
Record smoking status for patients 13 yrs old and older
Denominator
Number of unique patients aged 13 or older admitted to the EH or CAH’s inpatient or emergency department (POS 21 or 23) during the EHR reporting period.
Numerator
Number of patients in the denominator with smoking status recorded as structured data.
Threshold: > 80%
Threshold increased from 50% to 80%
SNOMED Codes required
8 smoking status selections to include cigar & pipe smokers

14. Clinical Decision Support (CDS)
Objective
Implement 5 Clinical Decision Support interventions related to 4 or more clinical quality measures at a relevant point in patient care for the entire EHR reporting period
AND
Implement drug-drug and drug-allergy checks for the entire reporting period
Attestation Requirement: Yes/No
Increased from 1 to 5 CDS Rules
CDS must relate to clinical quality measures
Incorporates Drug-Drug/Drug-Allergy Interaction Checks

15. Patient Electronic Access
Objective
Provide patients the ability to view online, download, and transmit information about hospital admission. 
Denominator
Number of unique patients discharged from the EH or CAH’s inpatient or emergency department (POS 21 or 23) during the reporting period.
Numerator
Access: Number of patients in the denominator whose information is available online within 36 hours of discharge
Engagement: Number of patients in the denominator who have viewed online, downloaded, or transmitted to a third party the discharge information provided by the EH or CAH.
Threshold:
Access: > 50%
Engagement: > 5%
Replaces Stage 1 eCopy of PHI objective
Requires 5% patient engagement
Denominator is now 50% of all discharged patients rather than those requesting

16. What Must be Available Online?
The EH or CAH can make additional information available, however, the following information must be available to satisfy the objective and measure:
Patient Name
Admit and discharge date & location
Reason for hospitalization
Care team including the attending of record as well as other providers of care
Procedures performed during admission
Current and past problem list
Current medication list and medication history
Current medication allergy list and medication allergy history
Vital signs at discharge
Laboratory test results (available at time of discharge)
Summary of care record for transitions of care or referrals to another provider
Care plan field(s), including goals and instructions
Discharge instructions for patient
Demographics maintained by hospital
Smoking status

17. Patient Portals & Minors
Parents as Personal Representatives
Personal representative has the right of the individual
Rights should be cut off at age of majority
Parent may not be personal representative for certain information, such as when a minor can consent under state law
Personal representatives and minors can pose significant challenges to the organization
Will the organization require authorization before establishing proxy rights to the portal
How will the organization handle revocation of authorizations? Restriction requests?
How will the organization ensure parent’s access is revoked once patient reaches age of majority?

18. Patient Portals & Minors
What can the organization do?
Ensure compliance with applicable Federal & State laws regarding minors
Consult internal HIPAA privacy liaison to ensure portal access/rights are consistent with Federal & State laws and other organizational practices
Approaches by other Healthcare Providers:
For patients under the age of 14, parents are able to access the portal with parental signed request
For patients aged 14-18,
Require the child to sign a release form
Restrict parental access to certain sensitive data as required by applicable laws
Restrict portal access for minors ages 14-18
Providers can withhold information if they believe it would jeopardize the health of their patient in accordance with HIPAA privacy regulations
Consult internal HIPAA privacy liaison
Also note that there are differences for minors who are emancipated

19. Protect Electronic Health Information
Objective
Conduct or review a security risk analysis in accordance with the requirements under 45 CFR (a)(1), including addressing the encryption/security of data stored in CEHRT in accordance with requirements under 45 CFR (a)(2)(iv) and 45 CFR (d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the provider’s risk management process for eligible hospitals.
Attestation Requirement: Yes/No
Update risk management processes to address any newly identified risks since last SRA
Risk analysis function required to place emphasis on encryption of PHI stored in CEHRT
Objective not meant to replace, change, or supersede HIPAA Privacy & Security Rule

20. Clinical Lab Test Results
Objective
Incorporate clinical lab test results into Certified EHR Technology (CEHRT) as structured data.
Denominator
Number of lab tests ordered during the EHR reporting period by the EH or CAH’s inpatient or emergency department (POS 21 or 23) whose results are expressed in either a positive/negative or numeric format.
Numerator
Number of lab test results which are expressed in a positive/negative or numeric result are incorporated into CEHRT as structured data.
Threshold: > 55%
Moved from Menu to Core Set
Threshold increased from 40% to 55%

21. Patient Lists Objective Attestation Requirement: Yes/No
Generate at least one list of patients by specific condition to use for quality improvement, reduction of disparities, research, or outreach.
Attestation Requirement: Yes/No
Moved from Menu to Core Set
Must be based on information contained within the following fields: problems, medications, medication allergies, demographics, labs

22. Patient-Specific Education Resources
Objective
Use clinically relevant information from CEHRT to identify patient-specific education resources and provide those resources to the patient.
Denominator
Number of unique patients admitted to the EH or CAH’s inpatient or emergency department (POS 21 or 23) during the EHR reporting period.
Numerator
Number of patients in the denominator who are subsequently provided patient-specific education resources identified by CEHRT.
Threshold: > 10%
CEHRT is certified to use problem list, medication list, or lab results to identify educational resources
Education resources do not have to be stored within or generated by CEHRT
Utilize CEHRT in a manner where the technology suggests patient-specific educational resources based on information stored within CEHRT

23. Medication Reconciliation
Objective
The EH or CAH who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation.
Denominator
Number of transitions of care during the EHR reporting period for which the EH or CAH’s inpatient or emergency department (POS 21 or 23) was the receiving party of the transition.
Numerator
Number of transitions of care in the denominator where medication reconciliation was performed.
Threshold: > 50%
Moved from Menu to Core Set
Information included in the process of medication reconciliation is determined by the provider & patient

24. Summary of Care Measure 1
Objective
The EH or CAH who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care provides a summary of care record for each transition of care or referral.
Denominator
Number of transitions of care and referrals during the EHR reporting period for which the EH or CAH’s inpatient or emergency department (POS 21 or 23) was the transferring or referring provider.
Numerator
Number of transitions of care and referrals in the denominator where a summary of care record was provided.
Threshold: > 50%
Moved from Menu to Core Set
Must verify current problem list, current medication list, and current medication allergy list includes the most recent information known at the time
Can send paper or electronic copy of summary care record directly to next provider, or can provide it to patient to deliver to next provider (if patient can be reasonably expected to do so)

25. Summary of Care Measure 2
Objective
The EH or CAH who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care provides a summary of care record for each transition of care or referral.
Denominator
Number of transitions of care and referrals during the EHR reporting period for which the EH or CAH’s inpatient or emergency department (POS 21 or 23) was the transferring or referring provider.
Numerator
Number of transitions of care and referrals in the denominator where a summary of care record was:
Electronically transmitted using CEHRT to a recipient OR
Where the recipient receives the summary of care record via exchange facilitated by an organization that is a NwHIN Exchange participant or in a manner that is consistent with the governance mechanism ONC establishes for the nationwide health information network. The organization can be a third-party or the sender’s own organization.
Threshold: > 10%
Requires electronic transmission
The summary of care record must be received by the provider to whom the sending provider is referring or transmitting the patient

26. Summary of Care Measure 3
Objective
The EH or CAH who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care provides a summary of care record for each transition of care or referral.
Attestation Requirement: Yes/No
The EH or CAH must satisfy one of the two following criteria:
Conducts one or more successful electronic exchanges of a summary of care document, which is counted in Measure 2 with a recipient who has EHR technology that was designed by a different EHR technology developer than the sender’s CEHRT OR
Conducts one or more successful tests with the CMS designated test EHR during the EHR reporting period.
Incorporates Stage 1 Electronic Exchange of Key Clinical Information objective
“EHR Randomizer” will randomly match EH or CAH with a designated test EHR that is designed by a different EHR technology developer than theirs
Current Designated Test EHRs: McKesson, Meditech, iPatientCare

27. What Must be Available on the
Care Summary?
A summary of care record must include the following:
Patient Name
Procedures
Encounter diagnosis
Immunizations
Laboratory test results
Vitals signs
Smoking status
Functional status, including activities of daily living, cognitive and disability status
Demographic information
Care plan field, including goals and instructions
Care team including the primary care provider of record and any additional known care team members beyond the referring or transitioning provider and the receiving provider
Discharge instructions
Current problem list
Current medication list
Current medication allergy list

28. Immunization Registry Data Submission
Objective
Capability to submit electronic data to immunization registries or immunization information systems except where prohibited, and in accordance with applicable law and practice.
Attestation Requirement: Yes/No
Moved from Menu to Core Set
Successful ongoing submission is required

29. Electronic Reportable Lab Results
Objective
Capability to submit electronic reportable laboratory results to public health agencies, except where prohibited, and in accordance with applicable law and practice.
Attestation Requirement: Yes/No
Moved from Menu to Core Set
Successful ongoing submission is required

30. Syndromic Surveillance Data Submission
Objective
Capability to submit syndromic surveillance data to public health agencies, except where prohibited, and in accordance with applicable law and practice.
Attestation Requirement: Yes/No
Moved from Menu to Core Set
Successful ongoing submission is required

31. Electronic Medication Administration Record (eMAR)
Objective
Automatically track medications from order to administration using assistive technologies in conjunction with an electronic medication administration record (eMAR).
Denominator
Number of medication orders created by authorized providers in the EH or CAH’s inpatient or emergency department (POS 21 or 23) during the EHR reporting period.
Numerator
Number of orders in the denominator for which all doses are tracked using eMAR.
Threshold: > 10%
New objective
If a medication is ordered but not all doses of the medication are tracked using eMAR, then that order may not be included in the numerator

32. Advance Directives Objective Denominator Numerator Threshold: > 50%
Record whether a patient 65 years or older has an advance directive.
Denominator
Number of unique patients age 65 or older admitted to the EH or CAH’s inpatient department (POS 21) during the EHR reporting period.
Numerator
Number of patients in the denominator who have an indication of an advance directive status entered using structured data.
Threshold: > 50%
No changes from Stage 1
Patients admitted to the emergency department are not included in this objective
Providers need only to record the indication that an advance directive exists

33. Electronic Notes Objective Denominator Numerator Threshold: > 30%
Record electronic notes in patient records.
Denominator
Number of unique patients admitted to the EH or CAH’s inpatient or emergency department (POS 21 or 23) during the EHR reporting period.
Numerator
Number of patients in the denominator who have at least one electronic progress note from an authorized provider of the EH or CAH’s inpatient or emergency department (POS 21 or 23) recorded as text searchable data.
Threshold: > 30%
New objective
Text must be searchable
Drawings and other content can be included with searchable text notes

34. Imaging Results Objective Denominator Numerator Threshold: > 10%
Imaging results consisting of the image itself and any explanation or other accompanying information are accessible through CEHRT.
Denominator
Number of tests whose result is one or more images ordered by an authorized provider on behalf of the EH or CAH for patients admitted to its inpatient or emergency department (POS 21 or 23) during the EHR reporting period.
Numerator
Number of results in the denominator that are accessible through CEHRT.
Threshold: > 10%
New objective
No limitations on the resolution of the image
Native storage of the image is not required; images can be scanned into CEHRT

35. Family Health History Objective Denominator Numerator
Record patient family health history as structured data.
Denominator
Number of unique patients admitted to the EH or CAH’s inpatient or emergency department (POS 21 or 23) during the EHR reporting period.
Numerator
Number of patients in the denominator with a structured data entry for one or more first-degree relatives.
Threshold: > 20%
New objective
First-degree relatives include parents, siblings, and offspring
When applicable, structured data entry of “Unknown” is acceptable

36. ePrescribing (eRX) Objective Denominator Numerator Threshold: > 10%
Generate and transmit permissible discharge prescriptions electronically (eRX).
Denominator
Number new, changed, or refill prescriptions written for drugs requiring a prescription in order to be dispensed other than controlled substances for patients discharged during the EHR reporting period.
Numerator
Number of prescriptions in the denominator generated, queried for a drug formulary and transmitted electronically.
Threshold: > 10%
New objective
Electronic transmissions within and outside the organization should be included

37. Lab Results to Ambulatory Providers
Objective
Provide structured electronic lab results to ambulatory providers.
Denominator
Number of electronic lab orders received.
Numerator
Number of structured clinical lab test results sent to the ordering provider.
Threshold: > 20%
New objective
Methods that have no potential for automatic incorporation, such as “Portal View” do not count
Order must be sent electronically from the ordering provider in such a way that the hospital lab does not have to print a hard copy of the order to view it

38. Clinical Quality Measures (CQM)
Requirement
EHs & CAHs must report on 16 of 29 approved CQMs. Selected CQMs must cover at least 3 of the 6 National Quality Strategy domains:
Patient & Family Engagement
Patient Safety
Care Coordination
Population & Public Health
Efficient Use of Healthcare Resources
Clinical Processes/Effectiveness
Reporting
All CQMs will be submitted electronically to CMS
Must report on 16 of 29 approved measures
Electronic submission is required beginning in 2014

39. To Review… Stage 2 Objectives 3 Month Reporting Period in 2014
16 Core
3 of 6 Menu
Clinical Quality Measures
3 Month Reporting Period in 2014
Must be completed by September 30th
Can begin no later than July 1
Payment Adjustments begin in 2015
Start no later than April 1 to avoid adjustments

40. To Review… Menu Objectives Core Objectives Clinical Quality Measures
CPOE for Med, Lab, Rad Orders
Demographics
Vital Signs
Smoking Status
Clinical Decision Support Rules
Patient Electronic Access
Privacy & Security
Clinical Lab Test Results
Patient List
Educational Resources
Medication Reconciliation
Summary of Care
Immunization Registries
Reportable Lab Test Results
Syndromic Surveillance
eMAR
Menu Objectives
Advance Directives
Electronic Notes
Imaging Results
Family History
eRX
Lab Results to Ambulatory Providers
Clinical Quality Measures
Report on 16 of 29

41. Speaker Information Natalie Stewart, MBA
Managing Advisor, Meaningful Use
Purdue Healthcare Advisors
(765) (phone) (765) (fax)
Visit us on @ Purdue Healthcare Advisors